But because he was uninsured at the time, the surgery at a Reno, Nevada, hospital led to years of anguish. He said he owes the hospital more than $20,000 for the procedure and still gets calls from collection agencies.

“It can cause a lot of anxiety,” Rice said. “I can’t give you what I don’t have.”

Rice, 62, was born and has spent his life in Nevada. He said he fell through a gap in the tribal health care system because he lives 1,500 miles from the Prairie Band Potawatomi Nation home area in eastern Kansas, where he’s an enrolled member.

He receives primary care at the Reno-Sparks Indian Colony tribal health clinic in Nevada, but structural barriers in the federal Indian Health Service left him without coverage for specialty care outside of the clinic. Rice might have been eligible for specialty services referred by his tribe’s health system in Kansas, but he lives too far from the tribe’s delivery area to utilize the tribal health program that helps pay for services outside of the IHS.

“I shouldn’t need to move to Kansas City to be fully covered,” Rice said.

A new tribal sponsorship program in Nevada is aimed at getting tribal citizens like Rice covered and protecting them from incurring debt for uninsured care. It allows tribes to buy health insurance through the state’s Affordable Care Act marketplace for people living in their service area, including Native Americans from other tribes.

Tribal leaders and Nevada officials say the sponsorship model increases access to coverage and care for tribal citizens and their families by allowing them to seek medical care outside the tribal health care system.

A few dozen tribes have moved to set up the insurance programs since the ACA authorized them more than a decade ago.

“It’s not widespread,” said Yvonne Myers, an ACA and Medicaid consultant for Citizen Potawatomi Nation Health Services in Oklahoma.

Native American adults are enrolled in Medicaid than their white counterparts and have long faced worse health outcomes, higher incidences of chronic disease, and shorter life expectancy. Many rely on the IHS, a division within the Department of Health and Human Services responsible for providing care to Native Americans, but the agency is chronically underfunded.

In Nevada, tribes can sponsor their community members’ health coverage through aggregated billing, a method for paying the premiums for multiple individuals in a single monthly payment to the insurer. Another part of the program includes collaboration between Nevada Health Link, the state health insurance marketplace, and tribes to certify staffers at tribal health clinics so they can enroll community members in health plans. Program officials also said they are committed to providing further education to tribes about the accommodations available to them under the ACA.

Health agencies in Washington state and Nevada have helped set up tribal sponsorship programs. Independently, tribes in Alaska, Wisconsin, Idaho, Michigan, Montana, and South Dakota have rolled out individual programs, as well.

It’s already making a difference for Native American patients in Nevada, said Angie Wilson, tribal health director for the Reno-Sparks Indian Colony and an enrolled member of the Pit River Tribe in California. Wilson said patients have shown up at her office in tears because they couldn’t afford services they needed outside of the tribal clinic and were not eligible for those services to be covered by the IHS Purchased/Referred Care program.

The Reno-Sparks Indian Colony, members in 2023, is one of two tribes that participate in Nevada’s tribal sponsorship program and aggregated billing. Russell Cook, executive director of Nevada Health Link, said he expects more tribes to come aboard as the agency works to build community trust in tribes often wary of government and corporate entities.

The Fort McDermitt Paiute and Shoshone Tribe, with a reservation that spans Nevada’s northwestern border, was the first tribe to pilot the program. There are about .

As of December, 30 tribal members had been enrolled into qualified health plans through Nevada Health Link as part of the tribal sponsorship program, according to state officials, and more than 700 of those enrolled through the state marketplace self-reported American Indian and/or Alaska Native status for last year.

Through sponsorship, tribes may use their federal health care funding to pay the premium costs for each participating person. That, combined with cost-sharing protections in the ACA for American Indian and Alaska Natives enrolled in marketplace health plans, means beneficiaries face very low to no costs to receive care outside of tribal clinics. The also expanded eligibility for premium tax credits, making purchasing a health plan more affordable.

Because sponsorship in some tribes isn’t limited to enrolled tribal citizens, it can help the whole community, said Jim Roberts, senior executive liaison for intergovernmental affairs with the Alaska Native Tribal Health Consortium and an enrolled member of the Hopi Tribe in Arizona.

Since Alaska , Roberts said, it has not only increased the access to care for Native Americans but also significantly lowered the costs of care, “which is equally as important, if not for some tribes more important.”

In Washington state, where sponsorship in ACA plans began in 2014, .

Cook said the state exchange is seeing interest in the part of the sponsorship program that trains staff at tribal clinics to become certified exchange representatives, a role similar to that of a navigator who helps inform people about health coverage options.

He said the agency is working on a marketing campaign to spread awareness among Native Americans in the state about the sponsorship program. It will include translating resource guides and other materials from the agency into , such as Northern and Southern Paiute, Washoe, and Western Shoshone.

Cook said he’s surprised more states haven’t taken the initiative to create sponsorship programs in collaboration with tribes.

Nevada Health Link patterned its approach by looking at Washington state’s program, Cook said. Since launching its own program, the Nevada agency has been approached by officials in California who are exploring the option.

But leaders like Wilson are concerned that under the Trump administration the enhanced tax credits for ACA marketplace enrollees implemented during the pandemic will end. The credits are set to expire at the end of this year if Congress doesn’t act to extend them. Without the credits, nearly all people enrolled through the marketplace will see steep increases in their premium payments next year.

If tribal citizens or other community members become ineligible for the premium tax credits, that could jeopardize the tribe’s financial ability to continue sponsoring health plans, Roberts said.

“Whatever side of the fence people fall on, it does not take away that there’s a federal trust responsibility by the United States of America to its First Nations people,” Wilson said.

Wilson, who has been an advocate for sponsorship since the ACA was approved in 2010 and led the effort to establish the program in Nevada, said she is happy with the tribal sponsorship program but wishes it would have happened sooner.

“We’ve lost so much in Indian Country over time,” she said. “How many more Indian people could have gotten access to care? How much more of a difference could that have made in sustaining health care for tribes?”

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Click here for a transcript of the episode.

Episode 7: Fighting for Reproductive Sovereignty

Rachael Lorenzo works to address reproductive health disparities in Native communities. In 2018, they founded , a fund that provides financial help for Native people seeking an abortion.

Historically, the federal government has restricted Native people’s reproductive autonomy. Between 1973 and 1976, more than 3,500 Native people .

Today, the chronic underfunding of the Indian Health Service and the remoteness of many reservations create barriers for Native people to access testing for sexually transmitted infections, prenatal care, and contraception.

Lorenzo is determined to fight for their community.

“My people deserve accessible health care, and I will make it happen no matter what, because this is our land,” they said.

Episode 7 explores efforts to protect and expand access to comprehensive reproductive and sexual health care in the face of historical and contemporary efforts of the government to control Native people’s fertility.

Voices from the episode:

• Rachael Lorenzo, co-founder of — ; ;
• Sarah Deer, distinguished professor at the University of Kansas —
• Sunny Clifford, reproductive rights advocate
• Elizabeth Rink, professor of community health at Montana State University

Season 4 of “American Diagnosis” is a co-production of KHN and .

Our Editorial Advisory Board includesÌý,Ìý, andÌý.

To hear all KHN podcasts,Ìýclick here.

Listen and follow “American Diagnosis” on , , , or .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Covid hospitalization and death rates for American Indians and Alaska Natives had skyrocketed past those of non-Hispanic whites. Leveraging established systems like the Indian Health Service and tribal organizations, Native Americans urgently administered vaccines. Data from the Centers for Disease Control and Prevention showed they achieved the highest vaccination rates of any race or ethnicity.

Yet, tribal health officials said, they eventually ran up against the challenges that broadly stalled the U.S. vaccination campaign, particularly in persuading people to get booster shots.

Nationally, 72% of American Indians and Alaska Natives of all ages had received at least one dose of a covid vaccine as of March 28, and 59% were fully vaccinated — having received two doses of Moderna’s or Pfizer-BioNTech’s vaccine or one dose of Johnson & Johnson’s. A much smaller share had received booster shots — 44% of fully vaccinated Native Americans ages 12 and up, below the booster rates for whites, Asian Americans, and Native Hawaiians and Pacific Islanders.

Tribal health experts say data problems may be partly to blame, but there are other factors. It’s proved more difficult in recent months to find shots and book appointments. Some people weren’t convinced about the value of a third shot, a hesitancy fueled by evolving scientific understanding of the virus and a distrust of the federal government entrenched in tribal communities.

“Sometimes I think the people I talk to see it as, ‘Hey, we got our first and second shot. You guys have told us that’s what we need, and we’re going to be OK,’” said Angie Wilson, who until recently served as tribal administrator of the Reno-Sparks Indian Colony, a federally recognized tribe in Nevada with about 1,200 members.

Reno-Sparks provides a glimpse into what it takes to increase vaccinations. Before the omicron variant arrived in early December, vaccinations had plateaued, and many members were expressing apathy about getting additional shots, she said. After omicron caused a sharp rise in cases, Reno-Sparks mandated that its employees be fully vaccinated and boosted. It also used money provided by the American Rescue Plan Act to members: $1,000 for getting the initial doses and $500 for a booster, regardless of whether they lived on or off the reservation.

Those incentives and rising counts of breakthrough infections sparked renewed interest and persuaded roughly 130 people to get boosters within six weeks. Thirty-five percent of eligible Reno-Sparks’ tribal members had been boosted as of late March. The rates of first and second shots rose, too: 60% of members 5 and older had received an initial dose, while 56% were fully vaccinated.

The tribal land is in an urban area in Reno, and the reservation has a Walmart Supercenter.ÌýNevada lifted its statewide mask mandate .

With precautions to limit covid’s spread falling by the wayside, tribal officials fear what any gaps in vaccination will mean for their communities. American Indians and Alaska Natives have been at three times the rate of white Americans and have died of covid at double the rate of whites, according to the CDC. Nationally, as of March 28, fewer than half of booster-eligible Native residents .

“I can see where we’re heading, which is concerning,” Wilson said. “I worry about our tribal population, especially with our risk factors.”

The challenges were evident even before the FDA on March 29 dose of the Pfizer-BioNTech and Moderna vaccines for anyone 50 or older and certain immunocompromised people. Tribal members and health experts see several reasons that booster rates have not been higher, despite employing more aggressive vaccination measures than surrounding states and counties.

Virginia Hedrick, executive director of the California Consortium for Urban Indian Health, said, “I do think that IHS really rose to the occasion when it came to the pandemic and vaccine rollout.” Still, “any time we have something change,” she said of the vaccine, “it raises questions for folks.”

In the fall, Hedrick said, her mother-in-law saw ads for booster shots all over the place but still couldn’t get an appointment. “There was a general sense of frustration,” she said.

Another problem, which likely masks the true share of Native Americans who have gotten booster shots: data inconsistencies. Race data on Native Americans has long been hindered by accuracy issues, including misclassifications of people. With covid vaccines, the CDC receives data from a hodgepodge of systems that generally don’t communicate with one another: state immunization registries, pharmacy chains, and federal vaccine providers, including IHS. And race and ethnicity information is missing from a significant share of vaccination records.

The agency acknowledges that it can overestimate initial vaccines given and undercount subsequent doses because the data does not include personally identifiable information. As a result, different doses may not be connected back to the same person.

If a Native American receives the first two doses through the IHS but gets a booster elsewhere, the booster dose could be misclassified as a first dose. Many instances of this could create the impression that booster rates among Native Americans are lower than they really are.

“The counting might get confused because there’s no central system,” said Dr. Meghan O’Connell, a tribal medical epidemiologist with the CDC Foundation who works at the Great Plains Tribal Leaders Health Board in South Dakota.

Accurate federal data is crucial for assessing Native American vaccinations because of the large role played by the IHS, a federal agency through which 355 facilities, tribal health programs, and urban Indian organizations received vaccine shipments. State-level data on vaccination does not include administered shots from all federal vaccine providers, including the IHS.

Native Americans get vaccinated in and outside of tribal health facilities, but access to IHS facilities can affect overall rates.

IHS that have been delivered and administered in 11 IHS areas but not the number of people per area who have received those doses. The lone exception is Alaska, where tribes received vaccines from the state.

“Something I’m very interested in is knowing how these rates may differ between tribal communities so that we can learn more about best practices,” O’Connell said.

IHS received $9 billion to respond to the pandemic, the bulk of it from the American Rescue Plan. It did not respond to questions about efforts to increase booster rates among tribal populations and whether they differed from outreach done to encourage people to get the initial shots.

When asked how often Native American vaccination data is checked for errors, CDC spokesperson Kate Grusich said the agency “regularly provides feedback on data quality” and works to remove duplicate or incorrect records. “This is an ongoing process and includes strategies to improve the accuracy of all COVID-19 vaccination related data, including race and ethnicity data,” she said in an email.

Agnes Attakai, a member of the Navajo Nation six relatives to covid, got her first two vaccine doses easily, through a university drive-thru clinic. But when it came to her booster shot, she said, she had two options — CVS and Walgreens pharmacies, which had “a month- to two-month-long waits,” or her local public health department about 10 miles away. A resident of rural Pima County, Arizona, she chose the latter and got her shot in November.

Attakai, director of health disparities outreach and prevention education at the University of Arizona’s public health school, said she observed high uptake of booster shots. But there have been some clear differences compared with the early vaccine rollout.

Shots were “more accessible at the very beginning where there was a mass effort, a communitywide effort,” Attakai said. “When the boosters rolled out … [folks had to] actually find out where to get their booster shots and which was the closest location, when they were open. And, of course, some of them were open only during the daytime.”

The Navajo Nation, the largest tribe in the U.S., required its employees to get booster shots, building on an earlier mandate that they be fully vaccinated. As of March 4, 66% of Navajo Nation residents had received the first two doses, according to spokesperson Jared Touchin, above the U.S. rate at the time.

As officials brace for future covid surges, Wilson said tribal officials are trying to figure out how to best educate people on how to protect themselves. “If we don’t do that, I think that the issue’s going to be, ‘Well covid’s over, everything’s opened up, we don’t have to deal with this anymore, I’m back to living my life,’ without realizing that the danger is still there,” she said.

The hardship for the national pandemic response is that “there’s a validity in the fear in tribal communities,” Wilson said, “centered around the distrust of the federal government, rightfully so.”

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Click here for a transcript of the episode.

Episode 6: Right to Water

In 2020, during the first wave of the coronavirus pandemic, Zoel Zohnnie was feeling restless. Growing up on the Navajo Nation, he said, the importance of caring for family and community was instilled at an early age. So Zohnnie wanted to find a way to help members of his tribe. One need in particular stood out: water.

American Indian and Alaska Native households are 3.7 times as likely to lack complete plumbing as households whose members do not identify as Indigenous or Black, according to a 2019 on plumbing poverty in the United States.Ìý

“Climate change and excessive water use is exacerbating these struggles,” explained George McGraw, CEO of . “Much of the western United States has been in severe drought for years. Many rivers and wells on or near the Navajo land have dried up. As groundwater recedes, people are forced to seek water from unsafe sources.”

To answer that need, Zohnnie began hauling water to people who were without, and he founded . In this episode, listeners come along for the ride as he ― and his truck ― make one herculean trek across snow-covered roads in New Mexico.ÌýÌý

Episode 6 is an exploration of the root causes behind the Navajo Nation’s water accessibility challenges and a story about the water rights that some communities have effectively lost.

Voices from the episode:

• Dr. Ernestine Chaco, emergency medicine physician and lawyerÌý—
• Brianna Johnson, community health representative with the Naschitti Chapter, Navajo Nation
• George McGraw, CEO of — , ,
• Jeanette Wolfley, assistant professor of law at the University of New Mexico —
• Zoel Zohnnie, founder of and actor —

Season 4 of “American Diagnosis” is a co-production of KHN and .

Our Editorial Advisory Board includesÌý,Ìý, andÌý.

To hear all KHN podcasts,Ìýclick here.

Listen and follow “American Diagnosis” on , , , or .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Click here for a transcript of the episode.

Episode 4: Abandoned Mines, Abandoned Health – Part II

People living on and near the Navajo Nation have been grappling with the legacy of 40-plus years of uranium mining. According to Environmental Protection Agency cleanup reports and congressional hearings, mines were abandoned, radioactive waste was left out in the open, and groundwater was contaminated.

This episode is the second half of a two-part series about uranium mining on the Navajo Nation. Part I discusses the history and economic forces that brought mining projects to Indigenous land. It also explores working conditions uranium miners faced, and the response of the federal government when workers exposed to harmful radiation spoke out.

Abandoned Mines, Abandoned Health – Part II continues the conversation with former uranium miners. It explores what a coalition of Indigenous leaders and non-Native locals are doing to force the cleanup of hazardous uranium mining sites and seek expanded recognition by the , which provides remuneration to former uranium workers harmed by radiation exposure.

The push for attention and recognition from Congress was difficult. Along the way, former workers and local residents formed advocacy groups focused on documenting worker health.

Former mine worker Phil Harrison was among those who went to Washington, D.C., to push for a cleanup plan.

“Seven of us testified,” Harrison recalled, “and, based on that, they gave a directive to federal agencies who said, ‘OK, EPA, BIA [Bureau of Indian Affairs], Nuclear Regulatory Commission. This is what we’re going to do.’”

Citizens have also served as volunteers helping to shape environmental research on the lasting effects of uranium mining on the land.

Today, Indigenous groups say they continue to uncover pollution from the 1979 tailings pond spill near Church Rock, New Mexico. RECA is set to expire in July of this year unless Congress acts. Meanwhile, future uranium mining projects loom as a possibility.

Voices from the episode:

• Linda Evers, president of Post 71 Uranium Workers Committee and former uranium mine worker
• Phil Harrison, president of the Navajo Uranium Radiation Victims Committee and former uranium mine worker
• Larry King, activist and former uranium mine worker
• Judy Pasternak, journalist and author ofÌý“Yellow Dirt: An American Story of a Poisoned Land and a People Betrayed”
• Ben Ray Luján, Democratic U.S. senator from New Mexico

Season 4 of “American Diagnosis” is a co-production of KHN and .

Our Editorial Advisory Board includesÌý,Ìý, andÌý.

To hear all KHN podcasts,Ìýclick here.

Listen and follow “American Diagnosis” on , , , or .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Click here for a transcript of the episode.

Episode 3: Abandoned Mines, Abandoned Health – Part I

On the morning of July 16, 1979, a dam broke at a uranium mine near Church Rock, New Mexico, releasing 1,100 tons of radioactive waste and pouring 94 million gallons of contaminated water into the Rio Puerco. Toxic substances flowed downstream for nearly 100 miles, according to a report to a congressional committee that year.

In the 1970s, uranium mining was a good source of income, leading many Indigenous people and other locals to seek out jobs in the mines and the mills where uranium ore was processed in preparation for making fuel. The work was often grueling, but many young people didn’t have other options to support their families.

Episode 3 is an exploration of the forces that brought uranium mining to the Navajo Nation, the harmful consequences, and the fight for compensation that continues today. It is the first in a two-episode arc of reporting about uranium mining.

Judy Pasternak, a journalist formerly with the Los Angeles Times, covered the issue in her book, “Yellow Dirt,” in which she reported on the conditions in the mills, including the exposure of workers to “yellowcake,” a powdery radioactive substance that is produced as part of the uranium milling process.

Larry King, who is Diné and a former uranium worker, said he worked in his street clothes.

“So it was just usually one of my old shirts, my pants. No gloves. No respirator. Nothing. So everybody’s breathing all that dust.”

Another former uranium worker, Linda Evers, said she wasn’t told about the dangers associated with uranium exposure.

“When we had safety meetings, it was about regular first aid,” she said. “There was no mention of radiation — or any of the side effects from it.”

The consequences of radiation exposure can build quietly in the body, over decades and generations. It can cause multiple types of cancer, birth defects, and other ailments.

Voices from the episode:

• Amber Crotty, Navajo Nation Council delegate, Window Rock, Arizona —
• Linda Evers, president of Post 71 Uranium Workers Committee and former uranium mine worker
• Phil Harrison, president of the Navajo Uranium Radiation Victims Committee and former uranium mine worker
• Larry King, activist and former uranium mine worker
• Judy Pasternak, journalist and author of “Yellow Dirt: An American Story of a Poisoned Land and a People Betrayed”
• Edith Hood, activist, former probe technician for Kerr-McGee Corp.
• Cipriano Lucero, former uranium mine worker

Season 4 of “American Diagnosis” is a co-production of KHN and .

Our Editorial Advisory Board includes , , and .

To hear all KHN podcasts,Ìýclick here.

Listen and follow “American Diagnosis” on , , , or .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

“Mice are fairly trap happy and easy to catch,” she said. “But it can be kind of a miserable job in the winter.”

Kuenzi’s goal is to better understand how a type of hantavirus called spreads through these mouse populations.

Kuenzi, at Montana Technological University, and her colleague Angie Luis, at the University of Montana, are among a growing number of researchers working to predict where viruses may be likely to spill over from animals to humans. Sixty percent of human diseases, including the Sin Nombre hantavirus, originate in animals, and two-thirds of those originate in wildlife.

By understanding hantavirus and the complex ecology that governs it, Kuenzi and Luis also hope to create a model system to better understand the ecology of many other viruses, including coronaviruses.

The researchers have built six large enclosures at the , a University of Montana research facility. There, they can study how deer mice behave when they’re the sole occupants and then introduce the mice’s main rodent competitors, voles, to see how mouse populations, mouse behavior, and disease prevalence change.

“We’re asking how competitors affect the transmission of disease,” Luis said of the research, recently funded with a $2.5 million National Science Foundation grant. “We are trying to understand that as we stress animals, as we add or remove competitors, how does that change the transmission?”

The role of biodiversity in zoonotic diseases is complex and can have both positive and negative effects. For example, competition from other rodents can lower deer mice numbers and reduce how often the mice interact, limiting infections. At the same time, the presence of more competitors can stress deer mice, and stress in animals has been shown to lower their immunity and greatly increase their viral load.

Climate change is also a factor. Warmer temperatures and fluctuations in rain and snow are changing habitats, which can affect infection rates. The first recognized outbreak of hantavirus in humans, in 1993, is thought to have been driven by a wet winter that provided more food for mice.

The Montana study area has only two main rodents, making it a simple system for carrying out research. Kuenzi and Luis are also gathering data in the Southwest, where Sin Nombre is far more prevalent — and complicated. “At one site in Arizona, we caught 29 species of rodent-sized small mammals,” Kuenzi said. The larger number of species appears to decrease the prevalence of the disease, Luis said.

Sin Nombre, Spanish for “without a name,” is one of several types of hantavirus. It is transmitted through the inhalation of airborne particles from mouse droppings. The disease is rare in humans but can be deadly. In 1993, the first known outbreak was on the Navajo Nation in the Southwest. It killed 13 people, half of those it infected.

The disease is most prevalent in rural areas, where mice and other rodents are common, and public health officials urge people to take special care when cleaning homes or buildings that have been closed for the winter or when working in areas like crawl spaces or vacant buildings where rodents may be present.

In 2012, Sin Nombre in tent cabins in Yosemite National Park killed three people. In 2004, the deputy superintendent of Glacier National Park died from the disease. From Sin Nombre’s discovery in 1993 through 2019, fewer than 900 infections were reported in the U.S.

The hope for the research in Montana is that it will lead to recommendations on how to manage land in ways that don’t increase the prevalence of the disease.

This is just one thread in the tapestry of disease ecology. The long list of factors that increase the possibility that pathogens will spill over from animals to humans is getting a lot of attention from researchers around the world in response to the pandemic caused by SARS-CoV-2. Viral outbreaks are a product of the ways that humans are altering the natural world, though researchers are seeking to determine precisely how.

In the big picture, research from the past 20 years shows that keeping nature intact will help minimize the risk of another pandemic. “Evidence is mounting that biodiversity dilutes out disease,” Luis said. “As we lose biodiversity, we see greater disease prevalence.”

When animals can move to find food when they need to and avoid humans and domestic animals, “we are not going to see spillover events,” said , a professor at Montana State University, who studies the disease ecology of bats.

Activities that bring people into contact with wildlife — such as farming, logging, and building homes in wild areas, all of which change the ecosystem — may amplify the risk of spillover.

It could, for example, drive the competitors of deer mice out completely. “Deer mice like disturbance,” Luis said. As land is developed, species that compete with deer mice may scatter, and without competitors, deer mice increase in number. With more mice come more encounters between them and the spread of Sin Nombre.

Early studies of biodiversity and disease took place in upstate New York, where the fragmentation of forest habitat by development had led to the loss of foxes, owls, hawks, and other predators. Those changes drove a five-fold surge in the number of white-footed mice, which are potent reservoirs for the bacteria that cause Lyme disease.

But the idea that biodiversity has protective effects is more complicated than first thought. “There are lots of exceptions to this idea that biodiversity dilutes out disease,” Luis said. “You can get both positive and negative effects of biodiversity at the same time. There is an overall dilution effect because competitors lower the density of deer mice,” she said, but there might be amplification from stress caused by competitors.

is an ecologist with the U.S. Geological Survey’s Western Ecological Research Center in Santa Barbara, California, and studies the ecology of parasites. Focusing on the ecology of mice and hantavirus makes sense, he said: “If wild rodents … are going to become more abundant because we disturb the environment, then those particular diseases might be the kind of things we should worry about.”

However, the broad notion of protecting biodiversity to prevent disease is “wishful thinking,” he said. “That’s a vague and ineffective way to solve human health problems,” Lafferty said. Instead, he added, researchers should focus on how the viruses’ hosts respond to the environment.

Luis agreed that more work needs to be done on a complicated topic. “Outbreaks that are moving from animals to humans have only become more common over the last 30 to 40 years,” Luis said. “This is not the last pandemic. We need to understand how what we are doing leads to these outbreaks.”

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Click here for a transcript of the episode.

Episode 2: Decolonizing the Diet

Reagan Wytsalucy was looking for a lost orchard. Martin Reinhardt wanted to know more about and better understand the taste of Indigenous foods before European colonization in North America. They followed different paths, but their goals were similar: to reclaim their food traditions to improve the health and vitality of their communities.

Native foodways of hunting, fishing, gathering, and farming have been under threat since the arrival of Europeans. Colonization, forced relocations, and, later, highly processed foods fundamentally reshaped the diet of many Indigenous people. The effects of those changes have rippled through generations. Now, Indigenous people are twice as likely to have diabetes as white Americans, according to a 2017 CDC report.

In this episode, we’ll hear how the history of a scorched-earth campaign, and other disruptive policies, altered the landscape of Indigenous foodways and, in return, Indigenous bodies. History and food experts like Wytsalucy and Reinhardt are nurturing Native food traditions.

One result: The Southwest peach has become a symbol of resilience.

“So it’s almost just a way of saying, you know, we’re still here as a people. Despite everything that’s occurred, we are still here,” said Wytsalucy.

Voices from the episode:

• Reagan Wytsalucy, for the Agriculture & Natural Resources department, Utah State University
• Roy Talker, Wytsalucy’s father who served as a Navajo translator and assisted with foodways research
• Martin Reinhardt, at Northern Michigan University —

Season 4 of “American Diagnosis” is a co-production of KHN andÌý.

Our Editorial Advisory Board includes Jourdan Bennett-Begaye, Alastair Bitsóí, and Bryan Pollard.

To hear all KHN podcasts,Ìýclick here.

Listen and follow “American Diagnosis” onÌý,Ìý,ÌýÌýorÌý.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

Click here for a transcript of the episode.

Episode 1: It’s Up to You — T’áá hwó’ ají t’éego

Travel to the forests outside the Grand Canyon to follow Dr. Sophina Calderón and other Navajo Nation leaders as covid-19 tests the Diné people.

Roughly 30% of the homes on the Navajo Nation rely on wood-burning stoves for heat. Many of those households haul wood from nearby forests. That’s what Calderón was doing when she realized the pandemic’s reach wouldn’t stop at the hospital — it was going to create a heating crisis too.

This episode explores root causes behind why some citizens of the Navajo Nation lack access to electricity and other infrastructure, and how so-called social determinants of health made the Diné so vulnerable to the first surges of the pandemic.

Voices from the episode:

• Dr. Sophina Calderón —
• Jill Jim, Ph.D. —
• Dr. Ernestine Chaco —

Episode 1 includes audio of birds recorded in Coconino, Arizona, courtesy of contributor Parker Davis via the Macaulay Library at the Cornell Lab of Ornithology (ML153777441).

Season 4 of “American Diagnosis” is a co-production of KHN and .

To hear all KHN podcasts,Ìýclick here.

Listen and follow “American Diagnosis” on , , or .

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

They lived together, with their mother, Mary Thinn. They helped raise each other’s children.

And they died just weeks apart, at ages 40 and 44, after falling ill with COVID-19.

Close friend Lynette Goldtooth, a registered nurse and case manager, won’t go near the area of the hospital where they worked, knowing she’ll break down if she sees their empty seats.

“That’s where I used to go to see Corrina every morning,” Goldtooth said. “I used to sit in Cheryl’s chair. Corrina and I would just start talking, catch up on what we did during our time off, laugh and joke.”

Cheryl and Corrina are among hundreds of U.S. health care workers who died after helping patients battle the virus. The Guardian and KHN are investigating more than 1,000 of these workers’ deaths in the project.

The Navajo Nation was ravaged by COVID-19 this spring. In May, the highest per capita infection rate in the United States. As of Aug. 21, the sisters were among 489 members of the reservation who had died of the virus, according to the .

Experts attributed the spread to the prevalence of multigenerational housing and poor sanitation infrastructure — many homes lack running water. Like medical centers across the country, local hospitals across the Navajo Nation experienced shortages of personal protective gear.

In early March, Corrina, without personal protective equipment, saw a patient who was showing symptoms of COVID-19, according to her sister Chris. Corrina made sure the patient was comfortable and asked what else she could do to help. A couple of days later, that patient died, and a test for COVID-19 came back positive.

“Within days after that, she got sick really fast,” Chris said.

The sisters’ employer declined to comment for this story.

Corrina’s first concern was for Cheryl, who started showing symptoms of the virus around the same time that she did. Cheryl’s job as a utilization review technician required face-to-face interaction with patients to verify their insurance and discuss workers’ compensation. She had underlying health conditions, including rheumatoid arthritis.

“Corrina worked with people with RA when she was on Pima reservation, so she knows the effects of having it,” Mary, her mother, said. “I think that’s what worried her the most, because she thought it might make [Cheryl’s] immune system weaker.”

Chris remembers calling Cheryl on her 40th birthday, March 19. Cheryl joked about how, as the baby of the four siblings, she was “still young and pretty.” But she also complained that it was difficult for her to breathe. She was admitted to the Tuba City hospital the next day.

Corrina’s condition worsened as well, and she checked herself into the emergency room at Tuba City on March 21. Hospital staff tried assisted-breathing treatments on her, to no avail.

Cheryl was airlifted to Flagstaff Medical Center on March 24. She never knew that Corrina was briefly in the hospital with her.

Corrina was airlifted to Banner Thunderbird Medical Center in Glendale later that night.

Chris said that the last time she spoke with Corrina, she was still in the ER. “She just messaged us saying she was going to get flown out, that she loves us and that she was going to be back,” Chris said. “That was the last time we heard from her.”

Because of shortages, the sisters weren’t tested for COVID-19 until they were transferred out of Tuba City. They both tested positive and were then intubated at their respective hospitals. Cheryl died on April 11, and no family members were allowed to be with her.

“I couldn’t even hold my baby,” her mother said. “I couldn’t even hold her hand when she passed.”

The family had a small service before burying Cheryl next to their father, Navajo Police Sgt. Jimmie Thinn Sr., and Cheryl’s ex-husband, who died in January. Even after their marriage ended, the two remained close and co-parented Cheryl’s son, Kyle.

Chris said the whole experience felt “very lonely.”

Numbed by the pain of Cheryl’s death, the family shifted their focus to Corrina.

“You tell yourself that we just need to get her healthy enough to come home,” Chris said. “And then all of the sudden, she’s gone.”

Corrina died on April 29 — 18 days after her sister’s death and two weeks after her birthday, which she spent on a ventilator. Although she was unconscious, her nurse sang “Happy Birthday.”

Corrina’s oldest son, Gary Werito Jr., had tried for weeks to take leave from his Fort Bliss Army post in El Paso, Texas. His superiors declined his requests out of concerns he might contract the virus while on leave.

Separated from his mother by hundreds of miles, Werito tried to reach her through prayer.

“I would burn cedar,” he said. “I was trying to talk to my mom. I was telling her, ‘Mom, you’re going to get through this. You’re going to come home. You’re going to meet your granddaughter.'”

Werito and his wife were expecting their second child. The baby would have been Corrina’s first granddaughter.

Werito remembers his mother as a “model Navajo.”

“She left the reservation to get an education, and then she came home,” he said. “She could have worked anywhere else as a social worker, but she chose to help her own people.”

Before becoming a social worker, Corrina worked for the Tuba City Police District for more than 10 years. She ended her law enforcement career as a senior police officer.

Goldtooth, the sisters’ friend and colleague, said Corrina was particularly effective at the hospital because she spoke English and Navajo fluently. The Native language because it remained mostly unwritten at the time.

“A lot of people aren’t fluent in Navajo anymore,” she said. “When elderly people would come [to the hospital], they don’t speak a lot of English. She was there to talk with them. It would really surprise people.”

Cheryl was more soft-spoken than her sister. Mary remembers her as empathetic and insightful. Her siblings often sought her advice.

“That’s what we miss about her,” Mary said. “She might be the quiet one, but she always has important things to say to us.”

Both sisters left behind young sons. Corrina’s son Michael is 14, and Cheryl’s son just turned 12. The cousins are keeping each other company, reminding Mary of the way her daughters behaved.

Honoring her former service with the Tuba City Police District, law enforcement escorted Corrina’s body from Flagstaff to Tuba City. Her family was humbled by the outpouring.

“We had people lined up honoring her return,” Mary said. “They paid their respects, flying their flags. Some officers were standing along the road saluting her.”

Since June, the Navajo Department of Health has enforced strict curfews during the week and lockdowns over the weekend. Those measures have been effective, as they’ve seen cases decline over the past two months. The Navajo Nation began in mid-August, allowing most businesses to operate at 25% capacity.

In late July, Werito left the Army for good and came home to Tuba City. His daughter was born on Aug. 5 in the same hospital where his mother and aunt worked. Her middle name is Lois, the same as Corrina’s.

Werito said he sometimes forgets his mother is gone and expects her to come home from work.

“My grandmother told me it’s a little peace of mind that I’m home now,” he said. “It kind of fills that void that my mom and my aunt left.”

This story is part of “Lost on the Frontline,” an ongoing project fromÌýÌýand Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, pleaseÌý.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).