AMA Update
Dr. Barbara McAneny on disparities the Navajo Nation is facing
Dec 16, 2020
Featured topic and speakers
In today’s COVID-19 update, AMA's former president looks at continuing disparities, and discusses combined vulnerabilities faced by the Navajo Nation as well as approaches to effective COVID-19 vaccine distribution.
Learn more at the AMA COVID-19 resource center.
Speakers
- Barbara McAneny, MD, medical oncologist and hematologist, AMA past president
Transcript
Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're following up on the impact of COVID-19 on Native Americans. I'm joined today by Dr. Barbara McAneny, AMA's past president and a medical oncologist/hematologist in Albuquerque, New Mexico. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. McAneny, we last spoke in June and you were facing a pretty dire circumstance with the tremendous impact of COVID-19 on your largely Native American population. Let's talk about what the current situation it is that you're facing. And how's your practice affected by the surge that we're seeing across the country?
Dr. McAneny: Well, not well, actually. The rest of the country seems to have caught up with what the Navajo Nation has been struggling with for a long time. The entire state is now overwhelmed with people dying, a person dies a minute, I think, in the country now. And so, New Mexico is no difference. We are continuing to struggle. At the time we spoke before we were providing services, and we still are. That hasn't changed. We are taking care of cancer patients and rheumatology patients and pulmonary patients because we figure it's still our duty to keep our patients as healthy as possible. Cancer does not wait for COVID and neither do other intercurrent illnesses. So we're trying to maintain the health of our population and keep our people out of the hospital, because if we can keep them out of the hospital, both they're safer, because cancer patients have a three-fold chance of dying compared to others if they are exposed to COVID and catch the disease. But also, we know that our hospital colleagues desperately need to be able to focus on COVID and not be able to have to worry about other diseases at the same time. So, we continue to do that, but it's gotten tougher. We now have had some of our staff members infected, which puts a huge amount of strain on the entire practice.
Unger: I can only imagine. Since June, have there been any kind of additional public health measures that have been put into place that have had an impact on what you're seeing about with spread in the Navajo Nation?
Dr. McAneny: Yes, but what I'm seeing in the Navajo Nation and what I'm seeing in all of New Mexico, which I think everyone across the country can relate to, we are seeing a couple things. One is our governor has been very appropriately aggressive about shutting things back down, because we were seeing just a huge increase after the Labor Day holiday. The Navajo Nation continued to have a lot of their processes in place where they would continue to manage patients and keep people isolated. One of the things we're really discovering is the PPE process is not getting better, particularly out on the reservation. The local hospitals out there are overwhelmed and are struggling. On the reservation for the Navajo Nation and also the Zuni and Hopi tribes that are also using those IHS hospitals, they are so overwhelmed right now.
They are set up to usually provide a lot of the outpatient primary care, as well as all the inpatient work for the area. And that is just completely overwhelmed. The delays are long. People who have a lot of diabetes and other complications are struggling to get their care given. And diabetes can be pretty lethal too if you end up with some of the complications of that. We are also seeing, particularly in our Gallup Clinic, later stages of cancer, which means that when people present, they've been watching something, or waiting, or delaying getting mammograms, or delaying getting colonoscopies, because they're afraid to go anywhere near a hospital, with good reason. So, we're seeing patients who present with a slightly more advanced stage of disease.
So interestingly, while we've seen our visits drop down, we've seen the drug costs go up, because when people present with more advanced disease, they need more aggressive chemotherapy medicines to try to get it back on track, and that means that it's more expensive. So, we're seeing the worst of all worlds. Later disease, harder to cure, more expensive to take care of, in a population that can barely afford it.
Unger: That is a very, very difficult combination and emblematic of COVID really exposing risks that were already there, especially in this particular patient population. So, given that, how do we better support patients in Native American communities at the federal state and local levels and what can physicians do to help given the circumstances?
Dr. McAneny: Well, physicians need to advocate and to recognize that the social determinants of health are as much of factor towards patient outcomes almost as anything else that we do. We, the Navajo Nation has gotten some of the CARE funds, but we're really having a hard time actually accessing any of those funds for patients. As I may have mentioned last time, we have a foundation that helps patients with the non-medical expenses of being sick, of having cancer, and paying the mortgage, and paying for food, and paying for supplies and things that patients need. And our demand has gone way up, but our ability to fundraise has dropped down significantly because nobody has any extra money.
We're seeing that be even worse. On the Navajo Nation a lot of families live on one or two breadwinners for a big extended family. When that breadwinner gets sick, or loses his or her job, it is devastating to the population. The other thing I think physicians can advocate for, particularly with the interest in telemedicine, is looking at broadband as a health care issue. So, we have students on the reservation who take their computers up to the top of a mesa or to the local chapter houses, the only place that they can get internet access to try to do schooling. We also can't do telemedicine visits, and sometimes we can't even do phone visits with our patients to check on them, because they don't have access to broadband. And I never before this pandemic thought of broadband as a health care issue, but now I've realized that it truly is. That being able to connect to this highly disadvantaged population with a mechanism that allows them to stay in their house and not spend those scarce resources on another tank of gas to drive to my clinic or drive to a local hospital to see if they need care is hugely important.
And I worry very much that telemedicine is going to increase the digital divide, increase the health disparities we see between the haves and the have-nots, and will become a nice tool for affluent people to be able to manage their care while leaving the less affluent behind.
Unger: I'd never thought of it in those terms, but given the critical importance of telemedicine in the pandemic broadband and access to that is absolutely a health outcome issue. Well, speaking of things in development right now, let's talk a little bit about vaccines.
Dr. McAneny: Yes.
Unger: We're hoping that vaccines are going to be available soon, and plans are being made for who has access to those vaccines first. Should Native Americans be a high priority group for vaccination, and do you foresee hesitancy on the patient side related to getting the vaccine?
Dr. McAneny: Two very interesting and important questions. First of all, this is a community that has been devastated. So yes, they are very high risk. They are not listed with the first wave, which is health care workers and people who live in nursing homes or assisted living facilities. But I think they should be because people who don't have adequate housing, have no running water, are incredibly susceptible to getting COVID. How do you wash your hands 20 times a day if you don't have running water? So, I think we need to look at that population. As to vaccination, my practice is actually applied with our local Department of Health to be a vaccination center, both here and in Gallup, where we think we should be able to assist with that because the need is so great. In my Gallup clinic, I have a traditionally built hogan, a Native American house that we could use for that. But the Indian Health Service is at this point planning on trying to do the vaccinations themselves. They're appreciative of our offer and are willing to take us up on that if the need arises. So, we will try to do everything we can.
As for information, it's going to have to be very delicately done. The Navajo Nation, and many of the Native American populations, tend to be a bit skeptical of the intentions of Western medicine, and just the way they've been treated by the country. So, they tend to be a little bit more skeptical about things that are suggested. So, I think we need to very carefully have the Indian Health Service, who understands the culture very well, really do a massive campaign to explain. The problem of course is, they live on subsistence money, they're chronically underfunded, and so now with COVID consuming resources in every hospital, I don't know where we're going to find the funding to be able to do the outreach that's necessary.
I think this is an important thing for all doctors across the country to realize. This affects all of us. If we decide we're going to neglect some population, somewhere, or do it state by state so that some states have vaccinated people and other states do not, we will still have a starter culture to re-start this virus from those people who did not get vaccinated, from people who are still having the infection. So, we cannot afford as a nation to leave any of our people behind.
Unger: It's an enormous challenge, and very expensive, as you point out to raise awareness to the levels that we need to. And that is a tough thing because the next few months are forecast to be some of the worst of the pandemic. Do you see any signs that some of the needs of this particular community are finally going to get met?
Dr. McAneny: Well, I haven't seen anything about bringing broadband, and our governor and the president of the Navajo Nation are working together very well to try to bring some of this. They did get some of the CARES Act money. We've actually asked for our foundation to be able to be part of the distribution of that because we see patients and we know our people, so we know who's in real need, to be able to supply patients with food and housing. We need to be able to work more on that. It was inadequately funded before. The CARES Act will help. I am very worried when the landlord decree that says that you can't throw people out on the street for not paying rent, for families who don't have the ability to pay rent, is going to hit right at the time when we're in winter and Merry Christmas everybody, you've just lost your house. I can't imagine anything worse.
And so, we are working hard, locally, to raise money to try to keep at least our patients, at least that subset of the population with food and housing during these terrible times.
Unger: There is someone from the Navajo Nation on Biden's proposed pandemic taskforce.
Dr. McAneny: Yes, Dr. Jill. Yes.
Unger: Do you foresee that as being a benefit?
Dr. McAneny: I do. I was thrilled to see in our local paper that she was put on the task force, because I think that is a voice that absolutely needs to be heard. She's an impressive physician, and I think she will do a great job. And if anybody can bring things home to New Mexico, I think it will be Dr. Jill.
Unger: Well, Dr. McAneny, thank you so much for being with us here today. I wish there were better news in the follow up to our original episode back in June. Your team clearly has its work cut out for you, and I hope that things do progress in the coming months. Thanks for joining us on this COVID-19 update. We'll be back with another segment tomorrow. For resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us, please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
