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The Lancet Infectious Diseases

Limited resources, lack of data, and years of neglect and discrimination are worsening the impact of COVID-19 on American Indians and Alaska Natives. Talha Burki reports. Historically, pandemics tend to be particularly hard on American Indians and Alaska Natives. Their mortality rate from the 2009 H1n1 influenza was four times higher than the general population. Alaska Natives represented 80% of the state's death toll from the 1918 Spanish flu. COVID-19 has continued the trend. From January to June 2020, American Indians and Alaska Natives were 3·5 times more likely to be diagnosed with the disease than non-Hispanic whites and their mortality rate was almost twice as high, according to the US Centers for Disease Control and Prevention (CDC). The Color of Coronavirus project estimates that the 4 weeks to Feb 2, 2021, saw 958 deaths among Indigenous Americans, making it the deadliest stretch of the pandemic for them so far. Casinos and tribal businesses have been forced to close, depriving communities of desperately needed income. The pandemic has killed scores of elders, custodians of the languages, history, and traditions of Native Americans. As of Feb 7, 2021, 181 576 cases of COVID-19 among American Indians and Alaska Natives have been reported to the Indian Health Service (IHS). But this is only part of the story. The IHS is mandated by the federal government to provide healthcare to Indigenous communities. It either does so directly, or by disbursing funds to the tribes to arrange their own clinics and hospitals. The various organisations that provide healthcare to American Indians and Alaska Natives do not consistently collect or submit data on outcomes for these populations. “The excessive absence of data among AI/AN [American Indian and Alaska Native] persons represents an important gap in public health data for AI/AN persons and suggests a need for additional resources to support case investigation and reporting infrastructure in AI/AN communities”, noted the CDC, in its analysis of COVID-19 cases among Native Americans. The US federal government recognises 574 tribes. Each one is distinct. The Navajo Nation, whose territory sprawls across three southwestern states, is a very different place from the Mohawk settlements in the northeast of the country. An estimated 5·6 million Americans have part or full American Indian or Alaska Native heritage. According to 2010 census data, 22% of American Indians and Alaska Natives live on reservations or other trust lands, and 70% live in urban areas. In short, there is no single Indigenous experience. But there are common factors that have left American Indians especially vulnerable to the ravages of pandemic disease. “There is a very long history of discrimination, and suboptimal healthcare which means that American Indians have started off at a greater risk of complications from COVID-19”, explains Dona Upson, professor of medicine in the pulmonary, critical care, and sleep department at the University of New Mexico Health Sciences Center (Albuquerque, NM, USA). “Severe social inequities exist in a lot of American Indian communities; people do not have basic resources”, adds Melissa Begay, associate professor in the same department. American Indians are more likely to live in so-called food deserts, a contributory factor to the community's high rates of diabetes, obesity, and heart disease. 23% of American Indian and Alaska Native adults are current smokers, compared with 14% of the general population. Chronic obstructive pulmonary disease is widespread. “It can be difficult to know how to address smoking, because tobacco use is sacred in many Native American populations”, notes Upson. “You have to find a way to distinguish between commercial tobacco consumption and that which is associated with ceremonial use. But it is not easy, and sometimes people shut down or get defensive when the subject is brought up”. Median household income is US $20 000 lower for American Indians than for non-Hispanic white households. Life expectancies are lower. American Indians are more likely to live in overcrowded and multi-generational households. In the Navajo Nation, the second biggest tribe in North America, there are 13 grocery stores and 12 medical facilities scattered across more 27 000 square miles of land. One in three inhabitants do not have access to electricity and one in three do not have access to running water. The tribe has an unemployment rate of 40%. Internet coverage is patchy, making it tricky to obtain information on COVID-19 or to manage virtual healthcare appointments. The IHS has an overall budget of $6 billion to take care of the health needs of around 2·5 million people. On a per capita basis, this represents far lower resources than that of Medicare, Medicaid, and the Veterans Health Administration (though not all American Indians rely exclusively on the IHS for their healthcare). The IHS has received an additional $2·4 billion to tackle COVID-19, but this cannot make up for years of serious underfunding. In the Navajo Nation, where Begay grew up, people often have to drive for hours to get to a healthcare facility. Even those who live relatively near a facility can struggle to access transport. “At the beginning of the pandemic, there were definitely delays in people getting diagnosed because of the difficulties in getting to hospital”, Begay told The Lancet Infectious Diseases. “It is also very possible that people died because of the lack of medical services”. The Navajo Nation does not have a tertiary intensive care unit. “We are talking about a region the size of West Virginia and yet if patients need high level services, they have to fly out to university hospitals”, said Begay. By the middle of last year, the Navajo Nation had a higher infection rate from SARS-CoV-2 than any single state in the USA. The tribe has taken strong action to tackle the pandemic, including a lockdown and weekend and evening curfews. “We have been very thankful for the leadership of the tribal governments”, said Michael Toedt, Chief Medical Officer of the IHS. The Wabanaki Public Health Department in Maine established an alert system for isolated elders. If they needed help, they would stick a red piece of paper in their window. A yellow paper signified that supplies were required, a blue paper meant they would welcome a friendly ear, and a green paper indicated everything was OK. Gallup, New Mexico, which has a sizeable American Indian population, has set up several “respiratory shelters” where people who may have been exposed to SARS-CoV-2 can safely isolate. The IHS is overseeing the distribution of the COVID-19 vaccines to roughly 2 million American Indians and Alaska Natives (the remaining population expect to obtain vaccines from the states). As The Lancet Infectious Diseases went to press, the agency had shipped 500 000 doses. Around 284 000 American Indians and Alaska Natives have received the first shot of the vaccine. “It is a huge logistical challenge” said Toedt. “Some of the places we need to get to are really remote; we have a clinic at the bottom of the Grand Canyon, we have another one above the Arctic circle”. A recent survey by the Urban Indian Health Institute found that 75% of respondents would be willing to take the COVID-19 vaccine. Nonetheless, the injustices of the past have resulted in some lingering distrust of the structures of healthcare and government. Begay is confident this can be overcome. “Native Americans have a lot of experience with devastating infectious diseases”, she said. “Our grandparents still talk about smallpox and tuberculosis, these diseases are very real to us. Now we can add COVID-19. People know that the one way to save ourselves and protect our culture is to get vaccinated. I think they will embrace the vaccine”.

COVID-19 among American Indians and Alaska Natives