COVID-19 worsens health disparities on reservations

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during the kick off of the fifth installment of The Sesame Street/USO Experience for Military Families at the Franklin County Veterans Memorial in Columbus, Ohio April 14, 2011. (USO Photo by Fred Greaves)

Rx REPORT

By Marie Lemelle

Contributing Writer

Katherine GeeBah Footracer is a Navajo Indian and a physician assistant certified by the National Commission on Certification of Physician Assistants. Among the many hats she wears, she is a member of the Los Angeles County Disaster Healthcare Team.

Footracer is the first to admit that she was not good at being Navajo, Diné, which translates to “The People.” Footracer, a registered member of the tribe, was born, raised and resides in Los Angeles. She does not speak the language, Diné Bizaad, spoken by an estimated 175,000 people throughout the United States.

With a population of about 300,000, the Navajo Nation is the largest Native American territory in the United States. Among the 55,000 homes on an approximately 27,000-square-mile reservation, 15,000 do not have electricity or access to running water.

Data from the COVID-19 Tracking Project reported that the pandemic had killed more than 500 people in the Navajo Nation in the southwest United States and infected more than 10% of the small tribe of Choctaw Indians in Mississippi. The numbers are still increasing.

The pandemic was destroying the Navajo Nation and Footracer was compelled to help her people. In May, she volunteered with the Indian Health Service in the Kayenta region of the Navajo Reservation where she worked in the influenza-like illness section of the Emergency Department.

ML: What triggered your need to volunteer? Tell me about the health disparities you witnessed on the Navajo Reservation.

KGF: After reading about how the pandemic was decimating the Navajo Reservation, I took time off to volunteer with the Indian Health Service on the Navajo Reservation. For two weeks in May, I served with the Kayenta Health Center in northeastern Arizona. I was assigned to the section of the Emergency Department where patients with coughs and fever were triaged.

Behind layers of protective gear, I examined patients, offered guidance and medication to manage symptoms, gave reassurance that most people come through their illnesses, arranged in-patient care as needed, and I listened to patients’ stories. Some were positive for COVID-19, others negative, but all were afraid.

I knew that health disparities existed on the reservation and in the American Indian population, but I had not realized the extent until the pandemic hit.

The beauty of the Navajo Reservation comes from its open horizons and wide skies. Unfortunately, these same expanses can make health care difficult. At my Los Angeles workplace, many of my patient visits for chronic conditions such as diabetes and hypertension are conducted by phone or video. On the reservation, cell phone service and internet access are spotty, which limits access to telehealth, causing many patients to postpone care.

In Los Angeles, some of my patients complain if they have to drive seven miles to see a specialist.  On the reservation, most specialists are 1-2 hours away, turning a 30-minute consult into a half-day undertaking.

Unemployment is around 40%, so some of those who are employed work hours away off the reservation during the week and have difficulty receiving routine health care. The reservation is a food desert and there are only about a dozen grocery stores — not just convenience stores — for an area the size of West Virginia. Without a nearby store, frequent grocery trips are impossible, and people rely on nonperishable foods.

In most of Los Angeles, the nearest hospital is literally across the street and the next a 20-minute bike ride away. On the reservation, there are only 222 Ihospital beds and when I volunteered there, they were filling up rapidly. The nearest hospital to Kayenta Health Center is an hour away by car.

For safety, we are advised to limit in-person social interactions and to wash our hands often. About a third of people on the reservation lack either electricity or running water, which makes connecting with friends and family via phone or video difficult and hand washing for 20 seconds multiple times a day nearly impossible.

All of these complicating factors drive COVID-19 infections and complications, and the Navajo Reservation has been hit hard. We talk often about what it will be like to “return to normal,” but for many people — especially those of us who identify as Black, Indigenous, or people of color — the old “normal” was not working. I am hopeful that a new “normal” will be a better normal that is more just and equitable for all people.

ML: The Indian Health Service reported Navajos have a 20% diabetes rate and a high incidence of heart disease and both conditions are also known risk factors for severe COVID-19. What are other challenges facing Native Americans regarding COVID-19?

KGF: One challenge facing Native Americans in regard to COVID-19 is the increased underlying health conditions that are more than the general United States population. Native American populations may have slightly higher rates of diabetes, hypertension and other diseases, but they have much higher rates of complications and from dying from these diseases. As an example, among the U.S. population overall, the prevalence of diabetes that has been diagnosed is 13.0% and for American Indians, 14.7%, which doesn’t seem like a big difference. However, when you examine the mortality rates, there is a big discrepancy.

Mortality per 100,000 people from diabetes in the general U.S. population is 20.8, but among American Indians, it is 66.0. There are similar discrepancies in mortality rates for chronic liver disease, substance use disorder, and suicide. The obesity rate among the general U.S. population is 31.1%, but among Native American populations, it is 48.1%. The CDC has declared that diabetes, obesity, chronic liver disease and hypertension are all conditions that increase the risk of having severe illness from the COVID-19.

Another challenge facing the Navajo population is the Navajo Reservation is rural and the population spread out, which complicates basic infrastructure such as utilities. Approximately one-third of the households on the Navajo Reservation lack either electricity or running water, cell phone service is improving but still spotty in places, and many households also lack landline phones. These limitations all affect the ability to wash hands frequently, launder clothing, keep perishable food for more than a few days, and call for assistance when ill or injured.

ML: How has the pandemic affected the health care facilities serving the 573 federally recognized tribes throughout the country?

KGF: The Indian Health Service has some chronic problems that are affecting how health care is delivered during the pandemic.  The Indian Health Service provides health care to the 2.2 million members of the nation’s tribal communities but the IHS is understaffed, in part, because many of its locations are rural and it can be hard to attract and retain permanent staff in those areas. IHS sometimes has to rely upon contract employees, which leads to less patient/provider relationship building, inadequate cultural sensitivity as providers leave before developing a deeper cultural understanding, poor institutional memory, and increased expenses for training.

Frequently, IHS personnel did not have access to adequate personal protective equipment such as N95 masks, surgical masks, etc. When I was at Kayenta, staff had brought in sewing machines so that they could stitch Tyvek-type materials into jumpsuits for the nursing staff and clinicians because there were such limited quantities of surgical gowns available.

Chronic underfunding of the Indian Health Service is also causing pre-existing problems to worsen during the COVID-19 pandemic. Medicaid spends about $7,789 per patient per year, and Medicare $12,829. In contrast, IHS spends only $3,332 per patient per year. For those American Indians who live in urban areas, we have multiple options for health care. For people living on a reservation, the only available health care within miles may be IHS.

ML: What was the most impactful lesson you learned from connecting with your Navajo heritage?

KGF: COVID-19 is a difficult disease. It can show up in many different ways with different levels of severity and can be unpredictable on how it affects a person. There are several patients from Kayenta whose stories still haunt me.

I remember a woman in her 60s had developed a cough the day before she came to the health center. She was diagnosed with COVID-19. She started crying and told me that she had just lost her sister to the disease that morning. My patient was too stable to be hospitalized and had no other family nearby with whom she could stay. She had family off the reservation but refused to contact them for fear of exposing them to the disease. I held her hand and all I could offer her was compassion and love.

The pandemic made me think about what I value and how we interact with others. As in-person exchanges are curtailed, we hunger for connection. For patients who are hospitalized, social isolation is exacerbated as hospital visiting hours are restricted or eliminated. A patient’s only contact at this time may be hospital staff who are gowned, gloved, masked, and face shielded into near-anonymity. This necessary protective gear makes smiles hard to see and muffles warm voices. It may be harder now for patients to see and hear the caring of those who practice medicine, but it is present beneath the layers we wear.

Many people say that when they die, they would like it to be at home surrounded by loved ones. During this pandemic, too many people are dying in hospitals without their family by them to ease their way.  There may only be medical staff in the room, but even so, these patients are still surrounded by those who love them. In Kayenta, every patient knew someone who had the disease, and most also knew someone who had died from it.

When I entered physician assistant school, I had a symbol representing “compassion” tattooed to remind me of why I was starting on this path. My time volunteering on the reservation deepened my understanding of what I committed to and strengthened my belief that as a society we need to address health disparities and provide equality for all people.

Marie Y. Lemelle, is the founder of www.platinumstarpr.com and a film producer. She can be reached at MarieLemelle@platinumstarpr.com. Follow her on Instagram @platinumstarpr.