Responding to Covid-19 in the Navajo Nation: A Front Line Perspective

While the tribal nation reports the highest case rate of any state, the territory continues to lead the country in testing.

Navajo Nation resident Verna Martinez pumps water for fellow community members in April, 2020.  Infrastructure challenges exist for many parts of the nation, but health providers are working to ensure access to care.(Photo by Jonathan Schell for Direct Relief)
Navajo Nation resident Verna Martinez pumps water for fellow community members in April, 2020. Infrastructure challenges exist for many parts of the nation, but health providers are working to ensure access to care.(Photo by Jonathan Schell for Direct Relief)

In the Navajo Nation — a sovereign territory spanning 27,000 square miles — responding to Covid-19 comes with unique challenges.

A third of residents don’t have access to running water. Grocery stores are few and far between. And many must travel hours to reach the nearest hospital.

While the nation has the highest case rate of any state in the country, it’s been successful in containing the spread of the virus through stay at home orders and strict weekend curfews. When the pandemic began, the territory quickly ramped up testing and contact tracing investigations. The Navajo Nation now boasts the highest testing rate in the country with roughly 40% of all residents having been tested for the virus.

On this episode of the podcast, we speak with Dr. Jonathan Iralu, an infectious disease doctor at Gallup Indian Medical Center in New Mexico. He discusses how he and his staff adapted to treat an influx of patients during the peak of the outbreak and what they’re doing now to ensure continued access to care.

Direct Relief is providing ongoing support to tribal health facilities within the Navajo Nation, including shipments of requested supplies, such as personal protective gear, intensive care medications, and oxygen concentrators.

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DR. JONATHAN IRALU: The virus probably came from people returning from large metropolitan areas in the bordering States. We initially saw spread related to a sporting event where somebody traveled to a sporting event and returned. And then later on, there were all kinds of venues where it spread–just as it’s been spreading throughout the country–at church events and things like funeral proceedings. The virus spread through the community, initially, through those ways.

AMARICA RAFANELLI: Are there any circumstances that are unique to the nation that may have exacerbated the severity of the outbreak?

IRALU: Hmm. Yeah. So, the thing that concerns us in Indian country is the lack of infrastructure. We have a tribe that has a beautiful culture. They live in very rural sites, but, unfortunately, some of the parts of the Navajo Nation do not have things like running water and electricity. And so, for a person to come in and get seen in a hospital they might have to drive a long distance, sometimes on dirt roads. So, infrastructure is an issue.

And so that makes things like self-care and patient care more challenging, but it’s not something that’s totally insurmountable.

RAFANELLI: Can you give me an idea of what your typical shift looks like right now? How has your hospital changed?

IRALU: So the hospital has changed, as most hospitals in the United States have changed, dramatically.

So when we learned that Covid-19 was starting to spread on the West coast and then on the East coast it really concerned us because we knew we lived in a rural area and that could potentially cause difficulties for us here. So we had to make a lot of dramatic shifts in the way we deliver care.

So for instance, early on we shut down our clinics and left a sort of skeleton crew back in the clinics to just handle emergencies and do medication refills et cetera. And we transferred a lot of the staff into the inpatient and to the emergency department areas so that we can enhance the care of people coming in with COVID.

So for instance, we very quickly instituted drive-up testing where folks can drive up get their swab testing and then go home. And we were doing that very, very early on in the outbreak. We also made modifications to our emergency rooms, so that a lot of the triage is done outside of the main hospital building. So a person could come in and if they had mild complaints, they could actually be seen in sort of like a medical tent, do their screening down there, and can get some of their care there. And if they’re not critically ill, they could be sent home from there and the people who are really sick would have to be taken into the main emergency room.

The hospital itself–we had to create inpatient ward space for COVID patients. And what used to be office space, we had to move folks out of their offices and convert those rooms into COVID care units and that included making modifications in the air ducts and installation of new digital pharmacy equipment so that we can give out meds safely.

A lot of modifications had to be done to keep people safe. So, the day to day life in the hospital has changed. So clinic visits, like many parts of the country, involve telemedicine where we telephone patients and do our quarterly updates over the telephone.

So those are some of the things that have changed: You have to create COVID units in the inpatient service, like out of a vacuum, and then the clinic has moved from fewer face to face and more telephone visits.

RAFANELLI: I do want to follow up on that and just ask: Is access to technology a challenge for your patients that you’re trying to reach through telemedicine.

IRALU: Not everybody has access to technology. Sometimes the family will have a shared cell phone. if a person lives in a remote part of the Navajo Nation that’s far from the cell phone tower it’s sometimes difficult to get service. We’ve had people had to drive to the top of the mountain in order to make telephone calls. So you can imagine that would be challenging.

RAFANELLI: Do those same patients in remote areas face challenges accessing in-person care as well.

IRALU: Ah okay. In the pre COVID era, and partly during the COVID era, we have used homecare extensively for infectious diseases. So, the tribe created a beautiful tuberculosis treatment program along with the Indian Health Service back in the 1970s where they utilize a program of what we call community health workers. I’m sure you’ve heard that term before, but these are folks who are adept at speaking the Navajo language, and many of them are, that have some medical training and they will go into the homes and deliver medications for tuberculosis for instance and this worked well for decades.

Roughly I think about 12 years ago we started doing the exact same thing with HIV care. And so we have a long-standing history of having Navajo speaking healthcare workers who are community health workers go into the homes and do direct care. During the COVID emergency we had to curtail the HIV program cause the staff were needed elsewhere, especially in the clinics. The tuberculosis care, which is run by the Navajo Nation, was continued.

So when people aren’t able to come in here, we’re able to get to them.

And I would also like to mention a really nice program that was started by two of my colleagues, Dr. Jenny way of UTI and Dr. Mia Lozada. They worked with the state of New Mexico, McKinley County and many many many many other agencies full of volunteers to take care of people in motels who do not have a place to stay during the COVID emergency. So for instance, if somebody develops COVID and there were healthy relatives at home we would ask that person to stay in the motel for their 10 day isolation period to keep them from infecting other people in the community. If someone was exposed to COVID at home and did not have a place to quarantine themselves they’re also sent to these places. And then lastly, there are people who can’t return home because there’s COVID at home and they need a place to stay. So my colleagues working with state of New Mexico and many other volunteer agencies and universities across the country have sent volunteers to assist in this.

It’s a beautiful effort. So though they have a whole group of people who do not have a place to stay, they have ended up staying in the local motels. They get fed. They get looked after by doctors and nurses who come and visit them in the motel room. They’ve done a beautiful job with this and I think it’s been a real benefit to the community that prevents the spread of COVID.

RAFANELLI: Given the scale of the outbreak in the Navajo Nation, how has your hospital, in particular, been impacted?

IRALU: So, in early March like everybody in the country we were desperate for supplies. Nobody you know could have imagined that this pandemic would hit the United States.

So we were just like everyone else. We were short on N-95 respirator masks, surgical masks, gowns, gloves, sterilizing wipes–all that kind of stuff. We were short just like the rest of the country. We have all the same suppliers as everyone else. So, the hospital had to create a personal PPE committee to spend a lot of time ordering and tracking and projecting what the needs would be for the hospital. So that obviously impacted us.

As I mentioned before, we were short on space. We only had two medical surgical wards plus a small intensive care unit. And we had to create a couple extra wards. So, we transformed office space into these COVID units and that was challenging to get the ball rolling, but we were able to do it over a period of a few weeks.

We had to do some HVAC renovations to kind of strengthen the air flow in some of the parts of the hospital, but that really impacted us a lot in in April when we were at the peak of the COVID emergency.

Here, as it is now, things are better and we’re kind of catching our breath.

RAFANELLI: Obviously you’re treating a number of COVID positive patients. but have you seen an uptick in the number of patients experiencing health issues unrelated to COVID, but due to some of the circumstances that the pandemic has created?

IRALU: Sure. So what I think what you’re alluding to is that when you have to convert a hospital into a COVID care unit things like routine primary care might be put on the back burner.

So for instance, a diabetic who would ordinarily see either their provider every three months might not get to see one for a while and their sugar goes up. This is a common scenario. And now that things have quieted down, we’re able to do catch ups by telemedicine. So for instance I spent the morning doing that. I’m catching up with a number of patients using telemedicine, so that’s how we’re hoping that we can get back into the swing of regular primary care again here.

RAFANELLI: As an infectious disease doctor, what are your thoughts on the current situation? Are you concerned or do you feel that things are under control?

IRALU: Today, at this location, I am cautiously optimistic that things are going to be good for the near future.

I’m worried about the possibility of importation of cases of the virus from the neighboring states. The Navajo Nation is a part of New Mexico, a big part of Arizona, and part of Utah and then we have patients coming in even from Colorado.

So, we’re in the four corners area and a couple of those four corner states are seeing an uptick in cases. We’re worried about the possibility of reintroduction of the virus from one of these bordering States. That’s our concern.

RAFANELLI: Do you feel like your hospital’s response has differed from other hospitals across the country because of the region you serve?

IRALU: On one level we would be different from the average small rural hospital in the United States in that we’re the public health service. We do direct patient care and we’re responsible for the public health needs of the patients that we serve. So another hospital would do the direct patient care and then make a referral to the stage or local health care jurisdiction like the county department of health or in the state department of health to do the contact investigations and do the other work.

While we do work a lot with the states that we are adjacent to we have to do the public health ourselves. So we have a group of public health nurse across Navajo Nation and other epidemiologists from the Indian Health Service et cetera at different service units or that are doing things that ordinarily are done by states. So we kind of we do two kinds of healthcare both public health and direct patient care.

And then I think that some things that are unique are that we serve the Navajo Nation and in some parts they do not have the kind of infrastructure you might find in an urban area–people don’t have running water, the things we already talked about–cell phone access, roads et cetera makes things more challenging than they would be in an urban area or perhaps in a more rural area but one with better services than we have here.

RAFANELLI: Can you explain the difference between public health and direct health?

IRALU: Oh yes. So, for instance, as an infectious disease specialist, I have spent the whole morning doing direct patient care. So, I I did a consultation in the inpatient units and then I did a number of telephone calls, telemedicine visits, face to face visits in the clinic. So that would be direct kind of direct patient care that we would do.

Tomorrow my teams are going to be meeting to do public health work. So, we’ll be following up on persons who have tuberculosis and we’ll be following up on persons who have HIV in the community working with Indian Health Service staff and working directly with tribal workers. So, they will be fulfilling more of a public health role to try to stop outbreak in the community of those infections I mentioned. And so, we have a whole section of the Indian Health Service hospital where I work–it’s called Public Health Nursing. So they would not be doing direct patient care, but they would be doing contact investigations, looking after people with COVID. They’re doing a really beautiful job. I’m proud of their work.

This transcript has been edited for clarity and concision.

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