Bridging the Gap: Ensuring Vaccine Equity for Native Communities

ROBERT JOHNSON:
This is Public Health Review, I'm Robert Johnson.

On this episode: how to build vaccine confidence among American Indian and Alaskan Native people.

ANNE ZINK:
I think inherently vaccines are, in some ways, hard to trust. It's a shot in your arm. It's something you don't totally understand.

GARY LANKFORD:
We're lucky that we have a taskforce of actual member Native physicians from all medical disciplines. They're working in tribal communities, rural reservations, and urban all across the country. And they've been vital in helping us to create messaging and offer their own expertise.

JOHNNY DELGADO:
You're making a commitment when you make a commitment to any Native Americans. And when they trust you, they're going to trust you until you pull away from them. And once you pull away, you may never get that trust back.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we examine how public health organizations are trying to address vaccine hesitancy and equity among American Indian and Alaskan Native people.

Gary Lankford is with the Association of American Indian Physicians in Oklahoma City. He explains the messaging that resonates with these populations. Johnny Delgado is the Grants Program Director with the Bakersfield American Indian Health Project in California. He reminds us that trust is a key consideration when asking communities to encourage vaccine uptake among their members.

But first, we hear from ASTHO president and Alaska Chief Medical Officer Dr. Anne Zink. There are 229 federally recognized tribes in her state.

ZINK:
I think inherently vaccines are, in some ways, hard to trust. It's a shot in your arm, it's something you don't totally understand. I remember when my child got her first immunizations—you know, I teared up. It's not just a natural thing that you inherently trust as humans, I think. So, I think that at baseline as humans, we're all going to have some vaccine hesitancy. And so, it's about building vaccine confidence.

I also think that there have been many ways that, historically, our healthcare structure and our public health structure has not always had the best interest of individuals, particularly individuals who belong in marginalized or minority communities, at heart. Many people have been injured or harmed by science, by healthcare, and by public health. And so, I think that there's real reasons that people of many different races and ethnicities don't trust the healthcare system, don't trust public health.

And then when you add on top of that something that feels so non-intuitive, like getting vaccinated, and you're trying to address something you can't see or feel or necessarily know the threat of such as COVID—particularly when you see people getting very mild disease, you know, see many people recover just fine, maybe people who are asymptomatic—that's a lot of different parts for people to be able to put together; and, as public health officials, be able to explain why this is such an important tool to keeping yourself healthy, but also your family and your larger community.

So, this has been an issue as long as vaccines have been around. This isn't anything new. And there are many—both current as well as historical—features that have exacerbated that problem. Alaska specifically knew that we were up against a hard uphill battle when we were looking at vaccine. We've always struggled with vaccine hesitancy, building vaccine confidence in our state—be it flu, basic childhood immunizations—and I knew that COVID would be a challenge.

We have, over time, seen increase in particularly our Alaskan Native population in their vaccine rates. And in general, in our state, we have better vaccine rates amongst our Alaskan Native community than we have across the state as a whole. And I think there's many reasons for that. But the biggest reason, I think, is because of a real investment in having local, community-driven health workers who understand a community's health needs in our tribal system. And in Alaska, they're called community health aides who live in a community, are trained in the community, serve the community, and they're oftentimes the ones who are recommending vaccines, offering vaccines, the ones who are actually doing the vaccination in communities. So, that local trusted messenger is key, and I think has been a huge part of the success over the slow improvement of vaccination, particularly amongst with the Alaskan Native people.

JOHNSON:
Do you think vaccine equity is a challenge for these populations in Alaska?

ZINK:
I would say yes and no. We have seen disproportionate impacts on the Alaskan Native people in every pandemic and epidemic as far as we've ever recorded. So, we've known that diseases are disproportionately affecting those communities. A lot of it has to do with the structural setup of where people live, work, and play and we know that that is a big determiner for people's health—you know, 80% of our health is determined by those social determinants. So, you know, in Alaska we have 36 communities without adequate running water and sewer. And we see everything from, you know, increased otitis media to decreased learning to higher respiratory diseases. And it's really hard when you're telling a community to wash their hands and avoid COVID when they're living in a house with five, 10 other people, and very crowded multi-generational housing, and don't have adequate running water and sewer. So, there are some real structural limitations to being able to just protect one's health and one's healthcare, particularly in many of our rural villages.

That being said, with vaccination specifically, we have higher rates of vaccination amongst Native Alaskans than we have amongst most of our other races and ethnicities in the state. And again, I think that is a little bit different than other states. And it's a huge part to the incredibly impressive tribal health system that is established in Alaska. Again, it's a little bit different than other places in the country. But we have 229 federally recognized tribes. They are organized into 13—really 12, functionally—what are called THOs, or tribal health organizations. And that structure, again, really is to have people in community to provide local health and local health information and for vaccines, local vaccination.

JOHNSON:
How do you manage all of that?

ZINK:
The state very early on during the COVID pandemic was clearly stepping on the toes of our tribal partners and tribal partners were also stepping where we were—so, we would both send testing supplies to the same area and neither one would send to the other. It was very hard to work in real time with each other.

In other examples, such as our Healthy Alaskans 2030, we do that in conjunction with our tribal partners. So, it's not a state-led program, it is state and tribal land. And we've consistently found that when you build in voices of equity, when you've built in that structure ahead of time, you're able to get better outcomes. And so, we really quickly pivoted within our COVID pandemic and tried to make sure that we built in our tribal partners in as many places as we specifically could to make sure that we were addressing equity from the beginning.

So, we have a vaccine, you know, team within our section of epi, within our division of public health, but we stood up a completely separate vaccine team for the COVID-19 vaccination effort. And at every single level, we made a tribal partner in conjunction with a state partner. So, be it payment reimbursement, be it the shipping and logistics, be it allocation at every single level, we had a tribal partner with a state partner. And through that process that continued to build trust and confidence with our tribal partners and, ultimately, all 229 tribes opted to not go via the Indian Health Service (IHS) route, but to come via the state.

And what that really allowed us to do was to use our resources in collaboration together. So, instead of a small allocation being sent to one village or one community, particularly then when it was tiered up where, you know, you might have one healthcare worker in one community and the next one's 100 miles away. And you can't just take one part of one vial, and then go to the next one and the next one. So, when we were able to pull together IHS-allocated vaccines and state-allocated vaccines together, and we were able to collaborate. We were able to then ship out vaccine collectively, and we were able to get out vaccine much more efficiently.

The other thing is by recognizing tribal sovereignty—their vaccine was to use in the way that they saw best fit—and that also built a lot of confidence. So, we saw many communities opt to vaccinate the only remaining language speakers in their community first before they did others. They could prioritize who was most important in their community or who they felt like was critical for vaccination.

Another example was pilots. You know, many of our communities are not connected by road. They are intimately connected by rivers in the summer, and this happened in the winter. And so, pilots are just absolutely critical for getting everything from mail to vaccination to food. And so, some communities said that, “We're going to prioritize all the pilots because we know that everything else is dependent on that travel.” We saw communities prioritize, you know, they did their elders, they did their language speakers, and then they did their teachers. And that was both tribal and non-tribal, because they were like, “We have to have our kids in school, and this is going to be a priority.”

So, by allowing and really augmenting that tribal sovereignty in communities, we were able to look at what their specific needs were and be able to prioritize that. And I also think that that builds confidence, and it also accelerated the vaccine efforts. And we saw increased vaccination in, once again, Alaskan Native people specifically because of that kind of collaboration and built-in equity.

JOHNSON:
You have spoken many times about the 1918 pandemic, so I think I know the answer to this, but tell everyone listening how history and previous experience impact vaccine hesitancy and equity.

ZINK:
You know, I was just so impacted by the stories of the 1918 pandemic during my time working in this role. And being in the hospital in Dillingham that was built as an orphanage as a result of the 1918 pandemic, meeting person after person after person who told me, “My great aunt told me of her entire family dying,” “My grandmother took everyone out, you know, and lived in the woods for a year and came back and only saw dogs and young kids still alive, everyone else had died.” There was just this very palpable sense in this state about just the devastating impacts of the 1918 pandemic, and it hit different parts of the state disproportionately.

So, the communities that were hit really hard primarily came in from either seafood or from mail. And there was a real desire to make sure it did not come in particularly via those ways. And what happened in the communities where the 1918 pandemic hit hard is there was a huge loss of culture, identity, and of language because so many people had died. However, in the communities that were really protected from the 1918 pandemic, language thrived, community thrived, arts thrived. And 100 years later, that story is still the story that communities remember, and remember the devastation of the 1918 pandemic, and those who survived and those who didn’t.

And so, I'm really hopeful that’s what we take from this pandemic, and particularly the Alaskan Native communities who did phenomenal work to help to reduce the risk for community. I mean, we've got communities here in the state that had 100% of their entire community vaccinated against COVID-19 before they even had a case. We had communities with no running water and sewer that were able to identify a case isolated, quarantine and completely have it end. And we have many, many communities in the high 90s percent of everyone in their community who was eligible to get vaccinated amongst our Alaskan Native communities. And I do believe that is the story that I have seen from our Alaskan Native communities. It’s a story of resilience, of growth, and remarkable resistance to this virus. And I hope that that story of strength is what they tell it for the next 100 years.

JOHNSON:
Many states are coordinating daily with tribal communities. What lessons can they take from your experience in Alaska?

ZINK:
You know, I think that the lessons learned from the Alaskan Native tribal health system are applicable to every health system. And I would say that it is non-Native healthcare within Alaska, let alone the lower 48, let alone the rest of the world. This focus on mental and physical health as being one, thinking about social health as a part of physical health—and so, water, culture, sewer—all of these things as a part of it, are part of our health.

The thing that I think has allowed the Alaska tribal system to really stand out is their organization. The tribes have been able to organize themselves into these like, again, 13 different tribal health organizations. They're represented by Alaska Native Tribal Health Consortium (ANTHC), this kind of one conglomerate, and then they have a separate group called ANHB, Alaskan Native Health Board, which kind of represents all of them.

So, from a state health official perspective, it's much easier for me, I think, than it is for some states that have way fewer tribes, even, because I have a couple of key inroads to the tribes and I can say, "Help me understand this priority, help me focus on what this is, let me know what needs to happen here.” And sometimes that top organization can make the decision right away. Sometimes they say, “That's going to require a tribal vote, and our next tribal meeting is in a month, and we'll vote on it. And maybe that's going to happen or not.” And I'm like, "Okay, that's your tribal sovereignty, you make that decision.”

But I would say the organization within the tribal health organization is a democracy, and it’s a robust democracy that allows representation but also allows communities to function in a way that allows for advocacy, collaboration. You know, there's no way for—for example, our vaccine team—that we could have had representatives from 229 tribes on every single one of our assets. We couldn't have had that much representation. But because they were able to organize and collaborate, they were able to then designate one person to work with our one person on these levels.

So, their organizational structure, I think, is what really stands out here versus other areas. And I think that that's a model for every community in the way that they do health. I wouldn't say this is just tribal versus non-tribal. We all want sovereignty. We all want representation. We all want our voice spoken. And then, when we build in equity into our teams, when we build in voices into our teams, we're able to get better outcomes.

So, yes, I would say the structure is replicable. And I would say beyond just tribal state relations, it's replicable in many different areas where we need to address equity or we're trying to really promote the health and well-being with a group, with a region, with an area that's needed to be represented.

JOHNSON:
Gary Lankford is with the Association of American Indian Physicians. He says much of the success vaccinating American Indians and Alaskan Natives is thanks to early work done on the Navajo Nation.

LANKFORD:
Early in the vaccine rollout, American Indian/Alaskan Native people were really, in many ways, leading most other groups when it came to actually getting vaccinated. And a lot of that has to do with the success that the Navajo Nation had because they were really early in making sure that people understood the vaccination and the virus, and they did a lot of work to make sure that their people were getting vaccinated. And they did an incredible job.

But I think many American Indian/Alaskan Native people, just like others in the overall population, were hesitant—but for different reasons. Some people obviously wanted to wait and see how the vaccine affected people and if there were any serious side effects before they were vaccinated themselves. They wanted to know that it was safe. I think some people were wary of getting anything first, if you get my meaning, if they believed it was really still being tested. And for that reason, they were a little bit hesitant.

I think, also, we knew that the vaccine was only going to lessen the severity of the symptoms of the virus, that it wasn't an actual cure. A lot of people wanted to see a cure. And that just wasn't possible with something like this. And I think there's a lot of people that believe that "Hey, I feel healthy, I feel good. My last checkup was fine when I saw my doctor", and they might have thought, just based on that, that their bodies are strong enough on their own to fight the virus, and maybe the vaccine wasn't necessary for them. So, there's definitely some hesitancy based on the fact that vaccine came out so quickly. I think people were worried about how quickly it came out. But obviously that was something that had to happen based on the severity of the illness itself.

But there's another part, another concern for Native people that we have to take into consideration. And that is that many Native people across the country are wary of anything they feel as mandated by the government. And that's due to basic distrust of the federal government based on the failure of that government to honor historical treaties in different areas with Native people. And that in itself causes a certain amount of wariness or distrust of the government that is actually specific to American Indian/Alaskan Native people.

And then, you add in also social media disinformation and misinformation that people were seeing, and that's also caused the problem.

JOHNSON:
What messaging works best with these audiences?

LANKFORD:
One of the messages that we put out there that seemed to resonate with people—and often does resonate with Native people—is the vaccine is not only going to protect you, but it's also there to protect your family and the elders in your tribe and in your community. And that's something that across the board, no matter where you are in this country, if you're in a tribal community that's something that's going to resonate. It's going to be important to people because they really do want to protect our elders. And so, that's something that I think helped get that message out there and help people to kind of lessen hesitancy and lessen some wariness. And some people maybe that thought early on that they weren't going to get vaccinated, might hear that message and think, “Yeah, you know, I really need to protect my aunties, or my grandmother, or my grandparents that are here to teach us about the history of our tribe and tell us these stories.” And that's important, and I think that helped in many ways.

JOHNSON:
What would you say are some of the obstacles to vaccine access and equity?

LANKFORD:
So, I think overall, the government did a really good job of getting that information out there and making the vaccine itself available.

Where equity comes into it is if you are a Native person, for example, who lives in an area where it's really rural, or if you don't have reliable transportation, and say your vaccination center is two or three hours away. Now, that's a problem. We've got to find some way to make this available to those people who may not be able to get to a vaccination center but do want to take the vaccine.

And that's where the Navajo Nation really stepped forward with their mobile vaccination units that they took out to these more rural areas and showed that, you know, if you take the vaccine to people who can't get there to a hospital or a clinic to take it—if you take it to them, they'll take the vaccine, because they see the importance of it. You just have to find some way to get it to them. And unfortunately, you know, not all providers or clinics or hospitals have the resources to do that. But in places where they did have the resources, that worked really well and helped decrease the amount of maybe equity problems that we might have seen otherwise.

JOHNSON:
Your members are physicians, they are the providers on the front lines. What role do they have in all of this?

LANKFORD:
You know what, they've been great. They've been really great. They're a very, very important part of our messaging. We're lucky that we have a taskforce of actual member Native physicians from all medical disciplines. They're working in tribal communities, rural reservations, and urban all across the country. And they've been vital in helping us to create messaging and offer their own expertise.

They've also been fundamental in alerting us to any kind of trends or upticks in the numbers of Native people getting vaccinated or when we see different variations of the COVID virus starting to pop up or spike in certain areas. They've given us that information so that we can make sure and expand our messaging. What they've done really for us over the past three years or so is really helped us to tailor our messaging to be as effective as it can be. I think without our base of member physicians, that would have been very difficult. And we need those people that are working in tribal communities to get that word out there.

And they, so far, offered their time, created video and audio PSAs that were running in different markets, on television and on radio and streaming services all across the country. And they've taken part in online townhall sessions to answer questions about COVID and the vaccine and the side effects. They've done interviews with some online publications to stress the importance of vaccination and the safety of the vaccines. And they've also offered educational presentations at national conferences, where they're able to talk about trends of vaccination in tribal communities. And also, again, answer questions about efficacy.

JOHNSON:
Wrapping up, what is your key takeaway from the pandemic experience related to vaccine hesitancy and equity in these communities?

LANKFORD:
Tribal communities that really on the whole have done a really good job about getting people vaccinated. And that's the ultimate goal, of course, of what we do here and what a lot of organizations out there are doing across the country.

So, I think there's lots to be learned, just by messaging. And by making sure that people understand maybe, even if you have a greater, larger community, or if you're in an urban area, for example, that's still a community. And you can still use community-based messaging to get those things across and how important it is to protect others as well as yourself.

JOHNSON:
Johnny Delgado is the grants program director with the Bakersfield American Indian Health Project (BAIHP) in California. He's managing vaccination outreach projects and learning the role that trust plays in their success.

DELGADO:
Last year, BAIHP was awarded funding through Community Action Partnership of Kern (CAPK). We utilize that funding to engage the community and promote awareness for vaccine equity amongst American Indian/Alaskan Natives. What that consisted of was creating informational items to give out to the community, collaborating with other organizations to have events and also have information about other events of our own. With that, we actually have an FNP on staff that we were able to give vaccinations out to the community and incentivize that using gift cards. Depending on the event, they received anywhere from $25–100 in Target gift cards for receiving the vaccine.

JOHNSON:
How has that work gone, so far? Are you getting the uptake you're looking for?

DELGADO:
We had huge improvements. To give an example, we had a total of about 38 vaccines for the first half of the year, and that was prior to getting the funding. After we received the funding, we received, in total, 247 vaccines. Now, those totals do include influenza, because we did offer the flu vaccine while we were offering the COVID-19 vaccine. But, as you can see from the numbers, it was a huge increase.

JOHNSON:
And is the program running today?

DELGADO:
No, the funding ended for that program. We still offer the vaccines, but as it's no longer being incentivized the interest has kind of died off. In early January, there were some stragglers who attempted to receive the vaccines at our events but weren't able to get them, and which we honored for them to receive those vaccines in January. But outside of that, it's pretty much come to a standstill.

JOHNSON:
Tell us about some of the challenges that you encountered while you were putting the program together and then taking it out into the community.

DELGADO:
Well, the most difficult challenge we had was how to utilize the funding. At the time when we got into it, it was—CAPK, we'd never received funding from them before. So, it was developing that relationship with them, and of how to invoice them, figuring out the logistics of that portion of it.

And then, what we’re able to utilize the funds for—generally speaking, with the funding we receive, there's a lot of limitations on it. Like, you can't buy food, you can't use it for like advertisements, and such. Whereas this funding was not restricted in that manner. However, the documentation, everything spent needs to be heavily documented, so there's a lot of work to do with it. The other challenges that we had were how to engage the community on a wide level. So, you know who to talk to, what events to have, how do we get this out of committee, and then addressing the issue the community had in its own.

JOHNSON:
Give the audience a little more detail about the work you've done and what you've learned from it.

DELGADO:
We engaged the Tübatulabal tribe, which is located in Lake Isabella. It's not very far but, because of the road, it's about 45 minutes or an hour drive to get there. And we received huge resistance from that community.

We offered $100 gift cards for a vaccine. It was our December event. We had food from a local restaurant that's very popular, giving out hot plates. We had food boxes from Community Action Partnership of Kern. We gave out tons of resources. And, like I said, $100 gift cards to get the vaccine. We only gave out, I want to say around 20 something, 30 vaccines during that event, which is the lowest turnout from all our events.

However, with that, it sparked the interest of that community to now build a relationship with them. Whereas before, they had mentioned wanting to build a relationship, but they didn't. So, if we had had more time, we could have better engaged that community prior to and increase the vaccination numbers. Because the largest part of it is building the trust, which Natives don't easily give due to the issues they've had with the government, in general.

JOHNSON:
Do you have any words of wisdom for others who might be thinking about doing this kind of work in their communities?

DELGADO:
I would say, build it. You know, you build your action plan, but also build a sustainability plan behind it. Because once you get the foot in the door, you don't want to back out and then leave it without any resources. So definitely, that's something that I would say you definitely need to have.

You're making a commitment when you make a commitment to any Native Americans. And when they trust you, they're going to trust you until you pull away from them. And once you pull away, you may never get that trust back.

Make sure that you have your community partners established as well, who's going to assist you and your objective and what you're trying to do. We learned several things about the tribe when we were out there that we weren't aware of before, and now we're looking at ways to assist them long term. But they did invite us to a community event that we're going to be attending. It's a tribal-only event, so it's an honor for us to even take part of it. But that shows them to extend the hand back out to us, and we're going to take it. But also, by taking it, it's going to grow the commitment we need to have with them as well, though, and that's something that we have to prepare for.

So, what I would say that ,if you're looking to engage in that community, you need to make sure that you're able to assist them with everything you're promising to do for them because they're going to call on you, they're going to remember you. And if you don't deliver, the entire community—not just that community, every other community that they add, anybody that community talks to—you're going to hear about it.

JOHNSON:
Thanks for listening to Public Health Review. If you liked the podcast, please share the episode with your colleagues on social media. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's P-R at A-S-T-H-O dot org. You can also follow us using the follow button on your favorite podcast player.

Finally, stay up to date on everything happening at ASTHO by tuning in every morning for Public Health Review Morning Edition. We cover news like this every day. We've got a link to the newscast in the show notes. We'd love to know what you think.

This podcast is a production of the Association of State and Territorial Health Officials. For Public Health Review, I'm Robert Johnson. Be well.