Ready or not? Warnings for tribes as COVID-19 epidemic spreads
The words Dean Seneca used took on a sense of urgency after the recent “damaging news” from the Centers of Disease Control and Prevention.
“I want to make sure that I stated that Tribes are not prepared for the coronavirus,” he texted Indian Country Today a day after an initial interview. The day before that he was more cautious, saying, “I don't think that we are as prepared as we should be.”
What changed? Two reasons: The infection rate and the amount of time a person is asymptomatic.
The first example of this was the Diamond Princess cruise ship incident where one passenger aboard, and one who left early, tested positive for COVID-19. A two-week quarantine resulted in 45 of the passengers who were then infected. These passengers left the cruise ship to go home on buses, subways, airlines, taxis, rideshares, or private vehicles.
Now we know “that people will have this virus, not show symptoms and still be able to transmit the virus,” he said. “That is scary.”
Usually viruses are contagious at the peak, he said. For example, in the first two days you’re slowing getting sick and on the third day, you’re at a height of an infection. People you come into contact with can get sick. It’s for sure.
But this person carrying this virus can walk around from day one to day seven and show no symptoms. “ I can easily transfer that virus over to you,” Seneca said. “And that's, that's very unique with this virus, compared to other similar infectious disease flu like agents.”
Seneca, who is the executive director of Seneca Scientific Solutions, brings more than 18 years working in the CDC’s Office for State, Tribal, Local, and Territorial Support and he has been on the frontlines of fighting epidemics like polio in Ethiopia and Ebola. He was a first responder to the h1n1 influenza virus. The Seneca tribal citizen also carries a masters in public health from the University of Hawaii at Manoa.
Seneca has a deep knowledge and experience with epidemics and he is concerned about Indian Country’s preparedness.
He said, the tribal epidemiology centers “don't have the capacity to do good surveillance for the tribes regarding this.” Seneca used to work for the Great Lakes Inter-Tribal Epidemiology Center. “We don't have links with our tribal health departments and/or state health departments in order to share data or real-time incidence, prevalence and any kind of mortality data or information related to this. Our systems are just not in place in order to do good active surveillance.”
According to the World Health Organization, a public health surveillance is where health officials can keep continuously and systematically collect, analyze and interpret the data that is needed to plan, implement, and evaluate public health practices. This can include early warning systems for public health emergencies, documentation of the impact of intervening and track progress, and monitor the epidemiology of the public health emergency that will help public health policy and strategies.
With 574 federally-recognized tribes, 12 epidemiology centers, a severely underfunded Indian Health Service, more than 320 reservations, and 5.2 million American Indian and Alaska Native people, there is a significant opportunity for imperfection and chaos when it comes to public health emergencies.
Kevin English, DrPH and director of the Southwest Tribal Epidemiology Center in the Albuquerque area, serves 27 tribal nations in New Mexico and Colorado.
English said the center doesn’t have access to the data at the state health department that would allow them to track the virus in real time. However, the tribe can request it from the state and the center is simply the liaison to make sure the community receives the data.
“States do typically share AI/AN data with us at the county level, which we can then utilize to identify hotspots, target outreach efforts, and monitor over time,” English said. “This type of data sharing may vary by state and [tribal epidemiology center].”
The center is currently educating tribal leadership, tribal members, and health care providers about COVID-19 using CDC educational materials.
So is the case up north where Oregon saw its third presumptive positive case of the virus. The the Confederated Tribes of the Umatilla Indian Reservation confirmed the case to be an employee at the tribe’s casino.
(Previous story: Oregon tribal casino employee 'presumptive' positive for COVID-19)
Victoria Warren-Mears, director of the Northwest Tribal Epidemiology Center, that serves Oregon, Washington, and Idaho. Washington has already seen six deaths as a result of COVID-19. She feels that tribes in her state are ready for the virus.
“What I can tell you is that the tribes do have preparedness planning. Anytime there's something new that comes up though there's definitely some feeling out of what strategies are the best for tribes and for just the general population to deal with that,” she said. “And so I think in general, tribes are fairly well prepared.”
The Confederated Tribes of the Umatilla Indian Reservation was prepared. And it was also great timing.
Chuck Sams, a spokesperson for the tribe, said the tribe had been on a conference call on Friday and Saturday with the CDC, the Oregon Health Authority, all the counties, and nine tribes. They wanted to lay out potential scenarios and establish an emergency management team.
Before those calls, the tribe had an approved public health emergency plan for epidemics and and pandemics from 2018. They also had an agreement with their local clinic with support from their county.
“And the plan paid off this morning,” he said. “We’ve been able to do table top exercises to prepare for it.”
The tribe received a call from Governor Kate Brown about the case of COVID-19 at 7 a.m. Monday and the person was an employee of the tribe’s casino. By 12 p.m. their Nixyaawii Community School, head start, daycare and senior center were closed as well as the Wildhorse Resort and Casino. Community events on the Umatilla Reservation were cancelled for the week.
The Navajo Nation also took the initiative on Thursday when the President Jonathan Nez and Vice President Myron Lizer established the tribal nation’s COVID-19 preparedness team.
The preparedness team consists of the Office of the President and Vice President, Navajo Department of Health, Navajo Nation Division of Public Safety, Navajo Nation Division of Social Services, Navajo Nation Department of Emergency Management, Department of Diné Education, Navajo Nation Division of Community Development, U.S. Indian Health Service, U.S. Bureau of Indian Affairs, and the U.S. Bureau of Indian Education. Nez wants to bring in the community health representatives so they can educate the elders they visit and coordinate with hospitals and clinics.
Nez and Navajo Department of Health Executive Director Dr. Jill Jim talked on one of their tribal radio stations, KTNN, to give updates and prevention tips.
“We’re bringing these entities together to ensure that we are communicating and coordinating efforts to educate the public. There are no cases of the coronavirus on the Navajo Nation, but this is a very serious health concern, and it’s vital that we continue to provide information with everyone, including students, elderly, and community members,” President Nez said.
The Inter Tribal Council of Arizona and California Tribal Epidemiology Centers have been disseminating information to their tribes within their states. California is also contingency planning and developing scenario-based exercises for their tribal health clinics. The Rocky Mountain Tribal Epidemiology Center sends out COVID-19 documents from the CDC and “daily key points” to the tribal health directors.
The Great Plains Tribal Epidemiology Center is working with their tribal, state, and federal partners to distribute information to the community and health care providers. “We have also been working to support cross-sector collaborations and alignment with these partners to ensure a coordinated and proactive response,” said Director PJ Beaudry.
Weekly updates are being sent out to tribal health clinic directors from the Great Lakes Inter-Tribal Epidemiology Center. Education and emergency planning activities are happening at their center. It serves 34 tribes, three service units and four Indian health programs in Minnesota, Michigan, Wisconsin, and Chicago. Medical epidemiologist and director of the center German Gonzalez said they requested participation in calls and activities with three different state health departments. “We have requested feedback from our tribes to address their needs,” Gonzalez wrote in an email.
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At the Puyallup Tribal Health Authority in Tacoma, Washington, Dr. Walter Hollow, Sioux and Assiniboine, said they’re ready.
“So our clinic is taking the stance it's not if the virus is going to reach our doorstep, it's when,” he said. They have a room to quarantine the infected patient away from the regular patients in the clinic.
“And if we determine that there's a strong likelihood that they have it, we'll take them from that world to one of the facilities nearby that is designed for quarantine,” he said. “Now all of this is in an attempt to continue to contain the virus, but as you're probably aware there's, unfortunately, increasing evidence that the virus is already spread out into the community. And so, we probably need to move from containment to treatment and minimizing the spread.”
They’re prepared for that, too. They have had the plan in place for over a decade and made modifications and updates to it over the years.
Dr. Hollow is also president of the Association of American Indian Physicians. They’re planning to talk about it at their monthly board meeting next week. Little was known about COVID-19 at their last meeting so they didn’t talk about it.
“Our mission is to help Indian Country respond to the health needs of the community so we will do anything that we can to support other organizations and tribal communities, as they need this on flop,” he said.
Abigail Echo-Hawk, Pawnee, director of the Urban Indian Health Institute and chief research officer for the Seattle Indian Health Board says this will hit the country's economy and Indian Country's.
"So we're possibly going to see economic impact, particularly as employees who either think that they have symptoms or diagnosed with coronavirus will not be able to come in and work," she said. "We need anybody who has symptoms to stay home. That's one of the things that's the public health concern too is making sure that people do have symptoms, they do need to stay home. So we need to ensure that they have the ability to do that."
In addition, she says we have to "think about the impact that has on the economic level" for all tribal and non-tribal enterprises that are exposed to the general public.
The resources needed to tackle this epidemic
Seneca said tribes need the resources to tackle this epidemic threat head on.
“The other is that our health care systems are really not in place nor do we have experts, as physicians and nurses that know or are familiar with this kind of foreign virus,” he said. “I just wanted to make it clear that we are not ready for this. We really are not ready for it now.”
Echo-Hawk stressed the need for Indian Country to be represented as funding streams are increased.
"As these emergency coronavirus is going on, we don't know what those funding mechanisms look like right now. But it is very likely they will emerge as people work to ensure that we can do whatever we can to control the spread of the virus,” Echo-Hawk said while at the Reservation Economic Summit in Las Vegas, Nevada.
She emphasized that when the funding mechanisms do roll out, “they need to ensure that there are the words and there is funding directed toward tribal entities including the urban Indian health programs because the tribes are going to need any kind of, you know, if there's opportunities for subsidies around economics that may have been precautions and other things going into the programs to ensure we have the correct medial supply and medical personnel.”
The National Council of Urban Indian Health sent a letter to Congress on Feb. 28, urging them to honor the trust responsibility to urban Indians. When passing emergency funding, the organization asked to include “Urban Indian Organizations” to prevent and treat COVID-19. They also requested “at the very least $94 million for emergency funding and health education/promotion” for urban Indian organizations.
Francys Crevier, executive director of the organization, said in a Mar. 2 press release, “As Congress moves forward on its consideration of funding for the Coronavirus-Covid 19, NCUIH would like to ensure that funds are available to our 41 urban Indian organizations. The U.S. government cannot allow UIO patients to die during a Covid 19 outbreak due to unavailability of critical services. UIOs operate on such low funding margins that interruptions in daily operations (including those leading to funding shortfalls) have dire effects and have been forced to close entirely.”
Urban Indian organizations receive their funding from one source: Indian Health Service. The entity only has one budget line for urban Indian health for the 41 urban Indian organizations in 22 states. According to the 2010 Census, approximately 70 percent of the American Indian and Alaska Native population resides in urban areas.
The AP reported yesterday that Vice President Mike Pence told state governors that money is coming for COVID-19 is coming. Florida Gov. Ron DeSantis said Pence told governors, “Do what you’ve got to do.” And the money will be reimbursed.
There’s already a known shortage of physicians in the Indian health system. Hollow agrees and says to an extent that this crisis could have an additional impact.
“So if there's a tribe that only has 50 percent staffing, obviously they're gonna struggle more than the tribe that is fully stacked,” he said. “Okay, yes, it could have an impact, but it would vary by tribe and location.”
He advises the tribes with the shortage of resources to start a planning committee to discuss the various ways they can meet the onslaught if the coronavirus enters their communities. He said they’re going to want to focus on containing the virus or moving on to treatment in isolation.
“That would be up to each tribe. And of course the tribes that are run by the Indian Health Service, they're going to have access to an epidemiologist, which will be very helpful,” Dr. Hollow said. “Contracting tribes usually don't have access to an epidemiology person unless they work closely with the health department in their county.”
That’s the challenge of the separate 12 tribal epidemiology centers across the country serving different tribes in different states. There’s no shared database.
“Unfortunately, yes there's probably no one place that's a clearinghouse for what kind of data, each epi-center has access to,” said Warren-Mears. “I wish there was but at this point in time we all have different kinds of access based on our partnerships with our states that we serve and, and, or the states that we're located in and the tribes we serve.”
Exercising tribal sovereignty
Seneca says tribes have additional tools that could be used.
“It's really the tribes responsibility to exercise its public health authority,” he said. “It shouldn't have to wait for the Indian Health Service or the Centers for Disease Control to make active measures that this virus is in their community, or not.”
The CDC is the public health authority for the United States.
An example of a tribe exercising their public health authority is not letting anybody within its borders if the virus is prevalent and outside the tribal communities.
Another instance is if the federal government or Indian Health Service was to isolate a tribe or block a road, the tribe has a right to intervene and say, ‘We need this road for our resources and services,’ Seneca said. The road can’t be blocked. Figure out the roles and responsibilities of the Bureau of Indian Affairs, surrounding counties and cities, especially when there’s not a strong emergency infrastructure.
“What I'm saying is that before the federal government puts any kind of public health restrictions or exercise in public health authority, it needs to consult with tribes on a government to government basis,” he said. “Let's say there is a pandemic and it does hit the United States, that does hit with the severity as it is in other countries. This will be the big issue for Indian Country. Where does public health authority lie and what is our sovereign right to exercise tribal sovereignty?”
Seneca encourages tribes to take on the responsibility rather than relying on outside entities like local, state, and the federal governments.
“We are the ones that hold our destiny," he said. “We need to make sure that tribal communities do our best and have the resources to build our own emergency preparedness and response efforts.”
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This story has been updated since it's initial publication. Last updated at 2:28 p.m. EST.