Over the summer, rural Washington state’s Okanogan County, located in the north central area of the state, was threatening to become a COVID-19 hotspot. In a county of about 40,000 people, cases surged to over 600 per 100,000 population. At one point, the county had the highest percentage of new COVID-19-positive patients in the state.
Larry Dean Smith, DO, the clinical director of the Colville Service Unit under the Portland Area Indian Health Service (IHS), is responsible for the care of all members of the 12 tribes of the Colville Nation who live on a nearby reservation and represent about 13% of the county’s population. Because an estimated 80% of his patients have risk factors for severe COVID-19 illness, his health care team has been working extra hard to provide up-to-date information and encourage social distancing and mask-wearing for a population that places significant cultural value in large gatherings.
“So many of our patients have diabetes, hypertension, rheumatological illnesses or autoimmune diseases, and most are on some kind of immunosuppressant drug treatment,” he says. “Of course, that creates a potential problem.”
Fortunately, that hard work has been paying off. Thanks in part to a strong information campaign from IHS in cooperation with the Colville Nations Tribal Council, cases in Okanogan County have started to level off and the death rate remains around 1%.
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In this edited Q&A, Dr. Smith discusses IHS’ collaborative efforts with the tribal government to keep the population safe, the unique challenges of providing care from a distance in a rural area, and how a possibly disastrous event has become a public health success story.
What was the Colville Nations’ initial response to COVID-19?
COVID-19 started out really slow here. We thought it might not hit us, but it ended up nailing us.
The Colville Tribal Council closed down everything at first. At the end of every bridge on the border of the reservation, there were signs up asking people to stay out. Casinos were closed, and government workers were sent home. They jumped on this early. They were excellent, ahead of state and county guidance. But in the community, people initially had trouble following strict guidelines.
Where do you think the outbreak stemmed from?
We have a lot of apple orchards on tribal land and agricultural workers who live in small cabins and bunkhouses on that land. I believe a good amount of the outbreak started there and spread in those cramped conditions. Then there were interactions with the Native American population in shared spaces like stores.
Culturally, my patient population is very social and has frequent meetings and get-togethers. It’s very unusual for them not to visit their family and friends. It’s not uncommon for children to have many adults they see as parental figures. These are very close-knit groups.
We found early on that those meetings were spreading COVID-19 among Native groups on the reservation. Many of those meetings have stopped, but it’s still often a big effort to track down all possible contacts of a COVID-positive patient.
What has changed between the height of the outbreak and now?
Specifically, among our patients at the two IHS clinics I work in, we were seeing five positive tests a day, and that has now gone down to three or four a week. Surrounding areas are seeing the same thing. It’s way better now.
It scared a lot of people that it hit us so hard so quickly. Before the outbreak, you’d go to the store, and in spite of a state mask mandate, you’d still see, in some stores, more than half of people without a mask on. Now, it’s nearly 100%. I haven’t seen a face without a mask in public in months.
What challenges has the rural location presented in terms of getting information out quickly?
The native population is very spread out in farms and houses. Cellular companies generally don’t do a good enough job to make sure they have cell or WiFi access. Many just don’t have either.
When everything was shut down, our patients lost a lot of access to care. It’s hard to do a telehealth visit when you don’t have cell service. It was really difficult to get information to our patients and let them know that we wanted to see them. Contact was all very difficult. And if they didn’t feel well and were far away, there was no way for them to get ahold of us because of the limits the state put on seeing patients in person (which have now been lifted).
What has the collaboration between IHS and the tribal authorities been like?
IHS has an excellent relationship with the tribal government. The Colville Nation is an independent nation, so they can make their own laws, but they’ve been working closely with us because they don’t have a lot of places to go for information.
Probably the most helpful support has come from the Northwest Portland Area Indian Health Board, an advisory organization based in Portland, Oregon that is run and organized by participating tribes in Washington, Oregon and Idaho. They set up Project ECHO (Extension for Community Healthcare Outcomes), and host what they call “Indian Country ECHO.”
For COVID-19, they have hosted a series of one-hour presentations devoted to keeping clinicians up to date regarding this illness. Ninety percent of what I know about COVID-19 I learned during these sessions. There has never been a time during my 28 years of practicing that I have been able to keep myself informed of a topic with so much relevant information in such a timely manner.
What has treating this population during COVID-19 been like for you personally?
My patients are the most sincerely appreciative people I have ever worked with. They are friendly and kind and just wonderful people. I’ve really fallen in love with them, as well as everyone I work with here.
Luckily, I have not experienced a loss of any patients I see regularly, but it’s been hard to see this illness hit this population so drastically. I feel a moral and ethical obligation to get these people through the pandemic as unscathed as possible.