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In today’s COVID-19 Update, Siobhan Wescott, MD, co-director of the Indians into Medicine Program at the University of North Dakota School of Medicine & Health Sciences, discusses vaccination in Native American populations and how tribal communities are serving as models for vaccine rollouts.
Learn more at the AMA COVID-19 resource center.
- Siobhan Wescott, MD, MPH, co-director, Indians into Medicine Program, University of North Dakota School of Medicine
Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we'll be discussing vaccination in Native American populations with Dr. Siobhan Wescott, co-director of the Indians into Medicine Program at the University of North Dakota School of Medicine and Health Sciences in Grand Forks, North Dakota. I'm Todd Unger, AMA's chief experience officer in Chicago. I'd like to acknowledge that the land that I live and work is the traditional homelands of the Council of the Three Fires, the Odawa, the Ojibwa and the Potawatomi nations.
Dr. Wescott, thanks so much for joining us today. Native American populations have been among the hardest hit in the country by COVID-19. Can you give us a quick snapshot of just how disproportionate that impact has been on these communities?
Dr. Wescott: I'll say that we know, just from the very little data that we do have, that it's at least twice as many cases. Death is a little bit more difficult to calculate. The Seattle Indian Health Board put out a report sharing which states were recording which information and American Indians were underrepresented in the reporting. If you don't have that data, we don't know actually what the impact is. But just from personal stories and hearing about loss of loved ones, it's significant and at least two and a half times higher, I believe, for cases.
Unger: And what's driving that in terms of the kind of co-morbidities and these disparities, what are you seeing as primary drivers of that?
Dr. Wescott: It's a bit difficult to tell because this is mainly cases, so that's less about complications, and probably it has a lot to do with a higher percentage of frontline workers, people who regularly interact with the public. For a lot of tribes, their main source of income is a casino or hotel or bingo hall even, and there you're interacting with the public. While many tribes shut down at various times during this past year of the pandemic, you still have gas station workers. And then, if there is multi-generations in the same household, it's hard to, obviously, isolate but I think it's probably... I mean, we'll find out over time what the actual factors were, but I would guess more being on the frontline.
Unger: A lot of what we hear is how hard it's been with a vaccine rollout to reach these communities that have been disproportionately affected by COVID-19. For tribal communities, we're seeing them referred to sometimes as models for the rest of the country to follow. Can you talk more about that? That's really interesting.
Dr. Wescott: The Indian Health Service has absolutely been spectacular. They have led the nation, probably the world at this point. Well, Israel might be ahead of them, but it would be close. I believe it's the Blackfeet Nation has already reached herd immunity, with enough people vaccinated, and just the efficiency of the Indian Health Service in getting doses. And actually, I got my vaccines two and a half weeks sooner through the Indian Health Service than I would have through North Dakota as a professor at the university. I just took a 10 hour roundtrip drive twice to get to the nearest urban Indian clinic, but they were so efficient, wonderful and traditional. For instance, you could smudge, which is a way of cleansing and re-centering yourself after you got your shot. I just could not say enough about how good the Indian Health Service has been with vaccines.
Unger: It's interesting because I think in conversations with Dr. Barbara McAneny, one of AMA's past presidents, one of the things she focused on was a lack of investment in the Indian Health Services. Has something kind of changed to enable what you see as a pretty successful vaccine rollout?
Dr. Wescott: I'm not entirely sure what happened. I know the Indian Health Service was part of the early planning last fall for, should there be a rollout with the vaccines, I believe it was called Operation Warp Speed, and there was specific planning with the Indian Health Service. And for whatever reason, whoever was in charge at IHS really did their job beautifully.
Unger: The getting shots into arms has been the big challenge, once the supply part has gotten in place. We're seeing tribal communities, again, be very effective in getting that done. Any kind of notes to why the success rate has been so high?
Dr. Wescott: Well, and I haven't seen exact numbers on this. However, I think mask use is very high amongst the Native community and where tribes have control over orders, for instance. Sorry. With Cheyenne River in South Dakota, they were able to have checkpoints, even on state or federal roads, coming into the reservation because they have sovereignty. And so, I've just seen a general excellent adherence to public health recommendations from the very beginning of the pandemic with tribes.
The extension of that is just the vaccine rollout. And, of course, there's certain people who are concerned and rightfully so. I actually was very concerned about the speed at which the vaccine trials concluded and I was digging around and, finally, I found the reason. Vaccine trials can end for several reasons, adverse events or there's something else wrong with the trial. But, normally, they take years because you have to not only recruit enough volunteers, which usually takes forever, and you have to reach a set number of cases. Usually, again, that takes years. They got all of that done in months because people wanted to participate in this trial and they reached the cases because the pandemic was spreading so quickly, so it only took months which is—
Unger: Yeah, we've had a chance to talk to a lot of people involved in that. And the way that that really rolled out is a lot of the space that usually sits between parts of the trials was cut out. A lot of the bureaucracy and red tape, that allowed the trials to move so quickly, which is excellent news. For you, are you seeing any kind of level of resistance that we're seeing in other parts of the country among this community?
Dr. Wescott: Well, that's the biggest concern that I would hear, but I have to admit my bias because, for my loved ones and friends, I go out of my way to essentially bully them to get the vaccine. I'm not the most sympathetic person if you have concerns, but that timing was the biggest one that I've heard. I'll be doing a PSA for the Center for Disease Control and Prevention this week on that, just that timing issue. And it just really... When I was just sitting at home in February thinking, "I've no idea when I can get the vaccine. No idea when I might be able to get my life back," and while I'm safe and able to work remotely, it was really getting frustrating.
And so, I reached out to one of my Native physician friends in Minneapolis, and she said, "We're not taking your age group next, but get on the list." I got on the list. I got an appointment the next week. Then I started working my circle to get other people who were kind of dragging their feet or just not sure that they should be assertive and trying to find spots where they might get the vaccine.
Unger: You mentioned a PSA. Tell me a little bit more about that. We have it actually to look at, but what's the background on that?
Dr. Wescott: The Center for Disease Control reached out to us and, of course, the Native population has been particularly hard hit by COVID, so they wanted to make sure that their messaging includes voices from Native physicians. They asked Dr. Warne and myself to make a video, and his is now ready. I'll show you here.
Dr. Donald Warne: Hello and thank you to all my relatives. My name is Dr. Donald Warne. My Lakota name is Pejuta Wicasa, which means medicine man. I was named after my grandfather, who was a traditional healer. I am a family physician, and I work at the University of North Dakota School of Medicine and Health Sciences in Grand Forks, North Dakota. I am the director of the Indians into Medicine Program and director of the Public Health Program.
The reason this is called Grand Forks is that it is the confluence of the Red River heading north and the Red Lake River heading west. This was a sacred gathering point for my ancestors, the Lakota and Dakota peoples. Long before there were highways, we used the riverways for transportation, so people could use their canoes to come to places like Grand Forks to meet and connect. These were social gatherings, as well as ceremonial gatherings, in many ways a very important part of the spiritual culture and makeup of my people.
I strongly encourage each of you to get vaccinated against COVID-19. The sooner we get vaccinated, the sooner we can get back to reconnecting with each other in a social manner and in a cultural manner, the way our ancestors have done for many generations. Please get the vaccination so we can all reconnect.
Unger: Well, thank you so much, Dr. Wescott. That's terrific, and thank you for working with the CDC on producing that PSA. Well, let's talk a little bit more about the nature of kind of hesitancy and mistrust, not just in the vaccine but in the health system among some Native Americans. What's behind that?
Dr. Wescott: Well, there's a long history of things done in the name of research that were wrong, just outright wrong. And one that is frequently quoted is the Havasupai case in Arizona, where Arizona state brought in researchers ostensibly to research a genetic cause for diabetes. There were all sorts of problems with methodology and informed consent was not always done properly. And then there was rumors that they were studying schizophrenia and genetics as well, which is deeply disturbing. And eventually, the regions of Arizona settled with the tribe for nearly a million dollars recognizing wrongdoing. But that's just one small example and that was probably 20 years ago. And there's certainly a longer history, including forced sterilizations.
But the way I like to describe it, if somebody is trying understand the Native resistance to medicine and research, I try and think of it this way. Where were you when 9/11 happened? And everyone who was old enough that I've asked can tell you exactly where they were, sometimes what they were wearing and the next hours. It's all very visceral. And think about, that was also 20 years ago. What if you, though, were in one of the towers and you got out, how long would your family talk about 9/11? It would be generations. That's part of the resistance. And I think, for a lot of providers or those who work in health care, they feel like, "Well, they're trustworthy, so I should be trusted." And they don't realize that they really need to earn that trust.
Unger: That makes it even more important to get the messaging right in the way that you communicate with tribal communities. I thought some of the things that we talked about were really interesting in terms of the decisions that you need to make with that kind of communication. Can you talk a little bit about how you tailor messaging for this particular community that's different than what you might see elsewhere?
Dr. Wescott: Well, I think really needs to be at the tribal level. And I have to say I'm incredibly impressed by the tribes that I've been working with, who have their own committees on getting the messaging out. And it often involves elders who are willing to say, "We need to do this. This will help protect us in the future." And the only little grumblings that I hear are younger folks who heard that there are side effects and they don't want to experience that. And that just takes some one-on-one discussion of, "Well, yes, there are side effects," and they were significant for me. I was really out for a couple of days. But then you're done and you're protected from, at least as far as we know, serious illness or hospitalization and certainly death.
Unger: One of the things I found was really interesting is that a lot of campaigns that you hear about focus on kind of individual decisions, which is not necessarily a message that's going to resonate with a tribal community. Why is that?
Dr. Wescott: Well, we're more about protecting the tribe. And I have also noticed that the Association of American Indian Physician has a national campaign, which is largely through social media, again, to highlight elders and Native physicians getting their shots. For those who are afraid, I think the more that it adds up, and we've seen certainly in polls that the direction is far shifting so that there's very much less vaccine hesitancy than there used to be.
Unger: And I think you mentioned Operation Warp Speed. There's a lot of the language that has surrounded rollout has been military in nature.
Dr. Wescott: That's not a good name.
Unger: How does that—
Dr. Wescott: It's not a good name. It's not a good name but a lot of it is just pure logistical planning, especially because the first two vaccines required a very cold freezer that isn't necessarily available at all Indian Health Service sites. But they worked through all those logistics with that early planning, and then they were ready.
Unger: Again, back to the success that we're seeing, hopefully so far, despite the mistrust and the obstacles that we talked a little bit about, a recent survey found that vaccine acceptance was relatively high among Native Americans. You attribute this to the kind of community before self mentality or is there something else at play here?
Dr. Wescott: I'm not entirely sure. But I will say I will celebrate it all day long, and I feel like there's such a mixture of messages on so many levels, starting at the grassroots level with the tribes and all the way up to the presidency, where everyone is saying, "Vaccines are safe. Vaccines are effective. If you have questions, we will work through them with you." And I think that multilayer strategy is working.
Unger: Is the focus on prioritizing elders first been an important part of the strategy?
Dr. Wescott: Absolutely. And Standing Rock was one of the first tribes, that straddles the North Dakota and South Dakota states, they prioritized traditional language speakers. It's protecting our elders. I mean, that's the priority for the nation as well but, certainly, there's so few speakers of the Native language that they felt it was important to protect them first.
Unger: Well, although it's been a relative success story so far for tribal communities and vaccinations, of course there are still going to be challenges. Can you talk about what needs to happen over the next few months and even longer term to make sure that we stay on a successful track?
Dr. Wescott: Please continue to wear a mask. Social distance if you can. It is tempting. We all want to get back to normal. However, it's an RNA virus, which I won't get too technical, but they create variants. That's their thing. And so, until we get enough people vaccinated and make sure that there aren't variants that are vaccine resistant, we need to continue to stay social distanced and wearing masks, washing your hands, all of that.
Unger: One of the issues that you brought up is this issue about forgotten tribes? How does that impact the vaccine rollout challenge?
Dr. Wescott: Well, it does get interesting with...I actually think federally recognized tribes did very well because they were covered under the Indian Health Service. And for those of you who don't know, the Indian Health Service was created out of treaty rights. These were treaties negotiated in the 1800s. And the reason it matters is because there wasn't much health care then, but health care was specifically mentioned and that was because they wanted to be able to quarantine Indians if there were outbreaks. We've come full circle, and actually the Indian Health Service is now leading the country in protecting Indians, so I couldn't be prouder. I think, though, tribes that do not have federal recognition, maybe only state recognition or unrecognized, might be having more difficulty getting access to federal resources.
Unger: Well, Dr. Wescott, thanks so much for being with us here today and sharing your perspective. We'll be back soon with another COVID-19 Update. In the meantime, for more resources on COVID-19 visit ama-assn.org/COVID-19. Thanks for joining us. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.