Cara Bushmaker, MLS(ASCP)CM, 2019-20 ASCLS-Montana President

Montana is known as the “Last Best Place.” As I thought about the topic of diversity, I would not have described Montana as a diverse place. I would venture that the feeling I have is largely due to our limited population. I felt my own hesitance echoed by my peers as we talked about our individual perspectives on the pandemic response in Montana and our state’s diversity. I struggled with knowing the limited scope of our patient diversity, society, and population in general, as well as how I could possibly contribute to a topic like this. Those feelings only intensified after a weekend of protests and unrest around the country, and increasing concerns around the transmission of COVID-19. The longer I reflected on our situation and listened to the stories of those all over the United States, I began to gain a little footing. I realized my own perspective on diversity should not be equated to a percentage or data set or, most importantly, the numbers I look up on the Montana Census website. My reflection on diversity is in sharing our story and how it makes us unique and yet still united.

Tribal reservations outlined over the Montana Public Health Laboratory Coronavirus Cases by County as of 6/01/2020.

We have just over one million people in our large state. Each individual resident spread out across the land would have six square miles of separation from another person. Six. Square. Miles. That number is probably as astounding to some people as a metropolitan city dealing with a pandemic is to me. That space makes us unique, unlike few other states. Our population and the description of our “wide open spaces” will sometimes deem us as “safe.” Surely, we have to be safer from transmission of COVID-19 because of all that space. In many aspects, we are much safer than an urban area is right now. I am fully aware of that. But being safe also assumes that we have the resources and abilities to implement necessary protections. That we have the “space” to act before it gets too big to handle. Or, that we have the resources to take care of our at-risk areas.

The Big Sky State is many things, but our population is not what we are known for. I have learned throughout my life that, as a Montanan, I am often perceived differently due to where I live. This rural state I have known my whole life is comprised of just 6 percent Native Americans. That 6 percent is our largest source of diversity in the entire state. We are home to seven Indian reservations that also happen to be one of our at-risk populations during this pandemic. Those include the Blackfeet, Chippewa Cree, Confederated Salish and Kootenai, Crow, Fort Belknap, Fort Peck, Little Shell Chippewa, and the Northern Cheyenne tribes.

“We will not be spared by borders or lines in the sand. The spread that we see is a slow burn that we hope does not turn into more.”

Our government addresses resources and allocations to our reservations through our Tribal Alliance agreements. I often wonder about this through the lens of the lab. Do they have the trained professionals to use these resources? Do they disperse them to people effectively? Are they worried, like I am, about a lack of weapons to fight this effectively? I don’t have the answers. Even though we are rural, we are still at great risk from COVID-19 for a variety of reasons, space being one of them.

Recently in one of our tribal counties, local health set up a drive-through sample collection site to test for SARS-CoV-2. The call for mass testing had not been widespread in Montana due to lack of reagent and preservation of supplies. This collection site opened and immediately our state data took a very different turn. We went from a model state to reflect the reopening process, to a steady rise in cases. This rise reflected my own worry of what this will do to our current situation and how we will be able to handle it. These Native American reservations with invisible walls will still be at great risk for infection in our state. We will not be spared by borders or lines in the sand. The spread that we see is a slow burn that we hope does not turn into more.

June 1 started the first day of Phase 2 for Montana’s reopening plan, and we watch daily as our numbers start to inch higher again. We take this time we have, and we focus on what we have learned from places like New York, New Jersey, and the other hot spots of Coronavirus. We are learning from those people on the front lines.

We were implementing PPE preservation plans and responding to material shortages along with the rest of the nation even before we had a positive case in our state. We disseminated the latest research on proning patients in our facility without having had a positive inpatient. I, as well as others, was shedding my work attire before coming home to my family long before we ever cared for a positive inpatient in our facility. We used the information we had and adapted.

We held on to what little science we could find, BUT we still have barriers. SO, we deal with less. We worry about all the same things that people around the world are worrying about. We are uniquely diverse in a different way, yet so connected with the global issues as well. The sad reality is we are all just as exposed to this novel threat. The realities of our state are laid out in resource allocation, supply wait lists, at-risk population statistics, and space, lots and lots of space.

I still feel we don’t have an adequate testing strategy, along with many laboratorians all over the world. I worry, along with the rest of the country, as we reopen, will we be able to handle it. I know we need to reopen for many reasons, but as a healthcare worker, I hesitate. I worry about our perception of diversity here in Montana and how it affects our supply, our ability to test, and our ability to maintain our PPE. At the end of the day, I write protocols to answer the questions. I focus on the answers I know, based on the data and science available to me.

We are rural, but not alone.

On behalf of ASCLS-Montana, I thank all the men and women working hard on the front lines during this pandemic. We can’t describe how much your efforts and knowledge have helped us. Thanks for all you are doing and for sharing our work.

Cara Bushmaker is Technical Supervisor at Marcus Daly Memorial Hospital in Hamilton, Montana.