NCUIH on PBS: Why Indigenous people in cities feel invisible as pandemic wears on

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

NCUIH in the News: Practical hurdles, cultural distrust in Native communities could hamper vaccine distribution

Meredith Raimondi, the director of communications at the National Council of Urban Indian Health, said the consequences could be dire: “A big concern is that you make the wrong decision, and you choose the state, or you choose IHS and then one of those doesn’t go according to plan and you have no vaccines. I mean, it’s a gamble at this point.”

Cold-chain and two-dose requirements for promising vaccine candidates pose serious challenges for Native American communities without reliable electricity or transportation.

On the Hopi Nation in northeastern Arizona, the remote nature of its communities and transportation obstacles present logistical challenges to the tribe’s pandemic response. Here, homes line the top of the village of Shungopavi, one of three villages on Hopi’s Second Mesa. Hopi Tribe

When Timothy Nuvangyaoma, chairman of the Hopi Tribe, heard there were two coronavirus vaccines that both showed promising data of more than 90 percent efficacy, he felt initial relief that soon transitioned to cautious skepticism.

That’s because the logistic and cultural challenges of delivering a Covid-19 vaccine with precise temperature requirements and two-dose administration to members of the Hopi Tribe are vast: Hopi often live in remote locations and only one-third of the population has reliable means of transportation, according to officials with knowledge of vaccine distribution planning. Hopi lands span more than 1.5 million acres and encompass parts of both Coconino and Navajo counties in northeastern Arizona.

Power supply is always a concern, brownouts are common, and generators are a luxury. The Hopi Health Care Center has to outsource much of its care.

Full coverage of the coronavirus outbreak

Meanwhile, the Pfizer vaccine requires transportation at minus 94 degrees Fahrenheit and must be ordered in units with a minimum of 1,000 doses. And while this week’s preliminary results from biotech company Moderna Inc. showed encouraging data that its candidate was 94.5 percent effective, that vaccine still requires long-term storage at sub-zero freezer temperatures, short-term storage in a refrigerator and a two-dose administration separated by multiple weeks.

Other options progressing through the pipeline aren’t as finicky; one of the Johnson & Johnson candidates, for example, has a one-dose regimen and is expected to remain stable at basic refrigerator temperatures for longer periods of time.

Added to the logistical challenges is the broader, long-simmering cultural mistrust of vaccines and clinical trials felt by tribal communities as a result of historical trauma, making their skepticism about the safety of vaccines more pronounced.

“There’s always that reluctance as a Native American,” Nuvangyaoma said. “I have to make sure that it’s going to be able to help. And I don’t want to get people’s hopes up.”

Chairman Timothy Nuvangyaoma.
Chairman Timothy Nuvangyaoma. Hopi Tribe

For Nuvangyaoma and leaders across other tribal nations, Covid-19 has been an extraordinary crisis.

The pandemic has highlighted long-standing structural inequities and health disparities for American Indians and Alaska Natives, many of which are rooted in the federal government’s chronic underfunding of tribal and urban health care systems, despite legal and treaty obligations to do so. According to the Centers for Disease Control and Prevention, the Covid-19 infection rate is 3.5 times higher for American Indians and Alaska Natives, who are also more likely to suffer hospitalization or mortality than non-Hispanic whites.

The collapse of tribal economies due to the virus, as well as problems and regulations around the distribution of emergency federal funds, stalled any potential recovery even more.

Amid America’s mismanaged response to the pandemic, few communities have borne the brunt quite like smaller tribal nations. For the Hopi, a people who have maintained a connectivity to their traditional ways of life and identity, the loss of even one member is amplified.

The virus “has taken elders who should have been able to pass this down to the younger generation,” Nuvangyaoma said of the tribe’s cultures and traditions. “It’s taken the younger generation who should be the ones that are picking up where we’re leaving off, to continue with our story.”

‘It’s a gamble at this point’

Throughout the pandemic, tribal leaders have faced rushed processes and deadlines to make consequential decisions involving vaccine readiness, such as whether to receive vaccine allocations through the state or the Indian Health Service. Some Urban Indian health clinics were told one day before the presidential election that they needed to make the choice by the end of that week.

Tribal leaders are making “life and death decisions within their tribal communities on the reservations and villages right now . . . so they may not always have the time to respond in a week,” said Abigail Echo-Hawk, a citizen of the Pawnee Nation of Oklahoma, director of the Urban Indian Health Institute and chief research officer for the Seattle Indian Health Board.

IMAGE: Oraibi village water well site
Chairman Timothy Nuvangyaoma and others on the site of the new water well system that will supply water to the Oraibi village, funded with CARES Act funds. That will help with pandemic response by increasing hand-washing and sanitation, especially in individual homes. Hopi Tribe

Meredith Raimondi, the director of communications at the National Council of Urban Indian Health, said the consequences could be dire: “A big concern is that you make the wrong decision, and you choose the state, or you choose IHS and then one of those doesn’t go according to plan and you have no vaccines. I mean, it’s a gamble at this point.”

The Hopi Tribe opted to receive allocations through the Indian Health Service, the federally funded health care system responsible for providing services to approximately 2.6 million American Indians and Alaska Natives. According to officials involved in the logistics planning, the Hopi Tribe is preparing for a direct-shipment scenario from the manufacturer or a “hub and spoke” strategy using ultracold storage in a central location like Phoenix as a distribution hub.

Supply chain experts like Julie Swann, a professor at North Carolina State University who previously advised the CDC during the 2009 H1N1 pandemic, are greatly worried about the logistics involved in cold-chain management of the vaccine for these communities.

“Pfizer kind of acts like that’s going to solve the problem and to some extent, the federal government acts like that, as well,” Swann said of the company’s direct delivery approach that ships vaccines in specialized containers packed with dry ice.

While Pfizer’s strategy would work for a mass vaccination clinic, she explained, it would not be as effective for a health care provider trying to allocate small amounts of vaccine to multiple people over time.

“I think the changes in the Moderna vaccine make it much easier to give that one in rural or sparsely populated areas,” Swann said.

Moderna’s vaccine can remain stable at standard refrigerator temperatures of 36 to 46 degrees Fahrenheit for up to 30 days once thawed.

NCUIH in the News: Executive Director on Native America Calling Program on COVID-19 Impacts on Indian Country

Listen to Recording

WASHINGTON, DC (July 21, 2020) – On July 21, 2020, NCUIH Executive Director Francys Crevier joined Native America Calling for a program on the COVID-19 impacts on Indian Country.

From the Koahnic Broadcast Corporation:

In hotspots for COVID-19 around the United States, Native people make up a disproportionate percentage of infections. This is especially true in the Southwest, where Native American residents significantly outnumber other populations who test positive for the coronavirus. In addition, a new report finds young people of color experience social conditions that put them at greater risk if they contract COVID-19. We’ll take a look at some of the factors that contribute to increased Native representation among those who are infected and how some tribes are working to turn it around.


Abigail Echo-Hawk (Pawnee) – director of the Urban Indian Health Institute and chief research officer at the Seattle Indian Health Board

Francys Crevier (First Nation Algonquin) – executive director of the National Council of Urban Indian Health

Leonela Nelson (Navajo) – Research Program Supervisor Johns Hopkins Center for American Indian Health

Warren Goklish (Apache) – Contact Tracing & Expanded Testing Coordinator at the Johns Hopkins Center for American Indian Health