Donald WarneTribal communities have long struggled with disparities in health and services, from higher rates of mental illness to less access to health care. The coronavirus pandemic is exacerbating those gaps, leaving American Indian communities struggling to contain the virus and its impacts.

“Higher rates of depression, higher rates of (post-traumatic stress syndrome), higher rates of substance abuse and higher rates of suicide — that is the baseline,” said APHA member Donald Warne, MD, MPH, a physician and researcher at the University of North Dakota. “That's where we are as the baseline. Then throw on top of it, a pandemic.”

His comments came during a May 28 media briefing hosted by the Robert Wood Johnson Foundation and organized to highlight the health and economic impacts of COVID-19 on American Indians. Such communities have experienced some of the highest per-capita COVID-19 rates in the nation — even higher than in epicenters like New York and New Jersey.

During the briefing, Warne discussed how COVID-19 is straining an already-frayed health system and further threatening the health of American Indians. For example, despite already high rates of mental illness among American Indians and the added stress of COVID-19, mental health services remain scarce in many tribal communities. 

“If I allowed you to guess how many of the community mental health centers were located on reservations, it would be zero, believe it or not,” Warne said during the briefing. “Zero. And that's where the greatest need is. So, we have all kinds of challenges in terms of access to services.”

Such care gaps extend to medical care as well, with many tribal communities lacking the hospital resources needed to fight COVID-19, such as ventilators and intensive care units — that is, if they have a hospital at all, Warne said. While American Indians have a legal right to care via the Indian Health Service, he noted that IHS lacks the funds to fully meet the needs of its communities. 

“IHS is terribly underfunded if you look at the data,” Warne said. “Medicare, for example, is funded at over $12,000 per person per year. IHS is around $4,000 per person per year. So some of the outcomes of that, of course, are inadequate health services and inadequate public health programming.” 

On top of access-to-care gaps, tribal communities also face a number of inequities that make COVID-19 control and prevention even more difficult. For example, he said, inadequate housing makes isolation and quarantine particularly impractical for many families, while limited public health capacity makes disease control especially challenging.  

“(COVID-19) really is shining a light on the lack of public health infrastructure and the social determinants of health and tribal populations,” Warne told reporters. “We have minimal lab capability for contact tracing. We don't have the workforce that we need to address this type of public health challenge.” 

Warne called for increasing IHS funding, as well as investments in public health infrastructure. When asked if the pandemic could force improvements at IHS, Warne underscored the need for change. 

“In truth, I hope we don't get back to normal because normal wasn't good enough for indigenous peoples,” he said. “We need to get back to better.”

For more information and resources, visit the National Indian Health Board. For more on the pandemic and health equity, visit APHA’s COVID-19 and Equity page.