Though Indigenous people account for only about 1.3% of the U.S. population, they remain disproportionately impacted by a host of health issues. In the case of COVID-19, for example, as of March 2, one in 390 Indigenous Americans have died because of the virus (or 256 deaths per 100,000), compared to one in 665 white Americans (or 150 deaths per 100,000). In that regard, COVID-19 joins HIV, diabetes, poverty, and drug dependencies as another structural calamity that oppresses the community.
Looking at drug dependencies—which hurt Indigenous people in the same way that breast cancer does Black women—one wonders why the federal government has not yet recognized it as an existing comorbidity, similar to HIV, asthma, or obesity. The most obvious reason is that people who are living with vulnerabilities to drugs are still regarded punitively, rather than as people deserving of care.
Given the disproportionate vulnerability to drugs that Indigenous people experience—as well as the overlying intersections with other health outcomes—TheBody has dedicated part of our National Native American HIV/AIDS Awareness Day coverage to why people living with drug vulnerabilities should be granted COVID-19 vaccine phase 1B prioritization.
An Alarming Scale of Drug Dependencies
Indigenous people suffer the highest mortality rates from COVID-19 and HIV among all racial and ethnic groups in the country. When paired with illicit drug use, that vulnerability explodes exponentially. For example, Indigenous people contract HIV from intravenous drug use at higher rates than any other group in the country. According to the Centers for Disease Control and Prevention (CDC), Indigenous men seroconvert through injection drug use alone or male-to-male sexual contact and injection drug use at a rate of 17%, while Indigenous women contract HIV through injection drug use at an alarming rate of 44%.
But the disproportionate effect that drug use has on Indigenous communities goes beyond HIV transmissions. With her eye on vaccine prioritization, Sheila P. Vakharia, Ph.D., M.S.W.—the Drug Policy Alliance’s deputy director of research and academic engagement—says, “People who have substance use disorders have incredibly high rates of comorbidities.”
While acknowledging that some of those comorbidities are a result of health care discrimination and low engagement with the medical system, Vakharia points out that “drug use practices and risk behaviors can increase the likelihood of developing certain kinds of conditions.” She adds, “Stimulant use can result in a negative cardiovascular impact, higher blood pressure, cardiac risk factors, respiratory challenges, or bloodborne, skin, and soft-tissue infections.” And this is particularly true for Indigenous people.
A study from 2020 that focused on deaths caused by methamphetamine overdoses between 2011 and 2018 found that Indigenous people suffered the highest mortality rates among all racial groups in the U.S. Overdose death rates increased among Indigenous men from 5.6 deaths per 100,000 people in 2011 to 26.4 deaths per 100,000 in 2018; they increased from 3.6 to 15.6 deaths per 100,000 people among Indigenous women. In contrast, white people in the U.S. had the second largest methamphetamine overdose death rates at 2.2 to 12.6 deaths per 100,000 people among men and 1.1 to 6.2 deaths per 100,000 people among women.
The issue has not abated with time. The Substance Abuse and Mental Health Services Administration’s (SAMHSA) latest data on drug dependencies found that in 2019, 10.2% of Indigenous adults had a substance use disorder and 3.8% of all Indigenous adults were dealing with both a drug dependency and mental illness. Meanwhile, 15.7% of Indigenous adults were found to have dependencies related to psychotherapeutic drugs, hallucinogens, inhalants, methamphetamines, cocaine, or heroin.
Though drug dependencies can approximate, initiate, or exacerbate comorbidities, as of yet, there is no standard for including them as part of the vaccine rollout plan.
One reason for this omission is that each of the 50 states operates like an independent country, with little federal oversight to guide their vaccine dispersal. “There is incredible variability from state to state, which has created a more fragmented approach, so a lot of times it’s luck of the draw where you live in terms of what you’re eligible for,” says Vakharia. She adds, “The pandemic has highlighted broader structural challenges in our health care delivery system.”
This includes having consistent internet access, technological literacy, trusted sources to counter misinformation about the vaccine, or the wherewithal to sit and refresh web pages. Adding the possibility of living with a dependency on drugs into the mix for already marginalized and, historically, financially distressed communities only increases the need for expanded vaccine prioritization.
Redressing these compounding challenges starts with acknowledging that providing care to a targeted community must begin with equality as well as equity, because “people are not all starting at the same place,” says Vakharia. “A blanket policy is still going to disproportionately impact some people and leave others behind.”
A Model for Equality, Equity, and Culturally Responsive Care
Last year, Minneapolis experienced an HIV outbreak that affected 18 people, the bulk of whom were Indigenous people. Along with drug use, there was also an increase in homeless encampments. Though the city eventually responded by sheltering people in hotels as a first step towards getting people the housing they needed during the COVID-19 pandemic, Sharon M. Day, the executive director of Indigenous Peoples Task Force—an organization that implements culturally appropriate HIV education and direct services to the Native American community in Minnesota—says, “Anything that was bad before just became worse.” Fortunately, there has been a turnaround in recent months.
Day says that Minnesota’s health department allocated vaccines and money to the state’s 11 tribes to facilitate their rollout plan, but when she called her local reservation to make an appointment in February, she was told that they were only serving citizens who were living on site. “I’m a little older, so I had to advocate for myself, which is a little difficult,” Day says. “But I’d made it through last year, so I said, ‘I’ll be damned if I’m going to go without getting vaccinated.’ So I just kept calling.”
Her tenacity paid off. Day has been fully vaccinated, as have all of her staff members who wish to be, because they count as essential workers. Currently, the rollout plan at her affiliated reservation has been so efficient that anyone over the age of 18 is able to get vaccinated, whether they are living on or off site.
This adaptability to the community’s needs matches the same understanding that Day and her colleagues started with when they founded Indigenous Peoples Task Force in 1987. Rather than follow a policy that had been developed for the people of San Diego’s La Jolla neighborhood, they looked at the needs of the people they were serving and adjusted accordingly.
Day agrees that it is important to provide vaccine prioritization to people who are living with drug dependencies, but she says that any move to do so has to be implemented with cultural understanding.
She says this as someone who has been in recovery from chemical dependency for 45 years. Beyond her personal experience, she developed this insight while working as a chemical dependency counselor in halfway houses and on policy as the special assistant director of the Human Services Department’s chemical dependency programs division for Minnesota.
After observing recommendations from “so-called experts,” she initiated her own study into how people recover. At the time, 12% of people in the state’s drug treatment programs were Indigenous people, even though they only accounted for 4% of Minnesota’s overall population. The study started after she placed an ad in the newspaper asking for Indigenous women to share their experience with drugs. The response was larger than what she’d expected.
State Mandates Are Steeped in Impractical Modalities
Over the course of Day’s study, she learned that Indigenous women entered into recovery programs by tapping into their spiritual practices—and that, in and of itself, exposed a problem. “The state creates rules that govern how you are to provide treatment,” says Day. “Most of the time those provide the minimum, but they become the maximum of what treatment programs do, which leaves a huge gap for providing what Indigenous people need, because it is steeped in Western philosophy.”
Contrary to their adherence to state-imposed methods, Day discovered that many of her Indigenous colleagues were also in recovery and would attend “ceremonies and pow-wows, but then came to work and did something totally different from their cultural practices that kept them in recovery.” Unfortunately, she says that this approach has not changed in 30 years. The result is that Western modalities continue to dominate policies for Indigenous people, even though Indigenous people are rarely included in surveys designed to address the needs of their own communities.
This occurs when addressing intersectional communities as well. Five years ago, while attending a presentation on the health needs of the LGBTQ population conducted by the Minnesota-based research organization Rainbow Research, Day was disappointed to learn that they had not included data on Asian, Latinx, or Indigenous communities. When she asked why, she was told that the sample size was too small. She responded, “You knew that in the beginning. Why did you not over-sample the missing populations to get a good cross-section?”
Even if people living with drug dependencies are given vaccine prioritization, Day says, it will not matter unless they are engaged in ways that speak to and serve them. That means providing access to people, especially when they are labeled “hard to reach.”
A Viable Vaccination Plan Must Go Beyond Good Intentions
President Biden’s recent announcement that he wants the COVID-19 vaccine to be available to all adults across the nation by May 1 will hopefully result in increased outreach to disadvantaged or off-the-grid communities. From that standpoint, Vakharia notes that the focus should be on reaching the intersections of marginalized, stigmatized, and oppressed individuals.
Vakharia believes, “If we can design a COVID vaccination strategy that gets every trans, non-binary, sex-working person who is living with HIV and who uses drugs in Black and low-income neighborhoods vaccinated, we will show that this plan has succeeded.”