LUMMI NATION, Wash. — They hastily piled all the dumbbells and treadmills in the back of a gym to make room for 23 extra hospital beds. The beds aren’t needed yet, but on a reservation where residents suffer high rates of disease that exist throughout Indian Country, the Lummi Tribal Health Clinic in Washington is bracing for the deadly coronavirus.
Two thousand miles away at the Cherokee Nation in Oklahoma, where 11 people have tested positive for the virus as of Friday and one has died, "We're preparing for the worst," Chief Chuck Hoskin Jr. said. Health workers plan to move hospital beds into a nearby university and a job training facility shuttered because of the pandemic. "This is the worse public health crisis we've had in a generation."
At the Navajo Nation that crosses three western states, 270 people were infected as of Saturday with 12 fatalities, the most in Indian Country. A shelter-in-place order was imposed by President Jonathan Nez. "Some won't listen, but we're doing everything we can," Nez said. "We're doing . . . road blocks, handing out . . . booklets to share with relatives and community members. We need everyone to take this virus seriously."
Coronavirus is ravaging the United States, but experts say more than 5 million people who identify as American Indians and Alaskan Native are especially vulnerable.
“When you look at the health disparities in Indian Country — high rates of diabetes, cancer, heart disease, asthma and then you combine that with the overcrowded housing situation where you have a lot of people in homes with an elder population who may be exposed or carriers — this could be like a wildfire on a reservation and get out of control in a heartbeat,” said Kevin Allis, chief executive of the National Congress of American Indians.
"We could get wiped out," Allis said.
About half of Native Americans live on reservations mainly in the West, Midwest and South, according to the National Congress of American Indians. They live in small homes, where the virus can easily spread through families. Houses often lack electricity and running water so that washing hands is more challenging, health experts at Johns Hopkins University said.
And they suffer disproportionately from hypertension, asthma, cancer, heart and cardiovascular disease — maladies that put them at a higher risk of fatal complications from the coronavirus. American Indians are 600 times more likely to die from tuberculosis and nearly 200 times more likely to die from diabetes than other groups. More than a quarter under age 65 lack health insurance.
American Indians have a dark history with infectious disease, dating back hundreds of years. In the last century, the 1918 flu struck the group four times harder than the general population, according to a 2014 study in the online archive JSTOR. At least 3,200 died, including 72 of 80 residents at the Iñupiat village of Brevig Mission, Alaska, according to the National Institutes of Health.
Tribes "suffered hideously," the study said, citing reports from the time. "The Navajos' situation of 1918-19 was an almost perfect storm." Considering the conditions that made them vulnerable, the researchers said, "it is remarkable not that so many of them were lost but that so many survived."
Conditions a century ago were similar to what exist today in Indian Country: multigenerational families living in close quarters, struggling with poverty, poor nutrition, and underfunded health care programs.
"We have very limited data right now because of lack of surveillance systems, but we are hearing disproportionate level of severity of health impacts from coronavirus, a higher need for intubation and ICU-level care and more severe stress," said Laura Hammitt, an associate professor of the Johns Hopkins Bloomberg School of Public Health, which works with the Navajo Nation.
Nez watched in frustration as the virus spread through the population of 327,000 Navajos. As infections more than tripled from 71 to about 270 in just over a week, he said the Navajo couldn't quickly get federal funding for American Indians allocated by Congress in early March because he had to apply for it through the Centers for Disease Control and Prevention. Nez said money should have come directly to the tribe so he could quickly buy protective gear for health workers.
"I'm pretty pissed," Nez said. "I think you really need to let the people know the federal government again is shortchanging tribes throughout the country. We're always at the bottom of the list. That money has already been given to the states. What they want us to do is beg for money."
From California to New York, tribal presidents and chiefs expressed similar frustration. When the economy shut down last month, so did the casinos and tourism that funded their way of life. Tribal gaming operations are the 13th largest employer in the United States, with a workforce of about 640,000.
Joe Kalt, a professor and co-director of the Harvard University Project on American Indian Economic Development, said tribes' casino revenue is going to "get hammered."
"Just like a county or city collecting taxes, tribes use their casino revenue to provide for their citizens and the travel and tourism industries are going to take a direct, immediate hit," Kalt said.
The Cherokee Nation in Oklahoma doesn't know how it will pay 4,000 workers laid off when its 10 casinos and hotel operation closed more than two weeks ago. The Cherokee are losing $40 million per month, Hoskin said.
“If you imagine a state’s entire tax base turning off like a switch, that’s what’s happened to us,” Hoskin said. “Our revenue stream for education, health care, housing — all of that is tied to our businesses.”
The tribe promised to pay the employees through the middle of this month, but "it's unreasonable to think we can do this for periods of months and months," Hoskin said. The federal government has to step in to prevent a catastrophe, he said. "We expect the U.S. government to understand that if a tribe has its entire revenue base ripped out from underneath it from a pandemic, they ought to be made whole."
A third stimulus package passed by Congress on March 27 included $10 billion for American Indians but allocating the funds could take weeks, Allis said.
Less than adequate health facilities are another concern. At the Ogala Sioux in South Dakota, President Julian Bear Runner said the federal Indian Health Services facilities "are not well equipped." For the tribe's 50,000 members, there are 24 coronavirus test kits, six ventilators and four beds set aside for quarantine at the Pine Ridge Hospital.
"If we were to be infected or have an outbreak of 10 or more people that's going to be overwhelming for IHS here and they're going to be unable to handle that," Bear Runner said.
Which is why so many tribes are walling off the outside world.
The Chippewa Cree in northern Montana erected checkpoints at the borders to block anyone who didn't belong. The Crow and Northern Cheyenne in that state ordered curfews.
The Ogala Sioux's president plans to enlist retired veterans to help run checkpoints at the dozen entrances to its 3.6 million acre reservation in South Dakota. "We're trying to limit the amount of travel coming and going and to educate people that aren't aware of the dangers," Bear Runner said on March 27. "Right now, none of our tribal members have it."
No tribe has been more proactive than the Lummi. As early as Jan. 22, when there were only a handful of confirmed cases in the United States, clinic physicians on the reservation started ordering medical supplies, including test kits.
"Any time there was an opening for an order, we just ordered," said Dakotah Lane, the clinic's executive director. "We were always a week ahead of everyone else and that gave us an advantage."
On March 3, the clinic declared a public health emergency. It started testing early, confirming the reservation’s first infection on Mar. 12 — a worker on the reservation who lived in Seattle and wasn’t a tribal member. By March 27, the Lummi health clinic had conducted more than a third of the 330 tests in surrounding Whatcom County, despite having only two percent of its population.
Eighteen people have tested positive for coronavirus at the clinic, so far with no fatalities. A tribal elder at a nearby nursing home experiencing an outbreak died in early March.
Tribal leadership attribute the low infection to dogged prevention efforts put in place before similar measures by Washington Democratic Gov. Jay Inslee.
“The public health team kept pushing — we’d be right back at the table a day or two later — and it really started to sink in,” Lummi tribal councilman Nickolaus Lewis said.
It took time because defenses against coronavirus — separating elders and children — are offensive to the Indian way of life.
"Social distancing is at odds with the Cherokee culture," Hoskin said. "It probably feels to people like we're saying break up the family but literally going to see elderly grandparents is putting them in peril. It goes against the natural inclination of Cherokee Nation."
American Indian attachment to family is tighter than the general population and isn't easily discouraged, said Allison Barlow, director of the Johns Hopkins Center for American Indian Health.
“It’s such a strong reverence for elders but it’s also terrifying,” she said. “Elders have a different meaning from other communities. They are the speakers of the native language. The meaning of this virus in tribal communities is incredibly traumatizing.”