Nurturing Innovation at the Roots: The Success of COVID-19 Vaccination in American Indian and Alaska Native Communities

• Published in: American journal of public health (1971) 2022-03, Vol.112 (3), p.383-387
• Main Authors: Haroz, Emily E, Kemp, Christopher G, O'Keefe, Victoria M, Pocock, Katherine, Wilson, David R, Christensen, Loretta, Walls, Melissa, Barlow, Allison, Hammitt, Laura
• Format: Article
• Language: English
• Subjects: Air quality; Alaska Natives; American Indians; Biological warfare; Cardiovascular diseases; Colonization; Community; Coronary artery disease; COVID-19; COVID-19 - ethnology; COVID-19 - prevention & control; COVID-19 vaccines; COVID-19 Vaccines - administration & dosage; Cultural Competency; Diabetes; Diabetes mellitus; Documentation; Electric contacts; Electricity; Ethnic factors; Ethnic groups; Food; Genocide; Health education; Health Service Delivery; Health services; Health surveillance; Heart diseases; Hospitals; Housing; Humans; Immunization; Immunization Programs - organization & administration; Immunization/Vaccines; Indians, North American; Indoor air pollution; Indoor environments; Infectious diseases; Internet; Lung diseases; Marginality; Minority & ethnic groups; Mortality; Native Americans; Native North Americans; Opinions, Ideas, & Practice; Oppression; Pandemics; Poverty; Prevention; Public health; Roots; Smallpox; Sovereignty; Telemedicine; Tribes and tribal systems; United States - epidemiology; Vaccination; Vaccination Hesitancy - ethnology
• ISSN: 0090-0036; 1541-0048; 1541-0048
• DOI: 10.2105/AJPH.2021.306635

American Indians and Alaska Natives (AI/ANs) experienced some of the highest rates of COVID-19 disease and death in the United States1,2: an estimated 1 in 475 AI/ANs have died from COVID-19, in contrast to 1 in 825 White Americans.3 Infectious diseases have caused catastrophic losses among Indigenous populations since the first contact with Europeans; the distribution of smallpox-infected blankets by colonizers and federal officials is the earliest documentation of germ warfare and remains a devastating memory.4,5 The disproportionate impact of COVID-19 in AI/AN communities is a result of historically rooted systems of colonization, oppression, and marginalization.6 High rates of poverty, lack of running water, inadequate access to healthy food and transportation, poor indoor air quality, and overcrowded housing have all contributed to increased risk from COVID-19, especially on tribal reservations. Lack of electricity, Internet, and cell service, and inadequate infrastructure also created barriers to sharing prevention guidance, access to telemedicine, and health education. Chronic underfunding of the Indian Health Service resulted in insufficient resources and capacity to care for COVID-19 patients; many had to be transported off reservations to regional hospitals. High rates of underlying chronic health conditions, particularly those that contribute to more severe outcomes-including diabetes, heart disease, and lung disease, which are driven by these same social determinants-exacerbated the effects of COVID-19. Public health surveillance during COVID-19 has also failed at times to appropriately count and consider AI/ANs, an issue deemed "data genocide." Despite these challenges, the COVID-19 vaccination efforts in many AI/AN communities have been major successes; AI/ANs have the highest COVID-19 vaccination rate of any racial or ethnic group in the country (Figure 1). How can this success inform the ongoing implementation of vaccination efforts elsewhere? We draw from four decades of work in partnership with tribes to outline several key lessons. Ultimately, we argue that the COVID-19 vaccination effort in AI/AN communities has been successful because it was nurtured at its roots by a deep well of community strength and by respect for tribal sovereignty.