Six months in, tribal nations cautiously optimistic about COVID-19 response
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In the early days of the coronavirus pandemic, there was great concern about the potential impact the virus might have on Native American tribes in Minnesota.
Now, a little more than six months since the state registered its first case of COVID-19, tribal nations in Minnesota are measured in their optimism about the effects of their efforts to manage the pandemic — but looking cautiously ahead to what health officials warn will be a difficult fall and winter.
The locations of most reservations in Minnesota provided a buffer against the early spread of the virus, allowing tribal leaders time to prepare their response. They knew they would have to act quickly. Tribal health care has long been underfunded and is often a patchwork. High rates of chronic health conditions, including diabetes and obesity, put American Indians at high risk of severe complications from COVID-19.
There’s been a steady trickle of cases on reservations since midsummer. Late last week, the Leech Lake Band of Ojibwe’s tribal government released a statement noting a jump from three active cases to 27 over a two-week period, and urged tribal members to wear masks and practice social distancing. Many of those cases are linked to groups gathering in recent weeks.
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But overall, the firestorm some feared would sweep through reservations so far hasn’t happened.
“I think the statistics that we're seeing really bear that out that we're not seeing these explosions of cases on the reservations,” said Nick Lehnertz, a medical specialist with the Minnesota Department of Health. “The fact that the tribes were able to get on top of that, and sort of stop the spread, I think is a testament to all 11 tribes in the state.”
But while tribes have slowed the virus, the serious effects of COVID-19 are still hitting Indigenous residents hard.
American Indians have the highest proportion of cases that result in hospitalization or the need for intensive care. They also have the highest rate of deaths among those who test positive for the virus, Lehnertz said.
“Everybody in the tribal community and on the reservations understands that because of the high rate of diabetes, if we have a huge community spread, we're going to have a lot more people die,” said Jackie Dionne, American Indian Health Director for the Minnesota Department of Health, and an enrolled member of the Turtle Mountain Band of Ojibwe in North Dakota.
Before COVID-19 cases started showing up on Minnesota reservations in June, tribal leaders here watched as cases exploded on the Navajo Nation. There have been more than 10,000 confirmed cases and 552 deaths on the sprawling reservation that covers parts of three states in the southwestern U.S.
As the coronavirus threat moved closer to home, most tribes in Minnesota responded aggressively, closing casinos, launching communication campaigns, urging social distancing and requiring the use of masks.
The Red Lake Nation in northern Minnesota declared medical martial law and has restricted travel across reservation borders.
"The urgency in what happened, and what is happening, is pretty significant — with tribal leadership saying, 'I'm going to practice this because I don't want my people to die'," Dionne said. She is in regular contact with leaders of the 11 tribal nations in Minnesota.
Tribal leaders across Minnesota talk with each other regularly, and tribal health officials coordinate with the state health department on testing and best practices.
Crucial preparations
Mille Lacs Band of Ojibwe officials report 19 cases of COVID-19 on the central Minnesota reservation since March.
“I feel like we’re doing okay and we’re managing, but I believe a huge part of that was the work we did on the front end to be ready for the pandemic,” said Nicole Anderson, the band’s health and human services commissioner.
A tribal emergency response committee was set up early in the pandemic to plan and prepare, for all potential needs of a pandemic and ensure coordination across agencies.
“All the monitoring, all the testing, all the contact tracing. We had staff trained and ready to go internally, because we know that our tribal members were expecting our tribal employees to be there during this event,” said emergency management director Monte Fronk.
Testing and contact tracing — in which health officials work with patients who test positive for COVID-19 to alert others they might have exposed to the virus — have been critical to managing the spread. Tribes are using rapid testing to help them understand how the virus is spreading in reservation communities, and quickly respond to support people whose tests come back positive.
Mille Lacs recently started testing tribal members for the coronavirus antibody — which indicates whether a person’s immune system has been exposed to the virus — to better understand the coronavirus’ spread.
Tribal officials knew early on they would need to handle contact tracing with their own staff, public health workers who had community trust, rather than have state workers — who handle much of the contact tracing statewide — making those calls.
"If you think about the historical relationship between tribal members and the state, it wasn't always the best,” said Anderson. “So when someone from the state's calling you, you may not want to answer your phone. But if your public health nurse calls, you are more likely to answer and be willing to provide information.”
Reservations are tight-knit communities. Everyone knows everyone — and that helps quickly isolate and quarantine contacts when someone tests positive for COVID-19.
The downside of those close social networks is that rumors can also spread quickly. That's why Anderson is convinced that consistent, repeated communication with tribal members has also been critical to managing the virus. Tribal leaders post updates on social media and community outreach efforts are ongoing.
"We work for the community, we serve the community. We need to listen to what they say, combine best practices with that and figure out a way to move forward and that's really what we did," said Anderson.
Mille Lacs developed a unique COVID-19 response plan to meet the needs of each of the reservation’s districts. For example, in some areas, internet access is reliable, and social media is a successful communication tool.
Other communities have little or no internet access, so tribal staff go door to door to answer questions and share information.
Protecting elders
Officials on the White Earth Nation in northwest Minnesota took a similar community-oriented approach, prioritizing protection of its most vulnerable: Tribal elders.
The coronavirus has proven most dangerous to older people and those with underlying health conditions, and American Indians have higher rates of chronic health conditions than other populations across the state.
“Our greatest concern is our elders, and we hold our elders in high regard here within White Earth and have to take care of our elders, especially during this time,” said COVID-19 incident commander Ed Snetsinger.
That has meant meeting elders’ needs so they can minimize interactions outside their homes — and limiting their possible exposure to the highly contagious virus. Snetsinger said his team is delivering 724 meals a day to the tribe’s most vulnerable members.
White Earth is also delivering traditional medicines, and has set up a hotline for residents to address any concerns or problems related to the pandemic.
Community councils — long-established groups of people who work as volunteer liaisons between tribal communities and tribal government — have helped ensure their neighbors are taken care of.
“That's a lot to ask for people that probably have jobs, have family responsibilities,” Snetsinger said. “But at the same time, they make that sacrifice to their community."
White Earth’s remote location in northwest Minnesota has provided a natural buffer against the virus’ spread that’s given officials more time to prepare for the pandemic, Snetsinger said.
Still, managing the virus has been a constantly evolving challenge, said Snetsinger.
As the pandemic has worn on, some people have said they don’t want to be identified as having had COVID-19, which has occasionally made contact tracing difficult. But he thinks consistent monitoring of social media, managing rumors and encouraging people to follow best practices, has for the most part been effective.
Finding services can be more challenging for the thousands of American Indians who live in the Twin Cities metro area — and often don’t have direct access to tribal programs, said Dionne. About 30,000 American Indians live in Hennepin and Ramsey counties, she said, and many don’t have tribal connections in Minnesota.
Preparing for the coming wave
While tribes in Minnesota have managed to limit the virus spread on reservations, they recognize that success is fragile, with flu season and public health officials’ warnings of a second COVID-19 wave approaching.
"We've managed to skirt some of the horrible rates that we saw in Navajo Nation, knock on wood,” said Mary Owen, director of the Center of American Indian and Minority Health at the University of Minnesota medical school.
But she said those efforts at communication, contact tracing, support and testing that have so far helped tribes mitigate the virus’ worst impacts will be crucial into the fall and winter.
“We're not through this yet,” she said. “We don't have a vaccine in place, so it could be like one of those fires we're seeing on the West Coast, where something happens and — poof — you know, any of our tribal communities could light up."
And Owen, who is also president of the Association of American Indian Physicians, worries about the pandemic’s long-term effect on mental health and the economic disparities that already exist.
She knows strong social networks improve health outcomes for Native Americans, but those networks have been weakened, in some cases, as important social gatherings like pow wows and spiritual ceremonies have had to be canceled, modified or moved online. And the loss of revenue from closing tribal casinos — in many cases, a primary means of revenue for tribal services — could widen existing economic disparities.
“I don't see those things improving,” she said. “I see them being worsened over a long period of time as a result of what COVID has done to our ability to gather and support one another.”
Tribal officials say they will continue to fine-tune their response in preparation for the next few high-risk months.
State health officials know Native American residents of Minnesota still face disproportionate risk from COVID-19, but medical specialist Nick Lehnert said that tribal leaders’ efforts at getting ahead of the pandemic have gone far to prepare them for the continued fight ahead.
“They're saying, we're going to take this seriously, we know it's going to impact us in a disproportionate fashion, and so let's just do the things we need to do to prevent these outbreak situations,” he said.
“I think that if everyone stakes an eye towards how this is going on on reservation land we can learn a lot.”