key: cord-0829013-kgb75bt3
authors: Begay, Melissa; Kakol, Monika; Sood, Akshay; Upson, Dona
title: Strengthening Digital Health Technology Capacity in Navajo Communities to Help Counter the COVID-19 Pandemic
date: 2021-03-30
journal: Annals of the American Thoracic Society
DOI: 10.1513/annalsats.202009-1136ps
sha: 38a9a4c199eb636c29b094f2785223e6a134b87f
doc_id: 829013
cord_uid: kgb75bt3

nan

In May of 2020, the Navajo Nation (population of 173,000) had the highest number of COVID-19 cases per capita in the United States. By August, the disease had killed more people per capita than in any U.S. state (4, 5) . As of the most recent lockdown on November 20, 2020, there were 8,140 COVID-19 cases per 100,000 people and 618 deaths in the Navajo Nation. The Southwest reservation's 27,000 square miles extend into New Mexico, Arizona, and Utah. Despite the low population density, physical distancing is often difficult because of multigenerational housing, cultural practices, and frequent travel over vast distances to more populated areas for water, groceries, and health care. Community participation is an important aspect of traditional gatherings and spiritual ceremonies. In New Mexico intensive care units, it has been common to have multiple family members with COVID-19 in adjacent rooms.

Up to 40% of households on the Navajo Nation lack running water; 30% do not have electricity (6) . There is limited access to telephone services and reliable broadband (high-speed) internet is uncommon. These telecommunication deficiencies challenge patient education, emergency response, and critical services. Its provision has the potential to dramatically improve health outcomes in the Navajo Nation.

The Indian Health Service (IHS), an agency within the U.S. Department of Health and Human Services, provides health care to members of federally recognized tribes, including the Navajo Nation. The IHS is obligated to provide financial resources as a result of federal relationships that include treaties that exchanged land for health care and education. Chronic underfunding of the IHS has complex reasons and has been a persistent barrier to implementing a large-scale telehealth infrastructure.

The 2018 Broadband Deployment Report describes quality internet capability as sufficient to create and relay high-quality voice, data, and video. Broadband is defined by law as 10 megabits per second (Mbps) downstream (download speed) and 1 Mbps upstream (upload speed). The percentage of Native Americans experiencing year-to-year increases in Mbps wireless mobile network capacity has remained flat at 64% (7) . Videoconferencing applications such as Zoom and Skype require 3-8 Mbps. Over 1.2 million people on tribal lands lack basic mobile Long-Term Evolution (a standard for faster data transfer speeds and capacity) broadband speeds of 10 Mbps/3 Mbps. Fixed terrestrial speeds of 10 Mbps/3 Mbps are significantly behind those in urban areas.

In a July 8, 2020, testimony to the U.S. House of Representatives Committee on Energy and Commerce, President of the Navajo Nation, Jonathan Nez, identified these broadband challenges as deepening the digital divide and exacerbating institutional inequities in many areas, including the prevention of critical public health announcements and limiting emergency healthcare command operation responses. Furthermore, because half of the 110 Navajo communities lack any broadband access and as per the Rural Digital Opportunity Fund, underserved census blocks failing to meet the Federal Communications Commission minimum speeds of 25 Mbps for downloads and 3 Mbps for uploads were demonstrated over a vast portion of the Navajo Nation (8, 9) ( Figure 1 ).

In live town halls, Navajo community members have expressed concern regarding their lack of internet to access real-time information and culturally appropriate education on COVID-19. Tele-education could supplement the great asset of Navajo community health workers' efforts and improve language barriers by providing resources such as certified Navajo medical interpreters to translate medical information efficiently and accurately. Many Navajo communities rely on tribally run radio signals to disseminate information in the traditional language. Complexities of the virulence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and necessary preventive measures are frequently lost in translation. Webinars or brief spots on hand washing, social distancing, and patient education could be enacted with better videoconference capabilities.

Traditional Navajo healers are working to integrate within modern tribal health systems while adhering to physical distancing. Telehealth allows them to interact with patients via live videoconferencing. Although traditional healers have been integrated within the Navajo IHS, many traditional medicine practitioners need greater assistance with internet service, Wi-Fi hotspots or telecommunication supplies (i.e., phone, laptop). Some traditional healers are conducting prayers by phone or Face Time, acknowledging the necessity of physical distancing and the need to integrate traditional ways with technology. In conversation with one of the authors (M.B., a Navajo physician), a traditional Navajo medicine man expressed interest in these opportunities if they would benefit patients (M. Bahe, B.A., oral communication, May 1, 2020).

The pandemic has created a dilemma for health care in the Navajo Nation. The number of patients requiring care has increased, whereas primary care and specialist practices have shut down. Innovative solutions are needed to support quality rural multidisciplinary healthcare teams. The Project ECHO (Extension for Community Health Outcomes) program at the University of New Mexico provides longitudinal telementoring to multidisciplinary providers caring for patients with COVID-19 on tribal lands, using an interactive structured curriculum (10) . Providers attend voluntarily, regardless of whether they present a case, to view didactics, partake in case discussions, contribute insights from their practices, and learn from expert panels and their peers. Providers benefit from access to experts at the hub or spoke sites between sessions by e-mail or telephone.

The ECHO model uses technology such as multipoint videoconferencing and the internet to leverage scarce mentoring resources, a disease-management model proven to improve outcomes in other diseases by reducing variation in processes of care and sharing best practices, a case-based learning technique, and an internet-based database to monitor outcomes (11) .

Since March of 2020, the Tele-ECHO COVID-19 program has provided structured, long-term telementoring, differing from traditional telemedicine in that providers typically assume short-term care of individual patients. Unlike traditional didactic lectures or webinars, the model provides real-time, interactive discussion of cases with expert panels. The discussions are contextualized followinglearningtheoreticalprinciples,suchas deliberate practice, social cognitive theory, and situated learning, and communities of practice.

This creation of a virtual community of practice emphasizes reciprocity, which promotes trust and respect by acknowledging Although access to the program is limited by lack of telecommunication capacity, it has the potential to revolutionize health care in the Navajo Nation.

Current COVID-19 test-based surveillance does not effectively capture medically vulnerable rural populations in the Southwest. Home-based testing would fill a critical gap for Navajo communities (12) . Rapid home-based serological and antigen tests, similar to fingerstick glucose tests and home pregnancy tests, will be accessible soon. Smartphonebased devices containing a cartridge-housed microfluidic chip that uses isothermal amplification of viral nucleic acids from nasal swab samples, detected using the smartphone camera, may soon be available. Self-test kits may be combined with prepaid mail-back, mobile app-based, or telemedicine interpretation approaches. The Food and Drug Administration has granted emergency clearance for an at-home nasal self-swab kit (Pixel; LabCorp), which includes mail-back to the company for conducting the polymerase chain reaction assay and online access to results (13) . Policy interventions are needed to minimize financial barriers and improve access to postal services on the vast Navajo Nation, which currently has only 11 post offices. The need to drive long distances to these services creates ongoing challenges to embracing these new technologies. PERSPECTIVE reported an extremely close match with the Kinsa smart thermometer (Kinsa Inc.) and influenza data (R 2 of 0.96) (14) . Google released an open online resource that aggregates anonymized location-tracking data from mobile devices to share large-scale mobility trends, such as the percentage change in visit volume for churches or casinos. Use of contact-tracing apps and Global Positioning System-tracking telephone bracelets may be helpful as connectivity improves in the Navajo Nation.

Delivery of home goods, including medications from commercial or government services, has been hampered by lack of a physical address for many Navajo people, as well as by long distances between locations. Google Maps and the nonprofit Rural Utah projectcollaboratedtocreate"Plus Codes," sixdigit numbers based on latitude and longitude coordinates. The codes also facilitate access by first responders. The National Guard and countless volunteers have delivered food and water to regional centers using this approach.

SARS-CoV-2 vaccination programs will require a robust cold-chain supply, a delivery system thatmaintainstheintegrityofbiologicallyactive, temperature-sensitive vaccines from manufacture to administration. Medical coldchain requirements present unique challenges due to health risks, complexity, governance, and potential product recall (15) . Temperature concerns could slow the rollout of new vaccines on the Navajo Nation, such as those requiring 220 C to 270 C, exacerbating vaccine inequities. Internet-based models that integrate themultifacetedaspectsof theprocess havebeen described. In China's Shandong Province, an animal vaccine program used the system "Internet of Things" to coordinate temperaturesensing technology, radiofrequency identification technology and network communication to maintain the cold chain (16) . Increased use of technology could improve the cold chain in the Navajo Nation through solarpowered (photovoltaic) refrigerators, cell phones for communication, and software resources to assist planning and management.

An early response to the pandemic was the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Passed by Congress with overwhelming bipartisan support, it was signed into law on March 27, 2020. Congress recognized that lack of high-speed internet in tribal and rural areas impedes telemedicine, access to unemployment insurance, small business loans, and remote education. The CARES Act provided for a more than $23 million investment by the U.S. Department of Agriculture (Broadband ReConnect Program) in rural broadband across New Mexico, mostly in the central and southern parts of the state. Funds were appropriated via loans and grants for the costs of construction, improvement, or acquisitions of facilities and equipment needed to provide broadband service (17) . The Navajo Nation was allocated over $600 million from the CARES Act. Delays in funding, due to legal challenges, and refusal to release sensitive tribal information that Native communities needed to fight the disease may have resulted in increased illness and death (16) . There has been widespread support in the Navajo Nationtousethefundstopayforcritical infrastructure. A majority has been allocated for water projects, such as portable water storage, hand-washing stations, and shower units (18) . The CARES Act fund simultaneously allocated financing for technology infrastructure, recognizing the importance of both projects to the Navajo people. Urgent requests were also made to use funds for personal protective equipment, food distribution, and disinfection of government offices. In August of 2020, the Navajo Nation allocated $32 million from the CARES Act to increase internet services, broadband expansion, and mobile towers. In October of 2020, another $18 million was allocated to provide more internet services to the Navajo Nation (19) . Funding from the CARES Act was significant and welcome, but it only begins to address the challenges faced by the Navajo Nation. Additional Congressional bills pertinent to Native people have been submitted (Table 1) (20) .

Despite its early interventions to decrease spread of SARS-CoV-2, the Navajo Nation has experienced vastly disproportionate illness and death. The pandemic has exposed the devastating impact of decades of inadequate services to Native Americans, services promised years ago in exchange for land. The IHS is chronically underfunded and understaffed, providing $4,078 per capita for health care, less than half of what is spent on federal health care for non-Native Americans ($9,726); in the general U.S. population, $13,185 is spent per Medicare beneficiary (21) . There is a 30% provider vacancy rate within the Navajo Nation (Figure 2) , affecting patient access, quality of care, and employee morale (1) . Although there are several initiatives to increase the number of clinicians, including collaborative efforts among the American Thoracic Society, the American College of Chest Physicians, and PA Consulting (Clinician Matching Network) (22), many are temporary patches. Long-term solutions will take time and considerable funding. A promising realistic approach is to dramatically increase telehealth capacity (23) . Despite challenges imposed by the pandemic, its devastating effects, and a bipartisan, bicameral Congressional letter to the Federal Communications Commission (24) to extend the tribal broadband application deadline (2.5-GHz Rural Tribal Priority Window), the window to apply for broadband expansion closed in early September of 2020, highlighting the difficulty for tribes to apply for broadband funding (25) .

In keeping with prior challenges to interventions in the Navajo Nation, an approach such as community-based participatory research (CBPR) would foster culturally appropriate programs that acknowledge local customs and cultural nuances. CBPR is essential for identifying the most effective manner to build technological infrastructure within Native communities (5) . Collaboration with community stakeholders and tribal and/or federal programs would allow telehealth and tele-education to occur in a manner comfortable for community members. It would foster culturally appropriate programs that acknowledge local customs and cultural nuances. CBPR would facilitate ownership of telehealth and allow sustainability, with long-term value being placed on its role in sharing knowledge. In addition to addressing critical determinants of health, closing the digital divide is a key component of achieving health equity for the Navajo Nation.

Author disclosures are available with the text of this article at www.atsjournals.org.

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