Harrah, Wash. • As the coronavirus outbreak in Washington state’s Yakima County worsened last month, Tashina Nunez recognized more and more of the patients who arrived in her hospital. They had coughs, fevers and, in some severe cases, respiratory failure. And many of them were her acquaintances and neighbors, members of the tribes that make up the Yakama Nation.
Nunez, a nurse at a hospital in Yakima County and a Yakama Nation descendant, noticed that Native Americans, who make up about 7% of the county’s population, seemed to account for many of the hospital’s virus patients. Because the hospital does not routinely record race and ethnicity data, she said, it was hard for Nunez to know for certain.
“Not being counted is not new to us,” she said.
Without firm figures, she and other health care providers for Native communities said they struggled to know where or how to intervene to stop the spread.
“You don’t know how bad it is until it’s too late,” Nunez said.
By mid-July, more than 650 members of Yakama Nation, in central Washington state, had contracted the virus — about 6% of the total membership. Twenty-eight people have died, Delano Saluskin, chair of the Yakama Nation, said in a video update.
“We all grieve those losses,” he said. “This has been devastating for many families on the reservation, and it means that every week, a family member is impacted.”
The situation in Yakama Nation is not unique. Even with significant gaps in the data that is available, there are strong indications that Native Americans have been disproportionately affected by the coronavirus.
The rate of known cases in the eight counties with the largest populations of Native Americans is nearly double the national average, a New York Times analysis has found. The analysis cannot determine which individuals are testing positive for the virus, but these counties are home to 1 in 6 U.S. residents who describe themselves in census surveys as non-Hispanic and American Indian or Alaska Native.
And there are many smaller counties with significant populations of Native Americans that have elevated case rates, including Yakima County. The Times identified at least 15 counties that have elevated case rates and are home to sizable numbers of Native American residents. Those counties ranged from large metropolitan areas in Arizona to rural communities in Nebraska and Mississippi.
“I feel as though tribal nations have an effective death sentence when the scale of this pandemic, if it continues to grow, exceeds the public resources available,” said Fawn Sharp, president of the Quinault Indian Nation and of the National Congress of American Indians.
The situation has been stark in the Navajo Nation, where high infection rates have created a crisis in the largest U.S. reservation. But health officials said the same worrying trends are repeating in Native communities across the country, and congressional leaders have prompted the U.S. Commission on Civil Rights to examine the health disparities compounded by the pandemic.
In New Mexico, Native American and Alaska Native people have accounted for nearly 40% of virus cases, even though they make up 9% of the population.
Native Americans in the Phoenix area have been infected at four times the rate of their white neighbors. The Fort McDowell Yavapai Nation extended a shelter-in-place order July 18 because infections were continuing to multiply. The Salt River Pima-Maricopa Indian Community also reported mounting infections this month.
Outbreaks have been reported among the Lumbee Tribe in North Carolina, Choctaw communities in Oklahoma and Mississippi, and at two reservations in Thurston County, Nebraska.
Hospitalization rates published by the Centers for Disease Control and Prevention also suggest that Native Americans are overrepresented among those who become seriously ill from the virus. The data about COVID-19 is collected from a sample of counties and provides an incomplete picture, but the conclusion is unsurprising to epidemiologists who study the health of Native Americans.
“The disparities we see there with COVID are aligned with those that we see for hospitalizations and deaths due to influenza and other respiratory viruses,” said Allison Barlow, director of the Center for American Indian Health at Johns Hopkins University.
Native Americans — particularly those living on reservations — are more prone to contract the virus because of crowded housing conditions that make social distancing difficult, she said. And years of underfunded health systems, food and water insecurity and other factors contribute to underlying health conditions that can make the illness more severe once contracted.
Yet understanding the extent of how Native American people have been disproportionately affected by COVID-19 is extremely difficult.
Calculating how many people who identify as Native American have had the virus and how many have died of it is nearly impossible because federal data tracking individual coronavirus cases often omits information about the race and ethnicity of people; such information is missing from about half the cases reported to the CDC, which serves as a clearinghouse for cases reported by state and local authorities.
Even when such information is collected, it is uncertain how accurate it is. Miscounting can begin at testing sites and health clinics, public health officials said, where health care workers sometimes do not record a patient’s race and ethnicity data, or simply guess without asking a patient.
The Indian Health Service has identified at least 30,987 cases among Native Americans and Alaska Natives, but tribal nations are not required to share their data. Just under half of tribal health centers and 61% of urban health services serving Native Americans have provided case information, an IHS spokeswoman said.
After suing the CDC, the Times obtained a database with the characteristics of 1.5 million individuals who tested positive for the virus through the end of May. The data showed that people who were Black or Latino were three times as likely to become infected as people who were white.
The data provided only part of the picture, though, when it came to Native Americans because of gaps in the data: It included geographic information and racial classifications for just 974 of the 3,143 U.S. counties and did not include some of the places where Native American people make up large parts of the population. What information there was did show a disparity: The infection rate for Native Americans was 1.7 times the rate for white people overall and somewhat higher in younger age groups.
In Yakama Nation, Haver Jim Ptxunu, a 42-year-old resident who works for the tribal power company and helps run a nonprofit group called the Peacekeeper Society, said he and his wife contracted the virus in June.
“It was physical torture,” he said, adding that one of his most debilitating symptoms was a constant eye irritation that he described like “a bad sunburn, but inside your eyes.”
Still, he felt fortunate that he and his wife recovered after about three weeks, because he had seen a few older couples on the reservation die.
The Peacekeeper Society operates a weekly food giveaway and delivers food and cleaning supplies to households where people have fallen ill. Jim said he suspected he caught the virus while out on such a delivery.
As soon as he recovered, Jim said, he returned to his work distributing food. On a hot July afternoon, he helped distribute boxes filled with potatoes, zucchini, cabbage and onions to a line of hundreds of cars. Families could choose between chicken and salmon waiting in two kiddie pools stocked with ice.
Adding to the toll of the virus among Native Americans has been swift and grim economic fallout.
“People lost jobs really quick,” he said. “We went from serving a dozen people a week to hundreds.”
Tribal epidemiology centers have fought for months to obtain case information from the CDC and are only now receiving snippets of what they requested, several of the dozen U.S. centers said. Without an accurate portrait of the rates of illness within their populations, tribal nations have struggled to receive federal funds aimed at economic recovery and protective gear.
“I think this historic, deep neglect is just coming into sharper focus because of COVID,” said Liz Malerba, policy and legislative affairs director for the United South and Eastern Tribes, a tribal epidemiology center. “It’s always been there, but now you are seeing more clearly what the depths are.”
A spokeswoman from the CDC said the agency was working to fill gaps in its data to better understand the impact of the virus.
“There is still more work to be done to ensure complete race and ethnicity data in the case report forms,” said the spokeswoman, Jasmine Reed.
Since April, the agency has increased its collection of race and ethnicity data from patients tested for the coronavirus, she said.
Malerba said many tribes did not receive federal emergency funds equal to their needs because the Treasury Department allocated the money using census data that undercounted tribal memberships.
“If you eliminate us in the data, you have effectively eliminated us for the allocation of resources,” said Abigail Echo-Hawk, director of the Urban Indian Health Institute.
In California, tribal epidemiologists have tried to uncover cases themselves. The California Department of Public Health publishes a daily count of coronavirus cases, and California Tribal Epidemiology Center pulls data from that tally in order to track the virus among the 87,000 Native people who access tribal health programs in the state.
“We can only see the number, but we don’t know more information about them — where they reside, their specific symptoms,” said Aurimar Ayala, the center’s epidemiology manager. “It means we cannot further investigate those cases.”
She added that the epidemiology center had created a workaround by contacting local clinics and tracking down the cases, but said that it was a cumbersome solution.
Although health officials are still struggling to fully understand the impact of the coronavirus on Native American people, the severity of the crisis in Yakama Nation is clear to residents, some said.
“It’s devastating to our community,” Nunez said. “We have these elders that have lived through residential schools and the outlawing of their own religion. They’ve been keeping this culture alive, and now COVID hits, and it’s taking them from us.”