Rapid spread of the coronavirus in many Native communities reflects longstanding social, economic, and political inequalities. Lack of data and widespread mistrust of the health care system exacerbates the problem. Tribal college educators say their nursing and public health programs are part of the solution.
By Katie Scarlett Brandt
When the presence of Covid-19 shifted from possibility to reality earlier this year,Twyla Baker couldn’t escape a sinking feeling in her stomach. As president of Nueta Hidatsa Sahnish College, which serves the Fort Berthold Reservation of North Dakota, she pictured her tribal college students falling behind and elders in the community getting critically ill.
“When you can see it coming, you have to try to separate yourself and be a researcher,” Baker said. “But you can’t [separate] when you’re living in your community.”
Like all tribal colleges, Nueta Hidatsa Sahnish College closed its campus and switched to virtual learning. In addition, Baker said a Mandan Hidatsa Arikara Nation Covid-19 task force meets daily and the tribal chairman provides regular updates. The reservation also instated a curfew from sunset to sunrise for tribal citizens. So far, the MHA Nation reports 35 confirmed cases.
This aggressive response reflects, in part, a sense of vulnerability felt by those who live in rural and under-resourced reservations. While national attention is focused on the Navajo Nation, where more than 5,000 cases and over 150 deaths were confirmed by late May, many Native communities are being disproportionately affected.
“American Indian communities have some of the highest rates of coronavirus in the United States,” the American Indian Studies Center at UCLA recently reported, and some, such as the Mississippi Band of Choctaw and White Mountain Apache, have rates of infection that are double or even triple the hardest hit states.
It is well known that federal policies and socioeconomic barriers have created a litany of inequities for people on reservations and in Native communities since colonization. During a mass crisis, however, those inequities are magnified, revealing a much deeper and systemic injustice, Baker argued.
“We’ve set indigenous people up for crisis, and now it’s here. Those shortfalls become so much more glaring in the light of something like Covid-19,” she said. “It’s almost not even the disease. This is systemic racism killing people. The disease is just the vehicle.”
Tribes are especially vulnerable to public health crises. Chronic health conditions, underfunded healthcare, and systemic racism have perfectly positioned them for disaster. Yet even as Covid-19 has upended normal life, there’s hope for re-imagining a better future — and tribal colleges are working to harness that hope.
Baker has a uniquely deep understanding of the large-scale problems that have left Native people more vulnerable during public health crises. Prior to serving as college president, she was a health researcher at the University of North Dakota, where she studied indigenous health systems and chronic diseases among Native elders. “That’s where I got my understanding about the crisis that was here before this crisis,” Baker said. And as a researcher she said one thing is especially frustrating about the current crisis: a lack of data about Native communities.
From the start, states that publicly report their Covid-19 cases and deaths classified them by age, sex, and geography. Increasingly, they also include race, which is key because it illustrates who is being exposed to Covid-19. However, the national media tends to focus on black and Latinx communities — not Native Americans, who represent a much smaller percentage of the nation’s population.
“When you don’t have data, when you’re unable to even parse out what the lay of the land is, you can’t address the problems. Our invisibility, our lack of voice — all of this adds up to everything being deadly. Invisibility is deadly,” Baker said.
There is no dispute that chronic diseases have disproportionately impacted indigenous people, and those chronic diseases put them at greater risk for a range of complications, including from coronavirus. Native adults are about three times more likely than whites to be diagnosed with diabetes and 2.5 times more likely to die from diabetes, according to the Department of Health and Human Services (HHS). Natives are 50 percent more likely to be diagnosed with coronary heart disease than whites, and more likely to have high blood pressure and obesity.
Of American Indian health overall, HHS reports that indigenous people “frequently contend with issues that prevent them from receiving quality medical care. These issues include cultural barriers, geographic isolation, inadequate sewage disposal, and low income.”
However, the federal agency does not mention as a cause the amount of government spending allotted per Native individual. Tribes in the U.S. receive less than half per capita for healthcare compared to the U.S. population at large — $4,078 in 2017, compared to a national per person health expenditure of $9,726 that same year.
“Indigenous elders have the same disease status as a non-Native ten years older. We have a diabetes crisis, and the other co-morbidities present — high blood pressure, kidney failure, heart disease — put us at enormous risk,” Baker said.
Lori Arviso Alvord, MD, became the first Navajo female surgeon when she began practicing in the early 1990s. In her book The Scalpel and the Silver Bear, Alvord wrote about her drive to meet patients where they are — to speak their language and approach their treatment in a way that honors their cultural beliefs and practices.
When Alvord returned to Navajo Nation from medical school and residency at Stanford University, she worked at an Indian Health Service’s facility in New Mexico — the Gallup Indian Medical Center. She wrote, “It often occurred to me that much of what we were treating were white men’s diseases — syndromes and conditions the people would never have known if not for the European colonizers….Diseases were caused by lifestyle changes, such as poor diet and inactivity — an indirect result of the influence of acculturation.”
Some of those diseases result directly from a lack of access to affordable, healthy food. A study published in 2019 in the Journal of Public Affairs looked at reservation households that receive nutrition assistance from the U.S. Department of Agriculture’s (USDA) Food Distribution Program on Indian Reservations (FDPIR). Thirty-four percent of participating households reported low food security, and 22 percent had very low food security — significantly higher than the national average of 8 percent low food security and 6 percent very low.
Additionally, Baker explained, many indigenous people only go to the doctor when they’re already sick. “The resources aren’t necessarily there for preventive health,” she said.
There is also an absence of trust. “When we signed our lands over, we had the guarantee of healthcare in perpetuity. The U.S. still has the land. They still have the resources that that land gives to the country, but they do not live up to their promises. We don’t get the benefits,” Baker said.
Nola Ragan, MSN, is the director of Sisseton Wapheton College’s two-year nursing program on Lake Traverse Reservation in South Dakota. She said the lack of trust also stems from the high turnover of non-Native healthcare providers who cycle through Native communities, working in partnership with the Indian Health Service. Many come from all over the world to experience treating a different culture. Once their six-week rotations end, they leave.
“There’s no continuity of care, which makes it even harder to trust. So people don’t go in until they’re deathly ill or their diabetes is so out of control they end up with kidney damage,” Ragan said. “We feel like we’re a bunch of pin cushions up here.”
When people started testing positive for Covid-19 in Lake Traverse communities, Ragan said tribal leaders implemented safety policies, such as instating a curfew, providing video updates via Facebook multiple times a week, and deploying medical mobile units and extra security. They were concerned that the virus would spread rapidly among extended families and people who live close together.
“We’re a very close-knit community with a lot of extended family, and we like to get together,” Ragan said.
If the virus spread too quickly, the 35-bed hospital wouldn’t have capacity to handle an influx of ill patients — another issue that puts Natives at greater risk during a crisis. “If people need to be on ventilators, they’re going to be shipped to Fargo or Watertown. And if [those hospitals] are overrun, they’re not going to take people from here. I know, being in the healthcare system for so many years, if we get overrun, you might as well stay home and die,” Ragan said.
A health crisis would be even more dire on Fort Berthold Reservation, which has a clinic but no hospital — and no hospital beds. “We were promised a hospital to replace Elbowoods Hospital,” Baker said, referring to the hospital that was destroyed when the U.S. government flooded tribal lands by building the Garrison Dam in 1948. “That promise, like a bunch of other ones, was never met. I would love to see more providers, more indigenous providers, resources, and facilities.”
Baker added, “The whole nation is in a state that Indian Health Service has been in for decades, responding to crisis after crisis. The structure and planning aren’t there. It’s colossally systemic.”
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Ragan has been a nurse for 37 years and has worked at Sisseton Wapheton College for 25 years. During that time, she said white people have called her “dirty Squaw” and “dirty Indian.” She channels any bitter feelings into educating Native students so they can in turn better serve their communities and build more trust and better health among Natives.
Native nursing students are “uniquely qualified because the people know them and trust them and will come to them with problems instead of waiting,” Ragan said. “Ideally, we would have more Native nurses, more Native doctors, just so we can get some stability for our people at the clinic.”
It would also give people in the community a chance to see themselves reflected in those serving them, and that presence would build trust — and better health. “Trust is such a huge thing because clearly we have no reason to trust these government structures that have done the bare minimum for indigenous people. To have somebody who looks like you, who lives in and is a part of your community — that’s a big deal,” Baker said.
Twenty-one tribal colleges offer nursing programs, and Diné College on Navajo Nation recently graduated its first class of students from a public health bachelor’s degree program. Eight graduates comprised the first class, and another 60 are currently in the program. The school also offers a public health certificate for high school students and is working with Arizona State University to create a path for students to go on to the master’s of public health program.
“We have movement in all parts of the pipeline,” said Mark Bauer, PhD, who was instrumental in starting Diné College’s program.
The goal: to show people that they don’t have to leave Navajo Nation for an education that will help them meet their community’s needs.
“We’ve seen very many talented and well-educated Navajo professionals who had to leave to get all the degrees they want. By then, they’ve married into the cities where they went,” Bauer said. “If they can stay here, they’ll be better connected with everything. They’re less likely to lose their language skills. They remain integrated into their communities.”
Bauer has taught public health for years at Diné College, including classes centered on outbreak investigation and surveillance. “There are some very draconian measures in the history of public health. Students couldn’t believe people would have to isolate themselves,” he said.
Now, with contact tracing and curfews, those same measures have been put into practice on Navajo Nation. It’s among the most crucial times in the past century to study public health, and students enrolled in the public health program’s Summer Research Enhancement Program will develop surveys to explore how the Covid-19 restrictions have impacted people. They’ll also have the change to do contact tracing, through a program with the Navajo Health Department and Indian Health Service.
Public health students learn to investigate diseases, but they also learn how to think about larger systems — “the environment people are in, what can be changed to make their health better, what can be done politically, what can be done to better advocate for people’s health,” Bauer said.
Working in the community on a pandemic health issue will bring public health to life for students, which typically happens, Bauer said, once they realize how connected everything is. “The healthcare system, employment, and education — all of the things we group under the term of ‘social determinants of health’ — the politics. All of that works together to create the health or lack of health in communities.”
As many communities take steps to re-open despite Covid-19’s continuing threat, Baker, on Fort Berthold, encourages caution. Natives remain at high risk for a public health crisis — that hasn’t changed. “The ones who benefit the most from this system are going to be pushing for a ‘return to normal.’ We can’t allow that normal. I have a lot of hope that we do not,” she said.
“But my practical side, having had to function and fight and fight and fight these systems, I really wonder.”
Katie Scarlett Brandt is a freelance writer based in Chicago. She is a regular contributor to Native Science Report.