Across the country, clinicians are seeing COVID-19’s disproportionate impact on minority communities. American Indian communities, which have long shouldered extreme inequities in this country, are some of the hardest hit by the virus. This week, Navajo Nation surpassed New York and New Jersey for the highest per-capita coronavirus infection rate in the US.
“The structural racism that allows a pandemic to spread unchecked is the same—whether it’s in Chelsea or the rural Great Plains,” says Dr. Tom Sequist, Chief Patient Experience and Equity Officer. Dr. Sequist is himself a member of the Taos Pueblo tribe in New Mexico. “The difference is, although they don’t have as high a risk of infection spread due to the population density seen in some of our Boston urban communities, they have nowhere near the same set of local resources we have here in Boston to deal with the pandemic.”
He explains that many hospitals near reservations are vastly under-funded, understaffed, and ill-equipped to handle a high influx of seriously ill patients. Necessary resources like food are also harder to access. In one area of Navajo Nation, there are only 13 grocery stores to service an area two-times the size of Massachusetts.
Additionally, despite their many strengths, many Native American communities have some of the worst health outcomes in the country. The Sioux tribes, who have reservations in the Great Plains in North and South Dakota, have the lowest life expectancy in the United States. They also top the charts for deaths contributed to alcohol, diabetes, injury and suicide. These long-standing disparities could exacerbate the blow of the coronavirus pandemic.
While our health system may be thousands of miles away, that doesn’t mean we’re not lending a hand. Clinicians from Mass General and Brigham and Women’s have had clinical relationships with several American Indian communities for over a decade.
The Great Plains
Mass General has had a partnership with the Rosebud Reservation in South Dakota since 2012. Through the Rural Health Leadership Fellowship, Mass General physicians are embedded in local practices as primary care physicians. They also offer teaching rotations, help with grant applications, and contribute to community outreach programs. Although the area has not yet seen a large spike in coronavirus, a severe outbreak could be devastating.
“The hospital in Rosebud has only a few patients at a time and no ICU,” says Dr. Matt Tobey, Program Director for the Rural Health Leadership Fellowship. He explains that right now, their team is in preparedness mode. They’ve helped set up telehealth systems, critical care plans, and ethics guidelines for treatment.
“COVID has come slower to many rural areas, but you never know when it could explode,” he says.
In the southwest, one of the hardest hit areas of the pandemic, the Brigham and Women’s Outreach Program with Indian Health Service (BWOP) has collaborated with the Indian Health Service (IHS) since 2008 to provide support to Navajo Area IHS hospitals and the Navajo, Hopi and Zuni communities they serve. They collaborate with Navajo Area hospitals and clinics in a variety of ways. Volunteer clinical specialists from Brigham Health travel to Navajo Nation to work alongside IHS providers to teach and train complex chronic disease management strategies in a clinic setting. These visiting clinicians also lead multidisciplinary and clinical education programs for IHS providers held in their community. Additionally, the BWOP facilitates distance teaching through telehealth and CME video conferencing on topics selected by IHS, remote clinical and second-opinion consultation, and hosts IHS providers in Boston at Brigham Health locations for more focused skills training and education.
Ellen Bell, MBA, MPH, Senior Project Manager for the BWOP, has witnessed first-hand how hard these communities have been hit by coronavirus. She’s seen local clinicians using the same mask for 30 days, clinics running out of gowns, and sky rocketing death rates.
“In fact, the death rate is likely higher than reported,” she says. “Since the sickest patients are transferred to hospitals in Phoenix and Albuquerque, those deaths aren’t counted as happening within the [Navajo] nation.”
She also explains that despite the overwhelming obstacles, she’s also seen perseverance and creative ingenuity. For instance, when clinics ran out of gowns, the community quickly created a pattern and assembled a sewing line to make reusable options. After every shift, PPE is washed and hung in the sun to dry.
In response to growing clinical needs related to the COVID-19 outbreak in Navajo Nation, our system has sent vast quantities of PPE along with needed items for community such as care kits and iPads to allow for safe communication between provider and COVID+ patients. Our clinicians have also participated in a telehealth information sharing system through Project ECHO to reach 400 IHS providers, offered peer-to-peer resiliency and support groups to frontline IHS clinicians, engaged in ethical consultations, and have designated on-call critical care physicians for urgent telephone consults from the IHS.
While the curve is just starting to come down in Massachusetts, the toll of coronavirus in Navajo Nation continues to rise. Our system will continue to support these vulnerable communities through the storm.
For further reading, Bell recommends this perspective essay, published in the New England Journal of Medicine, for an inside look at what physicians on the ground in Navajo Nation are facing during the COVID-19 pandemic. Bell is happy to hear from anyone who is interested to learn more about what is needed and how you can help make a difference in the lives of this tribal community.
For more information on Native American health disparities, read this recently published article from JAMA Internal Medicine authored by Drs. Sequist and Tobey, Investing in the Health of American Indians and Alaska Natives.