Walking In Beauty In The Time Of COVID-19
My heart broke for her as I silently listened to her weep. I had no other way to comfort her besides being present. I’m used to loved ones being at the bedside as they say their final goodbyes and being able to comfort families instead of delivering the message over a static phone line. It feels like this disease has robbed health care providers of their humanity. We are transformed into faceless workers under layers of PPE. We minimize exposure at the expense of bedside patient contact and rapport. When a patient is dying, we only allow one family member into the room, and even then we limit the amount of time they can be there.
Each day since I arrived in Navajo Nation, I had been taking care of her mother and updating her as she slowly declined. During the “before times,” I was a global health resident at UPMC in Pittsburgh. I had accepted a global health fellowship position through the University of California San Francisco’s Health Equity Action Leadership (HEAL) Initiative. HEAL is rooted in the principle of solidarity with the goal of achieving health equity for resource-denied communities. The program had asked me to come out to the reservation as a residency away rotation to help with the COVID-19 response since I will be working there for a year as the first half of my fellowship. I accepted without hesitation.
At the time of this writing, Navajo Nation had the highest COVID-19 infection rate per capita, surpassing even New York and New Jersey. The reasons for this devastating disparity are vast and complicated, but rooted in neglect and genocide of the Navajo/Diné people. The public health recommendations to prevent the spread of COVID-19 are difficult to follow on the reservation due to infrastructure inequalities. We cannot reasonably expect patients to wash their hands multiple times per day when 30-40% of the Navajo population don’t have access to running water. People cannot social distance when they live in multi-generational homes. There are only 13 grocery stores on the entire reservation, which is the size of West Virginia. Indian Health Service, the main health care system on the reservation, is chronically underfunded and understaffed. There have been hundreds of treaty violations by the US government since the conception of Navajo Nation in 1868, including treaties guaranteeing adequate infrastructure for the Navajo people. These disparities existed prior to the arrival of COVID-19, but the pandemic highlighted how devastating any additional blow can be to this already fragile ecosystem.
While it was a privilege to provide support for this community, it was not without its challenges. Discussions about death are considered taboo and providing prognostic information is considered “wishing that future” upon the patient. This made goals of care conversations particularly difficult. Many of the elders and even some younger people only speak Navajo, and interpretation would either have to be provided by a nursing assistant who spoke the language or an often misplaced iPad via a Zoom interpreter. Oftentimes we would have multiple generations of the same family hospitalized. If someone would decompensate and require intubation, they would have to be flown off the reservation to a nearby city or else the ICU capacity of the hospital I was at would be overwhelmed. As a white physician and an outsider, it was uncomfortable explaining to patients why certain traditional practices had to be avoided. I often had to counsel against the dangers of sweat lodges where it’s not possible to social distance and the chanting involved increases the risk of aerosolizing the virus. Everyone on the reservation has been affected by the pandemic, with some suffering from COVID-19 themselves and most knowing someone else who has suffered or died from the virus.
In spite of the destruction inflicted by this virus, the Navajo community has demonstrated amazing resilience and ingenuity, a reflection of the generations of adversity they have faced. People have come together to make masks and write public health messages that are understandable in Navajo. While outpatient clinics are temporarily suspended, health care workers have adapted to become contact tracers or participate in swabbing hundreds of people during “blitz” testing. People have been obeying the curfew mandated by the Navajo leaders, which is one of the strictest in the country.
There is a traditional Navajo blessing that translates as “Walking in Beauty,” a prayer my patient certainly would have been familiar with. One of the lines in the prayer, “Hózhóogo naasháa doo” means “In beauty I walk.” In Navajo culture, walking the Beauty Way is the action of living harmoniously with all of life as it is unfolding; to live in harmony with the Divine, with the natural world, with our own self, with our loved ones, and with our community. The response by the Navajo community to the COVID-19 pandemic has truly embodied this principle. I am humbled to have been able to serve in this community and look forward to returning to work in solidarity with the Diné people over the next year.
Patrice Zigrossi, MD, Fellow, University of California San Francisco’s Health Equity Action Leadership (HEAL) Initiative