番茄社区

This is the final story in a series by 番茄社区 examining the impact of COVID-19 on vulnerable populations. Past stories reported on the homeless, immigrants in detention, the undocumented, nursing home residents, incarcerated individuals, and African Americans.

Each weekday, Terrell Benally wakes up early to drive an hour to the nearest Walmart in Cortez, Colorado, 60 miles away from his home on the Navajo reservation in Utah, to pick up groceries for his community.

Benally, a Native American makeup artist, graduated from college last week, but delivering care packages for the he created is all he foresees himself doing until the COVID-19 coronavirus tearing through his community eases.

"It's a different world down here," Benally told 番茄社区. "When you hear that there is a new case in our county or on the Navajo reservation, there is a high probability that you know them personally."

As of May 20, there were reported in the Navajo Nation, the hardest hit reservation in the country, with a higher per capita rate of infection than any U.S. state. The Navajo Nation is one of more than 500 federally recognized tribes facing disproportionate rates of COVID-19 infection and death as a result of an insufficient Indian Health Service (IHS) budget, delays in federal relief funds, and social determinants of health that put American Indian and Alaska Natives (AI/AN) at an elevated risk.

'Setup for Disaster'

The Navajo reservation, which includes roughly 170,000 members in 11 counties across Utah, New Mexico, and Arizona, has seen twice as many cases as the entire state of West Virginia, despite having one-tenth its population, said Navajo Attorney General Doreen N. McPaul.

"We've had some really sad situations where COVID-19 has wiped out almost an entire family," McPaul told 番茄社区.

Health disparities afflicted American Indians long before COVID-19 breached tribal communities. IHS is chronically underfunded and understaffed, with a 25% provider vacancy rate across the country, and a 30% vacancy rate within the Navajo Nation as of 2018, according to a .

The IHS budget provides $4,078 per capita for healthcare spending -- less than half of what is spent for beneficiaries in the general population -- and covers just 16% of the estimated funding needed to fully fund all IHS federally operated, tribally operated, and urban Indian-operated facilities, according to a released April 30 by the Democratic Policy and Communications Committee (DPCC).

Tribes rely on federal services from the IHS, as well as Urban Indian Health Programs (UIHPs) and some independent tribally run health systems. Coordinating so many organizations amidst a pandemic is complicated when operating in a tri-state area like the Navajo Nation, or in the Northwest.

Although more than 70% of tribal citizens live off-reservation, just 1% of IHS funding goes to UIHPs, which provide direct services or referrals to tribal citizens living in urban areas, said Kerry Hawk Lessard, executive director of Native American LifeLines, which operates clinics in Boston and Baltimore.

"You start with the IHS that is already underfunded, and then the smallest portion of the budget goes to the majority of where people live," Lessard told 番茄社区. "That is a problem."

Because not all UIHPs provide direct clinical care, their COVID-19 testing capabilities are limited, Lessard said. As a result, she and colleagues have been directly calling all 770 active clients in their service area to ensure they know about COVID-19 risks, symptoms, and prevention, and to understand the rates of positive cases and mortality among a population they know is vulnerable, she added.

"We shouldn't have to be doing things this way," Lessard said. "The state epidemiological centers and tribal epicenters need to know these things."

The CDC did not report race/ethnicity data in weekly COVID-19 outcomes and in some areas, AI/AN can be classified as an "Other" race/ethnicity when a facility only records white, black, Asian, and Hispanic race.

"As a healthcare director, I can't rely on data from either of the states in which our program operates ... because that data is not being collected," Lessard said. "We aren't being represented, we are being 'othered' ... we can't even get a box to check and show up in data."

On reservations, the lack of federal funding has translated to an inadequate supply of personal protective equipment (PPE) and ventilators, a doctor on an Indian reservation anonymously told 番茄社区.

In the Navajo Nation, providers recently faced a 72-hour shortage of medical gowns, McPaul said. "With limited staff, we are seeing burnout, medical facilities at or exceeding surge capacity, and smaller clinics closing so staff at smaller clinics can relieve staff at the hospitals," she added.

Without adequate PPE, providers risk infection, and with IHS facilities already facing a staffing shortage, it did not take long for the system to become overwhelmed, the doctor on the reservation said. Many of the issues he and his colleagues are facing on the frontlines are similar to what is happening nationally, but in Indian Country, they are compounded by patients living in poverty and being isolated from healthcare centers, he said.

"Anytime you put a big stress on a system, it's going to expose its weak points -- think of it like a fishing net or a trampoline," he told 番茄社区. "Wherever there is a frayed strain, you are going to find out. It's just a setup for disaster."

Isolated From Resources

Native Americans are 10 times more likely than white Americans to live in areas with incomplete plumbing or kitchen facilities, which are critical in defending against COVID-19, according to the DPCC report. One in 4 receive some form of federal food assistance, and reservations are often located in food deserts, without access to fresh fruits and vegetables.

This puts AI/AN at an increased risk of some of the underlying conditions that have been linked to poorer COVID-19 outcomes. For example, AI/AN have compared to white individuals and are 50% more likely to be obese, per CDC data.

Moreover, it is common to live in multigenerational households on reservations, sometimes with up to five families in one building, rendering in-home self-quarantine, if necessary, virtually impossible, said Kyle Jim, a member of the Diné clan in the Navajo Nation, located in Shiprock, New Mexico.

"Families can't get resources, whether it's food or medical resources," Jim told 番茄社区. "Many people feel this emergency highlights our lifestyle here and that it will continue well after the emergency state has ended."

The Navajo Nation Health Command Center issued a stay-at-home order across the reservation on March 20, a few days after the first presumed case was identified in Chilchinbeto, Arizona. With COVID-19 rates continuing to accelerate within the reservation, the Navajo Nation implemented a curfew from 8 p.m. to 5 a.m. and an unprecedented 57-hour stay-at-home order over 5 weekends in April and May.

The Navajo Nation's sovereignty is clearly recognized by the surrounding states, which has given the reservation a unique capacity to mount its own containment and mitigation strategies, said Laura Hammitt, MD, the director of the Infectious Disease Prevention Program at the Center for American Indian Health.

"In areas where tribal sovereignty is not recognized or respected, that undermines the community's ability to respond in a way that optimally protects their people," Hammitt told 番茄社区.

In South Dakota, Gov. Kristi Noem if the Cheyenne River Sioux and the Oglala Sioux Tribes did not remove checkpoints they established along the reservation's border to prevent the virus from spreading on tribal lands.

In Michigan, where hundreds of people have many are flocking to their remote cabins upstate, near a reservation on the upper Michigan peninsula, said Aaron Payment, a tribal chairperson for the Sault Ste. Marie Tribe of Chippewa Indians.

"Because we aren't seeing a large number of cases in the upper Michigan peninsula, people are thinking we're safe up here," Payment told 番茄社区. "One proxy statistic is [the ratio of] deaths to cases, and that rate is about 15% for us and 9% for the state."

The Federal Emergency Management Agency (FEMA) set up two alternate care sites in Shiprock and Chinle in the Navajo Nation, and the national guard is delivering donated resources for distribution as well, McPaul said. Doctors Without Borders even sent a relief team to the Navajo Nation in a rare mission within the U.S.

Many local organizations and individual citizens have begun collecting and distributing food and supplies to families on the Navajo reservation to meet the overwhelming demand, especially to single parent households, or homes with exposed or elderly individuals who are home-bound.

Jim works with a team of about 50 other staff members and volunteers at the to serve more than 500 families in rural areas. In Shiprock, where he is located, there is one grocery store, which more than a dozen adjacent Navajo communities rely on, he said.

'We Get the Leftovers'

Tribes were ineligible for the CDC's Public Health Emergency Preparedness (PHEP) program and did not receive planning resources to increase capacity and public health response before COVID-19 began to take a hold of reservations, according to the DPCC report.

The CARES Act allocated $8 billion dollars towards COVID-19 relief efforts among tribal governments. In a meeting with President Donald Trump in the first week of May, Governor Stephen Roe Lewis of the Gila River Indian Community in Arizona said that amount was "woefully inadequate" to meet tribal needs and stressed the importance of capping the federal funding that any one tribe receives.

"We need to spread the limited resources currently available as far as we can, and to avoid allocating to a very few tribes and under-allocating to most others," he said at the meeting.

Regardless, the CARES Act funds were held up more than one month as a result of a legal dispute among tribes. On April 21, the Navajo Nation joined more than a dozen tribes in for failing to provide the $8 billion they were promised and alleging for-profit Alaska Native corporations, which were included in the stimulus package, were ineligible for federal payments.

Although litigation is still pending, a judge ruled in favor of tribal governments in early May, after which the Treasury released 60% of funds to tribal governments in the continental U.S., including $600 million to the Navajo Nation, McPaul said.

Trump also said he would provide Abbott ID Now tests to tribal nations, although this device was recently shown to .

Hammitt is working with Navajo leadership to improve testing and train about 100 contact tracers on the reservation. Currently, the Navajo Nation is testing close to 12% of its population, she said, which is higher than most parts of the country. Inadequate testing may be a but having enough contact tracers and supply kits is particularly critical in harder hit areas, Hammitt said.

On-reservation IHS hospitals have in-house testing capacity, which allows for a more streamlined process for isolating and tracing cases. However, positive cases are also reported voluntarily through UIHPs and other tribal programs, so the process is not uniform.

"We have to identify and isolate cases," Hammitt said. "The challenge we've had in the Navajo and other native communities is a lack of sufficient testing supplies and an unpredictability in that supply chain that makes it very difficult for the Navajo Nation or IHS to implement a consistent testing strategy."

Because UIHPs are not tribes, they cannot exercise sovereignty and do not have the same relationships with federal or state governments to advocate for PPE, testing, or other national strategic stockpiles, Lessard, of Native American Lifelines, said. In some cases, UIHPs have received PPE that was past the shelf-date or made direct purchases from third parties, she said.

One urban health program, the Seattle Indian Health Board, reported that was accidentally sent by the local public health department when they asked for medical supplies and PPE.

"What that tells me from a higher level is that in our own homelands, native people are still an afterthought," Lessard said. "We get the leftovers."

The Navajo reservation had issued 20,266 tests as of May 19 and reported a positive case rate of about 22%. In contrast, tribes in the surrounding Albuquerque area and the Portland area, which provides services for about 150,000 residents, both have a positive case rate of about 8%, per .

Tribes are finding new ways to honor the dead and protect their elders, who hold the tribe's sacred knowledge, McPaul said. Isolation is not a part of Navajo culture, and members are raised not only to take care of their immediate families, but their neighbors and extended families as well.

Benally's great aunt contracted COVID-19 last week, and had to be airlifted to a hospital in Salt Lake City to receive urgent care. Because family members are not able to visit, Terrell is shifting his energies towards his deliveries, to care for his community with his younger brother and sister.

"We are the first people of this nation ... and it feels like we are not even a part of this country at times," Benally said. "It frustrates me that it took this virus to have the rest of the people in this country notice we still exist."

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