With black headphones covering his ears, Mark Fox, chairman of the Mandan Hidatsa and Arikara Nation, folded his arms and rested them on the table in front of him, where a microphone stood. Having led the MHA Nation, also known as the Three Affiliated Tribes, on the Fort Berthold Reservation in central North Dakota for roughly six years, Chairman Fox had grim news to share on March 27 in a live update from the local radio station.

The first COVID-19 case had just been confirmed on the reservation.

“We knew it is going to come,” says Fox. “We were a little bit surprised that it came on that day. Some of us hoped that we’d have another week before it would hit. But we knew it was moving rapidly.”

When Chairman Fox says “we,” he refers to the tribal government he helms and the COVID-19 task force he had assembled to manage the MHA Nation’s preparation and response to the deadly virus. But for some of the 9,000 people living on the Fort Berthold Reservation, approximately two-thirds of whom are tribal members, the announcement dealt a blow.

“On that 27th, it was a Friday, up until that point, our people saw the coronavirus as something still far away, still on TV, still away from us,” Fox says. “Like a train that’s still 2,000 miles away.”

In the month and a half since, positive diagnoses on the 988,000-acre reservation grew to 35 out of roughly 950 administered tests as of May 11. No deaths have occurred so far.

Despite limited resources, Fox has pushed for massive testing, including a couple of so-called major testing events conducted in collaboration with the state of North Dakota. His goal is to reach 1,000 tests quickly before starting to chase the 2,000 mark, while maintaining a COVID-19 incidence rate below 3%.

“Our tribe has been more aggressive about testing than other tribes in the Northern Plains,” Fox says. “Because of our aggressiveness to understand how prevalent the disease is and to take care of our people, I believe we’ve gotten to a point where we can more effectively manage the impact of COVID-19 than a lot of our fellow tribes.”

Faced with an inadequate healthcare system, rampant exclusion from federal relief programs and little to no medical equipment, many Native American tribes across the U.S. have struggled to properly tackle the global pandemic.

According to the Indian Health Service, as of May 9, there are a little over 5,000 positive coronavirus cases across Indian Country. That figure relies on reports from IHS facilities as well as tribal and urban programs, which are not required to share data.

“The number of confirmed cases in Indian Country is likely underreported given a significant shortage of available testing kits, but also because of a critical shortage of medical supplies like respiratory swabs used to collect the COVID-19 specimen,” states a letter signed by about a dozen Native American health boards and addressed to U.S. House Speaker Nancy Pelosi (D-CA) and Minority Leader Kevin McCarthy (R-CA).

Coordinated by the National Indian Health Board (NIHB), the letter seeks $8 billion for the IHS ahead of any additional economic stimulus passed by Congress. Under the CARES Act, which President Donald Trump signed into law the same day MHA Chairman Fox announced the first COVID-19 cases in his Nation, the IHS received a little over $1 billion.

That sum is hardly enough, according to the letter, which states that IHS hospitals have an average age four times greater than that of mainstream hospitals, while maintaining a space capacity of a mere 52% of what is needed based on the size of the Native American population. Furthermore, there are purportedly only 33 intensive care units (ICUs) across Indian Country.

“We do not have any ICU beds in in the Great Plains area,” which includes the Dakotas, Nebraska and Iowa, says Joe Amiotte, director of field operations for the IHS Great Plains Area. “If a patient needs to be ventilated, they will have to go to one of the larger referral facilities near the reservation. We have to ensure that those larger facilities count our population in their [COVID-19 surge] planning.”

On the Fort Berthold Reservation, MHA Chairman Fox estimates that about 15% of the infected individuals have had to be hospitalized in the nearby cities of Mandan, Williston, Dickinson or Bismarck, the state’s capital.

The tribe runs the Elbowoods Memorial Health Center in New Town through a so-called 638 contract with the IHS, which funds the facility but does not manage it. Because IHS, which is habitually short on supplies, could not send any extra staff or equipment to the MHA Nation, Fox says the tribe turned to the state and private companies to acquire medicine, personal protective equipment and test kits.

“The only difference for us as a tribe versus some other tribes is that we recognized that you can’t trust nor rely on the federal government 100% because if you do, that’s going to be your demise,” he said. “We have to do things on our own when we have to. And that’s exactly what we’re doing right now in many ways.”

Chronic health disparities exacerbate Native communities’ vulnerability to COVID-19

The medical emergency spurred by the coronavirus on tribal lands is aggravated by the chronic health disparities that have ailed Native Americans for generations, stretching back to the arrival of European colonialists on the North American continent.

“With our [Three Affiliated Tribes], we have had a history of what we call ‘virgin soil epidemics,'” says Fox. “Epidemics in the past such as smallpox, to which we didn’t have any resistance, came in and killed 90% of our population during the late 1700s and 1800s. We have a history of knowing what a foreign virus can do to our people. We’re very apprehensive and very careful not to take it lightly.”

Today, compared to the rest of the U.S., Native communities have a higher prevalence of diabetes, cancer, heart problems and asthma, among other underlying diseases that are considered risk factors for COVID-19 patients.

“Our communities are uniquely vulnerable to the COVID-19 virus,” says Stacy A. Bohlen, CEO of NIHB. “When the Centers for Disease Control and Prevention puts out guidance that says people who need to be particularly careful are those living with diabetes, asthma and cardiovascular disease – well, these diseases are far more statistically present in American Indian and Alaskan Native populations than any other population in the United States. It is almost a perfect storm.”

She adds that the federal government spends less than $4,000 annually on healthcare for a Native American person, which is about a third of what it spends per non-Native individual.

Another facet that widens those health gaps is the lack of running water on some reservations (or at least, portions of them), which hinders regular hand washing, a basic recommendation to prevent COVID-19 infections. Moreover, multi-generational living permeates Native households, making quarantining at home hard, if not impossible.

The economic fallout of shuttered business and tarnished oil industry threaten MHA, the state

Intimately understanding the disadvantaged position of Native communities, MHA Chairman Fox says his administration began paying attention to the virus back in January, while it still ravaged mostly China. Fox set up a task force and implemented measures stricter than what North Dakota Governor Doug Burgum instituted in the state.

While North Dakota embarked on a plan to reopen the economy on May 1, the MHA Nation has persisted with rules such as limited travel, a sundown-to-sunrise curfew and a shelter-in-home directive, which the state never adopted.

Upholding these policies longer ensures Chairman Fox’s two primary goals of staunching the virus’ spread on the reservation and taking care of “our people,” he said in an interview on Native America Calling, a public radio program.

But these objectives come at a hefty cost.

Keeping the COVID-19 protocols in place clashes with the growing loss of revenues from local businesses as well as from oil production, a sector double hammered by the coronavirus-induced economic downturn and the turmoil in the global oil industry.

Partially straddling the oil and gas producing formations of the Bakken and Three Forks in western North Dakota, the Fort Berthold Reservation, home to the MHA Nation, produces about 300,000 barrels a day, Fox says. That is about a fourth of what comes out of the Bakken as a whole. The annual economic impact of the MHA Nation on North Dakota is about $6 billion, while oil directly contributes about 25% of the state’s general fund.

The distressed oil markets compound with the overall pandemic-triggered economic slowdown to pave a financially tricky path forward for both the state (budget cuts could reach 15% of current levels for the 2021 – 2023 biennium) and the Three Affiliated Tribes.

Due to the coronavirus, the MHA Nation had to pause infrastructure projects worth millions of dollars. During his time as chairman, Fox has spearheaded initiatives that enhance education, health and housing. But in a post-pandemic reality, the financial feasibility of such continued improvements is uncertain.

“With our role in energy and the possibility now that we are going to be devastated economically, it is going to be difficult to build out” of this situation, says Fox. “What worries me the most right now is that what we’re doing today, we’re doing it without a lot of duress. But now, you try to look ahead to May, June and July. You begin to calculate in your mind the impacts. Then, you begin to get very nervous and very concerned.”

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