A sign displays a message about staying safe from the coronavirus at the entrance to the East To’hajiilee housing community on May 25, 2020. Photo by Sam Wasson | Getty Images
When COVID-19 first hit the U.S. in early 2020, urban centers like New York City became a focus of national attention. But as the disease spread throughout the U.S. later that spring, the Navajo Nation emerged as a disease hotspot, with case rates rising higher than anywhere else in the country.
Newly compiled data reveals how severely the pandemic impacted Indigenous communities in Arizona at the onset of the pandemic, and it shows how the community’s response helped reverse the trends in 2021.
Arizona’s Apache County, home to portions of the Navajo Nation, had the highest excess death rate of any large county nationwide in both 2020 and 2021, while neighboring Navajo County had the fourth-highest rate in 2020 and second-highest in 2021. These largely rural areas were already vulnerable to COVID-19, facing barriers to healthcare access and high rates of chronic diseases prior to the pandemic.
After the initial spring surge, the Navajo Nation responded with strict measures such as community-wide lockdowns and stay-at-home orders to control the virus, then encouraged residents to get vaccinated in early 2021. The resulting high vaccination rates likely contributed to a sharp decline in COVID-19 death rates for Native Americans in counties intersecting with and around the reservation during the second year of the pandemic. At the same time, COVID-19 deaths rose for white residents of Navajo and Apache counties. Similar patterns played out for other counties bordering Navajo Nation in New Mexico, Utah, and Colorado.
In Navajo County, the COVID-19 death rate for Native Americans almost halved between 2020 and 2021, according to analysis of death certificate data compiled by the Centers for Disease Control and Prevention. In Apache County, this rate dropped by 36%. Meanwhile, white COVID-19 death rates in these counties rose by several times from 2020 to 2021.
Apache and Navajo counties score high on the CDC’s social vulnerability index. The index is calculated based on factors such as housing quality, poverty and unemployment. Residents in these communities are typically more vulnerable to extreme events such as natural disasters and pandemics according to Dr. Daniel Derksen, the director of the University of Arizona Center for Rural Health.
“On Navajo Nation, the tribes did an excellent job of pushing out vaccines,” said Mary-Katherine McNatt, a public health expert at A.T. Still University whose research has focused on health disparities.
The CDC’s mortality data show how vaccinations among Native Americans helped to save lives, as the death rates in Navajo and Apache counties dropped sharply from 2020 to 2021. Nearby counties with significant Native American populations experienced similar trends. For example, in Gila County, Arizona, the Native American COVID-19 death rate dropped by half from 2020 to 2021, while it more than doubled for white residents.
Navajo Nation’s COVID-19 response was “framed in community wellness” while also addressing the impacts of long-term disinvestment in Native Americans’ health, said Marc Emerson, a Diné epidemiologist at the University of North Carolina and co-author of a paper discussing the impacts of racism and colonialism on COVID-19 in Navajo Nation.
This long-term problem is not easily solved, Emerson said. In his recent paper, he discusses how “present-day inequity in socioeconomic position, food, and water security on the Navajo Nation underscores the impact of settler colonialism.”
These issues contributed to high overall death rates in counties like Navajo and Apache in 2021, even as COVID-19 deaths fell. Apache County had the nation’s highest rate of excess deaths (among counties over 30,000 people) in both 2020 and 2021, while Navajo County ranked number four in 2020 and number two in 2021, according to analysis from Boston University demographers. Excess deaths, a measure of deaths that occur above what researchers expect to see in a given time period based on past trends, are often cited as the true toll of the pandemic.
Life expectancy in Arizona decreased by 2.8 years during 2020, compared to 2.1 years nationally, according to a report from the Arizona Public Health Association. Among Native American residents, the decrease was “stunningly high” at 8.1 years, said report author and epidemiologist Allan Williams.
Patterns in Arizona and nationwide suggest that many pandemic-related COVID-19 deaths among Native Americans have gone undercounted, indicating that already high statistics may be underestimates of the disease’s true burden. One source of undercounting, McNatt said, is that Native Americans are not always classified correctly as Native American — especially if their deaths are reported by non-Native physicians or medical examiners.
Timian Godfrey, a Navajo clinical assistant professor of nursing at the University of Arizona, said distrust of the medical system also plays a role, as Native Americans “may face discrimination or racism or be poorly treated” in medical settings and elect not to go to the hospital. “So, a lot of the diseases that we see are underreported for that reason.”
Prior reporting by the Documenting COVID-19 project has highlighted staffing issues as a potential contributor to undercounted COVID-19 deaths. Indian Health Services facilities have long faced staffing shortages, according to a 2018 report from the Government Accountability Office.
McNatt also suggested that a more expansive definition of “COVID-19 deaths” may be helpful to fully understand the pandemic’s impact on places like Navajo Nation. “If somebody committed suicide because both their parents died of COVID, is that a COVID death?” she asked. Deaths from suicide, as well as from car accidents, gun violence, and alcohol poisoning, went up significantly in Navajo and Apache counties during the pandemic.
Improved data on COVID-19 deaths could be an important first step for public health action. “Data is a major political determinant of health,” said Daniel Dawes, executive director of the Satcher Health Leadership Institute at the Morehouse School of Medicine. With better data, researchers like McNatt and Emerson could better understand — and respond to — the health needs of Navajo Nation residents.
This article first appeared on Arizona Center for Investigative Reporting and is republished here under a Creative Commons license.
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