Where coronavirus could find a refuge: Native American reservations
S E E D E D C O N T E N T
The federal health agency that serves more than 2.5 million Native Americans has only limited ability to monitor and investigate coronavirus cases across American Indian communities and reservations , slowing its ability to respond to outbreaks and raising fears that a lack of reliable data could compromise national efforts to eradicate the virus.
The Indian Health Service is instead relying largely on Native organizations and health facilities to track the virus and self-report their findings to the Trump administration – an inconsistent practice further complicated by minimal testing capabilities, outdated health technology and provider shortages that Native groups warn could vastly understate the crisis across tribal lands.
That’s vexed public health experts, who say Native populations are particularly exposed to the risk of severe outbreaks, and worry that the virus could continue to spread throughout reservations long after President Donald Trump is ready to declare victory over the pandemic and move on. At that point, it will be critical to identify and isolate even small pockets of contagion to head off the potential for the virus re-enter larger populations and prolong the pandemic.
Those concerns have come into sharp focus over the past week, as coronavirus began to hit tribes across the nation – and represent just the beginning of the bureaucratic complexities hampering tribal leaders’ efforts to stand up a public health response.
Decades of underfunding and lack of resources have left the IHS ill-prepared to manage a large-scale health emergency, and tribes nervous that any federal assistance will be too little and come too late, according to interviews with Native groups, health officials and others close to the situation.
“There is not an agency that I’m aware of that has dedicated resources in any meaningful way to epidemiology in Indian Country,” said Bryan Newland, chairman of the Bay Mills Indian Community in far-north Michigan. “We’re doing this all on the fly.”
The IHS now counts 110 coronavirus cases across the nation’s tribal areas, up from single digits at the beginning of last week. Yet that figure serves only as a rough estimate, and relies extensively on tribes to voluntarily submit data.
“This is likely an underrepresentation of American Indians and Alaska Natives who might have tested positive,” IHS Chief Medical Officer Michael Toedt said during a Thursday call with tribal leaders.
‘This is going to be a huge challenge’
Just about one-sixth of 423 health facilities serving Native Americans are run by the IHS and required to regularly report cases. The rest are operated by tribes or urban Native organizations, which must choose to self-report coronavirus patients to the federal government. By contrast, the Centers for Disease Control and Prevention regularly collects data from public health labs and health departments in all 50 states.
“This is going to be a huge challenge, and I really haven’t heard the discussion of data collection and cohesiveness,” Nicole Redvers, a professor at the University of North Dakota who works closely with tribal organizations, said of the informal case tracking occurring across many tribes.
The piecemeal reporting has already sparked confusion in at least one major instance: the death of Merle Dry, a Cherokee Nation citizen in Oklahoma who was believed to be the first among the Native population – though for days afterward tribal leaders could not say for sure.
The March 19 death was reported by Oklahoma’s state Department of Health, but was not reflected in IHS’s own public data, which listed zero deaths through March 22. The category listing the number of coronavirus deaths was subsequently eliminated completely.
An IHS spokesperson said the agency’s data only include patients treated at IHS, tribal or urban Indian facilities – much of which is submitted voluntarily. IHS removed the category listing deaths to avoid underreporting, noting it may also not be notified of patients diagnosed at an IHS facility but later transferred outside the Indian health system.
Health data is inherently difficult to collect across Indian Country, where tribes operate as sovereign entities and have varying connections to federal and state authorities. On remote reservations, a lack of Internet or landline phones further hinders communication.
Yet tribal leaders and American Indian health experts also say the agency simply doesn’t have the resources to track and investigate cases across reservations, due to chronic underfunding that’s only been exacerbated by the growing public health emergency. IHS’s budget is smaller than most major federal health agencies, and it has weathered near-constant scandal and leadership turnover – cycling through five leaders since 2015.
The current highest-ranking IHS official, Deputy Director Michael Weahkee, was nominated to run the agency in October. He has yet to be confirmed.
A system ‘far, far behind’
Congress in recent weeks earmarked more than $2 billion in additional funding for American Indian health services, in what lawmakers and tribal leaders say recognizes the looming challenge for facilities and tribal organizations whose finances are already stretched thin.
But there remain institutional barriers: IHS hospitals face widespread shortages of doctors and nurses, and communication of patient data across that hospital network is slowed by its reliance on an archaic electronic health record system first introduced in the 1980s.
“Our system is far, far behind – and one of the immediate problems with surveillance is we do not have interoperability,” said Stacy Bohlen, executive director of the National Indian Health Board, which represents tribal government on health care issues.
American Indians and Alaska Natives collectively face glaring health disparities compared with the rest of the U.S., including lower life expectancy and higher rates of the respiratory conditions that put coronavirus patients at higher risk of death.
One in six households on reservations qualify as overcrowded, increasing the odds of rapid transmission. On some remote reservations there is no plumbing to ensure adequate handwashing, and the nearest health facility can be hours away. At the same time, the government spends far less on health care for Native Americans than for beneficiaries in other federal programs.
“There’s no mystery as to why Indian Country suffers from health disparities that are alarming and shocking, even when there isn’t a pandemic running across the globe,” said Kevin Allis, CEO of the National Congress of American Indians. “We’re in a very precarious situation right now.”
That public health gap has grown more stark during this pandemic. As the virus spread, tribal leaders said the administration abruptly pulled roughly 170 of its Public Health Service officers out of tribal areas, redirecting them to help combat coronavirus elsewhere – and leaving tribes without the trusted health professionals who had spent months embedded in Native communities.
The IHS disputed that figure, saying that approximately 137 officers had been temporarily deployed elsewhere “in support of HHS-wide efforts” to fight the virus – and that it’s working to ensure patient care for Native populations is not affected.
As test kit production increases and private health labs speed testing of Americans nationwide, tribal leaders also say IHS hospitals remain unable to conduct tests of their own due to a lack of the necessary certifications.
Those facilities must instead send swab samples to labs for evaluation. Of the 2,646 patients the IHS said it's tested as of Friday, results for 1,023 are still pending.
An IHS spokesperson said wait times vary by location, and that results will come back faster as more commercial labs begin to offer testing.
Red tape and severe shortages
Medical supplies have similarly been slow to arrive and mired in red tape. Federal officials for weeks urged tribes to seek aid directly from states and regional partners, which tribal leaders say have in turn directed them to local authorities – many of which are overrun with requests and redirect them back to the federal government, which is supposed to work directly with Native American tribes and organizations due to long-held federal trust obligations.
“Often the problem is the federal government not dealing directly with Indian nations and our health systems as sovereign to sovereign,” said Chuck Hoskin Jr., principal chief of the Cherokee Nation, which operates the nation’s largest tribal health system. “We’re the front line of public health in this region. We need a streamlined way to get these resources.”
Some larger tribes have so-called cooperative agreements with the CDC that’s allowed them to access funding and supplies more easily, including drawing from the nation’s Strategic National Stockpile. Navajo Nation – whose massive territory covers parts of Arizona, Utah and New Mexico – is receiving two shipments of medical supplies this week after a tenfold jump in cases prompted leaders to put it under lockdown, IHS officials told lawmakers.
Others are left waiting on the IHS, or forced to appeal to states and counties already under strain. One urban Indian organization, for example, sought supplies after its state received a shipment from the Strategic National Stockpile. But county officials told the organization it was so far down the priority list that it would likely not receive anything.
Trump on Tuesday touted the new production of millions of masks, respirators and other protective equipment, though tribes said they’re unsure whether and when they’ll get access to those supplies.
IHS said only that it’s shipped out 1.3 million respirators this month that are expired but deemed suitable for use, and that its regional supply centers have another 3.4 million on hand. The agency on Friday announced plans to spend an additional $40 million on protective equipment.
One crucial piece of equipment that won’t make it to large swaths of IHS and tribally run hospitals and clinics: ventilators, which IHS officials told lawmakers must be operated by trained professionals. IHS facilities don’t have those experts, meaning patients requiring intensive care must instead be transferred to non-IHS hospitals.
“If we don’t have them then the ventilators don’t do any good,” said Rep. Deb Haaland (D-N.M.), adding that for patients in remote areas, finding a second nearby hospital will be a near-impossibility.
There are currently just 81 available ventilators across the IHS system nationwide, the agency said, emphasizing that “the core competency of IHS is primary care” and that regularly relies on a network of non-IHS facilities to provide specialized or intensive care.
An initial $40 million allocated in early March was held up for two weeks – and even after the Trump administration doubled that amount, bureaucratic restrictions prevented some smaller and poorer tribes from accessing the initial round of payouts.
They’ll now have to apply for grants to access the rest – meaning more waiting at a time when tribes fear the next major outbreak may have already arrived.
“I don’t think people really appreciate what kind of risks really exist,” Allis said. “Over a million of these folks are elders. The numbers, if things don’t get contained and controlled – I’m not trying to exaggerate this – you could see potential death rates at a number with a lot of zeroes after it.”
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American Indians and Alaska Natives collectively face glaring health disparities compared with the rest of the U.S., including lower life expectancy and higher rates of the respiratory conditions that put coronavirus patients at higher risk of death.
One in six households on reservations qualify as overcrowded, increasing the odds of rapid transmission. On some remote reservations there is no plumbing to ensure adequate handwashing, and the nearest health facility can be hours away. At the same time, the government spends far less on health care for Native Americans than for beneficiaries in other federal programs.
“There’s no mystery as to why Indian Country suffers from health disparities that are alarming and shocking, even when there isn’t a pandemic running across the globe,” said Kevin Allis, CEO of the National Congress of American Indians. “We’re in a very precarious situation right now.”
That public health gap has grown more stark during this pandemic. As the virus spread, tribal leaders said the administration abruptly pulled roughly 170 of its Public Health Service officers out of tribal areas, redirecting them to help combat coronavirus elsewhere – and leaving tribes without the trusted health professionals who had spent months embedded in Native communities.
The Navajo Department of Health and Navajo Area Indian Health Service announced 20 new confirmed positive cases of COVID-19 and three new COVID-19-related deaths Monday. The total number of confirmed positive cases has now reached 148 with five confirmed deaths.
Sure you can trust the government - just ask an Indian.
This is something a friend of mine shared on Facebook last night. It's a bit awkwardly formatted, since I C&P'd from Facebook. They need supplies, and they need people, badly.
A plea from the Navajo Nation... from both IHS and tribally run hospitals, of which there are only a handful serving an area the size of West Virginia... Please read.
Many are feeling alone on the Navajo Nation right now, especially in the remote community of Chilchenbito, which is essentially on lockdown due to the major outbreak of SARS-CoV-2, the virus causing COVID-19.
As a public health physician living in this area for the past 8 years, I am part of the Epi Response Team, and have already witnessed the terrible impact this virus has had, and it’s only just the beginning. It is rapidly spreading to surrounding communities, mostly due to a multi-church gathering that occurred in Chilchenbito in early March, and the handful of emergency rooms on the Reservation are already overwhelmed with people presenting in respiratory distress. Many are being intubated, stabilized, and flown out to tertiary care centers scattered across AZ, NM, UT, and CO; but many are also dying at home or shortly after arrival to the ER, and not being tested at all because we don’t have a system in place for post-mortem testing. General testing is also not widespread, so the true numbers are grossly underestimated. Our tertiary care centers in the surrounding states are filling up fast - likely reaching capacity by next week - and we will have to keep these incredibly sick patients at our facilities on the Rez, without enough critical care nurses or PPE. We have smart doctors here and we are actively surge planning: designing respiratory care units in existing spaces and purchasing more ventilators (that are on back order), but it’s just not going to be enough.
I want to share why the Navajo Nation, especially this small community of Chilchenbito, is so incredibly vulnerable to this virus (and pretty much every communicable disease in existence):
The Navajo (Dine) people suffer from high rates of obesity, diabetes, hypertension, lung disease, and autoimmune conditions (to name a few), but this is only a small part of the story here.
Poverty - It’s hard to practice proper hand hygiene when there is no running water. Many have to haul water, but as the more physically mobile members of the family get sick, they are no longer able to do so. And many do not have the income to purchase soap, hand sanitizer, or even food... especially when they have to drive an hour to the closest store (if they have the money for gas) only to find that things are out of stock. USPS does not deliver to homes on the Rez, and many homes do not have a physical address where items can be delivered by even UPS or FedEx.
Overcrowding - When there are multiple generations, and perhaps multiple families, living in one small household, it’s hard to isolate those that are sick from those that are well. Entire households are falling ill.
Limitations of sheltering in place - related to overcrowding, if an entire household is sheltering in a small place, and unable to isolate those that are sick, and do not have the resources for proper hand hygiene and disinfection, it is easy for the virus to spread to everyone in the house. Additionally, it is difficult for these families to obtain things like groceries and other goods when they don’t have anyone that can safely leave the house...
Numbers - There are over 160,000 living on the Nation. There are only 28 ventilators on the entire Reservation. We need at least double this amount if the models/projections for this disease are correct. And that doesn’t take into account the number of medical professionals needed to take care of these critically ill patients: doctors and nurses that are continually getting exposed to the virus and being quarantined because they do not have enough personal protective equipment (PPE)
Access to information - When much of this community is comprised of elders that speak their traditional language and do not have a smartphone or social media, it is hard to disseminate information quickly to stay up to date... many households do not have land lines or television or even electricity. And when this information isn’t disseminated widely and effectively, many traditional gatherings and ceremonies,
including funerals, continue to take place and spreading occurs.
Protection for healthcare workers - When the nearby health centers do not have enough PPE to safely see patients presenting to the hospital, let alone to perform vital home visits for assessments and face-to-face education, everyone is put at risk. The EMTs responding to 911 calls are also put at tremendous risk!
We are trying our best out here, but it is so incredibly difficult.
Please be mindful of the challenges we face.
But also be aware of the grassroots efforts by the local health centers, the Johns Hopkins Center for American Indian Health, and the Navajo Nation to obtain and allocate resources (including food, water, soap, disinfectants, educational materials, etc) and to provide the best care possible.
That being said, the Navajo Nation government and Indian Health Service Area office doesn’t have the infrastructure or organization to handle what is happening (and what is about to happen) at this kind of scale. We need additional help, perhaps from the National Guard, public health service, or other organizations. We need more critical care nurses, more PPE and other supplies. Sure, there have been funds from the stimulus package slated for the IHS and tribe, but this will take precious time to actually reach this area... and will likely get here after the worst has already occurred. Plus, the money is not worth a whole lot when vendors are out of stock and we can't find nurses to pay.
Thank you for reading.
Sincerely,
Nina Mayer Ritchie, M.D.
MedPeds physician