Indian Country already has some of the highest rates of illness in the nation. Can it withstand COVID-19?
Indian Country in America has long been described, despairingly, as a “developing nation” — a place not unlike remote parts of Africa or Asia, where survival is a daily struggle. Today, amid the coronavirus pandemic, there are fears that the struggle will be lost.
There is no question among public health experts that Native Americans are among those most vulnerable to the disease, owing to generations of inadequate healthcare, grinding poverty, and a chronic lack of safe drinking water and healthy food, among other essentials. Up to a third of homes on tribal lands in New Mexico and across the country have no electricity or indoor toilets, according to federal government reports. Large extended families are crammed into single-wide trailers, which make social distancing an impossibility.
Native peoples in New Mexico and across the nation have the lowest life expectancy of any U.S. race, according to the Centers for Disease Control. “These afflictions result from historical insults and injustices,” such as mass murder, genocidal policies — and epidemics from introduced diseases, the CDC notes in a 2017 report. Chronic under-funding by the federal government and gross mismanagement by the Indian Health Service hasn’t helped.
The IHS, the agency responsible for serving some 2.5 million Native people, is often cited as one of the worst-run health systems in America. The agency is accused of such poor medical care and other egregious offenses that it has landed several times on the GAO’s notorious “high risk” list, reserved for government programs and operations that are highly prone to fraud, abuse, waste and mismanagement.
And now the IHS is ground zero for fighting the most catastrophic virus in modern times. How can it succeed? And how can Indian Country cope?
In New Mexico, home to 19 Pueblos, three Apache tribes and a large swath of the Navajo Nation, these are pressing questions. The Navajo Nation — which stretches 27,425 square miles across some of the most remote country in New Mexico, Arizona and Utah — is at particular risk: The roughly 175,000 tribal members living there are plagued with some of the highest rates of chronic disease in the country, including diabetes, heart disease and lung disease. And that was before the arrival of COVID-19.
As of March 23, 29 coronavirus cases have been confirmed on the Navajo Nation. Eighteen cases occurred in the area of Kayenta, Arizona, where the illnesses have been linked to a March 7 church rally, the Navajo Times reports. At the time, public gatherings — and casino traffic — were still allowed. On March 20, the Navajo Nation ordered all residents aside from essential workers to stay home and self-quarantine.
What will happen now that the virus has landed? To discuss these and other issues, Searchlight New Mexico sought out Dean Seneca, a national tribal health expert and former senior health scientist for the CDC’s Center for State, Tribal, Local and Territorial Support. Seneca, a member of the Seneca tribe, has been on the ground in Sierra Leone to fight the Ebola epidemic and in Ethiopia and Afghanistan to combat polio. He is well familiar with tribal governments in the Southwest, and he has also aided efforts to contain the H1N1 influenza virus. He served as director of the Great Lakes Inter-Tribal Epidemiology Center, one of 12 tribal “epi” centers charged with collecting health data and performing tasks like “contact tracing” to pinpoint people exposed to viruses in an epidemic. Today, he is the CEO of Seneca Scientific Solutions, a company that provides consulting and assistance on health issues.
We caught up with Seneca by phone. This interview has been edited and condensed for clarity.
Q: In early March you were one of the first to announce that the tribal epidemiological health system isn’t equipped to handle the coronavirus pandemic — which caused quite a kerfuffle. What are you most worried about?
A: We are simply not ready for this. I’ve said that boldly. And I have to say, that upset some people! You know, it upset some of my tribal epidemiology colleagues.
Q: You’re talking about people who work at the tribal epidemiological centers?
A: Yes — and quite honestly, they don’t want to show the public that we don’t have the capabilities to do this work. And what I’ve said to them is this: “What you’re doing is providing a false sense of security. Because you’re trying to tell people that you can do the work, and you can’t! Because the systems are not in place.
Q: Many people in Indian Country are in poor health and at high-risk for respiratory infections, which raises the risk for serious illness or death from COVID-19. Plus, it’s tough to get medical care on tribal lands. People don’t have cellphone service to call a doctor, and often ambulances can’t make it up the muddy roads. I also heard from a Navajo chapter president today that the tribal government closed down the only two health clinics in his community. It’s going to be even harder to fight the pandemic if things like that keep happening. If people get the virus, where can they go for treatment?
A: Well, here’s the sad part: If the virus starts running rampant, we don’t have any testing. Where are you going to go to get tested?
You know, this [Trump] administration has really screwed this one up. I mean, when we did Ebola, we had very good communications with the President [Obama], the CDC, and the FDA. We were connected at the hip. And that’s why I think we were very effective, for both Ebola and the Zika virus. But this president — if you can even call him that — he’s misleading the public with many of the things that he says daily. …We’ve really failed in this response, in my opinion. I mean, it’s just really bad. And for a country like the United States, it’s just awful.
Q: What does awful look like?
A: Okay, let’s say there’s a case of flu, or an STD, or chest pain or whatever the diagnosis is. A hospital or a clinic records that in their computer system. That information goes to a local health department or state health department where that information is compiled, assessed and analyzed. And then they’re able to spit out results saying, ‘We’ve had this many cases of this, and this many cases of that. And according to our population, this is how many are infected; this is how many cases we’ve had; this is how many people died.’ You know, it’s about having a real-time ability to do assessment and surveillance. I mean, that’s how these systems are supposed to be set up.
Our tribal epicenters? They have no system in place. There is none.
Q: Absolutely zero?
A: There’s nothing where the tribal health department says there’s a case of something and reports this information to a local center where the center is able to compile the information. In real-time, we cannot do this. So if I’m at an epicenter, and I want to find out how many cases were at XYZ tribal nation … I could never get that [from a central location]. I would have to call the individual tribal government, or I could call a state health department, and each one would give me different information.
My point being: We don’t have the systems in place to do this accurate, good epi surveillance and contact tracing that needs to be done during a pandemic. And I know this, very, very well. I’ve done this work.
Q: Can you walk me through that? If you’re in a tribal community and you go to your local health clinic, and you have symptoms or you test positive for coronavirus, where does that information go?
It depends on the tribe. The tribe may report that to the state. May or may not. They may report to the Indian Health Service. And then the Indian Health Service has limited capacity to compile this information.
And some tribes just fall underneath the radar. We have some tribes who don’t report anything. … Just from the data we have, we are already leading the nation in poor health conditions. But that’s not a full representation; that’s a severe undercount!
The situation is already getting dangerous on the Navajo Nation. In the Sanostee Chapter, south of Shiprock, the chapter house and the senior center reported that they had no sanitizing gel or disinfectant wipes. Now, the chapter is running out of the supplies it needs for its “meals on wheels” program for seniors, the chapter president says. And he’s afraid some of the elders aren’t taking the virus seriously.
Well, you know, I’ve consistently said that I’m really worried about our elders, related to this. This could have a devastating impact on a community.
If this gets into a bingo hall, it can run rampant and have devastating consequences. If it gets into one of the local casinos? Where mostly the elderly are the gamblers? It could have devastating consequences.
Q: Let’s say someone put you totally in charge, and you had a magic wand to fix things. What would you do?
A: (Laughing) How much power do I have? Am I the president of the United States in this scenario? Or am I a tribal leader? Because if I had a magic wand, I would first get rid of the president.
Q: Well, let’s say you have total authority to manage this crisis in Indian country. What would you do?
A: First, we have to do isolation. I want to go to the extreme measures that China did — what China did was correct. Right now, we’re mitigating the effects of this. We’re trying to delay the rapid influx of cases we’re going to see if we don’t get a handle on this. But isolating is the most important thing to do.
If I had the magic wand, what we need to do is a rapid amount of testing, find out who’s infected, isolate them, and make sure people who are infected are kept away from people who are not infected. And the other thing we have to do is contact tracing, which is really key. Contact tracing is when you investigate everybody that the infected person has come in contact within the last 48 hours. We have to do surveillance, as well, and find out if there are additional cases that have happened. That’s the first thing I would do.
The other thing I would do is let people know through messaging in the traditional Navajo language, for example, that this is out there now. That it’s real. And it’s up to each individual to practice good public health for the greater good of everybody. Because it just takes one person not practicing good public health for this virus to continue gaining strength.
Q: What’s concerning is that so many people don’t have clean running water from a tap at home. How can you wash your hands without clean water? And sanitizing gel is in short supply. So how can they practice good public health?
You’ve just got to do the best you can. Try to get water stations out there refilled and everything. I would put a lot of public health people out in the community who are real public health people — not just the people who are political appointees.
The other big thing is that I would get the colleges involved in this — you could involve Diné College [which has four campuses in Arizona and two in New Mexico, one in Shiprock one in Crownpoint].
It would be a great learning experience. They could partner with the University of New Mexico or the University of Arizona or other mainstream institutions, and they could actually do some lab testing, and utilize these guys to go out to the community and do testing.
There’s another issue, but this is the reality: Out of our tech directors [in Tribal Epidemiology Centers], only about two are Natives, and the others are non-Indian. I have to tell you, that’s a huge shortfall when it comes to these kinds of situations.
I just think our tribal nations have to put Native people into these positions. And it’s not like there aren’t Natives who are qualified for these positions. They need to put more Native people in these positions because they know the culture, they know the community, they know the context. They know the person in the tribal health department, they know the emergency responder, they know the ambulance crew. Those community connections are invaluable.
And they know the language! And these things are all very, very important, especially when you’re working with our elders, many of whom speak Diné.
Q: According to Indian Country Today, only about 0.3 percent of the CDC workforce is American Indian or Alaska Native.
A: When I was at the CDC, we had a good 10 Natives or so that were working [in my area]. Now, 20 years later, I’d say there are fewer Natives then there were when I served.
Q: How do you get the word out about COVID-19?
A: Facebook! So many of our Native people are on Facebook. Word of mouth works, too — targeted public health messaging.
Q: You’ve pointed out a lot of dire problems. Are you also feeling hopeful about things?
A: I sounded the alarm about two weeks ago. And now what I’ve been hearing is that more and more tribal nations are working very, very hard to become prepared. So that’s a good thing.
What I keep pushing for is tribal autonomy, and tribes using their public health authority to protect themselves. We cannot rely on local health departments. We cannot rely on county health departments that are based in adjacent communities. We cannot rely on state health departments to take care of the needs of tribal nations. That’s just not going to work. We’re just not a priority for many of those other communities. What I’m saying is, we need to exercise our tribal sovereignty, and we need to protect our own people.
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