Those who cannot remember the past are condemned to repeat it – at least, according to philosopher George Santayana. Most of us simply shorten that to say that history repeats itself. But is it true when it comes to healthcare? A look at Native American history suggests it is.
During the 1918 flu pandemic, the global fatality rate ranged from 2.5 percent to 5 percent. For Navajo Nation, though, the fatality rate hit a whopping 12%. If that sounds familiar, it’s because a century later, Native American reservations again suffered through catastrophically high Covid-19 infection and fatality rates, compared to the rest of the United States. The Navajo Nation had a higher Covid-19 death rate than any U.S. state. A CDC study found American Indian and Alaskan Native people were 3.5 times more likely to be diagnosed with the coronavirus than White people and 4 times as likely to be hospitalized. And while 35 percent of Native Americans who died from Covid-19 were under 60, that has held true for only 6% of White Americans.
Why did we see the same pandemic pattern play out twice? And more importantly, what can we do to stop the next healthcare crisis in Indian Country?
The answer to the first question is simple: a bridge of economic, cultural, and medical barriers connects both pandemics. The answer to the second question involves their demolition – but that’s more complicated.
Tribal facilities are notoriously underfunded. A U.S. Commission on Civil Rights report revealed the United States allocated an average expenditure of $9,207 per capita for healthcare in 2017 but allocated only $3,332 per capita for Indian Health Service. Yes, that was four years ago – but the first $2.2 trillion Covid-19 stimulus package of March 2020 was unevenly distributed as well. Stimulus funding covered $6,703 per person throughout the U.S. but covered only $4,552 per person on the Navajo Nation Reservation.
This underfunding translates to a paucity of medical resources, which can limit access to care and Covid-19 testing and treatment. While tribal communities typically try to close these funding gaps through casino profits and other business revenue, pandemic closures made that difficult.
While mainstream media tend to depict Native Americans as a homogenous group, there are 326 Native American reservations in the United States, and 574 recognized Native Nations. Dialects and languages can differ between communities. Limited internet coverage also can also make it difficult for tribal residents to access websites, social media, and other digital information. These factors presented a challenge for Covid-19 public health campaigns, many of which failed to reach their intended audience.
Sanitation issues also played a role in helping communicable disease spread faster. In some tribal communities, up to 35% of households live without indoor plumbing, making handwashing difficult. Crowded residences, which might contain as many as 15 or more family members, made it easy for one person to infect others.
Dr. Vikar Shankar, who’s practiced medicine in sub-Saharan Africa in the Peace Corps and in New York City ICU units during the height of the Covid-19 pandemic, said nothing in his previous experience came close to the poverty he observed in Tribal communities. “I was shocked to see the devastating impact it had on our Covid cases,” he said. “At one point it seemed as if everyone setting foot in our emergency department was infected.”
Finally, Indigenous Americans’ past experiences of unethical medical practices at the hands of the U.S. government has fostered plenty of distrust toward traditional healthcare programs. Initial reports of vaccine trials were met with skepticism – but eventually, community elders’ involvement and advocacy encouraged high participation in tribal vaccine programs.
Indian Health Service (IHS) clinics have an average provider vacancy rate of 25 percent – and an estimated annual 46 percent turnover for their physicians. Likely this is because more than half of American Indians reside in rural areas, where provider shortages are most dire. These shortages can force locals to travel hours for care or skip services altogether. Even if they do receive treatment at a distant clinic, they’re unlikely to develop a consistent relationship with a physician who understands their long-term health patterns.
Finally, the high prevalence of chronic disease rates in tribal communities intensified the disastrous effects of Covid-19. 1 in 4 Native Americans is food insecure, something that drives high rates of diabetes, hypertension, chronic respiratory conditions, and heart disease in Indigenous communities – making them especially vulnerable to the virus.
Building Healthcare Resilience in Tribal Communities
Dismantling the above barriers won’t happen overnight, but tribal healthcare leaders are leading the charge. Some strategies include:
- Enriching the Indigenous talent pipeline. Native Americans comprise just .04% of physicians, which means Native youth rarely see Indigenous clinicians and may not consider pursuing a career in medicine. Increasing clinician diversity can go far in building trust in healthcare providers.
- Culturally informed care. Cultural competency training helps providers understand community values and nuances. For instance, while medical students are taught to make eye contact with patients, looking an Apache elder in the eye can be a sign of disrespect. Traditional Indigenous therapies can also help foster stronger patient engagement.
- Staffing agility. The current staffing challenges in tribal areas won’t be solved overnight, but locum tenens staffing and telehealth can augment existing coverage. Onsite clinical training can help local providers learn new care delivery methods, building community confidence in their local resources.
- Behavioral health resources. Native Americans have one of the highest rates of deaths from alcohol poisoning and fetal alcohol spectrum disorders in the U.S – and the suicide rate for American Indians has risen 139% since 1999. Integrating primary, emergency, and behavioral expertise with the provision of wraparound support is critical to creating healthier Native communities and economies.
- Stronger representation in clinical research. Moderna and Pfizer vaccine trials had a disproportionately low percentage of Native American participants, according to Food and Drug Administration fact sheets – 0.8 percent and 0.6 percent, respectively, where the Native American population is 1.7%. Improving research diversity can improve not only clinical outcomes but strengthen community trust in new treatments.
The Covid-19 pandemic isn’t quite over yet, which means there’s no better time to implement transformative healthcare strategies in Indigenous communities. Another pandemic is almost inevitable at some point – but the disproportionate impact on Indigenous people can be a thing of the past.
Photo: grandriver, Getty Images