Vicki Lowe
Executive Director, American Indian Health Commission
Jessica McKee
Foundational Public Health Services Coordinator American Indian Health Commission
Taking Care of Your People
Vicki Lowe* and Lou Schmitz led the COVID-19 response for the American Indian Health Commission (AIHC) in Washington state, serving as the Executive Director and Emergency Response Lead, respectively. They fought against previous experiences of Native Americans and infectious diseases in the US to ensure Tribal needs were met. Jessica McKee was serving at the Washington State Department of Health and worked directly with AIHC and the Tribes in Washington which elected to receive vaccine from the State rather than Indian Health Services (IHS) and joined AIHC as staff in December 2022, taking on the Emergency Response Lead role.
*Note: The speaker in this piece is Vicki Lowe unless otherwise indicated.
A Better Pandemic Response For Tribal Nations
In 2009, after the H1N1 pandemic, the American Indian Health Commission made it part of their mission to ensure Tribal pandemic priorities would be built into the next U.S. pandemic response.
Vicki Lowe: During H1N1, the state and the local health jurisdictions did not understand Tribal sovereignty and their right to choose their own priorities. Tribes always pick their elders as a priority. And during that pandemic, the main government priorities were pregnant women and children. When Tribes said that they were also going to give countermeasures to their elders, some local health jurisdictions – supported by the state – withheld the vaccines and people died.
“We made it our work, at the insistence of our Tribal leaders here in Washington state, to make sure that never ever happened again. And I feel like we accomplished that.”
After 2009, AIHC developed mutual aid agreements among the Tribes and the local health agencies. Those agreements proved their worth in 2020 as they facilitated building Tribal priorities into COVID-19 vaccine allocations in Washington from the start.
“We spent a lot of time pushing on the Department of Health to change its emergency response plan to include language that honors Tribal sovereignty and their authority to have their own priority for medical countermeasures. In September, we met with the Secretary of Health… so that, by the time the vaccines were available, this language was part of the emergency plan and was supported in state policy.”
Vicki Lowe: The goal was to get as many people vaccinated as possible. That was the attitude here in Washington State. The Tribal leaders met with Governor Inslee weekly in the beginning of the pandemic. He would start each meeting saying, I’m here sovereign-to-sovereign, and I want to talk to you about how we’re going to keep our citizens safe. Those weekly calls with the governor were important. We also hosted weekly calls with the Tribes’ public health officers and the clinics, just so they could share what they were doing.
“Right before COVID, maybe November 2019, we did a point of dispensing tabletop exercise with the Muckleshoot Tribe where local health and the Tribes came together, and they went through what it would look like to give out medical countermeasures, working together across the Tribes, local health, and with the state. I think that really set us up for what happened during the pandemic, this time.”
Vicki Lowe: As a result, for the first time ever in the history of the Tribes and the United States and state governments, Tribal sovereignty was really honored when it came to COVID-19 vaccines. In our history, with smallpox and other diseases brought by settlers, there is that memory and a fear of that happening again. In the early days of smallpox, the federal government chose which Tribes were behaving well and gave them vaccines, but not other Tribes. To have it go right during COVID-19 for the first time ever was a really big deal.
Getting As Many People Vaccinated As Possible
The work to build bridges among Tribes and state and local health leaders in Washington was aimed at reducing disparities, and it worked in both directions. Not only did the effort facilitate tribal priorities, it also provided a stronger set of community options for the broader COVID-19 response.
For example, the S’kallam Tribe and the local community came together to distribute the first vaccinations for COVID-19 in the retirement community of Jamestown. The Tribe and the community pooled their vaccine allotments and opened a drive-through vaccine clinic for the whole community.
Vicki Lowe: It was a big deal in our community, because this is a retirement community, and we had a lot of elders that were worried about being able to get the vaccine and being able to call and make appointments. They had that computerized system that you could use that didn’t work well with elders. So, they were just able to drive up and get vaccinated.
“The recommendations were to begin vaccinating people 85 and older and then go down from there as they got vaccinated. I pointed out to the governor’s office that, when you look at who is 85 and older, it’s mostly white people. The Tribes went pretty quickly through their elders, and then their families, and then health care workers. The first weekend the drive-through clinic did 65 and older and opened it up more and more. It was a huge community effort.”
Different jurisdictions banded together to stretch scarce resources, like ultra-cold freezers.
Jessica McKee: One Tribe in eastern Washington is very small and they didn’t have an ultra-cold temperature freezer, but they wanted to vaccinate right away. They were interested in the Pfizer product specifically, which at that time required an ultra-cold freezer. They had a mutual aid agreement with their local county, which also did not have an ultra-cold freezer. But the county had a memorandum of understanding with a local hospital, which did have an ultra-cold freezer.
“All three organizations – Tribe, county, and local hospital – partnered together to make sure that the Tribal members could get vaccinated. Then they started working on health care professionals as soon as they were eligible…and then they collaborated actually on quite a few large drive-through vaccine clinic events to reach staff and community members. They also would go out and get teachers through if teachers needed to be vaccinated, which was really big when teachers were expected to be in schools that were opening back up but they had not been able to access vaccine.”
Bridging Divides Across the State
Vaccine clinics were staffed by uniformed officers, largely the National Guard, which spurred distrust among communities in more rural parts of the state and among people of color, particularly in eastern Washington. The NATIVE Project, an urban Indian health clinic, was poised to help with uptake.
Vicki Lowe: The original vaccination program was implemented to reach as many people as possible, but not necessarily as equitably as possible. Some barriers to vaccinating la comunidad Latina included identification requirements, use of known health networks where community members have experienced discrimination leading to mistrust, and limited bicultural or bilingual providers offering the vaccination. A key lesson learned is to engage community partners early in the process to identify locations and providers that are trustworthy and to create a bidirectional communication pathway to allow the opportunity for change. For example, in North Carolina, policymakers and state leaders were receptive to feedback and regularly attended LATIN-19 meetings.
A thoughtful response also required navigating a tricky history between the Tribes and other governments.
Jessica McKee: “When I was working at the Washington State Department of Health I met one-on-one with all the Tribes that were interested in getting vaccines through the state. We talked about the barriers for the different vaccine presentations in terms of storage and handling, minimum order set size, and logistics. I was regularly asked about the makeup of the vaccine studies, who was actually included in the studies, and were there Natives in the studies? I’m sure leadership at the Department of Health would have preferred to be the ones to talk about it. But I have the epidemiology background…and so I just did it because they wanted answers. We need to keep in mind that people are worried about how these things are going to impact them…There were actually a few Tribes here in Washington state that were participants in the clinical vaccine trials so talking with them about that was really helpful.”
Controversies that arose in Lowe’s community around public health orders motivated to run for her City Council. She and McKee both experienced local anger around vaccine and masking mandates, and felt targeted as public health professionals.
Vicki Lowe: On masking, there are not a lot of Tribal schools. I think that was easy – if the council says, you mask, then you mask. For the non-Tribal schools, in the county where I live, people showed up to school board meetings in a small room, not wearing masks, refusing to put a mask on…, which I think was really hard on kids. That was very volatile. Again, it wasn’t the people in the response that were working together, it was just small populations of communities really trained to exercise their privilege over the rest of us.
Preserving The Lessons
Tribes exhibited best practices in community planning, executing food delivery for neighbors, maintaining tribal culture and language programs through Zoom – even celebrating the 40-year anniversary of federal recognition.
“We did it all online. Our traditional foods program came around and brought everybody a box with their dinner and you heated it up. Then we sat on Zoom together and ate together and went through our whole program. The Squaxin Island tribe, their community health nurse, went around and taught elders how to use a tablet, they gave them tablets. She stood outside the window to keep them safe…and then talked them through how to use it so that they could use telehealth for appointments. That creativity was essential to overcoming the fear among our people of pandemics, based on our history…”
Jessica McKee: Something that we learned…through those Thursday morning meetings…is that Tribes really like to hear from each other. We have accumulated all of the best practices and the recommendations that Tribes made for themselves in the after actions and compiled that information into a big pandemic preparedness checklist for everyone…
“There were quite a few people who said, we didn’t have a public information officer (PIO), we didn’t have one person who was in charge of communicating out things with the public. Or they said we had a PR team so they handled it all. It was a wide variety. But now people can look at this checklist and they can say, “Oh, it would be good to get a PIO and put them through training, because that’s on the checklist and we don’t have that.”
Lowe and McKee encouraged documenting after-actions and best practices for overcoming divides among communities in health emergencies.
“Here in Washington, there’s going to be quite a bit of shifting around of our public health staff. I have already seen quite a few people that were involved in the COVID response step down and leave their organization to go to another one, myself included. I hope for all of us that we listen to these after-action reports and talk to people when they’re leaving, because you lose a lot of that knowledge when people leave organizations or agencies.”
Vicki Lowe: There were so many good things that happened during this pandemic that we need to preserve. We figured out how to pay for telehealth, including through Medicaid and Medicare. That’s going to help with a lot of other things. We saw success stories from vaccine clinics across the state.
Jessica McKee: We need to build on the successes we saw, while also working to address the gaps. COVID showed us that we can do that while working together, across different levels of government.