Self-governance and sense of community drive Tribal COVID response

Presented by Alaska Native Tribal Health Consortium

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In early 2020, as a new virus began to take hold in parts of Europe and Asia, officials in Alaska’s Tribal health system watched closely. From smallpox in the 19th century to the 1918 influenza pandemic to H1N1 in the early 2000s, infectious diseases have typically had an outsize impact on Alaska Native communities.

“We knew, with COVID as a respiratory illness, that particularly in our rural communities and even in the urban Alaska Native communities, that there would be an increased risk to have a disproportionate burden of cases, morbidity and mortality,” said Alaska Native Medical Center Administrator Dr. Robert Onders. “The consequences of infectious diseases and pandemics throughout the years have had a disproportionate burden on Alaska Native people.”

Alaska Native cultures are still recovering from the loss of language and traditional practices due to disease, displacement and the forced assimilation efforts of the 19th and 20th centuries. As younger generations embrace their culture in a way their parents and grandparents couldn’t do, the specter of another pandemic felt like a threat to the progress made.

“The idea of the loss itself is such a source of grief,” said Vera Starbard, a Perseverance Theatre playwright and writer for the PBS Kids show “Molly of Denali.” “I know it’s something that we talk about so much, and it gets overwhelming so quickly -- just what you can literally never have back.”

For example, there are only about 200 fluent Tlingit language speakers alive. About five of them died in the past year, Starbard said, some due to COVID.

“We can’t get that back,” Starbard said. “We can’t get that knowledge back. We can’t get what they meant to our communities back.”

This time, Tribal health care leaders were determined things would be different. And in many important ways, they have been.

Lessons from the past

Until the establishment of the Alaska Native Tribal Health Consortium in the late 1990s, Tribal health directives came from the Indian Health Service headquarters in Rockville, Maryland, and they were based on what was happening in Indigenous communities around the country. That one-size-fits-all approach often failed in Alaska, which has very different needs and challenges than other Indigenous communities in the U.S.

“If you look back, the healthcare way back when was poorly organized and mostly very ineffective,” said ANMC Vice President for Professional and Support Services Vivian Echavarria. “All of these contagious diseases swept through our villages and decimated the population. At the time, we had no experience with a lot of these infections. Given the close quarters and the lack of knowledge, it really resulted in quick spread.”

Local and regional entities within Alaska’s current Tribal health care system are self-governed but connected by shared representation through the Alaska Native Tribal Health Consortium. From the start, it was clear that the novel coronavirus would require coordination across all Tribal health entities.

“I think one of the wisest things that we did was we all came together, knowing our history of what had happened in the past,” Echavarria said.

In 2020, as COVID-19 began to overtake hospitals in New York, Alaska’s Tribal health entities began working together to share information and develop a plan for statewide response.

“I think the Tribal health system was at an advantage compared to other health care systems,” Onders said. “We had that infrastructure where we meet on a regular basis together. We were able to ramp that up quickly. That connectedness and communication was probably an incredible part of our success.”

Critically, it has also allowed the Tribal system to coordinate efficiently with the State of Alaska on an overall public health response.

“Tribal health in most communities in Alaska is a provider of services to everyone in those communities,” Onders said, not just Alaska Native people.

Rural Alaska at risk

One of the biggest concerns for the Tribal health care system and local authorities throughout the pandemic has been the vulnerability of rural communities.

“A wonderful thing about the villages is you have so many opportunities to see other people,” Starbard said. “The problem, of course, is that one person in a small village will end up infecting an entire village pretty quickly.”

A year ago, it seemed like COVID-19 was on a course to mimic past pandemics in its threat to Alaska Native people. According to Centers for Disease Control and Prevention data, Alaska Native and American Indian people had the highest COVID mortality rate from March to December 2020. That started to change in 2021, something Onders credits in large part to the rapid development and deployment of the vaccine.

“It’s just a very challenging disease to keep out, even if you’re doing quarantines and testing and all those components,” Onders said. “One of the challenges and what we saw is that as Anchorage case counts really skyrocketed, it was almost impossible to keep it out of rural Alaska.”

But the lessons of pandemic history weren’t lost on leaders in remote communities, who were willing to make “hard decisions” about precautions to prevent the virus’ spread, Onders said.

“The communities have learned from the past,” Onders said. “What I see is the willingness to put these quarantines in place, the willingness to adopt mitigation measures that we know work with COVID, the willingness in many communities to see the rapid adoption and high percentage of people being vaccinated. There’s some strength and learning from those previous experiences.”

This pandemic has also underscored the value of the Tribal health care system’s emphasis on community-based care, Onders added.

“Having a trusted health care resource to go to, to help inform your decision making, really helps with the outcome,” he said. “We’ve seen this in rural communities -- the health aides are trusted resources in that community, and they’re members of that community.”

Additionally, while there was a perception among some people that COVID-19 isn’t a concern because it mostly affects older people, in Alaska Native cultures, that emphasis is reversed, Starbard said: We need to worry about COVID-19 specifically because it mostly affects older people. Along with measures to protect Elders from COVID, Tribal health care providers and community leaders worked to prevent the isolation that had the potential to be almost as harmful as the virus itself.

“(We have) a very different value of what Elders mean to our culture, our community, our lives,” Starbard said. “It drove so much of the response and the speed of that response and the unique ideas about how to respond.”

Victories against the virus

Once vaccines were available, Tribal health organizations worked together to get them distributed as efficiently as possible. Due in part to their efforts, Alaska became the first state in the union to make vaccines available to all people age 16 and up.

“I have been so impressed with how fast the response was from Tribal health care across the state,” said Starbard, who has worked for Southcentral Foundation in the past. “It’s because they’ve had so much experience with what happens if you try and wait for government response and government care of Native people specifically.” In her own family, multiple cousins had to work together to secure a vaccine appointment for their white grandfather, while Starbard, who is Tlingit and Dena’ina, was contacted by her Tribal health care provider as soon as she was eligible.

Self-governance was the key to making it happen. In determining how to distribute vaccines, the federal government recognized Tribes as unique jurisdictions, providing health care authorities with an allotment of doses to administer based on the distinct needs of their respective regions. As a result, in most rural Alaska communities, vaccines became available based not on whether people were enrolled in the Tribal health care system but on categories like age and risk. In Anchorage, Southcentral Foundation was able to open its vaccine clinics first to non-Native family members and then to the entire community ahead of other vaccine providers.

That decision to open up vaccines to the community at large was reflective of Native values, according to Starbard.

“We have always cared about the people that live on this land,” she said.

With an infectious disease like COVID-19, protecting Alaska Native people also means protecting non-Native people, Onders said.

“We’re all interconnected and potentially present risks or benefits by having everyone protected,” he said. “You can’t just protect certain members of your community; you have to protect everyone in your community.”

The same was true pre-vaccine, when tests were the most critical tool in mitigating spread, Onders added. ANMC has a high testing capacity, so it was able to provide testing for other local providers.

“There’s no reason that machine shouldn’t be running at full capacity every day,” Onders said.

And that community doesn’t end at Alaska’s borders. Onders said he is concerned by vaccine inequality around the globe, with countries like the U.S. trying to convince holdouts to get the vaccine while other nations struggle to secure doses for their most vulnerable citizens.

“We’re all part of a global community, and there’s potential for new variants and mutations to occur over time” if the virus isn’t brought into check, Onders said. “It really benefits everyone to ensure those communities that may not have the same financial means get the resources there.”

What comes next

As vaccines have become widely available this year, many Alaskans have begun to relax. But the virus was still very much a part of daily life for health care providers and hospital staff even before the arrival of the highly contagious Delta variant, from which Anchorage hospitals are just beginning to recover.

“It has been all hands on deck,” Onders said. “We’re still in an incident command structure at Alaska Native Medical Center.”

The challenge now is getting reliable information about the vaccine’s benefits to people who haven’t yet received it.

“That decision-making process is going to be a huge emphasis now,” Onders said.

With children age 5 and older now eligible for the vaccine, education is the biggest hurdle -- primarily helping people understand that even though the COVID-19 vaccine is new, mRNA vaccines themselves have been thoroughly studied for decades.

“(Researchers) have a really good understanding of the genome,” Echavarria said. “It’s not something new, but it’s something that the scientists got together and said ‘This is what we’ve been doing; we think that this will work to try to address this pandemic.’ I would expect in 50 years that they will say ‘Wow, whoever put that out there to prevent COVID-19, they saved a lot of lives.’”

Echavarria worries that Alaska Native people who didn’t grow up hearing about the pandemics of the past may be more likely to buy into misinformation about COVID-19 that runs rampant on Facebook and YouTube. In her view, that’s the most significant risk factor remaining in today’s pandemic.

“I think, 50 years from now, (future Elders are) going to look back and say, ‘I was traumatized because my loved ones died because they believed the social media,’” she said.

This story was sponsored by the Alaska Native Tribal Health Consortium, a statewide nonprofit Tribal health organization designed to meet the unique health needs of more than 175,000 Alaska Native and American Indian people living in Alaska.

This story was produced by the sponsored content department of the Anchorage Daily News in collaboration with ANTHC. The ADN newsroom was not involved in its production.