Noble went to work at the Navajo Nation Hospital – Gallup Indian Medical Center in New Mexico – as part of the second group that made the trip out of UCSF. The first group arrived in April after responding to a call from Navajo Nation President Jonathan Nez for reinforcements from health workers. Around the same time, a similar size cohort of UCSF medical providers traveled to New York.
Noble’s group arrived in May. She was immediately impressed with the measures taken to ensure that more patients could be seen on site. “They installed plastic sheeting and gates to double the capacity of the emergency room and then took over an old pediatric clinic,” she recalls. “There were also tents outside for the less sick patients. ”
However, many Covid-19 patients had to be transferred to larger facilities in Albuquerque, New Mexico, or Flagstaff, Arizona, if their health deteriorated. Often, Noble had to call three to four different hospitals in these regions to find room for his sick patient. Now, with a spike in cases in Arizona, Noble is concerned that it will become even more difficult for patients to get the critical care they need.
Noble and her colleagues have been back in San Francisco for a few weeks, but she says their experiences are a constant reminder that Covid-19 is a “terrible disease” because she has treated dozens of suffering patients.
But she also stressed that it is a disease that has had a disproportionate impact on some populations compared to others, including low-income groups and communities of color.
Social and economic inequalities
The Navajo Nation, which has experienced social and economic inequalities for decades, is particularly vulnerable.
Large sections of the population at high risk for serious complications from Covid-19: More than a third suffer from chronic health problems, including 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.
A group of claimants wearing masks at the Gallup Indian Medical Center
Source: Dr. Nate Teismann
But the lack of basic services that many American residents take for granted is another more pressing problem.
Noble recalled how one of his patients, a man almost 70 years old, was ill with Covid-19 and released from hospital after recovering. His house was 50 kilometers away and he had no way of contacting his family. So he started to go home in blistering heat, eventually collapsing due to dehydration.
After being picked up by paramedics, the patient was sent back to the hospital, where he had just been discharged.
“He didn’t have a car or a phone and he was also diabetic and without insulin,” she said. “Unfortunately, it’s a relatively familiar story. Noble pointed out that there is a service that provides transportation for Navajo patients, but it’s not perfect. Sometimes there is no route available, or patients are not given a number to call.
Many Navajo live in overcrowded households with their families, where the virus can spread quickly and more than a third do not have access to running water at a time when hand washing is essential. In addition, the transportation of water can often mean breaking the guidelines for social distancing. There are only a dozen grocery stores and stocking up on basic groceries can mean three hours on the road.
“Everything is exacerbated by the fact that in this community, a high percentage of households have no electricity or running water,” said Dr. Nathan Teismann, emergency physician at UCSF.
“There is also a relatively large homeless population, high rates of chronic disease and behavioral health problems – and that fuels the flames of Covid-19. ”
All the doctors and nurses agreed that the government had to do much more to protect this population. Noble continues to be concerned about the lack of donations. She felt that at a minimum, funding was needed for mobile health units so that providers could visit patients at home, 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 isolate safely.
“These proposals could be costly, but we are talking about a basic human right for things like access to clean water,” she said.
Dr. Tara Sood, an emergency medicine specialist, recalled how one of her patients tested positive, but was ordered to go home to recover.
After speaking with him, she learned that he lived in a small one-bedroom unit with his wife and two others, which made it almost impossible to isolate himself.
“Fortunately, we got him a hotel room,” she said. But Dr. Sood noted that “socio-economic status” plays a huge role in both the exposure and the recovery of Covid-19. “There were so many patients living in houses with eight other people with nowhere to go,” she said.
Gallup Indian Medical Center emergency entrance
Source: Dr. Nate Teismann
The hospitals that serve Navajo patients were doing “heroic work,” according to Noble, to make the most of what they had. At Gallup Indian Medical Center, plastic sheets were used to increase the space for emergency departments 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 still on the verge of exceeding our supplies,” said Teismann, who worked at the hospital in mid-June. “I was constantly wondering while I was there, ‘will today be the day when there are no more intensive care beds’?” ”
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 can dry up, especially when large American hospitals are scrambling to get supplies.
A feeling of isolation
According to doctors and nurses, one of the hallmarks of Covid-19 is the isolation of many patients. During their stay with the Navajo Nation, they encountered older 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 family members and did not have a mobile phone. Some patients were flown to unknown locations, including larger hospitals in other states, which only increased their feeling of loneliness. Some of these patients ended up on respirators, and no one could visit them in person without adequate protective equipment.
“It’s horrible and it’s not how we wait for the end of someone’s life,” said Sood.
“It is an incredibly resilient and willful population and it has managed for itself for decades,” said Noble. “And there is a strong sense of belonging to the community,” she noted, adding that it made it even more difficult to separate people from close friends and family members.
All doctors and nurses reported having patients in their 20s, 30s and 40s who needed hospitalization, but the majority were older. Very few people died in hospital because the sickest were transferred elsewhere. But in one particularly distressing case, a Noble patient in his late 60s lost consciousness and died in the car on the way to the hospital.
“This pandemic will not be driven by human preference”
Doctors and nurses returning from the Navajo Nation have a message to share for their fellow Americans. Since this month, officials are reporting record cases of Covid-19 and a handful of states have been particularly affected by the virus. At the same time, people are anxious to get back to a normal life – 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 serious illness,” said Noble. “Wearing a face mask must be taken seriously and social distancing must be taken seriously. ”
“Just because you don’t experience it personally (Covid-19) does not mean that large chunks of the population are not,” said Sara Kaiser, a nurse practitioner. Kaiser said she observed the Navajo follow public health guidelines to the best of their ability and that many were very concerned for the health and safety of family members.
“People are tired, but unfortunately the course of this pandemic will not be dictated by human preferences,” added Teisman. “Instead, he will follow the biology of a contagious respiratory virus. “