By Kwan Kew Lai, MD, DMD
Navajo Nation had its first COVID wave in May of 2020 and on May 18, it quickly surpassed New York as having the highest infection rate. The second wave started in November and by mid-February 2021, it was slowly brought under control.
I had the occasion to volunteer with Project Hope at the Northern Navajo Medical Center during the second wave and participated in patient care, COVID testing, and the roll-out of the vaccination program.
At the Navajo Nation, there are 55,000 homes and businesses with no addresses, many rely on P.O boxes and hand-drawn maps. For those patients who are discharged from the hospitals and still have an oxygen requirement, the fact that there is no physical address poses a problem for the delivery of oxygen tanks. The lack of electricity in certain areas precludes the use of stationary oxygen concentrators. GPS often fails to locate the homes.
The Public Health Emergency — PHE — program for the COVID Care Clinic where COVID testing takes place, has evolved into a streamlined system whereby the patients are given education and handouts about the symptoms of COVID, its prevention within the household, and a work excuse if needed. They are swabbed for a rapid test, with results available in 15 to 30 minutes while they wait in the parking lot. If positive, they are given a home care package with food and other necessities and instructions to self-isolate. They are also swabbed for a PCR molecular test, a PHE nurse contacts them with the results, available in two to three days. Oftentimes, phone reception in the Navajo Nation is spotty or non-existent and some patients are cut off from their telephone service, waiting for the stimulus check or some kind of financial assistance to bail them out; making follow-ups impossible.
The most recent report from the Navajo Nation health officials states that a total of 30,255 people have been sickened or died from the coronavirus. Over the last two weeks, deaths have decreased by 62%. At least 16,430 people have recovered.
In the past two weeks, however, variants B.117 and B.1.429 were reported in the Western and Chinle agencies of the Navajo Nation, respectively. The more lethal U.K. variant, the B.1.1.7, first identified in U. K. in September 2020, spreads more easily than the older variants of the virus and is more deadly causing around 64 percent more deaths in people matched for age, gender, and ethnicity. It infected a fully vaccinated individual at the Navajo Nation. The variant B.1.429 (also called CAL.20C or 452R.V1), first identified in California, is spreading rapidly in the United States and has been found in at least 25 other countries.
The first COVID vaccines arrived at the Navajo Nation in mid-December 2020 and by the second week of February 2021, Navojo Nation led the country in vaccine roll-out. By then it was offering vaccination to people 16 years and older, far ahead of many states in the country. As of April 9, 86.5% of the population or 211,298 have received at least one dose of the vaccine, according to the Navajo Area Indian Health Service. Of those 90,942 people, or 37.2% are fully vaccinated.
Since April 2020, the stay-at-home (shelter in place) order and a daily curfew from 10 pm to 5 am has been imposed. That has undergone some relaxation and reinstatement throughout the pandemic. The 57-hour weekend curfew starting from 8 pm Friday through 5 am Monday continues. Navajo Nation remains vigilant because its incidence of COVID could be affected by its neighbors, Arizona and Utah which have recently lifted some of their COVID restrictions including mandatory mask-wearing in Utah.
The remoteness of the Navajo Nation which does not attract and retain long-term healthcare providers; its lack of amenities such as running water and electricity, and broadband connectivity, all make the fight against the COVID pandemic that much more difficult.
In this hard-hit remote corner of the underserved Navajo Nation where there is a real shortage of long-term healthcare providers, continuity clinics with the patients’ primary care physicians stopped as soon as the pandemic hit a year ago. Walk-in clinics are all that they have, waiting for hours or a whole day to be seen. It is rare to meet staff members who have been here for ten years or more. Most of the vacancies are temporarily filled with contract workers for a few months, they may then extend their contract or move on. It is hard to have continuity of care without a consistent cadre of healthcare providers.
But its successful vaccination roll-out orchestrated by the people of the Navajo Nation along with the volunteers is laudable and may yet help to stave off another wave with herd immunity in the offing, as the vaccine-elicited neutralizing antibodies are likely to remain effective against the B.1.1.7 and B.1.429. They may now have to concentrate their efforts on convincing the hesitant groups and to get to the hard-to-reach people of the Navajo Nation.
Kwan Kew Lai, MD, DMD is a Harvard Medical Faculty Physician at Beth Israel Deaconess Medical Center, an infectious disease specialist, disaster relief volunteer in various parts of the world, including the Ebola outbreak, the Syrian, Rohingya refugee crises and the war in Yemen, author of Lest We Forget: A Doctor’s Experience with Life and Death During the Ebola Outbreak and Into the Africa, Out of Academia: A Doctor’s memoir