Abstract
American Indian/Alaskan Native populations are suffering inequitably high rates of morbidity, hospitalisation and mortality resulting from Covid-19. The rate of hospitalisation rate among these communities is four times that of the general population, while their mortality rate is double that of the general population. 1 Data from the CDC also indicates that among American Indian/Alaskan Native populations, the Covid-19 infection rate was 3.5 times that among non-Hispanic white persons. 2 Furthermore, the people dying of Covid-19 in American Indian/Alaskan Native communities are much younger, on average, when compared with their non-Hispanic white counterparts. 3 Further examination from States, such as Arizona and New Mexico, indicates that the death rates for American Indian/Alaskan Native people aged 45–54 are similar to those of non-Hispanic white populations aged 75–84. 4
Although Covid-19 has negatively impacted many communities, the effects on this ‘forgotten minority’ of indigenous communities in the US have been particularly debilitating. 5 Not only because of the overall rates of morbidity, mortality, employment and income, but also because of its impact on crucial members in Tribal society. The significantly higher mortality rate among older adults from Covid-19 has led to many deaths in Tribal Elders, Native Language Speakers and Storytellers. Unlike many Western societies, where more traditional beliefs have been eroded by the impact of capitalist and neo-liberalism ideologies, the loss of such socially and culturally important individuals and their knowledge and skills undoubtedly has a wider and deeper impact on community life and structures. 6
As of 2017, it was estimated that 5.6 million people in the US self-classified as American Indian/Alaskan Native alone or in combination with one or more other races, representing 1.7% of the total US population. There are 574 federally recognised tribal nations in the US. These tribal nations are spread across 326, mainly rural, Reservations, with a total area of 227,000 km2. In addition to these federally recognised tribes are more than 100 tribes that are State recognised, while further tribes exist that are recognised by neither States nor the Federal Government.
The history of the treatment of American Indian/Alaskan Native communities in North America is a litany of shame for its colonising powers and the US Government. 7 It is a history of warfare, genocide, ethnic cleansing, expulsion and forced migrations. Further tactics to eradicate and subdue the native populations included the deliberate wholescale slaughter, almost to extinction, of traditional food sources, including both the Buffalo and the Churro sheep. 8 American Indian/Alaskan Native populations were faced with further threats of cultural assimilation through official attempts at proselytisation to Christianity in the 1800s, and more recently via an official policy of assimilation in the 1950s. Attempts at cultural genocide were more explicit among children. From the late 1800s, tens of thousands of American Indian/Alaskan Native children were removed, often forcibly, to a series of 150 boarding schools that attempted to expunge their native language and culture. Although this practice ended early in the 20th century, up to a third of American Indian/Alaskan Native children continued to be removed to foster care up until 1978, often on dubious moral, religious and social grounds. 9
The Reservations established by the US Government are themselves problematic. As well as being located on poor land that white settlers did not want, native populations also were often moved repeatedly as new resources were identified on such land, or nearby white settler populations expanded. A little known fact outside of American Indian/Alaskan Native communities is that, although reservations are officially sovereign nations, much of the land is not actually owned by the Tribes, but held in trust for them by the US Government. One notable impact of this is that house building on such land is incredibly problematic. This factor, combined with poverty, helps to explain the substantial proportion of American Indian/Alaskan Native communities living in overcrowded conditions as multi-generational families in trailers (mobile homes) on reservation lands. 10 An implication of this form of housing on Reservations is that it has the additional impact of stifling entrepreneurship, and thus employment and income among American Indian/Alaskan Native populations, as many business start-ups would often routinely use their house as collateral with banks in order to obtain preliminary funding. It should be noted that although Reservations officially have sovereign status, this has not stopped the US government selling mining rights on such land or, more recently, allowing oil pipelines to cross such territories. It is also significant that electricity provision and even basic sanitation in the form of running water is a real issue for some American Indian/Alaskan Native communities. Distance and sparsity of population often result in prohibitive connection costs to electricity companies, and contemporary estimates suggest that a third of Navajo Tribe members do not have running water. 11
Further assaults on the physical and mental health of American Indian/Alaskan Native populations include environmental racism in the form of numerous unremediated Superfund sites on Tribal Lands. These sites include, for example, former mines for uranium, as well as major toxic industrial plants. The adverse impact of such sites on humans, flora, fauna and water supplies are well documented. The US Environmental Pollution Agency is responsible for overseeing attempts at cleaning-up such sites. However, and alarmingly, the supreme auditor of the US Government, the federal Government Accountability Office, has specifically noted that the Environmental Pollution Agency has failed to identify, locate and map such sites effectively on Tribal lands. 12
Given the brief overview presented above outlining just a fraction of the low points in US-Tribal relations, it is hardly surprising that the health, educational and social status of American Indian/Alaskan Native has consistently been noted to be extremely poor across a wide range of indicators. Stark inequalities are evident in the high rates of poverty, unemployment, poor educational standing and historically high school drop-out rates, as well as in mortality and morbidity statistics. American Indian/Alaskan Native populations have notably high rates of medical conditions such as ischaemic heart disease, hypertension and stroke, diabetes and renal disease. The health status of American Indian/Alaskan Native communities is further compromised by education and stress-related behavioural factors such as obesity and smoking, as well as what may be termed the diseases of despair: alcohol misuse, drug abuse, problematic gambling and suicide. 13
Prime responsibility for providing healthcare to American Indian/Alaskan Native communities lies with the Federal Government’s Indian Health Service. 14 However, long before Covid-19 became an issue, significant weaknesses in the Indian Health Service were already obvious, and many of its deficiencies were being widely discussed. Comparisons of per capita expenditure between the Indian Health Service and other federal health programmes clearly reveal the inadequate funding it receives. For example, in 2010, Medicare received approximately $11,000 per capita, while Indian Health Service received only approximately $3000 per capita. 15 The result of this underfunding may be seen in both its increasingly out of date and aged facilities, and its lack of trained staff with vacancy rates running at 50% in some areas. Even more alarming is the significant under-provision of services for American Indian/Alaskan Native populations in the care of the Indian Health Service. Although it is responsible for the care over on excess of 2.5 million people, this federal organisation has just 1257 hospital beds, and only 36 ICU beds spread across what is often a patchwork of reservations measuring 227,000 km 2 (roughly the size of Great Britain), which in turn are spread across a country measuring 9.834 million km2. It is hardly surprising therefore that substantial numbers of American Indian/Alaskan Native communities that are officially covered by Indian Health Service care may be many hours from any Indian Health Service healthcare facility. Although one might assume that this deficit would be covered by reciprocal agreements with other healthcare providers, Indian Health Service policy does not cover care provided by other health systems.
Yellow Horse et al. state that ‘structural inequalities established the architecture for COVID-19’ among American Indian/Alaskan Native communities. 4 There is no doubt that this is correct. However, their analysis fails to adequately emphasise the impact of inadequate healthcare nor the impact of overt historical racism that has also impacted American Indian/Alaskan Native communities. This history of genocide, persecution, repeated force migration, racism and marginalisation has placed American Indian/Alaskan Native populations in multiple jeopardy of developing a host of chronic diseases. All of these factors combined with the impact of a chronically underfunded federal health system ostensibly claiming to support them has helped created the perfect storm of poverty, mistrust and ill-health that has enabled Covid-19 to be so devastating in this under-served population.
It is obvious that significantly improved health and social care systems are absolutely essential to protect American Indian/Alaskan Native communities. Equally, there is an urgent need for vastly improved social welfare and educational supports for these communities to help mitigate the cycles of deprivation and exclusion that are ongoing. Such interventions will require substantial amounts of additional funding supports. The question may be asked whether the US can afford to increase the money spent on health and social programmes for American Indian/Alaskan Native populations. However, the question is easily answered. In 2019, the US Government spent almost $720 billion on its military. In the same year, it spent less than $6 billion on the Indian Health Service. It is obvious that the US can afford to fund health, social and educational programmes for American Indian/Alaskan Native populations at a more appropriate rate, if it chooses to.
