Sriram Shamasunder, M.D. is an associate professor of medicine at University of California, San Francisco. He is also co-founder and faculty director of the HEAL Initiative, a health equity organization that gives its fellows the opportunity to work alongside underserved populations in Navajo Nation and nine countries around the world.
Harvard Political Review: What have you seen in Navajo Nation over the past few weeks, with regards to access to testing, equipment, available professionals, hospital capacity, and cooperation?
Sriram Shamasunder: I helped start a global health program in 2015 that has worked in Navajo Nation called the HEAL Initiative, which stands for Health, Equity, Action, and Leadership. It’s a two-year immersive program to train and transform front-line health professionals to get better at supporting underserved populations. It’s about taking care of really marginalized or poor patients and having health professionals – doctors, nurses, pharmacists, and community health workers – become good advocates for those patients. We’ve been doing that for five years, and one of the reasons we started working in Navajo Nation is because it has pretty large vacancy rates – 30% of physician and nursing jobs are unoccupied – so medical facilities have trouble filling those jobs. There’s always been a workforce shortage in Navajo Nation and around the country in Native American communities. I think over a four-year time period, while there are around 55,000 medical school graduates across the country, there are 101 Native Americans that graduate – less than 0.2% of total graduates.
We came to Navajo Nation specifically during the COVID-19 outbreak because our partner sites asked us to stand with them in this very difficult moment – in this crisis. Specifically, they needed a lot of nurses. There are shortages in emergency medicine nurses and critical care nurses. And so I spoke to our leadership at the University of California, San Francisco. Because we had largely flattened the curve [there] … our leadership was supportive of nurses coming out to Navajo Nation. I’ve been here for almost three weeks, and I’ve already seen a lot of progress.
I think we’ve seen the unsurprising impact of underfunding a health system for decades. The Indian Health Service has one-third the rate of funding per capita as the Department of Veterans Affairs or Medicare. The health system here and the public health response, even though the leadership is incredibly strong, are not working within a well-funded infrastructure. Second, sheltering in place has been very, very challenging for the community. 30% of Navajo people lack electricity, and 30% lack running water. If you don’t have a fridge and you have to go out and get provisions often and then shelter in place, you have eight or 10 or 12 people that live with you in close proximity. You are seeing the spread of COVID-19 in family clusters. I think a couple [of] weeks ago, there were four generations of family members that were all hospitalized at the same time and regularly taking care of siblings and an uncle and a nephew. And so, I think that’s the reality of the situation.
I think that there has really been incredible leadership and resilience that Navajo people have modeled in the face of increasingly difficult times. You’ve seen people take over the cafeterias, like a lot of our HEAL fellows, and sew their own PPE [personal protective equipment]. You see the management of extremely sick patients, and you see doctors determining when it’s safe for patients to stay in these facilities and when they need to be transferred out. We’ve been able to mobilize this incredible response of putting 125 high-risk patients into motel rooms. And we’ve been seeing those patients. That effort has been quite impressive, and the community really knows each other quite well – you hear and see this fabric of connection. And we’re also obviously in a surge [of the pandemic], so you’re seeing a lot of COVID-19 patients.
HPR: Could you also speak a bit about your own experience being on the frontlines as a healthcare professional?
SS: I think about the volume of patients we’re seeing. I’m essentially taking care of patients in Chinle, Arizona, and Gallup, New Mexico, and my job is to run the sprint of being here and support my Navajo colleagues who are running the marathon – this work in an underfunded and stressed healthcare system, a baseline that has really been ravaged by the volume of COVID-19 patients. I’m basically admitting patients from the emergency room as well as taking care of them in their Respiratory Care Unit. In several of these hospitals, there are all-COVID-19 wards, and so every time you go into a patient’s room, you’re donning a significant amount of PPE, aprons, goggles, masks – a N-95 mask and a surgical mask on top of it – double gloving, and wearing booting. And then a lot of rooms have two patients. They’re all COVID-19 positive, and you’re going in there and trying your best to listen to their lungs and take care of them.
A lot of the Navajo elders that are COVID-19 positive really trust the Navajo nurses. They’re able to lean over and speak Navajo into the nurse’s ear and gain a lot of trust. If you really pay attention to the eyes of patients, you can get a sense of their fear or comfort level. When I’m wearing a mask and often, the patients are wearing masks, it’s much more difficult to really make that human connection. And it’s been hard – I’ve seen some younger patients as well. I took care of a 44 year-old patient who came into the emergency room two or three days ago who was breathing very quickly. I could definitely see the fear in his eyes, and he was just saying that he didn’t want to die. I told him, “We’re gonna get through this,” a couple times, both for him and for myself to really hold the challenges of taking care of vulnerable patients in a disease trajectory that is hard to predict. I feel like I haven’t taken care of enough patients and I don’t know if anybody has, to really be able to predict someone’s disease trajectory. Now, being a doctor for the last 10 years …, when I see somebody and what shape they’re in, I know enough that I can tell if it’s going to be a rocky course or they’re going to be okay. Oftentimes with COVID-19, I feel humbled. There are people who are on a ton of oxygen and hit the peak of the virus, and then all of a sudden they’re doing well. And then there are folks who are on just a couple liters of oxygen, and then they just get worse and worse. Before you know it, you’re intubating them.
HPR: Have you seen any improvement in the situation? You’ve talked earlier about a slow or potentially inadequate response from the federal government – what do you think is necessary to better prepare for and improve in the face of whatever the future of this crisis holds?
SS: I think the leadership here, the Navajo Nation president and his office, are trying to have people shelter in place. I think the level of testing here is among the highest testing rates per capita in the world, and we’re getting our positive test rate below 10%, so we can safely isolate people in place. Now, you have the CARES Act money. After being held up in court for a while, I think there is $600 million coming to the Navajo Nation government. I think it’s extraordinarily challenging: once you have an outbreak and there’s a certain amount of volume in the population of cases, and those individuals are vulnerable and lack infrastructure, water, electricity, and live in close proximity, you’re trying to play catch-up. And I think regional governments both in New Mexico and the Navajo Nation are doing a good job of doing their best to have lockdowns, which are hard for the community, and support people with food and water at the same time. But it is an uphill battle. I think everybody here is waiting to see the flat inflection point where the curve starts to flatten. And I don’t think we’re there yet.
HPR: In what ways do you see this pandemic underscoring inequalities and exacerbating health outcome disparities in the United States?
SS: I remember reading a quote by Alexandra Ocasio-Cortez the other day that said, “COVID-19 didn’t necessarily create a bunch of new problems, it poured gasoline on existing problems.” I think for those of us who have worked in healthcare – it’s just the level of inequity across the country and the world. In Chicago, for example, 30% of the population is African-American, but African-Americans comprise 56% of COVID-19 deaths in the city. In New Mexico, much of the population is Native American, and nearly one-third of the COVID-19 cases are borne by Native Americans. So, this is really a health system that doesn’t pay attention to its most vulnerable. And that’s what a health system should be structured to do – you can’t base healthcare access on how much income you have. We’ve gutted our public health system, then there was no ability to contact trace at the level that we needed. The testing was incredibly slow. The fact that this virus brought the United States to its knees and specifically targets people of color who are being hit so much harder than our white population is unacceptable, and it’s also the history and the pattern of the United States. We’ve failed to reckon with the deep inequality that existed before COVID-19. I’m hoping as we go into the future, past COVID-19, that this is really a reckoning – especially in healthcare but in every sector – that we have to pay attention to our most vulnerable populations. We have to pay attention to our people of color, our LGBTQ population – those folks are more vulnerable.
HPR: What steps do you think policymakers should take in the future to deal proactively with disparities that come with a crisis like this and to generally better prepare the United States and perhaps countries around the world for a crisis like we’re seeing now?
SS: I think the first point would be to fund the Indian Health Service up to the level that provides dignity and respect to Native Americans. There’s been a history of broken treaties, underfunding, and significant uranium poisoning in Navajo Nation. You can literally see the injustice and historical trauma in the bodies of our patients. So, there really needs to be attention paid to funding the IHS – and health care for Native populations outside of IHS – to a level that allows for infrastructure that is the best the United States has available. And then, I think, how can we fix a corrupt health system in which an asymptomatic team of NBA players can get tested for COVID-19, but other symptomatic folks don’t get tested? And then, we need to understand the contributions of the most essential workers that we have in the United States – whether it’s grocery store employees or delivery people. Now, I think we all appreciate essential workers to a greater degree. In the future, can we respect them enough to provide a living wage and health care? So much of healthcare is not done inside the walls of a hospital. It’s about people having control over their lives – housing, water, the ability to not live paycheck-to-paycheck – to keep themselves healthy. And I think that conversation needs to be had. We’ve realized how essential working-class people are at this moment. We have to build all the things that will keep them healthy that we’ve ignored for a long period of time.
HPR: Although it’s difficult to know, do you have any sort of confidence or perhaps pessimism that any of what we’ve just discussed could be or can get done once this crisis passes?
SS: I definitely was a strong Bernie Sanders supporter. I think the idea of “Medicare for All” and the ideas that he was speaking to that became mainstream – guaranteed maternity leave, universal preschool, free and quality health care – are not radical in the richest country in the world. I think that as we come to realize how interconnected we are as a country despite [having] so many different demographics, we really rise and fall together. And I think that the so-called left wing of the Democratic Party speaks to some of those ideas that are becoming mainstream. Whether it’s on climate change or universal healthcare, the status quo is incredibly untenable. It’s always been untenable, but COVID-19 and this crisis has made us all realize that it is absolutely untenable. So, how do we move forward? Obviously, with the current political climate and the next president looking like it is going to be Trump, that’s somewhat discouraging. But I think that you do have these ideas feeding into the consciousness of the populace. This crisis, hopefully, is making us reimagine what it could look like in the United States with better education, better health care, and more equity across the board. Because at this moment, I think COVID-19’s differential outcomes for Native American, African-American, and Latinx populations are unjust.
Image Credit: HEAL Initiative / Sheila Menezes