Massachusetts General Hospital Vincent Program in Global OB/GYN
Tackling COVID on Navajo Nation:
The Power of Academic-Tribal Partnerships
The United States is a fabric made from intertwining threads of history, culture, and geography. Key to the national fabric are rural populations, many of which – such as those on the US-Mexico border, in Indian Country, in Appalachia, in the Mississippi River Delta, and wherever migrant farmworkers labor – face poor health outcomes. Breaking down barriers between our urban academic medicine departments and rural at-risk populations has the potential to avert crises and forge new connections that better align our nation’s health needs and its resources. Deployments from Mass General and other academic medical centers to Navajo Nation amid the vast disruption of COVID are remarkable and worth celebrating.
As Ms. Martin describes, she and her colleagues placed other people and communities before themselves in a time of great stress. Importantly, they also did so in partnership with a trusted, community-centered health system. Underscoring the impact of academic-rural connections, today Mass General-trained leaders of decades ago help direct the Chinle health system, having assisted its growth into a national model for integration of Diné (Navajo) traditional healing with Western medicine. Continuing to invest in such partnerships helps people on both sides share, learn, and grow. That is precisely what the nation – extolled for its rural vistas of spacious skies and amber grain – sorely needs in this time of health crisis and social fracturing. -- Matthew Tobey, MD, MPH
Dr. Tobey works as a clinician, researcher and innovator in interdisciplinary clinical partnerships at MGH. In 2015, he founded the MGH Fellowship Program in Rural Health Leadership, a unique program that offers post-residency training to physicians who seek ongoing training in rural health, health systems, practice transformation, medical education and clinical care.
Navajo Nation Snapshot
Navajo Nation is the largest federally recognized reservation in the US,
covering over 27,000 square miles and straddling the corners of Arizona, New Mexico and Utah.
The Navajo people call themselves Diné, literally meaning "The People."
Traditionally, the Navajos are a matriarchal society, with descent and inheritance determined through one's mother.
Anthropologists believe the Navajos probably arrived in the Southwest from 800-1000 years ago, crossing the Bering Strait land bridge and traveling south.
As of the 2010 Census, a total of 332,129 individuals living in the US claimed Navajo ancestry, with about half residing on the Navajo reservation.
Navajo Nation is one of this country's poorest and unhealthiest communities. A history of systemic racism, food insecurity, lack of basic infrastructure, widespread unemployment, and limited access to health care are among the many health stressors Navajo citizens face.
Notes from the Field
When the Ground Shakes:
Disaster Response Near and Far
Lindsey Martin, NP
MGH Disaster Response Team:
Jen Samiotes, Catherine “Skeeter” Welder, Lindsey Martin and Mary Sebert, Chinle Hospital Respiratory ICU
Jen Samiotes on shift at Chinle Hospital (left); outside Chinle grocery store (right)
Navajo nurse colleague watching the sun rise after night shift at Chinle Hospital
I am the Director of Global Disaster Response and Humanitarian Action (GDR) at the Massachusetts General Hospital Center for Global Health. Each year I lead teams of expert clinicians from within our institution into disaster zones to provide medical care for those affected. Historically, we have responded to “sudden-onset” natural disasters such as hurricanes and earthquakes. However, we know that man-made disasters are ongoing even when the sky above us and the ground below us are calm.
In response to the man-made crisis at the US/Mexico border, a team of 10 MGH clinicians was set to depart in March for a camp across the border in Matamoros. Our mission was to provide essential medical care for asylum-seeking migrants stuck in a dangerous limbo while waiting for their number to be called and asylum case to be heard in the US. Our team had visited the camp, coordinated with our partners, and prepared ourselves for the risks. But a week before our departure the ground shook below our feet in Boston. COVID-19 reached our city and hospital. We had to postpone our deployment.
At the time, postponing felt like a crushing disappointment. Were we abandoning the patients we promised to serve; were we prioritizing one community over another; were we too afraid of the unknown and for our personal safety? In that moment, when we were attempting to stand up for what we believed, we had to stand down for the good of our team and our institution. I felt deeply self-critical as both a clinician and humanitarian. However, what I could not know was that our patients at home would come from the same vulnerable, displaced, and neglected communities we would have encountered at the border. Throughout the months of the first surge the division between global and local became very narrow. From March to June I spent most of my time providing care for patients presenting to the Respiratory Infection Clinic and the surgical ICU. Our patients surged from Chelsea and East Boston, the North Shore and Brockton. I felt an intense sense of mission and understood why we had needed to stay home.
Then, in the middle of June, GDR received a request from longtime partner organization Project Hope. They were requesting a small team of critical care nurses to deploy to Chinle, Arizona, a high desert town in the Navajo Nation. The pandemic was ebbing in Boston and we felt this was the right time to invoke our global mission again. I was joined by three other seasoned critical care nurses who had spent the previous months steeped in intensive COVID care. This group of women (Mary Sebert, RN, Catherine “Skeeter” Welder, RN, and Jennifer Samiotes, RN) brought clinical expertise from months of being on what we have dubbed the “front lines.” Moreover, they brought an openness to the exchange of ideas about culture and medicine that would inevitably occur when we arrived in Chinle. We knew to tread lightly into a medical system and traditional medicinal practices that were unfamiliar. This team knew how to manage ventilators, prone patients, and titrate complex drips, but not how to palliate a dying Navajo elder or discharge a patient to a home with no electricity for an oxygen concentrator. Like any mission, we had more to learn than to offer.
The most striking lesson I took from my brief time on the Navajo Nation was not to underestimate the power of collective action to change the plot of a potentially terrible narrative. Prior to arriving we had been saturated with news images of desperate poverty and the ravages of COVID-19 on the Navajo Nation. These were the National Geographic variety of mostly nameless people in tragic circumstances. What we found was a strong, proud, and capable people unwilling to be leveled by an imported virus. The Navajo willingly accepted austere and painful social distancing measures for their greater good. Masks were universal; every night “lock-down” started at sundown and ended at 6:00 am the next morning; and every weekend families sheltered in place from Friday evening to Monday morning. A public service announcement on the radio featured a father telling his son he must wear his mask because the Navajo have survived smallpox, hantavirus, and tuberculosis and would survive COVID-19. The father counseled him to wear the mask not for himself but for his grandmother and grandfather.
Though the Navajo Nation had an infection and case fatality rate second only to New York City, the tribal leadership effectively enforced compulsory public health measures that prevented a much worse spread. These measures depended on a collective accountability where the right to survival of the community eclipsed the privileges of individuals. Our nation has a lot to learn from the Navajo.
In the next months, we hope to return to Matamoros to provide care for the migrants that remain stranded on the border. Until then, our team members will continue to care for the most vulnerable on the wards of MGH or further afoot. However, we will not make the mistake of equating vulnerable with powerless.
Author Biography:
Lindsey Martin, NP is a critical care nurse practitioner with a focus on surgical critical care and trauma, and the Director of Global Disaster Response and Humanitarian Action at Massachusetts General Hospital. Her deployments have included the 2015 Nepal Earthquake, 2016 Hurricane Matthew in Haiti, and 2017 Hurricanes Harvey in Houston and Maria in Puerto Rico. She has also participated in multiple training exercises and disaster simulations with MGH and its partner organizations.
Health Disparities in US Tribal Communities
The American Indian and Alaska Native people (AI/AN) have long experienced worse health outcomes when compared with other Americans.
Life expectancy for the AI/AN is shorter by 5.5 years. Morbidity rates exceed other Americans in many categories, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, and chronic lower respiratory diseases. These communities also experience a higher prevalence of suicide, substance use disorder, obesity and teenage pregnancy.
AI/AN mothers are almost 3 times more likely to receive late or no prenatal care as compared to non-Hispanic white mothers, and their infants are twice as likely to die from SIDS.
Domestic violence affects 4 out of 5 Native American women, more than triple the national average.
Native American women are sexually violated at the highest rate of any racial/ethnic group in the US. They are more than 3 times as likely to be raped and 10 times as likely to be murdered.
Honor and Remembrance
A mural depicting a Navajo woman warns residents of the danger of COVID-19 on the Navajo reservation
(Andrew Hay/Reuters)
Navajo Nation has suffered devastating losses due to the COVID pandemic. As of this writing, close to 12,000 residents have tested positive for COVID-19, and 584 individuals have died from the disease.
November is National Native American Heritage Month For a list of events commemorating the rich ancestry and traditions of Native Americans, click here.
Virtual Seminar Series: Gender-Based Violence in Disasters & Humanitarian Settings
Provided by Massachusetts General Hospital, Global Health & Mass General Brigham. The next session is
December 15 from 12:00-1:00 pm ET. For more information and to register, e-mail agoodman@mgh.harvard.edu
Acknowledgments
Deep gratitude for funding support Karen Johansen and Gardner Hendrie, Al and Diane Kaneb, Vincent Memorial Hospital and Vincent Club, Westwind Foundation, Bank of America Foundation, Wyss Foundation
Thank you to the MGH Global Disaster response team, to MGH Center for Disaster Medicine, and to the MGH members of the United States Trauma and Critical Care Team
for their work during the COVID pandemic.
The Strength and Serenity Global Initiative Against Gender-Based Violence seeks to create a worldwide consortium to share best practices, develop training programs, and publish on issues pertaining to sexual exploitation and abuse with the goal to end gender-based violence. To learn more, visit our Web site. We welcome your feedback about this newsletter. Please e-mail questions/comments to globalobgynnews@partners.org.
