Podcast Episode: COVID-19 is Particularly Tough on Native Americans. Here’s Why We Should All Care About That. Featuring Dr. Holly Pilson, Lumbee Tribe of North Carolina.

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There are 574 federally recognized Native American tribes in the United States, all of which were promised healthcare and other services as part of resettlement programs. But having limited democratic power and leverage, health services for Natives have been neglected over many decades. COVID-19 is now taking advantage of these vulnerabilities, but Black Lives Matter may be helping with some of their struggles. Universal messages about social justice and racial discrimination are gaining traction. On the day that DC Football officially shed its racist nickname, Dr. Holly Pilson talks about her Native American heritage and her experiences as a female physician in a profession dominated by white men. With Dr. Rose Gonzalez.

Episode Transcription

COVID-19 is Particularly Tough on Native Americans. Here’s Why We Should All Care About That. Featuring Dr. Holly Pilson, Lumbee Tribe of North Carolina.
[Posted on August 12, 2020]

There are 574 federally recognized Native American tribes in the United States, all of which were promised healthcare and other services as part of resettlement programs. But having limited democratic power and leverage, health services for Natives have been neglected over many decades. COVID-19 is now taking advantage of these vulnerabilities, but Black Lives Matter may be helping with some of their struggles. Universal messages about social justice and racial discrimination are gaining traction. On the day that DC Football officially shed its racist nickname, Dr. Holly Pilson talks about her Native American heritage and her experiences as a female physician in a profession dominated by white men. With Dr. Rose Gonzalez.

Dr. Gonzalez: Hello and welcome to this edition of the Health Disparities Podcast. I’m Rose Gonzalez, a nurse member of the executive steering committee of the Movement is Life Caucus. And I will serve as your host for today’s edition. I’m joined by Dr. Holly Pilson, Assistant Professor of Orthopedic Surgery at Wake Forest School of Medicine. Together we aim to discuss topics related to Native American health, culture and COVID-19. Thanks for joining us today. So, good to be here with you today. I’m honored because I know you’re part Native American, and I would love you to tell us a little bit about yourself for our listeners.

Dr. Pilson: Absolutely, Rose. And thank you so much to you as well as the Movement is Life Caucus for having me today. It’s an honor to be here to discuss these issues and yeah, so I’d be happy to talk to you a little bit about myself. I am a native of North Carolina and a member of the Lumbee Tribe of North Carolina. I’m also an orthopedic trauma surgeon at Wake Forest. I think, as a native person and as a member of a native tribe, and also as a female in orthopedics, I sort of have always felt like a unicorn of sorts. Always being in the least represented group of every circle I’ve been in.

And so, I think that native issues are important for us to discuss because native people are in one of the least represented in terms of numbers of minoritized populations in our country. So, I think it’s great that Movement is Life is bringing this to the attention of their organization and followers, and I’m just so grateful that we have the opportunity to talk about this today.

Dr. Gonzalez: And just for our listeners, the Movement is Life Caucus is really a collaborative of diverse professionals, academicians’, organizations, faith-based organizations, all gathered together, multi-disciplinary, to address joint pain illness and bring equity to that environment. One of the reasons Holly is so special is really because she’s Native American and she’s also a woman in orthopedic surgery, and that is a rare, rare, find. So, I’m glad I’m joined by this diamond today. It’s very difficult for natives to enter into the health professions. So, kudos to Holly, who’s maneuvered that journey and has joined us here. One of the things I’m really excited about talking with Holly is the fact that I also have a background where I was married to a Native American. So, my daughter is half Native American and she talks about natives as they are invisible in today’s climate. We see the Black Lives Matter, really rise in our nation, and take hold. And still today, if you ask people about Native Americans, they really, don’t understand. And so why don’t we talk about a little bit about the invisibility of Native Americans and maybe about your tribes’ plight with recognition.

Dr. Pilson: Yeah, that’s great. And so, I think you hit the nail on the head is that many native people, do feel invisible. I think that there are challenges that go along with being a part of the smallest minoritized or racial and ethnic group, in this country specifically. And the parallels really, aren’t that different than any other arena, being the least represented group in any other arena. I think there’s a general lack of cultural humility and understanding of Native American cultures. And I think, to be honest, one of the many colorful phrases that I’ve heard over the years, that brings light to the invisibility that many natives feel is, some variation of, “Wow, you guys really still exist?” As if, we are no longer a people. And, in recent news, speaking of the recent retirement of the mascot for the Washington NFL franchise, I think this just circles back around to the challenges of being one of the smallest minoritized groups, and I think, when the majority of Americans have no direct contact with a native person, no native friends, co-workers, family members, etc., it becomes easier to be complicit in degradation of native people and other groups who may have been tokenized as a mascot or in other ways. This is not a new fight. Natives have been fighting, for this for years, but sometimes the smallest voices in terms of numbers are often the least heard and respected. You mentioned the Black Lives Movement, and the other things that have recently come about in our country, and I think that this speaks to the value of allyship and unity and coming together, and some of these issues that affect us all at making real substantial change in some of these areas.

Dr. Gonzalez: We know way back when the government, the Federal Government, when they agreed to exchange land and take the land from the American Indians, and the Alaska Natives, they agreed that they would, cover their health. They would take care of the peoples. So, let’s talk a little bit about taking care of the peoples, the indigenous population. How does that happen in this country?

Dr. Pilson: Well, it’s really quite interesting. So, let me start by emphasizing that there are hundreds of native tribes and communities throughout the U.S. with a great deal of diversity, even among tribes in terms of cultures and practices, etc. So, there’s 573 federally recognized tribes in the U.S. and about 63 state recognized tribes. So, my tribe, the Lumbee tribe of North Carolina is a state recognized tribe, not a federally recognized tribe.

And what that means is that my tribe and other state recognized tribes do not get federal assistance from the Federal Government as do the federally recognized tribal members. And so, like you alluded to, the Federal Government is directly, responsible for Native American healthcare based on our constitution and numerous, treaties, laws, Supreme Court decisions, executive orders, etc., across the years, are directly responsible for the healthcare of federally recognized Native American tribal members.

The Snyder Act in, the early 1920s was one of the first acts to define authorized funding for healthcare services for federally recognized tribes. And then, the Indian Healthcare Improvement Act in the 1970s, provided some structure to how that would run. And then creation of the Indian Health Services came after that, which is the overseer of native healthcare administration in a federally recognized tribal community. So, you’re absolutely right in that, of all of the other, ethnic minority groups in the United States, Native Americans of federally recognized tribes are the only group that is born with legal rights to healthcare in our country.

Dr. Gonzalez: And it seems like the Federal Government is doing a really, lousy job of taking care of Native Americans. I mean much like I would say COVID-19 has illuminated the healthcare disparities in African American and Hispanic communities, it’s also illuminated the disparities, that occur in native communities. Even though many of them are not located in an urban area like New York City when it was hit hardest, and there were a lot of Latinos that were hit hard and died because of COVID-19, there is a different way of life in native communities. So, I hope that we could talk about, Holly, two things. How COVID-19 has impacted the native communities, but secondly, a little bit more about, the communities they live in.

Dr. Pilson: Absolutely. So, I think native communities are plagued with many of the same chronic diseases and comorbidities, that are common to other marginalized groups in our country. The top two that come to mind are diabetes and heart disease are the two big ones that drive comorbidities and outcomes related to a multitude of other, health care issues. And as you mentioned, COVID-19 has only further illuminated the health disparities that exist in these communities.

The Navajo Nation, for example, has the highest rates of COVID-19 per capita in the Continental U.S. This even surpassed New York City, which at one time, as you mentioned, was a hotspot. And I think this is definitely multifactorial. There are definitely opportunities, in terms of social determinants of health that can be improved or that have been affected by COVID-19. For example, on some tribal reservations, there is no running water. So, Indian households on some of these tribal reservations are almost four times more likely to lack complete indoor plumbing relative to other households in the U.S. And so, if you think about one of the primary strategies to avoid the spread of COVID-19 is frequent handwashing. Imagine how difficult this may be when you don’t have access to running water, in your home.

And there’s been other things that have been shown to potentially be a challenge, in terms of COVID-19 spread. One of those we’ve discussed before is that many tribal communities, there are multi-generational homes. Family is very, important to Native Americans. And so, there are homes that might consist of grandparents and great-grandparents and parents and children. And so, it’s very difficult to protect elders who might be more susceptible to COVID-19. It’s also difficult to socially distance, or remain, six feet apart or quarantine yourself, if you have a multi-generational home, it’s more difficult in native communities. And just like we’ve seen in some of our other non-English-speaking communities in the U.S. There are indigenous communities that have households that are non-English speaking have been shown to be more affected with COVID-19. So, this, I think ties into health literacy and some of the importance about public health dissemination in our indigenous communities, just as in some of our other non-English speaking communities that have played a role in COVID-19. So, these are just a few examples of ways in which COVID-19 has significantly impacted native communities.

Dr. Gonzalez: Wow. And I was doing some reading on, trying to prepare for this podcast, and one of the things that struck me was exactly, as you pointed out, a third of the Navajo homes are deficient in plumbing and kitchen facilities and do not have bedrooms. So, like you said, how are we going to wash our hands? Number one. How are we going to socially distance when we don’t have separate bedrooms? It’s not like you’re living in a multi-floor house or whatever or have rooms. You’re living together but living together is something that’s valued. The other thing that you mentioned was the elders are valued in the native community. They are the storytellers, they’re the keeper of the culture and the traditions. And so, they’re trying to protect them and how difficult it must be for all of them to try to protect them in the environment that they live in. The lack of water and social distancing really has hurt them. What do you think, or what have you learned about the Indian Health System and their incapability, they should have stellar healthcare if the Federal Government is responsible? What is lacking?

Dr. Pilson: I think the biggest thing that’s most obvious in the Indian Health Service specifically is it’s just grossly underfunded. Every year Congress appropriates funds to the Indian Health Service to fulfil all the trust responsibilities, to provide healthcare services for native people and federally recognized tribes. But, for example, in 2014, the Indian Health Service per capita expenditure for patient health services was only $3,107 compared to $8,000 per person for healthcare spending nationally.

So that’s less than half the amount of money that the Indian Health Service per capita was given to spend on Indian Health Services and establishment of clinics and hospitals, and just basic healthcare to native populations, less than half per person, for healthcare spending compared to national averages. And so, I think therein lies the primary problem is that there’s only so much you can do with the little bit of money that the Indian Health Service is allowed from the Federal Government.

Dr. Gonzalez: The Federal Government hasn’t kept up with funding and responsibility of Congress. And it’s almost like they deliberately, don’t honor the treaties, don’t honor the agreements and certainly appear to be underfunding where the cost of healthcare has risen, they’re certainly not keeping up with providing those services among the indigenous populations and keeping up with the funding. So, that’s horrible. So, turning to COVID, as you said, COVID illuminates these issues. They already have so many comorbid conditions. You started to talk about them, the diabetes, help us understand better some of the other comorbid conditions that they have.

Dr. Pilson: Yeah. I think diabetes and heart disease are definitely the two bigger ones. There’s also a higher prevalence of liver disease, and some cancers in some native communities. And going back to the Indian Health Service piece and being underfunded, I think in many of these communities, the issue, has been the hospitals and clinics ability to take on patients with COVID-19 in these communities has just been abysmal. Many of these Indian Health Service run hospitals do not have intensive care units. They’re very small. And so, they have required native people to have to seek or be transferred to facilities outside of their communities, hours and hours and hours away from their home communities and away from family. And so, that has put a significant strain on the system that’s already strained and underfunded, but also, it’s been really difficult for native communities who are, like I said, very value family and, live in multi-generational homes to figure out how to best get their family members, the care they need, during this pandemic. And I think that’s attributed to some of the higher rates of COVID-19 cases as well as deaths.

Dr. Gonzalez: My understanding is there’s a disproportionate amount of deaths within that community and probably citing what you said, which is it takes longer to get to someplace that has an ICU because Indian Health Service, they’re really a primary care provider. I think they try to take care of the basic daily family care, holistic and many of them, weave traditional medicine with our regular medical system. But then they don’t have access to, like you said, the ICU beds or the skilled providers at times to deal with these conditions that are coming their way. So, this is all a terrible time in the native communities. Decimated initially, here’s another virus coming in that’s really disproportionately impacting them. I read that Native Americans are being infected in high numbers in urban areas, such as Salt Lake City, Seattle, San Jose, and they can’t get access to the care. So, that’s an important piece to understand. It’s multiple, there are so many reasons why they’re being disproportionately impacted by this disease.

So, how can we move forward? I think, with this knowledge, Holly. Because I’m feeling really depressed about what’s going on in native communities. And I really would like to demonstrate also, I just don’t understand how our country has treaties and an obligation, to conserve Indian health. And here we are in the midst of a pandemic and they’re being disproportionately impacted. That doesn’t seem right to me.

Dr. Pilson: Well, despite all of these many challenges, which do, and should weigh very heavily on us, I think, native people are a beautiful and a resilient people, and there’s a lot to learn about the importance of cultural identity and its importance to native identity. And I think, despite the many numbers of different tribes and different cultural practices and beliefs, that there are some very, common beliefs that are woven through the culture of being a native person. And those are, deep respect for the fellow man, deep respect for the land and the earth, and I think those are principles that we can learn from native people, as we try to address some of the injustices and things of our present day. And I think a lot of this, when we think about, well, what can we do? What can we do about these things? A lot of it goes back to the idea of allyship, and coming together in unity to address issues as we see them and bringing more awareness to the challenges that exist in native communities and the ways in which visibility and allyship can have tremendous traction and gaining recognition and advancement. I think we were talking recently about how many people were not aware of the celebration of Juneteenth until recently when, it’s gotten more visibility. And I think, the squeaky wheel gets the grease so to speak. And right now, there’s a lot of squeaky wheels that are getting a lot of grease and it’s great for activism and allyship. And I think that once those wheels are greased, so to speak, they can accelerate some of the momentum of activism and change that’s been silenced and ignored in other communities as we’re seeing.

And we all have passions and causes that are near and dear to us. And some of them are born out of motivation, to sort of write the wrongs that directly affect us and those that we know and love. But I also think we should challenge ourselves to take a step forward and look outside of the issues that directly affect us to those issues that affect our fellow man.

If you want and expect someone else to be an active bystander for you, then you should also take the initiative to be an active bystander for others. So, pick an issue or a plight that doesn’t directly affect you and learn to understand the struggles of others and the right for reform. And, if that means that you’re an able-bodied person and you’re championing and being a voice for the disabled, that means that you’re a black or brown person, and you’re a voice for other disparaged racial and ethnic groups. I think those are the ways that we can champion the issues that affect those around us.

Dr. Gonzalez: Some of the things that I’ve seen lately where, the natives were, advocating for themselves, they were maintaining their ability to, oversee their border, to understand who can come in and who can’t come in, and I think some of these things are challenging in their culture. They are a culture that is not about the me or I it’s about the we. It’s about the community. What do we need to do about the community? Which I always found to be very beautiful and the respect for Mother Nature, the respect for don’t take from nature more than you need, more than you use, and always give thanks back to Mother Earth when you do take something from Mother Earth and be grateful for it. So, the respect for the elders, their storytelling tradition, their celebrations, which encompass everyone. Everyone has a role to play in the celebrations that they have. From the youngest to key, the drummers and the dancers, to the elders who know the songs to pass them down and the languages. And one of the things I want to say about the languages and bring it back to a little bit to COVID is they learn, they have an oral tradition. So, the history is passed down orally from generation to generation. The information that was coming out from COVID-19 was not in their traditional languages. So, not only are individuals isolated because they live in these rural communities, but they’re also impoverished communities, very impoverished communities without indoor plumbing or bedrooms or whatever, and they’re not even communicating with them in their native tongue. So, this virus is coming through with the lack of information and maybe sometimes access to information, because if you don’t have running water, you probably don’t have internet. Okay. So, isolation and then lack of resources, but they work hard to maintain the community and support one another. And one of the interesting pieces I read was that everybody was an auntie or uncle, and they care for their aunties and uncles and grandparents. So, everyone was one big community trying to help the other individuals in the community. And that to me is a beautiful thing. And as they respect each other, we have much to learn from the native culture and much that we should adopt in how we move forward with change. I know there’s a lack of a small number of Native Americans in the health professions. What do you think that people are doing to try to encourage more Native Americans to come into the health professions?

Dr. Pilson: Yeah, so I think there are, fantastic pipeline programs that are encouraging young native people to consider careers in the healthcare. There are some federally funded programs through the Indian Health Service that do provide some scholarship opportunity for native people to pursue healthcare careers, and also work in native communities. And it’s in a type of scholarship where students can attend health professional school and then pay back their scholarship by working in a service commitment type role in native community communities.

There are, groups such as the Association of American Indian Physicians that is the national organization of Native American physicians that champion the healthcare and fostering also young native people’s interest in becoming physicians. And so, there’s lots of things that are going on to encourage native people to consider fields in healthcare. And I think absolutely in the Indian Health Service, increasing funding would definitely help that effort even more so. Like we alluded to earlier, the Indian Health Services, main focus is on primary care type areas and prevention and basic healthcare needs. There is a lack of access to specialists when people need specialists, they have to go outside typically of the Indian Healthcare system. And there’s very, strict criteria on where they can go and who they can see. And so, I think also that while we do need more primary care providers in these communities, I think that we also need specialists in these communities as well.

Dr. Gonzalez: It sounds like we have primary care access, but specialists become an issue and would trust become an issue?

Dr. Pilson: Oh, absolutely. Trust is absolutely an issue. For obvious reasons, many minoritized communities have a lack of trust in the healthcare system for very understandable reasons, and when you do have to leave your home community, leave the opportunities to be treated by those members of your tribe, to go into a community that you’re not familiar with and be treated by someone that you aren’t sure if you can trust, that’s an absolutely a big reason that some people choose not to seek care outside of these communities.

Dr. Gonzalez: So, I’m a Latino woman who went into nursing and Hispanics, they’re a small number of them in nursing. And we also have a Native American Nurses Association. I always felt like I would count the room as a Latina woman and say, “Oh, geez, guess what? I’m the Highlander in the group and there can be only one Latina in this group.” And I always felt that sometimes the way I looked at things because of my ethnicity and culture, because even though I grew up in the South Bronx, the household could have been in Puerto Rico, we spoke Spanish, we cooked Spanish food. And I always felt different in that. And I felt really isolated in many ways going through the nursing program. But what advice would you give to young natives who come in because the journey is tough as it is? The health professions are not easy.

Dr. Pilson: Yeah. So, that’s a great point. And I totally agree with you. So, as I mentioned in the beginning, I’ve always been the unicorn. I’m the only orthopedic surgeon, from my tribe of over 50,000 members and I’ve never met another female Native American orthopedic surgeon. If, you’re out there, please contact me to meet you. So, I would say a couple things, for one, I would say, being from a very, small group, and if it’s ethnicity or race or sexual orientation or whatever that is, I think if you wait around to find a mentor who looks like you, you’re probably going to be waiting forever. So, I think you have to be somewhat courageous to step out and seek mentorship from others who may not look like you. And that’s what I had to do growing up there was no one. Once I really discovered that I wanted to be a physician and I wanted to go into orthopedic surgery, there was no one who looked like me, who did those things. And so, I had to seek mentorship from those who didn’t look like me. And I had to take a step out of my comfort zone and say, this is something I really want to do.
And I’m going to ask someone who they don’t look like me, but maybe if I ask them, they’ll let me shadow them. And they’ll let me get a glimpse into what their life is like and how they take care of patients, and they were absolutely happy to do that. And so, also, I think, just keeping in mind that sometimes you have to step outside of your comfort zone to pursue the things that you’re passionate about, and that’s no different in medicine. Many native people come from communities where they are the majority. They come from exclusive native communities, and needing to leave those communities to attend college, to attend medical school and residencies, they are going to be absolutely in the minority. In the 2019- 2020, data from the AAMC, American Indian and Alaska natives only made up a 0.2% of matriculants to medical school, and I think as you progress along, into orthopedics, for example, in 2019, native Americans and Alaska natives, again only made up 0.2% of active residents in orthopedic surgery in 2019. So, the pool doesn’t get any bigger as you progress along. And so, you have to become comfortable in who you are, realizing that there’s nothing about who you are and your identity that makes it impossible for you to do these things. It may just mean that you might have to be the first one, or you might have to be one of the few ones, to do it and stepping outside of your comfort zone I think it’s one of the first things I would encourage you to do, and then not being afraid to seek mentorship from others who may not look like you. And then also not forgetting that you have to sort of reach back and mentor those who were behind you.

Dr. Gonzalez: Well, I think that’s wonderful advice. I think I really appreciated that, and I hope our listeners appreciated that too, because I think the journey is hard medical school alone. Individuals who want to pursue those careers who find themselves to be the one, the only one. One of the few in a vast sea of others, to try to be successful and go back and, and help their communities.

I think this has been, a really, enlightening discussion with you, Holly. I appreciate that you have joined us here today to talk about, COVID-19 and Native American communities, health professions. Are there any last thoughts you want to share with us as we come to a close on this discussion?

Dr. Pilson: Yeah, again, I want to thank you, Rose and thank the Movement is Life Caucus. I think I shared with you before that I was only recently, actually, last year introduced to the Movement is Life Caucus, by Dr. Bonnie Simpson Mason. And, it has just been an amazing year of getting connected with the fantastic members of this group and following along the podcast, since I attended the Movement is Life Caucus last year.

And I think this is just a fantastic organization that is shedding light on all of the many areas in our country especially musculoskeletal health is affected by and the disparities that exist and really taking action to championing the issues and Medicare reform and so many others.

And so, I just want to, again, thank you, thank the Movement is Life Caucus, and thank you for allowing me to also shed light today on some of the issues affecting native communities. And I hope that this has been educational and informative, and that listeners feel that they have some additional ways in which they can be a voice for our native members of our country.

Dr. Gonzalez: Thank you, Holly. And, for those individuals who want to provide some financial support to native communities, there is a website called nativepartnership.org. They have a native relief fund that is providing funding for individuals on the reservations dealing with COVID-19.

I urge you to visit that website. I think I want to urge our listeners to read up on history and understand the history of our nation and understand, the nation’s responsibility to the indigenous communities, and maybe help us advocate for increased funding for the Indian Health Service and for the health care and for housing and support and plumbing for the indigenous populations. They are part of our, they are our history. They are our beginning, and we need to honor them. And so, as we move forward with, the recognition that equity is an uphill climb for all communities. Indigenous communities are in great need of our support.

I want to thank you, Dr. Pilson for joining us today. And I want to thank our listeners for joining us on this edition of the Health Disparities Podcast. We hope you find this discussion today was thought provoking, and I hope it urges you to learn more as I said about our Native American History, history of Indian Health Service, responsibility for indigenous populations, and also maybe inspired by some of their values and cultures and traditions.

From all of us here at Movement is Life and the Health Disparities Podcasts, we want you to stay safe, stay well, and we hope you join us again soon. Thank you, Dr. Pilson.

Dr. Pilson: Thank you.

Dr. Gonzalez: Thank you all. Till the next time, take care all.

[End of recording]

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