Last summer, the Navajo Nation had the highest per capita COVID-19 infection rate in the country.
The nation’s largest Native American reservation reported 2,304 cases per 100,000 people in mid-May, compared to the U.S. average in mid-May of 8 per 100,000.
On Nov. 21, Navajo Nation daily cases peaked at 401 — over 1.5 times the number of cases on the worst day of May.
But on March 22, the reservation had good news. There were no deaths or even new cases to report.
Tribal communities have been quick to vaccinate their populations. That, along with other evidence-backed strategies, were key factors in changing the trajectory for a group that has suffered disproportionately from the coronavirus.
“Navajo Nation tribal leadership took this disease seriously from the beginning. They know their history and the devastating toll that infectious diseases have had,” said Laura Hammitt, a Johns Hopkins Bloomberg School of Public Health associate professor and the director of the infectious disease prevention program at the Center for American Indian Health. “All of these mitigation measures helped slow the spread of the virus and the efficient rollout of vaccines has accelerated the decline in disease.”
The COVID-19 pandemic has further highlighted harsh health disparities experienced by American Indian and Alaska Native populations. This group has the highest death and hospitalization rates from the virus, Centers for Disease Control and Prevention data shows.
Structural issues the Indian Health Service has faced over the years and limited access to resources exacerbated the disparities.
Major progress came through the distribution of vaccines.
“It was critical that tribes with the supporting health care organizations were recognized as unique jurisdictions for vaccine distribution,” said Valerie Nurr’araaluk Davidson, interim president of the Alaska Native Tribal Health Consortium and an enrolled tribal member of the Orutsararmiut Native Council. “In Alaska, this meant that we received all of our monthly allocations at one time, not weekly, as was common throughout the rest of the United States.”
Loretta Christensen, IHS Navajo Area chief medical officer, said in late March that the tribe’s immediate goal was to get 80 percent of the adult population vaccinated. At the time, 50 percent of the eligible population had received both doses. She anticipated reaching the goal by April’s end.
Meanwhile, fewer than 29 percent of all U.S. adults were fully vaccinated as of April 13.
Abigail Echo-Hawk, Seattle Indian Health Board executive vice president and an enrolled member of the Pawnee Nation of Oklahoma, testified in March that her organization created the first national survey on vaccine acceptance among American Indians and Alaska Natives.
“What we found is that 75 percent of Native people were willing and wanted to take the vaccine, and their main reason for doing that was they saw themselves as an individual who had a responsibility to our community. And that is a core public health practice,” she told the Senate Health, Education, Labor and Pensions Committee.
That level of acceptance paid off. As of April 5, IHS reports that over 1 million doses have been administered.
The seven-day rolling average COVID-19 test positivity rate was 3.5 percent, below the often-recommended goal of 5 percent of tests, as of April 14. The national positivity rate per the Johns Hopkins Coronavirus Resource Center was 5.2 percent.
“Lots of local sites have been able to expand access to vaccination to those that have close social and economic ties with our tribal communities. This is an important part of our effort to achieve community immunity,” said Matthew Clark, safety and monitoring team lead for the IHS COVID-19 Vaccine Task Force.
Tribal communities' needs
Arnav Shah, a Commonwealth Fund policy and research department research associate, pointed to the prevalence of crowded, intergenerational housing; understaffed hospitals; and higher rates of lower respiratory disease as drivers of the COVID-19 disparity between American Indians and the rest of the country.
“The underfunding of the Indian Health Service made things really difficult for this group,” said Shah, who co-authored a report on these inequities last year.
A December 2018 Government Accountability Office analysis found that IHS spent $4,078 per tribal member compared to the $10,692 per patient spent by the Department of Veterans Affairs, $8,109 per Medicaid beneficiary and $13,185 per Medicare consumer.
The federal government, for its part, poured additional resources into addressing these disparities during the pandemic. The recent COVID-19 relief law (PL 117-2) appropriated $6 billion for IHS, with $600 million pegged for vaccine distribution.
The Choctaw Nation’s Director of Pharmacy Clinton Bullock said the tribe benefited from the steady supply of vaccines and supplies and the aid of Federal Emergency Management Agency workers.
The Bureau of Indian Affairs recognizes 574 tribes nationwide, and there is no uniform tribal experience. Specific mitigation strategies vary by region and tribe.
Melanie Nadeau, University of North Dakota assistant director for the public health program and a member of the Turtle Mountain Band of Chippewa Indians, said national data can be deceptive, as access and resources vary for different tribes. Some may be hundreds of miles from an IHS facility.
She leads a popular Facebook group that disperses information about local resources. Social media is a popular way for tribes to showcase local leaders expressing confidence in vaccines.
Nadeau said even before the pandemic, communities like hers had high vaccination rates and that contributed to the uptake of COVID-19 vaccines.
“There's a lot of mindfulness around prevention because obviously we don't have the dollars to address poor health outcomes,” Nadeau said.
Michael Toedt, IHS chief medical officer, told the Senate Indian Affairs Committee on April 14 that respecting tribal sovereignty has been crucial.
He said IHS moved from a system of allocating vaccines to tribes on a regional basis to asking tribes to order how much they expect to need.
“We have been able to fulfill all of their requests from facilities since switching to this system," he said.
Toedt said the new goal for April is not based on the number of vaccinations administered, but the percentage of fully vaccinated adults.
Their goal is 44 percent as a minimum. Some communities already surpass that.
Davidson said in Alaska, one of the most successful states at distributing the vaccine, allowing people to make local decisions was essential.
“Alaska Native people are incredibly resilient and innovative,” said Davidson. “Perhaps, with increased attention and allocation to respond to COVID-19 through testing and vaccinations, we will see the benefit of recognizing that we needed to disproportionately invest in the health of Alaska Native people.”
Some sense a change in mood in the population.
“I feel like there’s starting to be more hope now that the vaccine is starting to roll out that we're going to get through this and it's going to be over once we reach that point of herd immunity. That being said, our leadership is still promoting all the precautions,” said Bullock.
Widespread vaccination isn’t the only strategy responsible for decreased caseload. The most successful approaches follow a multi-faceted plan including mask mandates and broad testing.
“Once vaccine coverage is high enough, it should be possible to relax some of these other measures but for now, they remain critical to control efforts,” said Hammitt. “Communities that rely solely on vaccines, without continuing other public health mitigation efforts, will likely continue to see spread of the virus.”
Some tribes have restrictions, such as strict curfews, long after most states have begun easing restrictions.
The Hopi Tribe lifted its reservation-wide nighttime curfew at the end of March. Navajo Nation’s nightly stay-at-home order and curfew is still in effect from 10 p.m. to 5 a.m.
“We are experiencing a number of communities that are having some hesitancy with opening up and potentially increasing the risk to their communities,” said Julianna Reece, chief medical officer for IHS Albuquerque Area. “Those are all going to be very local decisions based on their tribal dynamics and the communities at risk.”
The situation continues to change.
On April 6, Navajo Nation reported its first case of the B.1.429 variant, which experts worry is more lethal and transmissible.
Findings in the April New England Journal of Medicine suggest vaccination is effective against the variant.
“I do think that there is hope right now and that hope is heavily dependent on our public health measures including an effective vaccination campaign,” said Clark.