Raymond Reid
Improving
the Lives of American Indian People Through
Research
Raymond
Reid, Navajo, MD, MPH, is field clinical
director
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
people,
especially
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.)
Update:
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.