Improving the Lives of American Indian People Through Research
Reid, Navajo, MD, MPH, is field clinical
for Johns Hopkins Center for American Indian Health.
He is based in Shiprock, New Mexico. For more than 20
years he has been participating in public
health-oriented, clinical research projects that have
been improving the lives of American Indian
infants and young children.
While Reid was a resident in medicine at Johns Hopkins University, he also earned his MPH at the same institution. He wanted to work on an Indian reservation and continue his affiliation with Hopkins, so he agreed to work for 6 months on an infant diarrhea project on the White Mountain Apache Reservation in Arizona. Dr. Mathuram Santosham of Johns Hopkins directed the project.
When Reid arrived the first day at the local Indian Health Service hospital, he was taken aback with the severity and magnitude of the problem. During a tour of the pediatric ward, he saw patient rooms and hallways filled with cribs containing babies who were severely ill with diarrhea. “I’ll never forget that image,” says Reid. “Some of the babies were severely dehydrated. Some did not survive.”
As part of the team, Reid joined in doing epidemiology studies to determine who was suffering from diarrhea, what was causing it, and how severe the problem was. One of the findings was that diarrheal disease was killing Indian infants at rates 7 times the national average. To deal with this enormous problem, Reid and his colleagues did a number of clinical studies to evaluate different methods for treating diarrhea. Fortunately, the team found that oral rehydration therapy (ORT) was highly successful.
In the early 1980s, Reid and other public health experts from Johns Hopkins trained local Indian people, who were fluent in the native language, to visit parents of study participants in their homes; explain research procedures, such as the use of ORT, to these parents; and collect research information from them. Partly as the result of the efforts of these field workers, the rates of Native American infants becoming severely sick and dying from diarrhea dropped dramatically. The White Mountain Apache Tribe was recognized by the Global Health Council for its contribution to the worldwide control of death due to diarrhea.
Addressing Potentially Fatal Diseases
Originally Reid had only agreed to work on the diarrhea project for 6 months. However, he was touched by the great needs of the population and the possibilities of enhancing the health of Indian people, so he stayed. “It wasn’t long before we discovered that babies on the reservation had other problems that were more severe in the Apache population than in the rest of the U.S.,” he says. “For example, over a 3-month period, 5 kids came into the hospital with meningitis caused by the Haemophilus influenzae type b (Hib) bacteria. We wondered if this represented an unusually high rate of Hib diseases. We went back into the hospital records to see how many other cases of haemophilus diseases (bacteremia, meningitis, septic arthritis, cellulitis) there had been in previous months and years. We determined that haemophilus diseases were about 100 times worse in the Apache population than in babies throughout the U.S.”
Reid remembers, “The local population had recognized that a number of babies would come down with meningitis, but they didn’t recognize the severity of the problem. When we told the Tribal Council about the severity of Hib diseases among Apache babies, they said, ‘You’re the experts. You do something about this.’”
The team broadened the study to include Navajo babies. They discovered that the rates of haemophilus diseases were just as high among these babies. At that time, there was no vaccine available to protect babies from these diseases.
“Between 1983 and 1990, we worked hard to identify a vaccine that was safe and would protect babies,” says Reid. “We found that some vaccines worked in the white population, but they didn’t work as well among Navajos and Apaches. Before that people thought vaccines were equally protective for all people. The articles that we wrote about our findings were published in a number of medical journals.”
The Critical Role of Field Workers
“In 1988 we began evaluating a particular Hib vaccine in babies as young as two months of age. In order to do our research studies, we had to get approvals from the tribe, the Indian Health Service, and Johns Hopkins. The last approval, which I feel is the most important, is from the mothers. They needed to be able to trust us with their babies.”
After being trained in some basic public health skills, the field workers played a key role in identifying mothers, who were open to allowing their babies to participate in the Hib study, and to securing the mothers’ informed consent. Reid says “The field workers gave the mothers detailed information about the study, including the possible risks to the babies. They told the mothers that to test the possible effectiveness of the vaccine, some babies would be given the vaccine while others would be given a placebo. They also explained that during the trial, neither the health professionals nor the mothers would know which baby was getting the real vaccine. The field workers further explained that this was the standard scientific method for evaluating almost all medicines and vaccines.”
“The field workers made it clear to the mothers that they didn’t have to have their baby in the study. Even if a mother agreed to give her approval, she could later change her mind. I think we gained the trust of a lot of mothers, even grandmothers.”
“Many parents willingly enrolled their infants in this study because they were familiar with the suffering caused by Hib meningitis,” reports Reid. “The new vaccine was found to work very well, and it was safer than some of the vaccines that are typically given to babies. The vaccine is still being given on reservations. Today death and disability from Hib hovers just above zero among all Indian groups.”
Identifying Another Need
During this Hib vaccine study, field workers, who had developed good rapport with the mothers, realized that many of the mothers were teens who needed support in caring for their babies. The findings of a study carried out by Reid and others led to the development of the Family Spirit Project in which teen parents get educational and emotional support from family health educators who visit them in their homes.
Center for American Indian Health Continues Research
In 1991 following the Hib study, Dr. Santosham founded the Johns Hopkins Center for American Indian Health with the mission of working in partnership with American Indian tribes to raise the health status and self-sufficiency of American Indian people to the highest possible level. Reid, who had been serving as clinical researcher, eventually assumed the title of Field Clinical Director for the Center.
Reid and his colleagues recently completed a study of a new vaccine to prevent serious illnesses, such as meningitis and pneumonia, which are caused by the Streptococcus pneumoniae (pneumococcus) bacteria,. Like Hib, pneumococcus disproportionately affected Navajo and Apache infants. At the time the study began, no vaccine was available to prevent pneumococcal diseases in babies less than two years of age. The team found that the new vaccine was safe and effective in preventing many cases of pneumococcal diseases. Because the vaccine is new, its effectiveness in protecting babies against pneumococcal diseases is still being monitored..
In 2002 the Center staff began studying a new vaccine to prevent disease due to rotavirus, the most common cause of serious diarrhea in infants in the U.S. and in many countries in the world. Other diseases affecting American Indian infants that Reid and his colleagues are addressing include bronchiolitis due to respiratory syncytial virus (RSV) and respiratory illnesses linked to the flu virus. In addition, the Center staff recently completed an epidemiology study of pneumococcal diseases in Navajo adults and found rates to be higher among Navajos than in adults in the general U.S. population. Data are still being analyzed to determine the causes and to look for ways to prevent these illnesses in order to bring down the high rates of disease and death.
American Indians With Public Health Training Are Needed
HIV, diabetes mellitus type II, obesity, child abuse, and spousal abuse are among the problems that Reid feels need to be addressed. “Having a background in biostatistics and epidemiology will enable people to design and carryout studies that will help us better understand and address these issues,” he says. “Both clinicians and non-clinicians with graduate degrees in public health can play a significant role in the team effort needed to improve the health of Indian people.”
Reid has played an important role in enhancing the lives of American Indians. He is devoted to this work and, thankfully, intends to continue his efforts well into the future.
This article was originally published in the Summer 2003 issue of Winds of Change. (The cover artist is Tina Santiago, Coushatta.)
1/4/07 Dr. Ray Reid reports: “There are updated information I can share. First, the pneumococcal vaccine that we evaluated (Prevnar) became licensed and was incorporated into the schedule of well-baby vaccinations for all infants. On the Navajo and Apache reservations, rates of pneumococcal diseases have dropped quite a bit for types of pneumococcal diseases and deaths that the vaccine is supposed to prevent. We continue to monitor the effectiveness of the vaccine.
Current studies of the pneumococcal bacteria and of the vaccine focus on learning more about the phenomenon of herd immunity or indirect immunity. We and a number of other researchers have found decreased incidence of pneumococcal diseases in families in which infants in those same family have been fully vaccinated with the pneumococcal vaccine even though other members of those same families were never vaccinated with a pneumococcal vaccine. These data were compared to families in which there are no infants or in which infants were not vaccinated with the pneumococcal vaccine. This is important information since rates of pneumococcal diseases are high in Navajo and Apache adults, and treating adults with pneumococcal diseases is becoming increasingly difficult.
Results of our pneumococcal research were presented at an international pneumococcal conference in Australia in the Spring of 2006. A number of Navajo and Apache research workers along with staff in Baltimore attended the meeting.
Regarding the rotavirus vaccine that we were evaluating, we stopped the study in 2004 since enough data and information had been collected that would provide reliable conclusions. Our study on the Navajo and Apache reservations was part of a worldwide study in which the vaccine was evaluated in many locations throughout the world. Analyses of the data showed that rotavirus vaccine was very effective in preventing serious diarrhea in infants. Serious diarrhea often results in deaths, thus the vaccine also probably prevented unknown numbers of deaths. The results of the worldwide study were published in early 2005; and the vaccine is now licensed in the U.S.A. We plan to write a separate manuscript for the study that was done on only the Navajo and Apache reservations.
Besides carrying on our studies related to indirect immunity of pneumococcal diseases, we continue evaluating the RSV vaccine. This is our third winter.
2008: Dr. Reid is the second author (Mathuram Santosham is the first author) of a paper entitled "Contributions of Native Americans to the global control of infectious diseases," published in Vaccine 25 (2007) pages 2366-2374. The article documents how the participation of American Indians and Alaska Natives in numerous biomedical studies over the last half century has resulted in prevention strategies and treatment interventions that have reduced illness and death not only among American Indian and Alaska Native children but also among children throughout the world. The 5 infectious diseases described in the article were identified as significant health issues by the Native communities.