Tracing saves tribal members
Wellness checks for most vulnerable aid efforts
PHOENIX – As the coronavirus ravaged the White Mountain Apache Tribe in eastern Arizona, Eugenia Cromwell did her best to stay home and to stay safe. Visits to the grocery store and post office were passed off to her daughter.
It came as a surprise to the 79-yearold Apache woman when she learned in August that she had tested positive for the coronavirus, which causes COVID-19, along with two others in her home. Knowing the virus could severely impact older adults, Cromwell feared for her life.
More than 15,000 members make up the White Mountain Apache Tribe, whose reservation spans 1.6 million acres (2,500 square miles) across three Arizona counties. Whiteriver, the tribe’s capital and largest community, is home to about 4,000 residents – including Cromwell.
In early June, the White Mountain Apache surpassed the Navajo Nation in total number of COVID-19 cases per capita – meaning it had one of the highest infection rates in the country. By mid-August, about the time Cromwell tested positive for the virus, there were more than 2,300 identified COVID-19 cases and 38 known deaths.
However, the tribe’s number of new daily and active COVID-19 cases dropped in the last few months. COVID-19 related deaths through the pandemic also remained consistently low, with a fatality rate last Wednesday of 1.6% – less than the state’s rate of 2.5% and country’s at 2.7%.
Health officials lend credit, in large part, to the robust contract tracing efforts on the Fort Apache Indian Reservation. So does Cromwell, who tested negative for the virus about three weeks after her initial diagnosis.
“I’m crying because I’m happy, these are wonderful people,” she said last month, with tears in her eyes. “I’m so glad that I’m alive today.”
A health care provider on the morning of Sept. 10 paid a visit to Cromwell’s
home to do a wellness check – reserved for patients considered high risk for complications from COVID-19.
Like clockwork, Cromwell quickly set up a chair on her front patio, wheeled out an oxygen concentrator and masked up. Several cicadas buzzed from a tree overhead while Victoria Moses, a health tech at Whiteriver Indian Hospital, checked Cromwell’s oxygen levels and asked her questions.
It was one of several visits made to Cromwell’s home since members of her family began testing positive for the virus in August. The wellness checks, in large part, involve monitoring a patient’s oxygen levels while sitting and walking – which for Cromwell also meant dodging a handful of ducks and a pig roaming her front yard.
“The patients get so used to our team that we’ll receive phone calls saying, ‘No one’s come to my house yet today, can somebody come see me?’ ” said Lt. Commander Laura Enos, acting director of public health nursing and leader of the hospital’s contact tracing team.
Generally speaking, contact tracing is the process of identifying and notifying people who may have been exposed to a serious illness, including COVID-19, according to the Centers for Disease
Control and Prevention. That notification could be in the form of a phone call or text.
At its peak, between 30 and 35 health care workers were trained in contact tracing for the White Mountain Apache Tribe, according to Enos. All of the tribe’s identified COVID-19 cases, totaling more than 2,400, were traced – and anyone who may have been exposed notified, which in some cases meant 15 or more people, according to officials.
The difference between the hospital’s contact tracing efforts and most others’ lies in these additional steps: determining who their most vulnerable COVID-19 patients are and providing them with daily wellness checks.
The in-person visits allow health officials to quickly respond to a COVID-19 patient whose health may be deteriorating, and identify cases in the same home that may have previously been unknown, explained hospital spokesperson Lt. Commander Justin Tafoya.
Between two and four health care providers each day travel within the tribe’s communities to see between 30 and 50 patients, Enos said. The visits typically continue until a high-risk patient is out of isolation or has “displayed notable clinical improvements” for two days straight, she said.
Moses, an Apache woman who is also a contact tracer, is one of them – visiting between seven and 10 patients a day, which in September included Cromwell.
Like the thousands of health care providers across the country working on the frontlines of COVID-19, Moses worried about what she might bring home to her husband, five children and two grandchildren. She also worried about her parents as they contracted and then overcame the virus.
The Whiteriver Indian Hospital, a 40-bed facility with no intensive care unit, is the closest Indian Health Service hospital to the White Mountain Apache Tribe. The nearest tertiary and ICU facility is at least a four-hour drive or onehour flight away, Enos said. There are also limitations to phone and internet services for residents in the area, she added.
Additionally, like many Native American communities, there are high rates of comorbidities among the White Mountain Apache Tribe, and multigenerational families often live under the same roof, making it difficult to slow the spread of COVID-19.
Ryan Close, a doctor at the hospital, wrote in an article for the New England Journal of Medicine that many twobedroom homes on the reservation house eight or more people, including a grandparent or a great-grandparent. He added that it was “rare” to come across a COVID-19 patient who didn’t live with at least one high-risk person.
“Several families in our community set up camping tents in their yards to quarantine infected household members, but the sharing of bathrooms and eating utensils contributed to secondary household attack rates above 80%,” he wrote.
Health officials say these challenges that rural and tribal communities often face are offset, and in some cases made better, during the COVID-19 pandemic by in-person visits with patients at their homes.
“Identifying high-risk patients who would benefit from early intervention became our top priority,” Close wrote. “Our tracing team went from asking, ‘Where have you been?’ to asking, ‘Who are your grandparents?’ ”