Underfunded Native nations battle coronavirus outbreaks

Native American health systems are stretching to a breaking point under a growing number of coronavirus cases flooding into rural clinics and hospitals that are unprepared for the case load.

At least 3,600 cases of COVID-19 have been confirmed by the Indian Health System. The vast majority of those cases are in Navajo Nation, where more than 2,200 people are sick.

There were stretches in April during which the number of coronavirus cases per capita was growing as fast in the Navajo Nation as in New York City, the epicenter of the American outbreak.

“We’ve been hit very hard with COVID in the Navajo area,” said Loretta Christensen, the chief medical officer of the Navajo Area Indian Health Service. “Our emergency operations center is working 24 hours a day, seven days a week.” 

The Indian Health Service, a division of the federal Department of Health and Human Services, has opened three sites to handle coronavirus patients across Navajo land, one in Arizona and two in New Mexico. 

Michael Toedt, the chief medical officer of the Indian Health Service, said the agency was working to dramatically expand testing and that the federal government had already distributed $1 billion in COVID-related funding to tribal governments, appropriated through the first three rounds of relief legislation passed in the last six weeks.

The Navajo Nation isn’t the only tribe to suffer; IHS teams have confirmed more than one hundred COVID-19 cases through its Albuquerque, Nashville, Phoenix and Portland offices. In Wyoming, four members of the Northern Arapaho tribe have died of the disease, more than half the total number of coronavirus deaths in the state. Dozens of members of the Cherokee Nation and the Choctaw Nation in Oklahoma are sick, as are more than 30 members of the Mandan, Hidatsa and Arikara Nation in North Dakota. 

In Oregon, the virus claimed the life of Bobby Begay, the leader of a village in Yakama Naton.

Native Americans who live on tribal lands may be uniquely susceptible to suffering severe symptoms of COVID-19, experts said. Households on tribal lands are much more likely to include three or more generations of family members. Underlying conditions that exacerbate COVID-19 are more prevalent among Native populations; they are twice as likely to suffer from respiratory illness than non-Hispanic whites, and more likely to suffer from asthma, diabetes and COPD.

“We know from past pandemics, for example the 1918 flu pandemic and the 2009 H1N1 that Native American peoples have had more severe cases and more deaths, in some cases 4 to 5 times more deaths,” said Allison Barlow, director of the Johns Hopkins Center for American Indian Health.

Many Native nations are in remote rural areas where cell phone service is limited, complicating basic epidemiological practices like contact tracing. But their remoteness has also helped delay the arrival of the coronavirus, and several tribal governments have taken steps that are more proactive than local non-tribal governments. Tribes in Montana issued shelter-in-place orders before the state did. The Navajo Nation is under curfew.

But when the virus does infect someone, that person is far less likely to have access to quality health care. A century of neglect and underfunding of Native health systems is now showing consequences.

“They were promised in perpetuity federally funded health care, housing and education. And that was never funded to the level that was needed, so the level of funding per capita has been lower than every other group the government funds,” Barlow said. “The infrastructure is so crippled, and when that happens over generations, you see this intergenerational transmission of health disparities like diabetes and heart disease.”

Native hospitals and clinics are also plagued by a chronic staff shortage.  

“In our small hospital, the leadership and Incident Command are not faceless administrators. The people making the Covid policies are the same people donning PPE and taking care of patients,” Heather Kovich, a doctor at the Northern Navajo Medical Center in Shiprock, N.M., wrote in an editorial in the New England Journal of Medicine. 

The billion dollars that has already been allocated to Native governments is only a first step. The federal CARES Act included $8 billion in funding for Native nations, the largest amount ever appropriated by the federal government to tribal governments. Included in a $20 billion provision funding hospitals is another $400 million carved out for tribal hospitals, said. Rep. Tom Cole (R-Okla.), a senior House appropriator and a member of the Chickasaw Nation. 

“The problem of course is that this pandemic reinforces and exaggerates the already substantial existing health care and health outcomes disparities between Native Americans and the general population. Moreover the health care infrastructure for Native Americans in general and remote reservations in particular is underfunded and weak,” Cole said in an email. 

Still, some in Congress said they planned to push for more funding for tribal governments.

“Tribes are doing all they can to make sure that this outbreak won’t be utterly devastating for their communities, but the federal government needs to hold up its end of the deal and fulfill its obligations to Native communities,” said Sen. Tom Udall (D-N.M.), the top Democrat on the Senate Indian Affairs Committee. “It is clear that the CARES Act is only the first step as Tribes across the country are facing rapidly evolving and dangerous situations.” 

Some are concerned that even after Congress appropriated so much money to tribal governments, that money has been delayed in arriving. Native nations have been asked to file reams of paperwork to qualify for the money, a hoop through which state governments did not have to jump. 

“Tribes are now having to write applications to get this funding, and the applications are really complicated,” Barlow said. “When the funding was appropriated through Congress, it went directly to the states, to governors, and there wasn’t this extra added stress of having to write applications to get this funding.”

The money has been further delayed by legal wrangling. A group of tribes went to federal court last month to prevent Alaska Native corporations, which are for-profit entities, from accessing CARES Act money. On Friday, a number of Native American tribes sued the federal government in an effort to get the money flowing faster.

“Tribes are facing unacceptable delays from federal agencies in receiving lifesaving funding,” Udall said. “Tribes need these resources now, and Congress and the White House need to step up to do their part.”