UCSF doctors fought Covid-19 in the Navajo Nation

Dr. Jeanne Noble has worked around the world as an emergency physician. So when the hospital where she works, UC San Francisco, asked if anyone was willing to fly to the Navajo Nation and help with a Covid-19 outbreak, she volunteered.

The Navajo Nation, which reported its first Covid-19 case in mid-March, has seen infection rates per capita among the highest in the country. So far, there have been 8,000 cases and more than 300 deaths. The reserve, which houses more than 170,000 people, stretches across the varied desert landscape of Utah, Arizona and New Mexico. People refer to themselves as Diné.

Noble went to work at the Navajo Nation hospital – Gallup Indian Medical Center in New Mexico – as part of the second group to make the trip from UCSF. The first group arrived in April after responding to a call from Navajo Nation President Jonathan Nez for reinforcements for health workers. Around that same time, a cohort of similarly sized UCSF medical providers headed to New York.

Noble’s group arrived in May. She was immediately impressed with the steps taken to ensure that more patients could be seen on site. “They had placed plastic sheeting and barriers to double the capacity in the emergency room, and then they took over an old pediatric clinic,” he recalled. “There were also tents outside for the less sick patients.”

Still, many of the Covid-19 patients had to be transferred to larger facilities in Albuquerque, New Mexico or Flagstaff, Arizona, if their health deteriorated. Often Noble would have to call three to four different hospitals in these regions to find space for his sick patient. Now, with an increase in cases in Arizona, Noble worries that it will be even more difficult for patients to get the intensive care they need.

Noble and her colleagues have been back in San Francisco for a few weeks, but she says their experiences were a constant reminder that Covid-19 is a “terrible disease” as it treated dozens of suffering patients.

But he also emphasized that it is a disease that has disproportionately impacted certain populations over others, including low-income groups and communities of color.

The Navajo Nation, which has experienced social and economic inequalities for decades, has been particularly vulnerable.

Large sectors of the population at high risk for serious complications from Covid-19: More than a third have chronic medical conditions, such as diabetes and heart disease. According to the CDC, American Indians and Alaska Natives have the highest prevalence of diabetes in the United States, more than double that of non-Hispanic whites.

But the lack of basic services that many US residents take for granted is another more pressing problem.

Noble recalled how one of her patients, a man in his 70s, had been ill with Covid-19 and had been discharged from the hospital after recovering. His home was 30 miles away, and he had no way to contact his family. Then he started walking home in the scorching heat, finally collapsing from dehydration.

After being picked up by paramedics, the patient was returned to the hospital, where he had recently been released.

“I didn’t have a car or a phone and I was also diabetic and I didn’t have insulin,” he said. “Unfortunately, this is a relatively familiar story.” Noble noted that there is a service available that provides transportation for Navajo patients, but it is not perfect. Sometimes transportation is not available, or patients do not have a number to call.

Many of the Navajo live in overcrowded homes with their families, where the virus can spread rapidly, and more than a third lack access to running water at a time when hand-washing is essential. Furthermore, transporting water can often mean breaking the patterns of social distancing. There are only a dozen grocery stores, and stocking up on staples can mean a three-hour trip.

“Everything is exacerbated by the fact that in this community, a high percentage of homes do not have electricity or running water,” said Dr. Nathan Teismann, UCSF emergency physician.

“There is also a relatively sizeable homeless population, high rates of chronic illness and behavioral health challenges, and that is fanning the Covid-19 flames.”

All the doctors and nurses agreed that the government must do much more to protect this population. Noble remains concerned about the lack of donations. He considered that, at a minimum, there needs to be funds for mobile health units so that providers can visit patients in their homes, as well as better access to clean water. She urges policy makers to consider solutions around housing, so there are more options available for people with Covid-19 to safely isolate.

“These could be costly proposals, but we are talking about a basic human right for things like access to clean water,” he said.

Dr. Tara Sood, an emergency medicine specialist, recalled how one of her patients tested positive but was told to return home to recover.

After talking to him, he found out that he lived in a small one-bedroom unit with his wife and two other people, making it almost impossible for him to isolate himself.

“Fortunately, we got him a hotel room,” he said. But Dr. Sood noted that “socioeconomic status” plays a huge role in both Covid-19 exposure and recovery. “There were so many patients living in homes with eight other people who had nowhere to go,” he said.

Hospitals serving Navajo patients were doing a “heroic job,” according to Noble, to make the most of what they had. At Gallup Indian Medical Center, plastic sheeting was used to increase the space of the emergency department and a reuse program with face shields. There were also creative solutions for designing dresses.

But the need to improvise revealed the underlying lack of supplies.

“We were always on the verge of running out of supplies,” said Teismann, who worked at the hospital in mid-June. “I was constantly asking myself while I was there, ‘Will today be the day when there are no more beds in the ICU?

Noble believes that there must be a long-term solution to ensure that hospitals in the poorest and most rural areas have adequate access to protective equipment. Donations may run out, especially as America’s largest hospitals rush to search for supplies.

One of the characteristics of Covid-19, doctors and nurses say, is the isolation that many patients experience. In their time with the Navajo Nation, they encountered elderly and sick patients who did not speak English well. And it was difficult to communicate with them if a translator was not available.

Many were isolated from their relatives and did not have cell phones. Some patients were transferred to unknown locations, including larger hospitals in other states, which only increased their feeling of loneliness. Some of these patients ended up on ventilators, and no one could visit them in person without the proper protective gear.

“It’s horrible and it’s not like we expect someone’s life to end,” Sood said.

“They are an incredibly resilient and determined population and they have defended themselves for decades,” said Noble. “And there is a strong sense of community,” he noted, adding that it only made it more difficult for people to separate from close friends and family members.

All of the doctors and nurses said they had patients in their twenties and thirties who needed to be hospitalized, but most were older. Very few people died in the hospital, as the sickest were transferred to other places. But in a particularly heartbreaking case, a Noble patient in his sixties lost consciousness and died in the car on the way to the hospital.

Returning doctors and nurses from the Navajo Nation have a message to share for their fellow Americans. Starting this month, officials report record cases of Covid-19, and a number of states have been particularly affected by the virus. At the same time, people are eager to resume life normally, and some researchers have called it “pandemic fatigue.” In some parts of the country, there is a general reluctance to wear a mask or follow social distancing guidelines.

“If you are young, you are not immune to becoming seriously ill,” said Noble. “The use of a face mask must be taken seriously, and social distancing must be taken seriously.”

“Just because you’re not experiencing it (Covid-19) personally, doesn’t mean they’re not a massive part of the population,” said Sara Kaiser, a nurse practitioner. Kaiser said he observed the Navajo following public health guidelines as best they could, and many were very concerned about the health and safety of family members.

“People are getting tired, but unfortunately the course of this pandemic will not be dictated by human preference,” added Teisman. Instead, it will follow the biology of a contagious respiratory virus. “