When Timothy Nuvangyaoma, chairman of the Hopi Tribe, heard there were two coronavirus vaccines that both showed promising data of more than 90 percent efficacy, he felt initial relief that soon transitioned to cautious skepticism.
That’s because the logistic and cultural challenges of delivering a Covid-19 vaccine with precise temperature requirements and two-dose administration to members of the Hopi Tribe are vast: Hopi often live in remote locations and only one-third of the population has reliable means of transportation, according to officials with knowledge of vaccine distribution planning. Hopi lands span more than 1.5 million acres and encompass parts of both Coconino and Navajo counties in northeastern Arizona.
Power supply is always a concern, brownouts are common, and generators are a luxury. The Hopi Health Care Center has to outsource much of its care.
Meanwhile, the Pfizer vaccine requires transportation at minus 94 degrees Fahrenheit and must be ordered in units with a minimum of 1,000 doses. And while this week’s preliminary results from biotech company Moderna Inc. showed encouraging data that its candidate was 94.5 percent effective, that vaccine still requires long-term storage at sub-zero freezer temperatures, short-term storage in a refrigerator and a two-dose administration separated by multiple weeks.
Other options progressing through the pipeline aren’t as finicky; one of the Johnson & Johnson candidates, for example, has a one-dose regimen and is expected to remain stable at basic refrigerator temperatures for longer periods of time.
Added to the logistical challenges is the broader, long-simmering cultural mistrust of vaccines and clinical trials felt by tribal communities as a result of historical trauma, making their skepticism about the safety of vaccines more pronounced.
“There’s always that reluctance as a Native American,” Nuvangyaoma said. “I have to make sure that it’s going to be able to help. And I don’t want to get people’s hopes up.”
For Nuvangyaoma and leaders across other tribal nations, Covid-19 has been an extraordinary crisis.
The pandemic has highlighted long-standing structural inequities and health disparities for American Indians and Alaska Natives, many of which are rooted in the federal government’s chronic underfunding of tribal and urban health care systems, despite legal and treaty obligations to do so. According to the Centers for Disease Control and Prevention, the Covid-19 infection rate is 3.5 times higher for American Indians and Alaska Natives, who are also more likely to suffer hospitalization or mortality than non-Hispanic whites.
The collapse of tribal economies due to the virus, as well as problems and regulations around the distribution of emergency federal funds, stalled any potential recovery even more.
Amid America’s mismanaged response to the pandemic, few communities have borne the brunt quite like smaller tribal nations. For the Hopi, a people who have maintained a connectivity to their traditional ways of life and identity, the loss of even one member is amplified.
The virus “has taken elders who should have been able to pass this down to the younger generation,” Nuvangyaoma said of the tribe’s cultures and traditions. “It's taken the younger generation who should be the ones that are picking up where we're leaving off, to continue with our story.”
‘It's a Gamble at This Point’
Throughout the pandemic, tribal leaders have faced rushed processes and deadlines to make consequential decisions involving vaccine readiness, such as whether to receive vaccine allocations through the state or the Indian Health Service. Some Urban Indian health clinics were told one day before the presidential election that they needed to make the choice by the end of that week.
Tribal leaders are making “life and death decisions within their tribal communities on the reservations and villages right now . . . so they may not always have the time to respond in a week,” said Abigail Echo-Hawk, a citizen of the Pawnee Nation of Oklahoma, director of the Urban Indian Health Institute and chief research officer for the Seattle Indian Health Board.
Meredith Raimondi, the director of communications at the National Council of Urban Indian Health, said the consequences could be dire: “A big concern is that you make the wrong decision, and you choose the state, or you choose IHS and then one of those doesn't go according to plan and you have no vaccines. I mean, it's a gamble at this point.”
The Hopi Tribe opted to receive allocations through the Indian Health Service, the federally funded health care system responsible for providing services to approximately 2.6 million American Indians and Alaska Natives. According to officials involved in the logistics planning, the Hopi Tribe is preparing for a direct-shipment scenario from the manufacturer or a “hub and spoke” strategy using ultracold storage in a central location like Phoenix as a distribution hub.
Supply chain experts like Julie Swann, a professor at North Carolina State University who previously advised the CDC during the 2009 H1N1 pandemic, are greatly worried about the logistics involved in cold-chain management of the vaccine for these communities.
“Pfizer kind of acts like that's going to solve the problem and to some extent, the federal government acts like that, as well,” Swann said of the company’s direct delivery approach that ships vaccines in specialized containers packed with dry ice.
While Pfizer’s strategy would work for a mass vaccination clinic, she explained, it would not be as effective for a health care provider trying to allocate small amounts of vaccine to multiple people over time.
“I think the changes in the Moderna vaccine make it much easier to give that one in rural or sparsely populated areas,” Swann said.
Moderna’s vaccine can remain stable at standard refrigerator temperatures of 36 to 46 degrees Fahrenheit for up to 30 days once thawed.
The Hopi Tribe anticipates hiring additional staff who will work extended hours to facilitate higher volume administration within the tight time frames. Getting patients to an administration site will also be a challenge for tribes in more remote areas.
“We live on the reservations where people do not have street addresses, so finding the people who are going to be classified as Phase 1 is going to be very troubling,” said a CDC official who has worked with Western tribes, but who did not have authorization to speak publicly.
“We have to really double and triple down on our logistics to make sure that we are able to hit very tight time windows,” the official said. “That's where the difficulty lies.”
Historical Traumas Fuel Distrust
Logistical hurdles are only intensified by past research abuse and negligence, such as when blood samples from members of the Havasupai Tribe that were given to researchers for studies on diabetes were stored and later distributed for unrelated studies. In addition, racial inequities have caused misclassification and gross underreporting of data for Native Americans.
“These memories, including the Havasupai case, and others of historical research harms are ones that are stories that are told in Native communities,” said Echo-Hawk, who also served on the committee that advised federal agencies on Covid-19 vaccine allocation.
“It has made our communities very hesitant to participate in any kind of clinical trials or research,” she said.
On the nearby Navajo Nation, where the coronavirus is currently considered to be in uncontrolled spread in 34 communities, President Jonathan Nez warned vaccine hesitancy in the U.S. is spreading and has contributed to some of his most vulnerable citizens choosing not to get the flu vaccine.
“We all know that the flu and Covid-19, if caught together, is deadly,” Nez said in an interview. “A lot of our elders have received the flu vaccine every year, but because of this hysteria that is happening off the nation that is coming onto the nation . . . our elders are beginning to question, ‘Hey, what’s going on here?’”
There is also a lack of culturally appropriate communications from drug manufacturers that have struggled to maintain widespread Indigenous representation in trials.
In October, the Lummi Nation in Washington state announced its withdrawal from the AstraZeneca trial after Lummi doctors cited “ongoing communications challenges with AstraZeneca representatives as a primary factor.” Lawrence Solomon, chairman of the Lummi Nation, said in a statement that the AstraZeneca trial “was not a good fit” for the tribe, which later submitted an application to participate in biotechnology company Novavax’s trials.
The Hopi Nation, which is landlocked by the Navajo Nation, notably decided not to join the Pfizer trials taking place on the latter. According to a breakdown of participant diversity on Pfizer’s website, 1 percent of the participants enrolled in U.S. trials are Native American. There are currently about 125 volunteers enrolled in Pfizer’s trials on the Navajo Nation, 75 percent of whom are Native Americans, according to Dr. Laura Hammitt, director of infectious disease prevention with Johns Hopkins University’s Center for American Indian Health, who oversees the trials.
In slides released by Moderna, the company detailed interim data of enrolled trial participants, categorizing them as white, Hispanic/Latino, Black/African American, Asian and Other.
“I respect everybody's freedom to make their own choices,” Nuvangyaoma said of the Navajo Nation’s decision to participate. “We already have the coronavirus here and I’m not going to subject my community members to be used as test models for something unless it’s safe.”
Despite his concerns, he is still hopeful.
“We've been dealing with this all our lives. We've had issues with sicknesses, pandemics, plagues come across our lands. We’re fighters and we’re resilient people, and it’s no different for us out here on Hopi,” Nuvangyaoma said. “We come together in times like this. And we’ll come out of this, also.”