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Disparities in access to health care, WiFi services, comorbidities, and even clean running water have led to a disproportionate number of COVID-19 cases among Native American populations. Neurologists who serve the Navajo Nation discuss the conditions that have led to those increases.

The novel coronavirus has hit Native American communities in the United States at such an alarming rate that Doctors Without Borders has sent teams of medical professionals to the American Southwest to help the Navajo Nation, which as of May 12 had more than 3,100 cases of COVID-19 and more than 100 deaths among its population of roughly 175,000 people.

If the Navajo Nation's reservation, which spreads across New Mexico, Arizona, and a corner of Utah, were a state, as of May 11, it would have the second-highest per capita rate of confirmed coronavirus cases in the countrybehind only New York. And as of May 14, 60 percent of the people who had died from COVID-19 in New Mexico were Native American, although they make up only 11 percent of the state's population.

Neurologists who work with the Navajo Nation and other Native communities told Neurology Today that the situation dramatically illustrates the historical inequities in access to health care, infrastructure and services affecting these communities, noting that many people who do not live in the area do not understand the difficulties of life on the reservation.

The Navajo Nation covers some 27,000 square miles, with about six people per square mile. There's a lot of space and not a whole lot of people, so you would think it would be easy to socially distance, says David M. Labiner, MD, professor and head of the department of neurology at the University of Arizona in Tucson.

But more than 30 percent of Navajos don't have running water at home. They have to haul water in on a truck every few days, which means there isn't the opportunity to wash hands as frequently and for as long as necessary. And to get their water supplies from water stations, or to get food from small general stores, people often have to break social distancing guidelines.

Amazon Fresh and Instacart don't deliver to remote areas of Arizona and New Mexico where you can drive for miles on unpaved roads without seeing a house. A lot of my patients don't have electricity in their homes, or necessarily reliable access to mail or phone or internet, said Mike Stitzer, MD, director of the Native American Neurology Service at Winslow Indian Health Care Center in Arizona, who has been a member of AAN's Diversity Leadership Program and its Health Care Disparities Task Force. Dr. Stitzer is also an enrolled member of the Enterprise Rancheria Estom Yumeka Maidu tribe.

There is also a lot of intergenerational living, with multiple generations of families living either in the same house or right next to each other, sharing food and water. It may be 20 or 30 miles to your nearest neighbor, but if a case makes it to one person in a family group, there's a high chance it will spread to everybody.

Access to health care can also be challenging. There are seven sites that serve the Navajo Nation: Chinle Comprehensive Health Care Center (60 beds), Tuba City Regional Health Care (73 beds), Northern Navajo Medical Center (69 beds), Gallup Indian Medical Center (99 beds), including six ICU beds), Tshootsoo Medical Center (56 beds, including ICU beds), Crownpoint Health Care Facility ( 32 beds), and Sage Memorial Hospital (25 beds), Dr. Labiner said.

But even though the network of facilities is very capable of providing care, when conditions become serious, people have to travel a long way for access to specialists, said Dr. Labiner.

It's not that Native communities are not working to stem the spread of the coronavirusin fact, precisely the opposite. The Navajo Nation has actually been significantly more proactive in addressing the risks of COVID-19 than many other states and governments, said Dr. Stitzer.

The first cases here appeared probably in early March. There had been a religious gathering in Chilchinbito, in the eastern part of Arizona, that drew hundreds of people from all over the Nation, and one person at that gathering later turned out to have tested positive. Within a week or two, we started seeing cases trickling out and as soon as that happened, the Nation began talking about social distancing and shelter in place for anything but essential servicesweeks before anyone else in Arizona was doing it.

The Nation also put out orders for residents to wear cloth masks in public in late March and enacted a nightly curfew on March 30, followed by complete weekend curfews. They have police on the road issuing citations, and there are thousand-dollar fines for violations, said Dr. Stitzer. We've also been very proactive at our health center, with a dedicated screening protocol and separate waiting rooms for anyone with any possible respiratory symptoms by the end of February.

The per capita testing rate for COVID-19 is also much higher among the Navajo Nation than in the surrounding region, Dr. Stitzer said. As of May 14, the Nation had conducted conducted 19,441 tests for its population of 175,000, compared with 175,455 for the state of Arizona (population approximately 7.3 million)which comes out to approximately 111 tests per 1,000 people in the Navajo Nation and 24 tests per 1,000 people in Arizona.

Despite these extraordinary efforts, a disproportionate burden continues to fall on Native peoplesand on the health care systems that serve them.

The pandemic is only magnifying the health care disparities faced by Native Americans, said Cumara O'Carroll, MD, MPH, an assistant professor of neurology at the Mayo Clinic in Scottsdale, AZ, who provides stroke services to patients at Tuba City Regional Health Care through a telestroke network. Dr. O'Carroll was also a participant in the AAN's Diversity Leadership Program.

We know that there are a number of factors contributing to the high rates of infection in the Navajo Nation, and some of that is increased susceptibility from pre-existing underlying medical conditions like diabetes, hypertension, coronary artery disease, and obesitymany of which are the same risk factors for stroke, of course. In this country, we have barriers to care that fall across racial and ethnic lines, and those barriers and disparities are exacerbated and accelerated in a pandemic like this one.

Health care systems serving the Native community, such as Tuba City, are struggling to get access to medical supplies, personal protective equipment, and other resources, Dr. O'Carroll said. What we are seeing and hearing is that they are being expected to provide the same level of services that they have always provided, but with fewer resources. Their system is being overwhelmed by more and more patients, and the patients who are coming in are critically ill.

As an example, she described a recent telestroke call with some physicians in Tuba City. We have algorithms and systems in place when someone comes in with stroke symptoms, and they are fine-tuned through many years of work, she said.

But because clinicians and staff are being spread so thin, these systems are breaking down. In this case, we had a patient with clear stroke symptoms who needed a CT scan immediately. They said to me, Doctor, we understand, but it can't be done immediately because we have a long line of critical patients waiting for care. This is a facility that usually runs very smoothly with a superior caliber of physicians. They're very resourceful. They can do it all. You could sense their frustration and stress. This pandemic is resulting, at times, in delays in care for acute stroke interventions. People are still getting treatment, but not in the timeline we are accustomed to pre-pandemic.

The Navajo Area Indian Health Service (IHS) does not have many hospital beds. There are just over 400 beds for the entire Navajo Nation. I don't know how many are ICU beds, but it's not more than a handful, and the same goes for ventilators, Dr. Stitzer said.

For comparison, the major tertiary care center for northern Arizona, Flagstaff Medical Center, has approximately 300 beds, of which about 55 are ICU. While none of the major hospitals in Arizona has been overwhelmed like New York and New Jersey have, the IHS hospitals in the eastern portion of the Navajo Nation have been very busy.

By mid-May, the state's hospitals have been hovering at only about 21 percent of ICU beds free, while it had been approximately 30 percent or so for March and the first half of April, Dr. Stitzer added.

Beds in use have slowly crept up over the second half of April. The cases per week in the state also continue to increase. With Arizona starting to roll back distancing measures, I am nervous that this will result in a spike of new cases. That would both make it harder to transfer the very ill patients out of the IHS hospitals to locations with more ICU beds, and also increase the chances of more cases coming from Arizona into the Navajo Nation.

To ease the burden on health care facilities in any outbreak areas, patients with non-emergent conditions are being urged to take advantage of newly expanded telehealth optionsbut the digital divide in Native communities means that this option, too, is less accessible to them.

Federal funding was given to the Navajo Nation several years ago to improve rural broadband and cellular service, and most of our patients do have cellphones at this point and many have smartphones, said Dr. Stitzer. But data are not yet reliable or fast enough for most people to do video chats. We have been able to do some successful video telemedicine visits, but my clinic often has been relying on telephone visits. However, patients may not have enough minutes to make all the calls they need.

Dr. Stitzer hopes that the response to COVID-19 will help start the spark of long term change needed to correct the massive, historical institutional challenges to improving health outcomes for Native Americans, such as the rate of poverty and issues associated with that, such as food deserts.

We need the rest of the country to understand the lack of resources that many of our patients have, and what this pandemic has meant to them. The fact COVID-19 is much more deadly in the elderly population is especially tough as they have a special place in Din society. They hold the traditions, language, etc. and pass it down to the younger generations. So a family and community losing someone is this group is hit particularly hard. It's not exactly equivalent, but my small tribe in Northern California, Estom Yumeka Maidu, has almost lost our spoken language as the elders are passing on. It's only minimally recorded and written down, so once it's gone it's gone. I have some understanding of what the loss of each elder to the tribe's culture is like, and it can be really difficult.

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