Overcoming Covid-19 disparities in American Indian and Alaska Native communities

Today, many US states and localities observe Indigenous People’s Day, to recognize the resilience and diversity of Indigenous peoples in the US. For Indigenous People’s Day, we’re sharing stories about the struggles and accomplishments of AIAN communities toward reducing health disparities during Covid-19.

A cultural book-burning”: The disparate impact of Covid-19

The Covid-19 pandemic has hit many American Indian tribes particularly hard. Overall, AIAN individuals are the most likely of any major racial or ethnic group to have been hospitalized or die from Covid-19; they are 3.5 times as likely to be hospitalized and 2.4 times as likely to die compared to whites.

When looking at rates adjusted by age and location, the differences get even more stark. According to a Brookings Institute report from earlier this year, the death rates for AIAN people age 45-54 in Arizona and New Mexico are comparable to those of white age 75-84. More than 5% of AIAN people over 85 in these states have died of Covid-19.

“American Indian people in Arizona and New Mexico are dying of COVID-19 at a rate similar to whites who are 30 years older than them.”

Brookings Institute report, February 2021

The speed and devastation with which Covid-19 hit many AIAN communities is a result of many factors rooted in structural racism: underfunded health care, systemic poverty, high rates of chronic health conditions, crowded housing, and lack of safe running water.

Delays in government aid early in the pandemic exacerbated the situation. For example, when public health researchers at the Seattle Indian Health Board asked the government for more protective equipment in Spring 2020, they received a box of body bags instead. “It was such a metaphor for how American Indians and Alaska Natives have been treated by the federal government,” said Abigail Echo-Hawk, the SIHB’s chief research officer, to The BMJ. “They’ll send us what they need to bury us, but not what is necessary to live.”

“We’re losing a historical record, encyclopedias. One day soon, there won’t be anybody to pass this knowledge down.”

Jason Salsman, a spokesman for the Muscogee Nation, The New York Times

The loss of elders has been devastating for many American Indian tribes, as these people held irreplaceable knowledge of language and tradition. In The New York Times, Jason Salsman, a spokesman for the Muscogee (Creek) Nation in eastern Oklahoma, compared the virus to “a cultural book-burning.” “We’re losing a historical record, encyclopedias. One day soon, there won’t be anybody to pass this knowledge down,” Salsman said.

“It protects the whole community”: Success in vaccination

In many AIAN tribes, the desire to preserve their culture and communities pushed leaders to fight hard against Covid-19 using the most powerful tool — vaccinations. As of mid-September, AIAN individuals the most vaccinated racial or ethnic group in the US: About 48% of American Indians and Alaska Natives were fully vaccinated, compared to 42% of Asians, 38% of white Americans, and 30% of African Americans. However, vaccination rates vary by location; in states where most AIAN individuals live in urban areas, disparities persist.

The success of vaccination programs in certain AIAN communities can be attributed to several factors: preparation in planning and logistics, being able to deliver vaccines independently, messaging from trusted community members, and the desire among community members to help one another.

Rather than deliver vaccines through their state, many tribes went through the Indian Health Service instead, and were able to control the rollout phases and eligibility criteria. This allowed communities to prioritize those with irreplaceable cultural and linguistic knowledge to get vaccinated early. Many tribes also offered vaccines to non-AIAN community members who lived in AIAN households or worked in tribal organizations or schools, which allowed their full community to be vaccinated faster. In the Diné (Navajo) Nation, they were able to vaccinate quickly with drive-through vaccine clinics across reservation communities.

“Every vaccine in the arm is one less person who is going to get sick, and that eventually protects the whole community,” said Dakotah Lane, a member and medical director of the Lummi Nation in Western Washington, in The BMJ.

Messaging was also key. In the Seattle area, Echo-Hawk and colleagues conducted a survey to find out the community members’ most common vaccine concerns and Covid-19 concerns. They found out that the speed of the vaccine development was a large concern, and that most respondents were most concerned with Covid-19’s impact on their community as a whole, rather than as an individual.

It’s not lost on AIAN leaders that America could use more focus on community health rather than individual freedoms. “As native people we recognize that the health of our families is the health of all the families we live and work with,” said Echo-Hawk in The BMJ. “This country needs to go back to public health values. They need to learn from Indians.”

“I have a moment of depression”: Ongoing obstacles to equity

Despite the success of vaccination programs in certain AIAN communities, there are still many obstacles to overcome. In Alaska, where cases have surged and hospitals are overwhelmed, Alaska Natives are especially struggling, despite their relatively high vaccination rate. Part of the problem is that Alaska Natives are more likely to live in rural parts of the state and don’t have easy access to critical care. As Alaska hospitals have become overrun, some have adopted “crisis standards” which ration lifesaving care; this policy could disproportionately harm Alaska Natives who are more likely to have chronic health conditions.

Transportation, misinformation, and lack of access to medical care are other obstacles that prevent more AIAN individuals from being vaccinated, according to recent data from the American Covid Vaccine Poll. Through this data, researchers find that messaging about the vaccine as a way to protect loved ones and community members, delivered by tribal leaders and Native health professionals, are promising strategies.

Having messages come from trusted leaders within the medical community is key, but unfortunately, the share of AIAN physicians in the US is embarrassingly low and has even shrunk over the past 20 years. Only 1% of the nation’s roughly 22,000 medical students in 2019 were AIAN, Stat News reports.

“Every time I see stark numbers like these, I have a moment of depression,” said Siobhan Wescott, an Alaskan Native physician and co-director of the Indians into Medicine program at the University of North Dakota, in STAT. Wescott urges medical schools to support AIAN students with mentoring, especially those who do not have family members in medicine and who may not know the “unwritten rules” of the system. These numbers “remind me how much work there is to do,” said Wescott.