Overview of Indian Health Provisions

Originally published by Casey Kuhn on PBS.

Like many other communities of color, Indigenous people across America have been disproportionately affected by the coronavirus because of historical health disparities, lack of basic resources in some parts of the country and poorly funded Indigenous health care.

Navajo Nation, the largest American tribe with more than 300,000 members, has been devastated by loss. As of February 21, at least 1,144 Navajo people have died from the virus. Centers for Disease Control race data from December in 14 states show COVID-19 mortality among American Indians/Alaska natives was 1.8 times higher than white people. In another study of data from 23 states last summer, American Indians/Alaska Natives tested positive for COVID-19 three and a half times the rate white people tested positive.

As COVID-19 began ripping through Reva Stewart’s Navajo Nation community, she started localized community help through an Indigneous store in Phoenix, delivering and making hundreds of care boxes. And then her worst fear came true.

After months of being careful, Stewart’s daughter, Raven, started feeling sick with COVID-19 symptoms over the summer.

“She’s 24, has asthma, low iron levels, and underlying issues, and I was so scared,” Stewart said.

Raven was the third person in Stewart’s Phoenix-based family who became infected with the coronavirus in June. Stewart moved from the Navajo reservation to Phoenix decades ago to pursue her schooling to work in health care. She tries to go back on the reservation on occasion to help her extended family.

“I’ve lost two aunties, three uncles and a couple of cousins,” Stewart said. “It’s sad because you can’t go to the funeral service. I can’t get up and travel to be with family.”

As COVID-19 has swept through Navajo lands, the tribal government enforces lockdowns and curfews, sometimes for weeks at a time. These measures are meant to stop the spread of the virus in a place where most of its residents have to drive long distances for their jobs, to haul water and to get groceries. The checkpoints set up by Navajo police also discouraged outside visitors to come into the area in an effort to contain COVID-19.

But according to census data, more than three quarters of the country’s Indigenous people don’t live on designated tribal lands. More than half of all American Indians live in cities. According to the Indian Health Service, at least 6,766 Indigenous people in urban areas tested positive for COVID-19 from the beginning of the pandemic in March 2020 to mid-February.

The Phoenix metropolitan area has the third-highest American Indian population in the country, after New York City and Los Angeles. Indigenous people also make up about 4 percent of the COVID-19 cases in Phoenix metro. The data also show that cases and hospitalizations rates for Indigenous people are double the total population in Maricopa County which encompasses Phoenix, one of the largest counties in the country.

When Stewart’s older daughter, Michelle, had symptoms that quickly deteriorated to the point where she felt like she couldn’t breathe and called 911, she was taken to a Phoenix hospital. The hospital found she had a 104 degree temperature and low oxygen levels, but released her from the emergency room after an hour of treatment.

“She said the security guard said she couldn’t wait in the front and had to get off the campus because she was COVID-19 positive, and had to wait down the street away from the hospital in the [100-degree] heat,” Stewart said. A hospital spokeswoman told PBS NewsHour it’s their policy to keep COVID-19 patients in the emergency room until their ride arrives.

Stewart was furious and terrified, as her two daughters and their father were now sick at the same time.

“I started to hyperventilate,” she said. “I put plastic everywhere, doubled up my mask, picked her up and didn’t want to scare her, but I was scared too.”

By July, Stewart said she was grateful they were all doing better, despite some lingering symptoms. “It was really stressful and scary.”

For American Indians living in urban settings, like Stewart, the Indian Health Service offers health care through more than 40 nonprofit health programs, called Urban Indian Organization facilities or UIO. These are not directly funded through federal money, but rather through IHS grants. Stewart’s daughter was not taken to an IHS facility like the Phoenix Indian Medical Center, which frustrated Reva.

‘Urban Indians are invisible’

“In general… urban Indians are invisible. A lot of times our urban Indian organizations may be missed,” said Dr. Rose Weahkee, acting director of the Office of Urban Indian Health Programs. “They’re an integral part to the IHS system. They provide culturally appropriate, quality health care to our Indian patients and are a safety net for families living off the reservation who want to maintain ties to cultural traditions, which is important when addressing COVID-19.”

Weahkee, who is a member of the Navajo Nation, said about $103 million from CARES Act funding is going to help urban Indian centers, with about half of that money going to COVID-19 testing. She also said the IHS has done outreach with urban Indigenous people to understand their specific concerns better.

“One way we wanted to get those urban needs is have the Indian Health Service director hold biweekly calls with urban Indian center leaders so the IHS can help provide updates, clinical guidance and testing data,” she said. “It’s also an opportunity to hear from urban programs on what their priorities are and needs and concerns.”

One concern is underreported COVID-19 positivity rates. While IHS hospitals on tribal lands often have the knowledge and resources to keep more complete racial data, tribes and urban Indian centers are not required to share their COVID-19 testing data on the federal level. That can lead to gaps in racial health data.

Abigail Echo-Hawk, director of tribal epidemiology center Urban Indian Health Institute in Seattle, worries the COVID-19 positivity numbers in urban Indigenous communities do not tell the whole story.

“From the limited data that we do have, we are seeing a disproportionate impact… our community is seeing and having higher rates of positive COVID tests,” Echo-Hawk said. “But we know that is a gross underreport. If we had the real data, I think that that disparity would be much higher.”

Echo-Hawk, who is Pawnee, said the best data on Indigenous people is typically collected on the reservations and by Indian Health Service facilities. Non-tribal entities, like hospitals, cities and counties, don’t always follow the best data collection practices for identifying someone’s race, Echo-Hawk said. Data is especially vulnerable for mixed-race people, which is the case for many Indigenous people.

“When you go into a clinic waiting room or your family fills out forms for you, they may not even have the box that says ‘check this box to identify as American Indian or Alaska native,’” she said. “Another problem is that we find a lot of people may be uncomfortable asking somebody’s race and ethnicity. For American Indian/Alaska native people, we are one of the highest-growing groups of multi-race individuals. So there is no specific look, no specific skin color. We need to be asked the questions.”

The Urban Indian Health Institute recently released a report grading each state on its COVID-19 data collection when it comes to complete Indigenous records. The average was a D+. More than a dozen states failed the assessment, which took into account whether the state includes American Indian/Alaska Native as a population on its data dashboards