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As the coronavirus spread outward from cosmopolitan hot spots it reached the rural Confederated Tribes of Umatilla Indian Reservation on Monday. In due course, it’ll reach more isolated rural areas. Think of a hamlet an hour or two down an unnamed dirt road in the Southwest or an Arctic village accessible only by plane.

Unfortunately, indications are rural areas harbor conditions that contribute to higher rates of infection and people getting more sick than in urban areas.

According to the First Nations Development Institute’s report Twice Invisible: Understanding Rural Native America, 54 percent of American Indian and Alaska Native people live in rural and small-town areas on or near reservations.

Edward Enoch, Yup'ik, unloads chunks of ice chipped out of a river and hauled home by snow-machine to melt for drinking, washing, and other uses. Location: Tuntutuliak, in western Alaska.

The Notah Begay III Foundation report Native Strong lists factors in Indian Country that contribute to diabetes and obesity. The same factors affect overall health. They include poverty, low educational attainment, and historical trauma. Housing shortages and overcrowding facilitate the spread of disease. A lack of self determination and cultural activities affect Native health too.

Those and the other conditions take a toll. “American Indians and Alaska Natives have a life expectancy that is 5.5 years less than the US all races population (73.0 years to 78.5 years, respectively),” the Indian Health Service reports.

Dalee Sambo Dorough, PhD, Inupiaq, is the chair of the Inuit Circumpolar Council. She said the health of Indigenous people living in rural Arctic Alaska, Canada, Greenland, and Chukotka (in Russia) is compromised by a range of conditions ranging from food insecurity to air pollution.

“The overall general condition of individual health and wellbeing is contributing to a lower life expectancy,” Sambo Dorough said. “We've had a whole history of epidemics that have devastated our communities in the past and tuberculosis being on the rise now, all of these things are compounded with other adverse impacts like climate change that make it really difficult for our communities to even respond to something like the coronavirus.

“So when you start out with health conditions that are worse than a majority of the people in the rest of, for example, the United States, you're already vulnerable and at risk,” Sambo Dorough said.

The village of Kivalina in Northwest Alaska is located on a barrier island on the Bering Sea. The sea used to reliably freeze up to 12 feet thick and protect the shoreline from fierce winter storms. The ice is no longer reliably there every winter. Melting permafrost makes the ground susceptible to erosion from storms. Oct. 9, 2014 (Photo by Joaqlin Estus.

Underfunded or understaffed hospitals and clinics with high turnover, and the lack of insurance coverage limit access to medical care. Overburdened health systems and limited access to specialty care create conditions in which people get the care they need only after becoming seriously ill.

A 2018 U.S. Department of Health and Human Services report on facility needs said Indian Health Service hospitals are almost four times older than overall U.S. hospitals. Age increases the risk of code noncompliance, lower productivity, and compromised health care services while raising costs for repairs and maintenance.

The report said Indian Health Service facilities are “about 52 percent of that required for the American Indian/Alaska Native population.” The federal government provides subsidies of $35 per capita for Indian Health Service facilities, compared to $374 per person for the overall U.S.

“We have had really decades of lack of public health measures to prevent the spread of disease. And then you add all these other layers including the limited space and capacity to treat patients with severe illness in rural areas,” said Sambo Dorough. “These are matters that are nothing new. And that's why the Inuit Circumpolar Council calls upon governments to take action to close those gaps.

“Every community is subsidized to a certain degree for basic services, basic infrastructure,” said Sambo Darough. “Why aren't our communities subsidized in the same way?”

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Overcrowding is a major factor in the transmission of diseases. Housing shortages can force families to live in small, older homes similar to this one in Kwethluk, Alaska.

In the 1960s, the Indian Health Service developed a unique style of delivery of health services to remote Alaska communities. Village clinics are staffed by community health aides. With several months of training under their belt, aides consult with physicians daily to provide emergency and primary care. When a higher level of care is needed, the patient is sent on a medically equipped and staffed flight to a regional health center or hospital, or for care by specialists at the Alaska Native Medical Center in Anchorage. The system experiences staff shortages but the framework, now run by tribal health organizations, is well established.

The Yukon-Kuskokwim Health Corporation in Bethel serves 56 villages in an area the size of Georgia. Corporation Vice President for Medical Services Jim Sweeney said he and health providers have been meeting in weekly teleconferences for more than a month. They talk with state and CDC officials to stay on top of information about the spread of coronavirus and prevention techniques.

"Wash Your Hands Often to Stay Healthy," is an oft-repeated CDC recommendation. That's not so easily done in rural communities that lack running water. Twice as many homes in Indian Country lack running water compared to other Americans. Shown here, in an office in the village of Tuntutuliak, two basins are set out for hand-washing.

Sweeney said the Bethel hospital has only four ventilators for coronavirus patients having breathing problems, but that’s enough because anyone needing specialty care goes to the state-wide Native hospital in Anchorage. “If we put somebody on a ventilator, by definition, we're gonna medevac them out. And Lifemed, the medevac company that we use to fly people in, is fully equipped for handling those types of patients,” Sweeney said. “So we basically will put them on the ventilator to stabilize them until we can get them on the plane and then they are taken in [to Anchorage] from there.”

No one wants to get that sick, so prevention is key. Covering coughs, staying home when sick, and the CDC recommends, “Wash your hands often with soap and water for at least 20 seconds,” to prevent the spread of COVID-19.

However, Indian Country has about twice as many homes without running water and flush toilets as other Americans. In its annual report on sanitation deficiencies, the Indian Health Service said of 68,000 American Indian and Alaska Native homes, “approximately 7,600 (or 1.9 percent) lack access to a safe water supply and/or waste disposal facilities, compared to less than 1 percent of homes for the US general population.”

Alaskans without piped water can buy water, which even if only ten cents a gallon is too costly for most villagers. Many collect rainwater and chip ice out of rivers and lakes to melt for daily use. When it takes that much effort to get water, people conserve it. The average American uses 100 gallons of water a day. They use a gallon each time they wash their hands. Villagers use an average of two gallons per person per day for drinking, washing, bathing, and all other uses.

Yukon-Kuskokwim Health Corporation spokesperson Mitchell Forbes said CDC does offer another option.

“They have pretty in-depth hand-washing guidelines that are the standard. With warm soapy water you wash your hands for 20 seconds, you sing happy birthday twice,” Forbes said. “But one of the guidelines that they include is, if you don't have access to running water, 60 percent alcohol hand sanitizer is in most cases sufficient enough to thoroughly clean someone's hands.”

Infectious diseases reach remote rural communities later than more urban cities. This is a scene near the village of Tuntutuliak in western Alaska, which is accessible only by boat, plane, and snow-machine.

When COVID-19 does arrive in Indian Country, some of the places it lands will be areas without long-standing systems of reliable access to primary and specialty care. In some places, it will land amid people living in conditions that contribute to higher rates of infection. Properly handled, however, risk can be minimized.

Chuck Sams, who is Cayuse, Walla Walla, Cocopah, and Yankton Sioux, is communications director for the Confederated Tribes of the Umatilla Indian Reservation in Pendleton, Oregon. On Monday, within hours of being notified a casino employee was ill with coronavirus, the tribe closed the resort and casino for 24 to 48 hours for a deep cleaning. Out of an abundance of caution he said they closed tribal offices, an educational center, head start and daycare center, and school. He said tribal leaders followed their emergency plans, and kept the focus on what steps needed to be taken to ensure public health and safety. Tuesday the tribe issued a statement that “Risk continues to be low” for the Confederated Tribes of the Umatilla Indian Reservation.

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Joaqlin Estus, Tlingit, is a national correspondent for Indian Country Today, and a long-time Alaska journalist.

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