Native American populations face many of the same challenges as the larger U.S. population during the COVID-19 pandemic, including lack of ready access to testing and shortages of personal protective equipment. But the added burdens of chronic disease and persistent underfunding of American Indian health systems have put the nation’s indigenous population at higher risk of poor outcomes from the disease.

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An episode of the “AMA COVID-19 Update” explores these challenges and notes ways to improve quality of care and outcomes. The April 30 episode, “The pandemic’s impact on the Native American population,” features a discussion with an Alaska Native physician and an American Indian physician, who discuss how COVID-19 is affecting their communities.

The AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center and the AMA’s physician guide to COVID-19.


Large families, long histories

To appreciate the challenges facing Native American populations during the pandemic, one must first note the difference in social units. Unlike some U.S. populations, American Indians and Alaska Natives often don’t live in nuclear families.

“The old joke is, ‘For the Navajo family, it's parents, children, grandparents and their anthropologist,’” said Siobhan M. Wescott, MD, MPH, assistant director of the Indians Into Medicine (INMED) Program at the University of North Dakota and a member of Alaska’s Athabascan tribe. There is “quite a bit of closeness and even sometimes living in the same quarters, which may or may not have running water. So washing your hands all the time, distancing from elders, from square one that can be very difficult.”

But the challenges transcend social structure, Dr. Wescott noted.

“There's higher disparities in chronic diseases, which can make people more vulnerable to COVID and have a worse outcome with it,” she said, noting that “these are long-standing problems.”

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Special status, but little funding

“One thing that's not very well understood is that American Indians are the only [U.S.] population that's actually born with a legal right to health services, and that's based on treaties in which our tribes exchanged land and natural resources for various social services, including housing, education and health care,” said Donald Warne, MD, MPH, associate dean of diversity, equity and inclusion and director of the INMED and Public Health Programs at the University of North Dakota. “So that's why there's a Bureau of Indian Affairs. That's why there's an Indian Health Service.”

Unfortunately, what little money flows into the Indian Health Service (IHS) is spent on medical care, not public health programs, putting Native American populations at particular risk in a pandemic, said Dr. Warne, who is a member of the Oglala Lakota tribe in South Dakota.

One example is the Navajo nation, which has “really been decimated by COVID-19,” Dr. Warne said, although government data demonstrating this is limited. As of late April, the Indian Health Service had administered only 27,000 tests for the novel coronavirus; about 3,000 had come back positive.

“The challenge is that IHS collects all of the federal Indian Health Service data, but many tribes actually operate their own health systems,” Dr. Warne said. “And we also have urban American Indian health facilities, and their reporting to that database is voluntary. So I would say that we're really underestimating the prevalence of COVID-19 based on some of the data challenges of the multiple data sets that we have to work with.”

Learn more about why racial and ethnic data on COVID-19’s impact is badly needed.

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Where there’s opportunity

One thing Native American communities have in common with the larger U.S. population is that telemedicine could dramatically improve their access to care. Most tribal communities don't even have a hospital, Dr. Warne noted.

The recently passed CARES Act sets aside $1 billion for Indian health programming, much of which supports telehealth activities. It also extends the Special Diabetes Program for Indians.

Meanwhile, the AMA has urged the Trump administration to collect and make available COVID-19 mortality data by race and ethnicity. It also recently worked with members of Congress to draft a bill on COVID-19 race and ethnicity data collection, which would expand the health care system’s ability to quell misinformation, improve access to testing and treatment and ensure equitable distribution of resources.

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