The uncertainty of how the COVID-19 pandemic will affect the world we live in is growing day by day. Many Americans are grappling with fear of losing friends and loved ones coupled with lost wages, and the broader economic impact this pandemic will have. While we will all feel the impact of this novel virus, it will have a disproportionate effect on already vulnerable populations, especially Native American communities. The impact of COVID-19 will magnify the ever-growing health disparities American Indians face as tribal communities struggle to maintain an already fragile health care system with inadequate support and funding.

There was tremendous foresight long ago by tribal leaders and elders as they elected to take part in the first pre-paid health care service under the federal trust responsibility, to ensure the survival and welfare of their people. This health care system is largely run under the Indian Health Service (IHS), which has historically been underfunded and understaffed by medical providers, making it difficult to provide high-quality, safe and culturally competent care.^1,3 While many tribes have opted to run and manage their own health care systems, they are still funded by IHS.

While we have seen that severe complications of COVID-19 can affect anyone, elders, and those with existing health conditions and compromised immune systems, are at increased risk. American Indians have higher rates of heart and lung disease compared with the national average, and higher rates of conditions that compromise the immune system including chronic hepatitis C and HIV infections.  Additionally, type 2 diabetes mellitus is rampant with rates that are three times the national average.² Further exacerbating the risk American Indians suffer are housing shortages with nearly one-third of homes on reservations considered overcrowded,⁴ making social distancing almost impossible and a nidus for infection. The CDC recommendations for isolation of a sick family member are impossible to follow for families without extra rooms to place the sick and medically fragile.  

Across the country, health care providers have begun sounding the alarm about the lack of availability of personal protective equipment (PPE) and adequate testing resources. In Oregon, a case of confirmed COVID-19 was found on tribal lands with no known exposure, indicating community spread. Despite confirmation of this early case, and the exposures of a number of community members, federal emergency funds were not released to IHS clinics for 20 days.⁵ The funding comes at a much-needed time for these communities, but the time taken to act exacerbates an already uphill battle.

This is not the first time a new disease has threatened to devastate Indigenous Nations, and it appears that history is on the verge of repeating itself.  There is a tradition of reconstructing life ways and putting individualism to the side for the good and well-being of the collective. This wisdom is passed down as the basis for social distancing where we place our selfish desires aside for the good of the community. We must take our social responsibility seriously to protect ourselves, to protect our loved ones, to protect our vulnerable populations and to protect our elders. And while we, like the rest of the U.S., are still grappling with uncertainty, the one thing we are certain of is that when push comes to shove, American Indians are here to stay as we are strong, resilient … Indigenous.

Andrew Steinfeldt, M.D., is a second-year pediatric resident at OHSU Doernbecher Children’s Hospital and a member of the Oneida Nation of Wisconsin. Allison Empey, M.D., is an associate professor of medicine (pediatrics) at the OHSU School of Medicine, the deputy director of the OHSU Northwest Native American Center of Excellence, and a member of the Confederated Tribes of Grand Ronde.

References:

1. Galewitz, P. (2017, July 13). Senate worried about Indian Health Service's Underfunding with Trump's Budget. Retrieved March 23, 2020, from Healthcare Finance News.
2. Indian Health Service. (2019, Oct. 1). Indian Health Disparities. Retrieved March 23, 2020, from Indian Health Service.
3. Kerry J. Cromer, Linda Wofford & David K. Wyant (2019) Barriers to Healthcare Access Facing American Indian and Alaska Natives in Rural America, Journal of Community Health Nursing,36:4, 165-187, DOI: 10.1080/07370016.2019.1665320
4. National Congress of American Indians. (2020, March 23). Housing and Infrastructure. Retrieved March 23, 2020, from National Congress of American Indians.
5. Orr, D. (2020, March 2). Oregon Health Officials Confirm 3rd Presumed Coronavirus Case. Retrieved March 21, 2020, from Oregon Public Broadcasting.