In 2009, when the H1N1 influenza flared up in the United States, American Indians died at rates four times higher than other racial and ethnic groups.
In 2020, Native Americans across New Mexico, the majority of whom live on remote tribal lands, are dying of COVID-19 at rates 19 times that of all other populations combined, according to data provided by the state Department of Health. They account for 57% of the state’s cases – despite only being 11% of the population – and have infection rates 14 times that of the rest of the population. Other states have also had disproportionately high rates of COVID in Native communities.
“Unfortunately, American Indians have the worst health status for infectious diseases,” said Dr. Michael Landen, the state epidemiologist, with the New Mexico Department of Health. “I would have expected to see a higher rate among American Indians. I would not have expected to see it this much higher; this is just so disproportionate.”
In addition to having higher rates of the illness caused by the novel coronavirus, Landen said, American Indians also have higher rates of complications, and the mean age of hospitalizations is 55, younger than that of all other populations. Native Americans account for 57% of the cases in New Mexico and 72% of the hospitalizations, Landen said.
“I think there’s been some very unfortunate circumstances,” he said. “There have been some gatherings that led to high rates of transmissions, the NCI (Na’Nizhoozhi Center Inc., detox center) situation in Gallup. … Then you have persons who have higher rates of complications who have been infected, persons with diabetes, hypertension, chronic alcohol use, those sorts of conditions.”
In early April, doctors said, as many as 110 people ended up contracting the virus after coming into contact with someone who had it at NCI.
But as for why COVID-19 in particular has had such an outsized effect, it’s too early to tell, Landen said.
“We’re early in this process,” he said. “We’re still trying to determine what explains this huge disparity that we’re seeing.”
But theories abound.
Researchers, advocates and lawmakers point to poor access to a health care system that has been chronically underfunded, high rates of chronic illnesses and environmental factors of heavy metals exposure and poor air and water quality.
In April, researchers with the University of Arizona and UCLA published a paper detailing their findings that early cases of COVID-19 on tribal lands were more prevalent in households lacking indoor plumbing and were less likely in households where only English was spoken. The research paper, “American Indian Reservations and COVID-19: Correlates of Early Infection Rates in the Pandemic,” compared rates of the illness in 287 American Indian communities with characteristics of those reservations. It looked at rates only before April 10.
Other studies have found that about 30% of the Navajo people lack access to running water, making it difficult to wash hands frequently – one of the key ways to combat the spread of the virus.
Because the researchers found that households with English speakers were less affected by COVID-19, they highlight the importance of providing the same information in indigenous languages that was provided about the virus in English.
“We had some rapid deployment of English and sometimes Spanish messaging for COVID-19,” said Stephanie Russo Carroll, associate director for the Native Nations Institute at the University of Arizona and one of the authors of the paper. “We didn’t have it in Native languages early on, and we didn’t have it through the mechanisms where it was going to get to the people who need it. In rural situations, are you utilizing radio, Facebook, flyers.”
Carroll said she would like to see the data around COVID-19 and indigenous communities collected with tribal input and shared among tribal leaders so they can determine for themselves what they need to do in the face of the pandemic.
“When we think about data for COVID-19, we want to make sure we have data that is meeting the governing needs of tribal nations,” Carroll said. “In terms of having access to data for cases, hospitalizations, deaths, that are relevant for whatever denominator they want to be using.”
In some cases, Carroll said, it will be more helpful to know how many people on reservation land have the virus, and in other cases it would be more helpful to know how many tribal citizens have it, regardless of where they live.
“We don’t yet know what the long-term ramifications of having been infected with COVID are and if there are health effects we’ll see in the future,” Carroll said. “Many tribes are interested in knowing about their citizens because often we have people who come home when they’re older … and we want to be able to provide for them when they come back.”
In New Mexico, health officials are collecting their racial and ethnic data during interviews with patients or from staff at hospitals or funeral homes, Landen said. He said there haven’t been any big outbreaks among urban Native Americans.
Although Landen said members of the Navajo Nation – the largest indigenous group in the state – make up a large percentage of the cases, smaller tribes also have disproportionately high rates.
And, he said, although it’s true that tribes are testing their members at very high rates – the Navajo Nation has tested more than 15% of its population, for example – that doesn’t fully account for the disparity of cases.
About 30 million tons of uranium was extracted from Navajo lands from 1944 to 1986, according to the U.S. Environmental Protection Agency.
Contamination from hundreds of now-abandoned mines has prompted ongoing federal cleanup and health impact studies.
University of New Mexico researcher Dr. Johnnye Lewis said it’s difficult to attribute high rates or severity of COVID-19 cases for tribes and pueblos directly to uranium exposure.
But her team’s yearslong studies of Navajo residents have linked heavy metals exposure to conditions that may increase susceptibility to infectious diseases such as COVID-19.
“Something mentioned by clinicians we have worked with on these studies is a general inability to develop an effective response to infection, and a requirement to treat much more aggressively,” said Lewis, the director of the UNM Community Environmental Health Program. “We see markers of (immune dysfunction) that are consistent in some of the markers that have been tracked in COVID infections as well.”
The team’s latest Navajo Birth Cohort study showed that between 25% and 35% of adult Navajo participants had uranium in their urine at concentrations higher than 95% of the U.S. population. Some children born to those adults also had elevated uranium levels.
Dr. Loretta Christensen, chief medical officer for the Navajo Area Indian Health Service, referred to the findings during an October 2019 Senate Indian Affairs Committee hearing.
“It’s like keeping your hand over a flame. You’re going to keep getting burned,” Christensen said. “If you’re continually exposed to this contamination, you’re going to keep getting these diseases.”
The researchers also see that Navajos with prolonged heavy metals exposure have higher likelihoods of hypertension, diabetes, kidney disease and cardiovascular disease.
Dr. Debra MacKenzie, deputy director of UNM CEHP, said the team has data on metals-induced chronic inflammation and altered immune system responses as well.
“If you’re thinking COVID, and you’re getting this massive cytokine storm, this could exacerbate the response,” MacKenzie said. “That is something that is of concern. Obviously, we have absolutely no proof of that. But when we see that metals can induce some immune dysregulation and some underlying inflammatory responses, the hypothesis would be that it could lead to increased susceptibility or worse outcome.”
Poor air quality
Heavy metals exposure and poor air quality from oil and gas operations present a “double whammy” for tribal communities during the pandemic, said Mario Atencio, a member of Diné Citizens Against Ruining our Environment, or Diné CARE.
“When BLM or BIA or the industry asked the landholders to sign off on (oil and gas) leasing, no one ever said, ‘These are the public health impacts,'” said Atencio, who lives in Torreón and serves on the state’s Methane Advisory Panel.
He is also on the Counselor Health Impact Assessment – Hozhogo’na’ada Committee, which studied the effects of oil drilling in Counselor, Torreón and Ojo Encino. In the spring of 2018, the committee placed air monitors outside some Counselor homes near well pads to measure pollutants, including particulate matter (PM2.5). The majority of residents in Counselor live within one mile of at least one oil or gas well, pipeline or other infrastructure.
Their report, released in January, found the sites had “considerably higher” levels of PM2.5 than similar sites in other states.
“With higher than average PM2.5 levels, residents living near a source of air pollution are at greater risk for developing or worsening respiratory or cardiovascular diseases,” the report says. “Chemicals from the source may combine with the particulate matter and travel to the deep regions of the lungs to cause respiratory problems or gain access to other parts of the body through blood-gas exchange.”
Long-term PM2.5 exposure may also make COVID-19 symptoms more severe and lead to higher COVID-19 death rates, according to an April 2020 study by researchers at the Harvard T.H. Chan School of Public Health.
The Harvard study has not been peer-reviewed. But the authors say findings are consistent with research showing that air pollution exposure “dramatically increased the risk of death” during the 2003 SARS outbreak.
“Although the epidemiology of COVID-19 is evolving, we have determined that there is a large overlap between causes of deaths of COVID-19 patients and the diseases that are affected by long-term exposure to fine particulate matter (PM2.5),” the researchers wrote.
When the United States signed treaties with sovereign tribes, many of them required the federal government to provide health care and public health services to indigenous people. But today’s federally funded Indian Health Service lacks the resources and funding needed to fully care for the population.
“Since IHS’s inception back in 1955 it has been chronically and pervasively underfunded,” said Shervin Aazami, the director of congressional relations for the National Indian Health Board.
And he ties this directly to the high rates of COVID-19 in native communities.
“The problem was the Indian Health Service was at a major disadvantage before COVID, and that’s placed Indian Country in a much more vulnerable spot,” Aazami said. “That’s why we’re seeing disproportionately high rates.”
For instance, Aazami pointed out, Veterans Affairs spends roughly three times the amount of money per patient than IHS does. As a result, IHS facilities and equipment are much older than the national standard, and may have a hard time hiring and retaining high-quality health care providers, including physicians, nurses, dentists and pharmacists. Across the board, IHS has about a 25% provider vacancy rate, and in some areas it’s as high as 31%.
“Less funding, less accessibility to care and less quality of care, for those reasons you have chronic underlying health conditions that go years and years without getting treated,” Aazami said. “You have less access to care and treatment, as a result health disparities increase over time.”
In the current fiscal year, the IHS budget is $6.04 billion; however, the National Indian Health Board recommends doubling it in FY 2022 to $12.79 billion.
To fully fund the agency, a coalition of tribal leaders estimated, IHS would need $48 billion.
The IHS recently received more than $1 billion from the federal CARES Act.
In a recent interview, Sen. Tom Udall referred to the relief package and said he hopes the federal government continues to pay attention to IHS after the pandemic’s immediate danger has passed.
“We’ve been increasing IHS resources and capacity in this time period, and I just hope we don’t slip back,” Udall said. “The IHS needs to be built up, it needs to be invested in, you need an infrastructure investment. I hope we change the way we’re dealing with the IHS and they end up in a much better place. That would be the smart thing to do.”
This story has been supported by the Solutions Journalism Network, a nonprofit organization dedicated to rigorous and compelling reporting about responses to social problems. Theresa Davis is a Report for America corps member covering water and the environment for the Albuquerque Journal.