Directly Observed Therapy for Tuberculosis in the Navajo Reservation

Akash Gupta, MD

Resident in Medicine/Pediatrics at Massachusetts General Hospital

PGY-4

March 21, 2019

As mentioned on my previous post, I have been on a month-long immersive clinical elective at Northern Navajo Medical Center, a small community hospital run by the Indian Health Service in Shiprock, New Mexico. As a future infectious disease fellow, I have a strong interest in tuberculosis, and was lucky enough to spend the day with the TB community outreach nurse, Dorothy.

Every day, Dorothy performs home visits to administer anti-TB medications under Directly Observed Therapy (DOT). She serves patients in a large catchment in the Four Corners region, and sometimes drives up to 2 hours to patients’ homes. On the particularly day I joined her, Dorothy had 3 patients who needed DOT: two had pulmonary TB, one had spinal TB or Pott’s disease.  I joined her for visits for two of these patients.

The patient’s lived quite far from each other, and in varied settings. One was an elderly woman living with her husband in a small trailer home in a very small town about 1.5 hours from Shiprock. She had severe rheumatic arthritis (a surprisingly common disease among the Navajo) and had recently been started on immunosuppression by a rheumatologist in Salt Lake City (some 3-4 hours drive from her home!). The suspicion was that she may have reactivated in the setting of immunosuppression. She and her husband were quite old, and appeared frail (her husband was on home oxygen). As a result of recent snow-melt, her driveway was extremely muddy. Their apartment was very cluttered, and was heated by a small central wood stove. They said that while the husband was able to drive, it was hard for either of them to do many of the manual tasks required around the house, and they were getting limited help from their children. They unfortunately also had some money stolen recently, and were very worried about both finances and their ability to manage their daily needs. Dorothy spent time discussing this with them, which she did almost daily.

The other patient was a middle-aged woman who had likely acquired TB while taking care of her mother, who had pulmonary TB several years earlier. Interestingly, this patient had taken a full course of isoniazid prophylaxis after caring for her mother, but still ultimately developed active TB. She lived in a beautiful home on a property overlooking mountains, and was active and robust.  The home was neat, well-decorated, and with many books. She had multiple other small buildings, dogs, and a lovely garden. It was a stark difference to the prior home visit.

The last patient also had pulmonary tuberculosis, but lived in the city of Farmington, which is the closest city to Shiprock. While I did not join for this visit, I believe the patient had a case of typical pulmonary tuberculosis.

Given the far distances, Dorothy and I spent a long time in the car together, driving across beautiful landscapes. She was a lively, animated, and extremely chatty woman. She could keep the conversation going for hours, narrating to me the history of various elements on the countryside, and telling me details of her patient’s lives. She also told me about her own life story and family, which was an incredible epic. I recommended she write a memoir one day, and she laughed. One of the beautiful sites she showed me was of a mountain of the neighboring Ute tribe, and a small building that used to serve as a jail cell, and is now preserved for history.