Friday, May 15, 2015

The Navajo Experience with Tuberculosis

Contrary to popular belief, although “Native” Americans populated the Americas long before Europeans and other immigrants, Native American history is also one of immigration and migration throughout the North American and South American continents.

Over 1000 years ago, the Athabascans crossed the Bering Sea from the Eurasian landmass and settled parts of Western Canada and Alaska. Through cultural, linguistic, and genetic research, it was recently discovered that the Navajo are descended from the Athabascans and most likely branched off in the 1300-1400s when they migrated to the American Southwest. Other Athabascans diverged and became present-day Apaches.

Traditionally hunter-gatherers, the Navajo learned from neighboring Pueblo tribes how to farm and cultivate the land. Over time, they fended off threats from the Spanish but eventually were defeated by US forces including Colonel Christopher “Kit” Carson in the mid 1860s. This defeat culminated in the widespread deportation of Navajo people away from their homelands to Ft Sumner from 1864-1866 that came to be known as the “Long Walk” and the signing of treaties that led to the formation of Navajo Nation. It is purported that this was one of the first exposures of the Navajo people to tuberculosis. By 1912, 10% of Navajo had TB, and TB was responsible for 50% of all illness seen among the Navajo.

The Navajo word for TB is “jei di,” which literally means “disappearing heart.” There is a commonly held perception that TB can be caused by contact with wood that has been struck by lightning. Navajo Medicine asserts that TB or jei di can be cured by the shooting way ceremony to achieve harmony.

By 1953, almost a century after the “Long Walk", TB incidence was 100x higher among the Navajo than among the general US population. Around this time, a brave lady named Annie Wauneka led a public health campaign to educate her fellow Navajo about the dangers of TB and to correct misconceptions surrounding the disease. She taught Navajo medicine men about TB, pioneered a model of directly-observed therapy for TB, and encouraged Navajo to complete their TB treatment.

Today, tuberculosis still plagues the Dine at a rate many times that of the general US population. As you may know, tuberculosis is a curious disease in its ability to remain latent for many years before reactivating during times of sickness or immunosuppression. TB is called the “Second great imitator” due to its protein manifestations. 

It is estimated that as many as 1/3 of all those who suffer from diabetes mellitus on the reservation have latent tuberculosis and are at risk for reactivation and transmission. As such, it is increasingly common for all those with DM to be screened for latent TB with a PPD or a serum quantiferon test.

Although TB rates and mortality have fallen drastically thanks to efforts by Annie Wauneka and others, TB is still a disturbingly common occurrence among the Navajo. While working with an infectious disease physician in Navajo Nation, I had the opportunity to meet and care for a kind lady on immunosuppressants for her rheumatoid arthritis who presented with severe hip pain. Although the thought was that she likely had a labral tear or her pain was a manifestation of her pre-existing RA, her joint was tapped and was positive for TB. She was treated with a 4 drug regimen, and before I left her pain had significantly improved. 

For context for those reading, during my 6 year general medical training in the United States, although tuberculosis has been on the differential many times, I have never cared for a patient with newly diagnosed tuberculosis. I have read and seen patients with TB in India and southern Mexico but not once in the United States. By and large, it is a disease of poverty and affects the most vulnerable both from a medical and societal perspective.

In my next post, I hope to speak more about structural factors that affect health in Navajo Nation.

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