News of how COVID-19 has struck the Navajo Nation has begun to penetrate national coverage of the pandemic. The first cases were believed to have spread at a church rally. Now, the coronavirus has overtaken the Nation, causing nearly 2500 cases and over 70 deaths, and continuing to wreak havoc in a region where running water and electricity are luxuries.
But the Navajo are not alone, of course.
Native American communities, often invisible or oversimplified in terms of their health inequities, are the most at risk in the U.S. for severe disease and higher death rates from COVID-19. The factors are complex: A history of higher infection rates from respiratory illness; a higher prevalence of underlying conditions, such as diabetes and heart disease; crowded living conditions that make physical distancing impossible; and for the 2.2 million Native Americans living on rural reservations, access to hospitals — which are under resourced — is limited. These hospitals serve populations of 15-20,000 in geographies that span the size of Delaware.
The meaning of the novel virus is different for Native Americans. Within their “recent” history since the arrival of the first European conquistadors, they have experienced waves of decimation from “novel viruses,” some systematically used by the colonists as germ warfare to wipe out their peoples.
In the late nineteenth and early twentieth centuries, when federal treaties were signed with the Native American peoples in exchange for enormous tracts of lands, Native Americans were promised federally supported free health care and education in perpetuity. In 1955, this responsibility was transferred from the Department of Interior to the newly minted Indian Health Service (IHS). Yet, never did our federal government adequately fund this new health care organization, a breach of trust and respect for the original North Americans.
One only needs to consider that the IHS average per capita spending per user today is $3,333 compared to $12,744 for Medicare and $9,404 for veterans medical spending. The IHS and Tribes have received significant federal funding to respond to the COVID-19 pandemic, but the challenge now is to be able to spend it on what is needed, given the global shortages in supply of health care equipment and personnel.
After a decade of work on infectious diseases with southwestern tribal communities, in 1991 we signed an MOU with Indian Health Service to leverage our joint resources to promote tribal health and health autonomy. During COVID-19, we have seen IHS staff — doctors, nurses and community health workers — put themselves and their families at personal risk, lacking personal protective equipment (PPE) and other critical needs much like many parts of the world.
In the communities where we have worked, we see the tribal sovereignty of Native peoples affords them a unique capacity to mount their own containment and mitigation strategies. In some places, tribal leaders issued strict ordinances to community members to shelter in place, even before the first cases were confirmed or local states made such declarations, and established unified command systems with IHS partners.
What is happening in Navajo Nation — with a rapid surge in COVID-19 cases and a considerable amount of household transmission — is what can be expected to happen in other communities heavily impacted by poverty. And the community mitigation strategies that the Navajo developed will have relevance in other settings. For example, in the hardest hit areas on Navajo Nation, local command posts have been established and staffed with strike teams that can deliver essential items — food, medication, wood for heating and cooking, hay for livestock — so that COVID-19 affected households don’t have to send people into the community for these items.
Further, due to the scarcity of available PPE, there has been swift mobilization for local citizens to sew urgently needed masks and gowns. Imagine, once we get to the other side of this public health emergency, these industries may remain and provide new sources of economic development for tribal communities.
The frugal innovations that will come from Indian Country during this pandemic will afford essential lessons for the world and it won’t be the first time. Three of the eight vaccines that all U.S. children receive in the first year of life were proven effective with Native American communities. Pedialyte, the standard of care for children to prevent deaths from dehydration during bouts of infectious vomiting or diarrhea, was based on proof of concept with the White Mountain Apache Tribe.
Yet, without additional and sustained resources for Native American health now and in perpetuity, as promised by our federal government, the First Peoples of this continent will continue to suffer the greatest health inequities in the U.S. COVID-19 will be no exception. What Tribal communities achieve in the absence of adequate resources will represent one of the most valiant battles in our country’s war against COVID-19. Together we are stronger.
Allison Barlow, Ph.D, is the director of the Johns Hopkins Center for American Indian Health and senior scientist of International Health at the Johns Hopkins Bloomberg School of Public Health. Laura Hammitt, M.D., is the director of Infectious Disease Programs at the Johns Hopkins Center for American Indian Health and associate professor of International Health at the Johns Hopkins Bloomberg School of Public Health.