Navajo Nation battling surging cases
UCSF doctor who made trip asks, ‘When is it going to stop?’
As San Francisco flattened the curve of coronavirus infection last month, and New York City reached and fell from the peak of its surge, in Navajo Nation, the pandemic’s grim statistics were climbing.
The sovereign American Indian nation reported its first confirmed case on March 17, a 46yearold tribal member near Kayenta, Ariz., about 250 miles north of Phoenix. The same day a second person tested positive, and four days later there were 26 cases of the novel coronavirus spread across four different regions of tribal land.
On March 29, Navajo Nation President Jonathan Nez issued an emergency order that warned that the reservation was “beyond containment and mitigation of risk” and the health care system was “rapidly exhausting available resources, including supplies and personnel.” In the weeks since, cases and deaths have continued to grow. As of May 10, the Navajo Nation has the secondhighest infection rate per capita in the United States.
To help combat that surge, 14 nurses and seven doctors from UCSF left the Bay Area for the Navajo Nation on April 22. There, the health care workers are treating COVID19 patients in emergency departments and intensive care units, supporting local providers in overburdened hospitals and battling the virus in a community particularly vulnerable to its spread.
“The curve is quite steep. It is surging,” says UCSF associate clinical professor of medicine Dr. Sriram Shamasunder. “The question is, when is it going to stop?”
The Navajo Nation stretches more than 27,000 square miles over a swath of Arizona, New Mexico and Utah, an area larger than the state of West Virginia, with a population of about 180,000. Despite decisive action by Navajo leadership, the coronavirus has raced through the reservation, spreading by exploiting close familial relationships and poverty. As of May 10, the Navajo Department of Health had reported 3,122 cases and 100 deaths — 60% more infections and more than double the deaths in San Francisco, a city with five times the population.
On the reservation, the pandemic has placed an extra layer of stress on top of an already strained health system. Even before the coronavirus hit, the treatyguaranteed Indian Health Service — the federal program for Native Americans and Alaska Natives — was underfunded and understaffed, and federal spending on medical care per capita was less than onethird the spending from the Veterans Health Administration or Medicare.
“Native American health has been neglected for as long as the U.S. has been in existence,” says Shamasunder. “You can see that impact literally in the bodies of the Navajo patients.”
Shamasunder is a cofounder of the UCSF Department of Medicine’s Health, Equity, Action and Leadership (HEAL) Initiative — a twoyear health equity fellowship that has been working in Navajo Nation for five years. Even before the coronavirus outbreak, HEAL had 49 current and former fellows on the reservation, about half of whom are Navajo. As infections grew, Shamasunder heard from local hospital leaders that they needed more emergency and critical care nurses to pick up shifts in facilities overwhelmed by the pandemic.
Shamasunder and the other volunteers have stepped in at three highvolume hospitals in Chinle, Ariz., and Shiprock and Gallup, N.M. At the 60bed Chinle Comprehensive Health Care Facility, the COVID19 unit is increasing by 16 to 20 new patients every day, Shamasunder says, with the sickest airlifted outside the reservation for treatment. In Gallup, a “border town” on the Navajo Nation’s southeast edge, everyone who enters the emergency room at the Gallup Indian Medical Center is a person of interest for infection. UCSF nurses treat patients in makeshift isolation rooms, and doctors intubate those struggling to breathe. Teams of volunteer health care workers visit unhoused community members in motels to keep them out of overburdened hospitals.
Even Nez has been exposed. The Navajo leader quarantined himself in April after coming into contact with a first responder who tested positive for the coronavirus.
As in San Francisco, where Latinos have been disproportionately affected by COVID19, the pandemic in the Navajo Nation has highlighted historical inequities and been intensified by them. Spread out over a vast rural landscape, many families lack running water and electricity, complicating measures to prevent viral spread like frequent hand washing and contact tracing. For those without refrigeration, following stayathome orders also means forgoing fresh supplies.
“One of the things we take for granted from a position of privilege is that shelter in place is an inconvenience instead of an impossibility,” Shamasunder says.
Rates of diabetes are several times higher than in the larger U.S. population, and patients with chronic conditions may not have internet service to access care online. Cultural traditions like families living together in multigenerational households put community elders at greater risk.
In Chinle, Shamasunder says, there were four generations of one family hospitalized at the same time. “Every patient I see, there’s a sister that’s intubated in Phoenix or a grandmother that had the disease first.”
Navajo Nation leadership, state governments and local medical personnel have all been struggling with the surge. In Gallup, New Mexico Gov. Michelle Lujan Grisham issued a lockdown May 1 under the state’s Riot Control Act, closing all roads into the city and instructing residents to leave home only for emergencies.
On the reservation, Nez imposed weekend curfews, requiring all but essential workers to stay home and setting up police checkpoints to issue citations to violators. Masks are required in public, and the nation has tested 8.5% of its population, approximately double the percentage in San Francisco. As the rate of infection ticks higher, the U.S. Army Corps of Engineers is transforming high school gymnasiums into isolation zones to keep coronaviruspositive patients away from uninfected relatives.
Shamasunder says the UCSF team is bolstering those efforts, supporting a health system ill equipped for the pandemic and local providers who’ve been slammed for weeks. Some UCSF nurses have asked to take on extra shifts in hopes of giving reservation colleagues the chance to catch their breath — and then keep going.
“There’s a level of fatigue, for sure,” Shamasunder says. “People have been sprinting for six weeks, and they’re not sure when the sprint is going to be over.” But he’s also witnessed remarkable resilience and perseverance from the Navajo Nation providers and the larger community. “We’re just here in solidarity in this moment.”
UCSF’s nurses are scheduled to return home in late May after a month of service, but Shamasunder says some have asked to stay longer, to see the surge through and leave the nation and its medical staff with the worst behind them.
“There’s a commitment,” he says. “If somebody’s house is burning down, you can’t leave in the middle.”