The next day aboard Air Force Two, Irum and I flew into Duluth, Minnesota. We were back out on the road, into the Northern Plains states and the Upper Midwest. We went where weather patterns and Covid-19 outbreaks told us we needed to be to get ahead of the pending surge. Fall and winter would soon be arriving in the Northern Tier states. We wanted to ensure that governors, mayors, health personnel, and tribal nations were prepared for the surge we saw coming; we had to share with them what we had learned from our previous trips, to the Sun Belt and the Midwest: Reopening safely was possible. Staying open was possible with active testing, masking, and avoiding unmasked indoor gatherings. Scott Atlas’s anti-testing message put them in peril. Proactive testing would lead us away from another surge.
During this trip, I reflected on our prior time away from the White House and how this upcoming round of state visits, and, specifically, of tribal nations, had been impacted by the previous visits we’d made throughout July and August. Along with the fifty states in the union, the United States is also made up of 574 federally recognized tribal nations, and just as the states were not a monolith in their response, this was even truer for the tribes. The pandemic affected people and communities differently; the damage Covid-19 was doing to people’s physical, emotional, and economic health was disproportionate, especially so for the tribal nations. In many places, the nations were ground zero for severe Covid-19 disease. After nursing home residents, the tribal nations were experiencing the highest case fatality rates of any race or ethnic group in the United States.
On this visit to Minnesota, we’d scheduled a meeting with members of the Fond du Lac Band of Lake Superior Chippewa. This wouldn’t be our first time on tribal lands. Our tribal visits had become a critical part of all our state visits, starting with our first trip back in June, when we met with President Martin Harvier of the Salt River Pima-Maricopa Indian Community in Arizona. To varying degrees, the 574 tribal nations have historically been underserved by public health agencies in this country. Those early meetings on the ground gave us a crucial window into some of the unique complications these nations were facing in their response to the pandemic.
Several factors were contributing to a high rate of significant disease and population-based fatalities among the tribes: multigenerational households, comorbidities, and economic issues being the most prominent. Poverty was deeply entrenched in many of these communities, contributing to the pandemic’s toll in myriad ways. At the start of May, the Navajo reservation across Arizona, New Mexico, and Utah had the third-highest per capita rate of Covid-19 infections behind New Jersey and New York, but the highest fatality rate. This trend continued, in surge after surge. We’d taken steps to intervene, as had the tribal nations themselves—with varying degrees of success. But the work was ongoing, and we needed to better understand the nations’ needs and efforts, so we could be more supportive and they could be more effective at battling the pandemic.
On the economic side, the news for all tribal nations was equally concerning. Many of them had improved their economic prospects over the last thirty to forty years by operating more businesses, including casinos. But because of the pandemic, many of these critical enterprises had to be shut down, cutting off employment opportunities. Also, much-needed revenues to fund tribe-operated services (law enforcement, public safety, and social services) had been greatly reduced. Many tribal-led businesses also shut down as the tribes imposed strict mitigation measures to prevent as much community spread as possible. The two-trillion-dollar CARES Act provided eight billion dollars to offset the economic impact of the virus to the tribal nations, but some of that was through the Indian Health Service, at HHS. But money sent directly to the nations, with its many strings attached, was often late and difficult to access. As with so many aspects of this crisis, we knew that what we were learning through looking and listening—what would be written up in a general summary—might not accurately reflect what was truly happening in a given locale.
President Harvier served a population of some 11,000 people who represented three pre-Columbian sovereign Indian tribes, the Pima, the Yaqui, and the Maricopa. Unlike other groups who had been displaced and moved, these peoples had a long history in the area. On our visit back in June, we had met with the president and several council members who helped administer services to their community, half of whom lived on reservation lands.
These officials saw their primary mission as implementing the CDC’s Covid-19 guidance, but one of the challenges they faced was the presence of significant underlying comorbidities among their members, including diabetes. Many tribal nations had the highest incidence of that potentially deadly condition of anywhere in the world. Patients needing dialysis were placed in triple jeopardy, with this significant comorbidity increasing their vulnerability to serious Covid-19 disease. Patients had to test negative for Covid-19 before being allowed into the dialysis clinic, but there often weren’t enough tests available for them to get negative results in time—a catch-22 that boggled our minds.
The Pima and Maricopa required very specific tests—the Abbott ID NOW or the desktop nucleic acid test, with results in fifteen minutes or under—to match their needs. But much of these critical supplies were going to large metropolitan-area hospitals with many testing options when they should have been going to the tribal nations and other disadvantaged communities across America. This problem was a subject of my running dialogue with the testing czar Brett Giroir. I needed to know why nearly 25 percent of all the test cartridges were going to California’s large, well-served hospitals and another 15 percent were going to CVS and Walgreens. In the case of those two retail outlets, none was located on the reservations. Test type had to be aligned with the unique needs of each community or population. Covid-19 underscored the public health crisis these tribal groups had long endured, and was another reminder that the United States needed large-scale reform to its public health system to be able to mitigate multiple future health crises.
The Pima-Maricopa health services people were doing a good job of tracking the infected, but they had encountered issues on multiple fronts: With insufficient laboratory personnel, notification of positive tests was often delayed, sometimes by more than two weeks, allowing the virus to spread. Similarly, there weren’t enough qualified, experienced public health officials integrated with the state’s health systems, which meant those systems had been operating from a deficit from the outset of the pandemic. This had been true for years before the pandemic. As a country, we had chosen to run two systems, with the public health system as a parallel stream to overall clinical care, creating inefficiencies and duplication of personnel, data, and other information. These systems needed to be integrated, with one common data set and analysis and with the data transparent and available to the public. We had learned from the hospitals that they were willing to provide real-time data to a national system, something that could be done without violating HIPAA rules. There were synergies that could improve the nation’s health. We just needed the will to enact them.
The antiquated Indian Health Service was another problem. A federal program created in 1955 as part of the Department of Health and Human Services, the IHS had been designed specifically to address the health needs of native peoples. Unfortunately, it wasn’t always as effective as it could have been. At times, it even appeared paternalistic, believing it knew better than the tribal health officials on the ground.
With the Gila River tribe and the Yaqui in Arizona, we had heard variations on the same theme. Tribal officials were being as proactive as possible in the face of severely limited testing kits and supplies, but when tribe members needed treatment, they had few options. Many IHS programs and local hospitals were often felt to be discriminatory and stigmatizing. Native peoples we spoke with talked about overhearing doctors and nurses talking about them outside their curtained hospital beds or at nurses’ stations, making assumptions about alcohol and drug use.
As a nation, as those involved in public health, we needed to apply what we had learned in Arizona. There were clear benefits to having culturally sensitive health clinics and hospitals funded by the IHS but staffed and run by tribe members themselves. While I’m certain there are many well-intentioned Anglo members of the IHS, Irum and I heard enough offhand remarks and entrenched perceptions from those providing these services to know there needed to be a change. Expectation and execution match up far better when programs are run by the same people whose needs are being served.
Even where available supplies allowed tribal nations to better track and test, safe spaces for the infected to isolate were severely limited in number. Not only was housing scarce, but the housing that did exist was often substandard. Poorly ventilated structures containing multiple generations were highly problematic in the face of a virus that lingered in the air—just as secondhand smoke had done in bars and restaurants before indoor smoking in such places was outlawed.
Those we spoke with also pointed out an inequity inherent in the tribal system. Their lands were held in trust by the federal government. This meant they didn’t actually own the land, and therefore lost out on the other important benefits of landownership. For this reason, building or updating a home became a futile endeavor. After all, you can’t accrue equity on a property you don’t own.
Irum and I had both spent a lifetime addressing this cascade of overlapping structural issues in Africa and elsewhere. And in the two weeks just before our flight to Minnesota, we’d seen how the same constellation of issues played out in Oklahoma. The Muscogee (aka Creek) Nation, the fourth-largest tribe in the United States, resided in this state after having been forced west from parts of various southeastern states in the eighteen hundreds. In time, they would develop their own college, build a long-term-care nursing facility on their reservation, provide social services to their tribe, and in partnership with Oklahoma State University, establish the first tribe-affiliated medical school to instruct and train doctors who would go on to serve their community. This was a real success story. The Muscogee (Creek) were finding local solutions to the issues they faced. In the near future, with a deep understanding of and respect for the cultural needs of their patients, they’d be able to fully care for their own.
But in mid-August 2020, the Muscogee (Creek) were experiencing a test positivity rate of 21 percent. This would rise at the end of the month to nearly 67 percent—nearly 95 percent higher than the state-level rate—illustrating not just the depth and breadth of community spread but also the fundamental lack of tests. Irum and I saw a photograph of a local, indoor funeral where unmasked people stood shoulder to shoulder, mourning the loss of one life while potentially instigating the loss of others. That image ran counter to what the Muscogee (Creek) had intended with their Protect Our People program, which called for masking, physical distancing, and outdoor gatherings only. Whether this funeral was typical or atypical didn’t really matter. It was a possible source of spread, and tribal leadership was aware of it. The leadership knew their issues and were working every day to find their own solutions. Still, our message of heightened vigilance needed to reinforce the risks of this kind of lapse.
We met with the leadership of several Oklahoma tribes in a casino ballroom in Norman, just outside Oklahoma City, sitting physically distanced around an enormous oblong table that filled the ballroom. The Oklahoma tribal leaders expressed some of their concerns and let us know they had just canceled one of their most important cultural events: a triennial dance ceremony. For months, in fact, they had been canceling similar such gatherings. Stomp dancing played a critical role in the cultural and religious life of the larger community. Their not holding this dance ceremony was on a par with the rest of the United States stopping all in-person religious services and canceling a major national holiday like Thanksgiving. The dance ceremony was a time for reflection and sharing, when the tribes’ sense of community spirit was cemented, a time of renewal. The tribal leaders in Oklahoma knew what needed to be done to limit the spread of Covid-19, and despite the pain and disappointment of missing out on this ceremony, they’d made the hard choice.
Amid all the discussions, Irum and I were struck by a comment one participant made: “Men see challenges, and women want to find solutions.” This lingered for us both. One of the solutions tribal leaders were hoping to find was to a problem facing the Iowa Tribe of Oklahoma. The Small Business Administration was enforcing arcane regulations (predating the pandemic) that prevented funds from being disbursed to businesses when employees worked from home. It was yet another area where Covid-19 guidance and other administrative regulations got tied up in knots. This was information we would take back to the White House. The issues we had confronted during our state visits spanned public health, the economy, and agency regulations—basically, all issues that come together at the White House and can be resolved at that level or at a specific agency. Each time I wrote to Intergovernmental Affairs or to the heads of other agencies, these issues were often addressed. The small changes enacted at that level made a big difference.
The Oklahoma tribes were also deeply concerned about where to relocate infected and exposed members of their community. With the casinos the tribes operated mostly shut down, they were using the casino hotels as housing for isolated quarantined individuals. They were finding a way, but overcoming the inequities inherent in the U.S. government’s long-standing treatment of native peoples and people of color wasn’t going to be accomplished easily. My eyes had been opened to their reality, and I found memories of my experiences in Africa rekindled. It was sad that it had taken this new global pandemic for me to become aware of conditions that existed right here in the United States.
In Africa, we had had to work at the local community and county level to ensure that resources and services were aligned with need. Sometimes, we found that several counties were dramatically underfunded by host governments, almost exclusively in locations where opposition to the government was strongest. As soon as we discovered it, we aggressively addressed this inequity in funding and services, using U.S. funding and resources to realign the balance, overcoming whatever political beliefs or ties were preventing equitable treatment. This is what is possible when you use the most granular data in real time.
What was happening among the tribes in Oklahoma and elsewhere wasn’t directly tied to the members’ political agency or to their voices on things like elections, but to the long, tragic history of mistreatment native peoples have experienced in this country. While it would be difficult for the United States to move out of this entrenched path, and though the structural barriers history had put in place seemed insurmountable in the moment, I was certain that with constant attention, the right policies and resources, shared partnership, and mutual accountability, the full force of the IHS and its affiliated subagencies at the federal level and similar groups at the state level could surmount them.
As much as most Americans were wishing for a return to normal at this moment in the pandemic, I couldn’t wish the same for any of the tribal nations we visited. We should neither accept nor return to the business-as-usual of 2019. Instead, we should expect a better new normal, one that addresses structural barriers to care and uses data to chart improvements and identify new gaps. In a better new normal, we would work toward decreasing comorbidities and ensuring that all Americans, no matter where they lived, could thrive. Yes, this sounds overly optimistic, impossible perhaps, but as I have learned from battling the HIV/AIDS pandemic, often what many believe impossible is actually possible if we listen, hear, understand, and support local communities.
IRUM AND I WERE reflecting on all of these lessons from our prior visits to tribal lands. Riding in a truck in Duluth, I watched as many small lakes flashed past the passenger window. I squinted into the glare of a late-August midday sun. We were about to meet with the leaders of the Fond du Lac Band of Lake Superior Chippewa, our first stop after deplaning. Jostled by the ruts in the dirt road our tribal driver was traversing, I saw a native family in a canoe in one of the lakes, in a patch of tall reeds near the shore.
“What are the people in the canoe doing?” I asked our driver.
“Harvesting rice.”
“By hand?”
“Yes. We’ve been doing it this way for centuries. It’s part of our tradition. It’s a way to maintain the long roots we have to our land and to our past.”
I had had no idea this kind of farming was still taking place in America.
“Perfect,” I said, and smiled.
Irum and I looked at each other. I could tell she was having the same thought: This was the first time she and I felt really at home working for the domestic Covid-19 response. For two decades, our work had been focused in Africa and Asia. We’d worked in similar communities, places where the continuity with the past was readily apparent, where people moved forward in unity, sharing a strong cultural identity.
I’d done my homework, but as the truck slowed and pulled into a clearing, I was both eager and anxious. I wanted to see how those two elements, history and culture, were being lived out on the reservations, but I was wary of how a representative of this White House, a member of the federal government, a body that hadn’t always dealt fairly with the native peoples, would be received.
In the clearing, several pickup trucks sat parked side by side. Masked and socially distanced tribal leaders stood waiting for us. After a brief (carefully distanced) round of introductions, I made a few opening remarks. I thanked them for agreeing to meet with us, and then gave a brief overview of what I’d seen and read. I told them I hoped to learn much more from them. Initially, my words were met with silence and dispassionate regard. A few people expressed their appreciation for our being there and said they were willing to listen. That’s when their apparent dispassion turned to passionate engagement.
The conversation began with a summary of what they’d been doing. Prior to the pandemic, the Lake Superior Fond du Lac Chippewa had created their own culturally appropriate and sensitive health services on the reservation, free from stigma or discrimination. They had elder care, community centers, early childhood education support, broad social services, and addiction support services. This tribe had been solution-oriented before Covid-19, and was still so in the midst of Covid-19. Over time, the Fond du Lac Chippewa and others we’d visited had recognized the need for greater agency over their social support services, public health, community health, and other aspects of their lives. They didn’t need another distanced layer of federal bureaucracy to manage their affairs. They needed sustained funding for the programs they had but also for programs they had established that were responsive to their unique population. Their accomplishments up to then could serve as a road map for other tribes to establish their own internal services. I was very glad to hear they had mandated mask wearing to enhance their physical distancing efforts. But they understood that these two things alone wouldn’t be enough.
They had heard the message on silent spread, and because so many of them lived in multigenerational households, they were keen to be as vigilant as possible with testing. As we had heard across the Southwest and Midwest, the tribal nations in the Upper Midwest did not have enough tests to combat community spread. They needed testing today, to mitigate their ongoing daily risk, and they needed results immediately, so they could isolate infected family members as quickly as possible. Tribal members also wanted to test more frequently and more widely—many of their younger members worked and interacted with people from the towns surrounding their tribal lands.
Despite the need, in many cases the IHS limited the tribes’ access to, or rationed supplies of, the rapid nucleic acid tests and rapid antigen tests Abbott had produced. As a result, the lag time between sample collection and test results was far too long. Without knowing who among them was asymptomatic or even presymptomatic, they weren’t able to isolate the early infected cases, and the virus had spread unrelenting through entire households, getting to those with underlying conditions that made them susceptible to severe Covid-19 disease. Complicating matters were the limited spaces available in which to quarantine. They had to get the infected out of the household, but had few places to relocate them.
It was heartbreaking to know that the sense of community and family the tribes cherished was a significant part of what was putting them at additional risk. There are many benefits to having several generations living under one roof—but with Covid-19 those benefits became a glaring weakness, with negative, sometimes fatal consequences. We had the tools to change this: testing and indoor masking for ten days if isolation areas could not be found. There were other commonsense solutions, but it all came back to testing and identifying who was positive.
These testing issues were particularly frustrating. We were failing tribal nations (and people elsewhere) who were making the behavioral changes we had hoped they would. The Fond du Lac Chippewa had imposed mask mandates. They were social distancing. They wanted to get tested. Having closed their casinos, they’d sacrificed one of their major sources of income, one that funded many of their programs. As with other tribes, their CARES Act funding, in comparison with state-level help, had taken two extra months to reach them. Instead of fully supporting this vulnerable group of people, the federal government was failing them. Again, we took this issue to Secretary Mnuchin, and he addressed the problem. Ever since the early March travel ban debate, he and Larry Kudlow always saw all sides of the issue and supported public health mitigation.
As the case of the Fond du Lac Band of Lake Superior Chippewa illustrates, producing more tests doesn’t mean they’ll get where they’re needed or that the tests will be appropriate for the particular population. As was the case in the United States overall, the tribes were, effectively, kept from using the rapid antigen tests because both the CDC and the FDA remained united in their preference for the nucleic acid tests, which had a longer turnaround time. The CDC didn’t think comprehensive, aggressively proactive testing was necessary, and the FDA didn’t think the antigen tests were as effective on asymptomatic individuals. Because of these objections, this critical frontline point-of-care test remained woefully underused. The antigen tests would have addressed many of the tribes’ concerns about supply and would have been the most effective at quickly determining the early onset of an outbreak. Rapid point-of-care tests weren’t perfect but they were better than nothing, and just then many areas of the country had nothing.
Throughout our travels, Irum and I were able to convince some local leaders to make full use of the rapid antigen tests to identify and mitigate early community spread, but it was a constant battle—one that lasted for months, until the summer of 2021, when the FDA finally recognized the undeniable fact that these tests could detect antigens for SARS-CoV-2 in the noses of the asymptomatic as well as the symptomatic. The tests (the very same ones we had in 2020) were finally made available for at-home use, but we lost twelve months. These tests aren’t perfect, but they would have constituted a good, commonsense approach. Once again, the good was lost to the need for the perfect.
Brett Giroir continued to answer my calls and emails from the field and worked to send more tests to the tribal nations and to the historical black colleges and universities throughout the late summer and into the fall of 2020. Aligning the specific type of tests with the unique needs of communities was a problem throughout 2020 and 2021.
During our discussions, the Fond du Lac Chippewa’s chairman, Kevin Dupuis, made an important point. As much as they had been able to enact measures to serve the needs of their own people, and despite living on a reservation, the tribe’s members weren’t completely isolated from the rest of the state. The mitigating measures Minnesota had put in place did have an impact on them. Members of the tribe who worked outside the reservation interacted with members of the larger community. Far too often, Americans seemed to forget that their actions, the personal choices they made, had consequences that extended beyond their own lives and the health and well-being of their families. The ripple effect of their actions extended out into their neighborhood, into the larger community, and far beyond.
Minnesota’s governor, Tim Walz, had issued shelter-in-place orders in late March, and these remained until mid-May, despite President Trump’s tweeting in mid-April, “LIBERATE MINNESOTA” (just as he’d done with Michigan). I had made several trips to Minnesota to understand what was driving the relentless infection rates in certain areas of the state. Jan Malcolm, the state’s health commissioner, and Ruth Lynfield, its epidemiologist, were both extremely dedicated. As was true elsewhere, Minnesota had great public health leadership, smart technical personnel, and brilliant physicians and nurses. The state government had gotten out of the gate aggressively. Still, health officials were never able to find the precise communities of ongoing spread and mitigate against them.
In Minnesota, looking at average case numbers and statewide seven-day averages, it was clear that the state was controlling the virus. But as was often true for this pandemic, those figures hid the silent spread in specific communities, rural areas, and in vulnerable pockets of Minneapolis, and continued to result in ongoing fatalities. We had seen the same thing with HIV/AIDS. When you use high-level data and statewide trends, it can hide pockets of infection, areas where you weren’t successful. To identify such places, you need deep data disaggregation—that is, the separation of the data into smaller units to shed light on underlying patterns and trends. The right data can make the invisible visible.
The Fond Du Lac tribal leadership was also concerned about neighboring Wisconsin. It wasn’t until July 2020, with case rates rising rapidly, that Governor Tony Evers issued a statewide mask mandate. This was, unfortunately, met with protests and condemnation, a painful reminder that not everyone shared the community-minded spirit necessary to ensure full mitigation against this insidious virus. Masking in indoor spaces made those spaces safer for those with underlying conditions—essentially, making those spaces accessible to everyone, not just the invulnerable and the young. Masks weren’t about limiting freedoms, but expanding freedom of access for everyone. If individuals chose to unmask at their friends’ or family gatherings, that was their decision, and it impacted only those who voluntarily chose to be there. Taking a personal risk in private is one thing. Making public spaces unsafe for others is quite another.
By placing the welfare and needs of the many ahead of the desires of the few, the Fond Du Lac tribal leadership and people stood in stark contrast to those who chose not to. It hasn’t always been this way. I have seen a more unified spirit in the United States many times. When natural disasters hit a state, or even another country, Americans are generous with their time and money. During 2020, I frequently wondered why this crisis hadn’t produced that same sense of unity and support—the kind of support we’d seen rallied in the New York City area at the beginning of the pandemic, in March 2020, with volunteer health workers and others coming from across the country to lend a hand. Yet, as the virus moved across the country, into regional surges, this spirit of unity and togetherness seemed to have vanished.
AFTER A WEEK ON the road, Irum and I returned to Washington with insights that would shape the next phase of the response and solutions we’d disseminate to the states through our weekly governor’s reports. At the time—but more so in hindsight—we recognized that our visits to the tribal nations had provided a road map for a more comprehensive, culturally sensitive approach, one that didn’t cost more but that required a willingness to listen and to do things differently. Whether programs and services were aimed at minority or majority populations, they needed to be decentralized and recalibrated to the diversity and vastness of the United States. One size and one policy did not, would not, fit all.
The road trips were grueling, and during them, I still had to attend to many other issues that cropped up daily, but my exhaustion abated with every meeting with state officials and others. We were learning what was working from each and every meeting. We could make a difference. A few times people in the states recognized me and offered their thanks for the work we were doing. It was a small gesture, but it made a big difference to my morale. Whether or not my efforts produced perfect results, I needed to feel I was making a difference, even if only a small one every day, that what I was doing mattered. And you just couldn’t know that from the isolation of the DC bubble.
Before our fact-finding mission to the states, several people from agencies in DC that helped manage tribal nations’ affairs told us that the tribal nations “can’t” or “won’t” do such-and-such, that they were resistant to or incapable of managing their own resources and public health. Our experience was the opposite. Sure, the tribes were sometimes resistant to measures being imposed from above. They’d experienced years, decades, of this management strategy failing them. For that reason, they were finding their own ways, their own solutions, addressing their own needs. They didn’t need more federal agencies telling them what to do. They wanted more local control. They wanted to engage in dialogue, a partnership, as Irum and I had done with them.
My experience on tribal nation lands in Arizona, Oklahoma, and Minnesota reinforced what I’d experienced in the military working on the HIV/AIDS crisis at home and then globally: If we talk through the issues together, we can find solutions that will work on the ground. More federal agencies were needed on the ground, not just in Emergency Operations Centers. Back in the 1980s, when Tony Fauci invited AIDS activists to his home, and they sat down at meals together, they’d discuss the issues and reconcile their conflicts. This gesture by Tony totally shifted the perspective that the government and the medical establishment didn’t care about finding a solution to that crisis. And these weren’t one-off discussions, but discussions that took place over months and years, that built trust. We had used this same approach at PEPFAR across the globe. This is what our federal agencies needed to do—not just for the Covid-19 crisis, but to address long-term health disparities and frailties across the United States. As became clear to me throughout the 1980s and my time confronting global pandemics, governing of any kind works best when we work together at the community level.
CDC personnel needed to be not in Atlanta, but embedded at the state level, working alongside their state and local counterparts, learning from them and ensuring that CDC guidance is clear, culturally appropriate, steeped in common sense, and implementable. The agency needed to see the solutions on the ground and bring those back to the federal level, sharing best practices in public health across the states.
For all the nuances among the various tribal nations we met with, one thing we heard consistently was fear of the approaching fall and winter, a fear that mirrored my own. Prior to the pandemic, the tribal nations had frequently felt isolated. Covid-19 had only heightened that sense. The pandemic was approaching the point at which it would become even more debilitating, especially as winter closed in and we saw the effects of the federally induced lack of preparedness during the spring and summer surge.
Later, in October, Irum and I would expand the scope of our learning by visiting tribal nations in the western United States. The threatened fall surge was emerging, and once again, need dictated where we traveled.
IN THE APTLY NAMED Wind River Hotel and Casino in Wyoming—you haven’t experienced wind until you’ve experienced Wyoming’s wind—I saw how, out west, geographical distances are great, but bonds are close. The reservation on which the Northern Arapaho and Eastern Shoshone tribes lived comprised 2.25 million acres. Tribal members dated their tribes’ history back centuries, when they were spread over large areas of the Rockies. As with other tribal nations we’d met, their land was held in trust by the U.S. government, so the tribes couldn’t use it as an investment or for most entrepreneurial enterprises, which exacerbated the cycle of poverty. The tribe needed a viable economic engine that would help drive better public health care and quality of life. As one administrator put it, referring to the aid the United States provided Western Europe to rebuild after World War II, “We need a Marshall Plan.”
A 50 percent unemployment rate across the tribes, seven hundred diabetes patients being treated at one local clinic, and a decline in life expectancy from fifty-three to forty-eight years—all these explained the decrease in the median age for residents to twenty-one. As several local tribal chairmen pointed out, if the comorbidities or Covid-19 didn’t take residents, diseases of despair would. Even before the coronavirus pandemic struck, substance abuse (alcohol, methamphetamine, heroin), murder, and suicide—real public health issues that hadn’t been addressed over the decades by the federal agencies—were already decimating the population.
As is often the case in the United States, it was a tale of two cities—in this case, two tribes—experiencing the best and the worst. The local tribe-led clinic’s special designation by the federal government’s Health Resources and Services Administration (HRSA) as a “Tribal and Urban Indian Health Center” got the Northern Arapaho access to federal dollars and support. The HRSA directly funds about 25–50 tribal-led clinics across the country, putting tribal communities in charge of executing their own culturally sensitive health care. Because the tribe operated its own clinic, Tribal Health, they were able to move quickly to get testing supplies and conduct their own mass testing of their tribal nation citizens. The IHS was not able to move as quickly, and therefore was delayed in supporting the Shoshone in their testing program.
At the time of our visit in late October, both tribes were tired, but the Northern Arapaho felt they could do even more proactively to prevent uncontrolled spread of Covid-19 among them. It all came down to more testing, and the Northern Arapaho were moving and could do more. Their very proactive IHS team understood partnership and were supporting the tribe from behind, instead of dictating to them. In contrast, the Eastern Shoshone were weeks and hundreds of tests behind, with greater viral spread and greater fatalities. Managing quarantining and isolation was taking a toll on the Shoshone’s limited human resources, including contact tracers, who had to advise how the infected should isolate in multigenerational homes, as they, too, were running out of space.
One thing was clear for both tribes: they believed all members of the tribe were their family. For this reason, they thought holistically about the services they needed and worked with suppliers to make sure there was enough food and shelter. With the Wind River Reservation officially “closed” due to the pandemic, regular communication with the people living on it was crucial for conveying the appropriate actions they needed to take to protect themselves. With the BinaxNOW rapid test recently made available in the state, we recommended that local and state health officials make distribution to the tribes an immediate priority.
As always, the great lessons of our meeting were followed by the reality of the daily risks the tribal members were facing by gathering together. A day after the meeting, we were notified that one of the leaders we met with had tested positive for SARS-CoV-2. Because our masks had never come off during our several-hour sit-down, we were pretty certain we were negative; still, the anxiety was there. Irum and I didn’t have easy access to testing on the road, and we didn’t want to use the limited state testing supplies. So, we checked constantly to see if our sense of smell or taste had changed, early symptoms of Covid-19.
We moved farther west, meeting with the Wyoming Shoshone’s sister Shoshone tribe in Idaho, who reside with the Bannock Tribe on the Fort Hall Reservation. The clinical director and I accompanied Devon Boyer, chairman of the Business Council, the tribe’s governing body, to our meeting. Three different agencies managed the reservation’s health clinics: the IHS, the Shoshone-Bannock Tribes Tribal Health and Human Services Department, and Federally Qualified Health Services (FQHS). Chairman Boyer was keen on testing, but again, supply issues had hampered those efforts. Testing was especially critical here. Since July, 46 percent of the deaths on the reservation were related to Covid-19—many times the percentage of New York City during March and May 2020.
To help the tribes reverse this trend, we asked the CDC to send staff to show them how to conduct testing on the reservation using the BinaxNOW test, asking for specific staff who had worked overseas in PEPFAR programs, staff whose practical experience matched the needs the tribal nations had expressed. Practical and solution-based personnel willing to listen and innovate with the community. These teams worked alongside each tribe to increase testing and quarantine options and provide isolation support. I had recognized the need for this kind of deployment of CDC personnel early on, even before I set foot in my first White House task force meeting.
We learned in our meetings in Idaho that, as with federal government on the whole, the Indian Health Service is only as good as its frontline representatives, its physicians and nurses. In the case of the Shoshone-Bannock Tribes, the local IHS team comprised progressive, innovative problem solvers who were united in deep partnership with the tribal chairman and other leadership. This team of IHS personnel knew the importance of listening in order to better understand, and of not bringing a standard stovepipe approach to the tribes’ unique needs. The IHS system may have been antiquated, but those working within it were, for the most part, passionate people working hard despite the limitations imposed on them by the bureaucracy. This IHS group was willing to learn, and so, the outcomes and impacts were greater.
We saw this across the western states we visited. In places where the IHS representatives were culturally sensitive and willing to listen and adapt, they were able to create a partnership and plans that effectively addressed the specific needs of a specific group of a specific tribe. They weren’t stuck on past perceptions or prior instincts.
I began to realize that the cultural trend of celebrating the benefits of failure had some merit. So much had gone so wrong for so long in the indigenous communities that they were willing to be open to new ideas. Within the CDC, the NIH, and many other public health agencies, so much had seemed right for so long that rigid use of past approaches had set in. The CDC excelled at outbreak investigation—tracking the source of a salmonella outbreak to a specific type of lettuce or spinach by tracking and tracing back to patient zero and then to the field. But with the pandemic, the agency was mired in the pandemic preparedness they themselves had set up. It wasn’t working perfectly, but no one wanted to admit this and find new solutions. But this inflexibility was keeping us from fully responding to the unique needs and specific barriers to wellness in state after state, county by county, tribe by tribe.
With a raging pandemic, there is no such thing as “good” news. Progress in one area is always met with deterioration in another; or it uncovers a new gap. And any progress you place on the scale can’t counterbalance the reality of lives lost needlessly. In examining the response of the tribal nations, I found areas of their approach that the states could learn from. Irum and I both felt an overwhelming sadness at how native peoples had been treated historically and how they were being treated during this pandemic. But after a long history of being underserved, at best, and largely ignored, at worst, the tribes didn’t seem to dwell on the fact that the government agencies didn’t serve them well. They had accepted this reality and crafted a new one for themselves, adapting and working over, around, and through obstacles that would have thwarted other groups.
We had seen the same can-do resilience in West Virginia and in the Covid-19 response team led by Governor Jim Justice, with critical insights from the state’s coronavirus czar, Dr. Clay Marsh. West Virginians believed they couldn’t rely on the federal government to support them, and like the tribal nations, they had come up with solutions on the ground that worked for them.
While many other communities felt they were too infrequently seen or heard by the federal, state, or local government, tribal chairmen and leaders—rather than resorting to denial, anger, or resignation—had taken a proactive, comprehensive approach to defending themselves against the ravages of the coronavirus. Certainly, they felt those emotions, but they moved forward as best they could nonetheless. This was especially important with rates of comorbidities in their communities so high.
The tribes drew on cultural memory as well, and had developed the mentality of “We can’t let this happen again.” According to a 2017 CDC report, tribal nations in the United States experienced to a far greater degree the effects of the 1918 Spanish influenza pandemic. They experienced an astounding 24 percent infection rate and had the highest death rate of any racial or ethnic group, losing 2 percent of their total population. More recently, in the 1990s, the hantavirus killed 75 percent of those infected. Nearly half of those who died were Native American. Yet this data, knowledge of these health disparities, had not transformed the federal response, and by the time the novel coronavirus arrived, the tribal nations were at the same starting point.
To combat the risk from within and without their reservation, the Fond du Lac Band of Lake Superior Chippewa took a culturally appropriate approach to its messaging. Taking the notion of “one blanket”—the historically suspect but metaphorically accurate belief that all it had taken was one blanket weaponized with the smallpox virus to wipe out a Native American population—they re-crafted it to remind their people not to let the coronavirus response be that one blanket. The historical resonance of this idea was clear and effective.
This sense of shared history was reflected in the tribal nations’ more integral approach to the pandemic. The tribal nations had maintained their sense of community throughout the pandemic, from one tribe to another tribe, across the country. This was true whether they resided in red states or blue. They valued the wisdom of their elderly and believed that ties extended beyond the family, to the entire community. This desire to protect everyone in the tribe through shared sacrifice was something the rest of America needed to learn.