On a mild morning in April at Arizona’s Whiteriver Indian Hospital, Dr. Ryan Close tested nasal swabs from two members of an eight-person household on the Fort Apache Reservation northwest of Phoenix. About half of the family had a runny nose and cough and had lost their sense of taste and smell — all symptoms of COVID-19 — and, by late morning, the two tests had come back positive. Close’s contact-tracing work began.
For Close and his team, each day begins like this: with a list of new COVID-19 cases — new sources that may have spread the virus. The 35 or so people on the team must rapidly test people, isolate the infected and visit the homes of any who may have been exposed. Again, and again. Recently, though, their cases have declined, due in part to something rare, at least in the United States: an effective contact-tracing and testing plan. Both the White Mountain Apache and nearby Navajo Nation experienced some of the country’s worst infection rates, yet both began to curb their cases in mid-June and mid-July, respectively, due to their existing health department resources and partnerships, stringent public health orders, testing and robust contact tracing.
“We’ve seen a significant decline in cases on the reservation at the same time that things were on fire for the rest of the state,” said Close, an epidemiologist and physician at Whiteriver Indian Hospital, an Indian Health Service facility.
Tracing disease transmission from COVID-19 is crucial to slowing its spread, but successful contact tracing has proven challenging for communities that lack the funds, community cooperation, personnel or supplies for rapid testing. The White Mountain Apache Tribe of Fort Apache and the Navajo Nation, however, have been growing a contact-tracing army, setting them apart from other tribes during the pandemic. As tribal communities brace for multiple waves of COVID-19, public health experts from the two nations have already successfully adapted contact-tracing programs.
The White Mountain Apache and the Navajo Nation “were hit hardest early on, and so they have had a little bit more time and opportunity to put these systems into place,” said Laura Hammitt, director of the infectious disease and prevention program at Johns Hopkins Center for American Indian Health, which is working with the Centers for Disease Control to develop a guide for tribal governments to train and grow their own contact-tracing workforces.
Across the country, tribes are employing a number of public health measures — closing reservations to nonresidents, setting curfews, providing free testing and aid to families and Indigenous language translations of public health guidelines — but few are actively contact tracing. Contact tracing requires fast and systematic testing and trained personnel. In March, Close trained eight Whiteriver Indian Hospital staffers, but the number has since grown to around 35, serving some 12,000 tribal citizens and residents. The relatively small team takes advantage of the firmly closed reservation boundaries and rapid testing to find and isolate new cases. COVID-19 cases were dropping in Fort Apache, which stayed closed, as the state neared its caseload peak in mid-June after the governor lifted stay-at-home orders, becoming one of the country’s worst coronavirus hotspots.
While most contact-tracing programs rely on phone calls to learn patient history, assess symptoms, encourage isolation and trace other contacts, the Whiteriver team relies on home visits. “I (can) come to your house to assess you, do a case investigation, or to inform you that you are a contact,” Close said. “The benefit of that is that, if you were ill-appearing, they can evaluate you right there.” Tracers can also determine whether other household members are symptomatic, checking temperatures and oxygen saturation, while health-care providers can check breathing with a stethoscope. The Whiteriver Hospital can turn around a COVID-19 test in a single day, a process that takes days or weeks at other public health institutions.
“We’re not just trying to flatten the curve. We’re trying to actually completely contain this virus.”
The Navajo Nation has succeeded in slowing the spread of the new coronavirus, even though the reservation spans three states — New Mexico, Arizona and Utah — so teams must coordinate across several jurisdictions. The nation has nearly 200 contact tracers spread across numerous health-care agencies. With scores of Indigenous communities to monitor over a huge geographic area, phone calls are its primary investigative tool. The Navajo Nation is setting its sights high. “We’re not just trying to flatten the curve,” said Sonya Shin, who leads tracing investigations for the Nation, “We’re trying to actually completely contain this virus.”
Still, critics say it is not enough. The most effective tracing relies on mass testing to catch asymptomatic people as well as those with symptoms. Due to a limited supply of tests, most tribes, like most states, can only test symptomatic people, so the number of cases is inevitably undercounted. “Contact tracing does not mean a damn thing unless you have really good tests, and you’re testing everybody,” said Rudolf Rÿser (Cree/Oneida), executive director of the Center for World Indigenous Studies. “Not just the people showing the symptoms, but everybody, whether they are Indian or non-Indian, in your area — you have to catch them all.”
Kalen Goodluck is a contributing editor at High Country News. Email him at kalengoodluck@hcn.org or submit a letter to the editor.
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