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While the United States flounders in its response to the coronavirus, another nation — one within our own borders — is faring much better.

With a mask mandate in place since spring, free drive-through testing, hospitals well-stocked with PPE, and a small army of public health officers fully supported by their chief, the Cherokee Nation has been able to curtail its Covid-19 case and death rates even as those numbers surge in surrounding Oklahoma, where the White House coronavirus task force says spread is unyielding.

Elsewhere in the U.S., tribal areas have been hit hard by the virus. The Centers for Disease Control and Prevention reports that American Indian and Alaskan Native populations have case rates 3.5 times higher than that of white individuals. The Navajo Nation, where Covid testing, PPE, and sometimes even running water are in short supply, has seen nearly 13,000 cases and 602 deaths among its roughly 170,000 citizens. The Cherokee Nation, with about 140,000 citizens on its reservation in northeastern Oklahoma, has reported just over 4,000 cases and 33 deaths.

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“It’s dire, but what in the world would it look like if we weren’t doing this work?’” said Lisa Pivec, senior director of public health for Cherokee Nation Health Services. Pivec leads a team that jumped into action in late February, holding coronavirus task force meetings twice a day, instituting procedures to screen thousands of employees, stockpiling PPE, protecting elders, ensuring food security, and educating residents in both English and Cherokee language. With no guidance on contact tracing available from the CDC early in the pandemic, Pivec researched the World Health Organization’s Ebola response to set up tracing protocols; after the first case appeared on the reservation March 24, she made many of the contact tracing calls herself.

She said the Cherokee Nation has seen no cases of workplace transmission; Sequoyah High School, with rapid testing and masks, reopened for in-person learning this fall; and elective medical and dental procedures have been widely restored.

The tribe’s Covid response meets the approval of global health leaders. “It’s very impressive. It’s a reminder of how much leadership matters and how even under difficult circumstances, with limited resources, you can make a huge difference,” said Ashish Jha, dean of the Brown University School of Public Health. “It fits with what I’ve seen in the world. You see countries like Vietnam. They’re not a wealthy country, but they’ve been following the science and doing a great job.”

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If the U.S. had acted as the Cherokee Nation did, “we would be doing so much better,” Jha added, “with tens of thousands of fewer deaths, and probably a much more robust economy.”

The Cherokee Nation mounted an earlier and more aggressive response than neighboring states that have waited months — and are still waiting — for a national response. Pivec and other Cherokee leaders remain incredulous at the continued lack of federal leadership. “It’s as if Russia had invaded the U.S. and the federal government said, ‘Every county should fend for itself,’” Pivec said.

Lisa Pivec
Lisa Pivec, senior director of public health for Cherokee Nation Health Services Courtesy Cherokee Nation

A citizen of the Cherokee Nation, Pivec has stewarded the tribe’s public health program for nearly 30 years; in 2016, she helped the tribe become the first to be accredited by the Public Health Accreditation Board. She said she’s inspired by none other than Wilma Mankiller, an activist who became the nation’s first female principal chief in 1985.

“She inspired me to stand up and say we can determine our own destiny. We can determine how we run our government, and we can determine how we respond to the coronavirus,” Pivec said.

Pivec gives much credit to Principal Chief Chuck Hoskin Jr., who leads the vast, 14-county reservation larger than Connecticut, in the rolling foothills of the Ozarks — land Cherokee citizens were forced to walk hundreds of miles to relocate to after the Indian Removal Act of 1830. A sign with Hoskin’s mask-adorned face graces the entrance to Cherokee Nation headquarters, and to highlight the importance of masks, he recently approved the masking of a statue of Sequoyah — saying the Cherokee statesman would have been first to mask up to protect his people.

“I have never felt so much support as a public health professional,” Pivec said of Hoskin. “He always comes through for us. He always listens to science.”

Hoskin, who says he is sure masks have saved lives and misery, implemented a mandate requiring Cherokee citizens to wear masks indoors and outdoors when around others, at the behest of his public health experts; the state of Oklahoma has yet to enact one. “I admire Dr. Fauci. I feel I have several Dr. Faucis,” Hoskin told STAT, referring to Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “We acknowledged early on we should defer to the expertise of our public health staff to let them do what they do best.”

The proper collection of data on Native American health in the U.S. has been notoriously poor. Not so in the Cherokee Nation. Early on, tribal public health leaders created a Covid dashboard with a seven-day moving average based on one created by Jha and his former colleagues at the Harvard Global Health Institute. They track cases closely. Pivec said David Gahn, the Cherokee Nation’s public health medical director, has been working around the clock to figure out how best to present tribal Covid data and keep it updated. “We just issued update #255,” she said.

Hoskin also worked to ensure tribal health care workers would have enough PPE. “It blew my mind that the wealthiest country on the planet would find itself short of PPE for its health care workers,” he said. The nation has donated spare PPE to non-Native first responder agencies in Oklahoma and to the Navajo Nation. Hoskin is now using CARES Act Covid-19 emergency funding to build and retrofit facilities so Cherokee workers can manufacture PPE, including N95 masks, locally. “We don’t want to be at the mercy of the U.S. failure to ensure our people are safe,” Hoskin said.

The mask mandate was on full display Sept. 30 when U.S. Attorney General William Barr visited Hoskin in the Cherokee Nation capital Tahlequah, just four days after he’d attended, unmasked, the White House Rose Garden ceremony for now-confirmed Supreme Court Justice Amy Coney Barrett that’s become notorious as a likely Covid-19 superspreader event. But in meetings with Hoskin — to discuss a recent U.S. Supreme Court ruling establishing that tribal citizens should be tried in tribal courts — Barr wore a mask.

“We have no problem enforcing our mask mandate, even on our attorney general,” said Hoskin.

Testing site
The Cherokee Nation offers free drive-through testing for Covid-19 at the Redbird Smith Health Center. Courtesy Cherokee Nation

It was July 24 when Dion Francis, 59, first started feeling ill, even though he’d been careful because of a compromised immune system. The U.S. Army veteran and retired FBI agent says what happened next exemplifies the superb pandemic response by the nation’s health workers.

He decided he would tough out the aches and fatigue at home. After his 19-year-old daughter started feeling sick and uncomfortable as well, the two decided to go to one of the nation’s drive-through testing facilities, where nurses approached the vehicle from both sides. “We stuck those swabs all the way up your nasal cavities into your brain,” Francis said.

They got the call two days later — faster than the long wait for results in much of the U.S. at that point: Both tests had come back positive for the coronavirus.

By then, Francis and his daughter were feeling worse. Mostly concerned for his daughter, Francis told staffers from the Cherokee Nation’s Covid hotline that they were heading to the ER. “I was hurting all over. Every part of me hurt, every joint, everything.” He made it to the hospital, just barely. “I parked and then something happened,” recalled Francis, a former college track athlete. “It all changed just like that. I could barely walk a step. I just barely made it to the door of the ER. I could barely talk. All I could say was ‘I’m sick.’ Almost like a cry.” Some of the health workers were people Francis has known for decades. He didn’t recognize any of them.

A CT scan confirmed he had pneumonia. “I wasn’t gasping for air, but I just didn’t have enough oxygen,” he said. He was placed in an isolation room at the nation’s W.W. Hastings Hospital, with just a window on the door — “like a cell,” he said.

All the hospital staff were fully garbed in PPE. “Not just a face mask, but a hazmat suit, everything,” he said. A nurse offered him remdesivir and blood plasma from recovered patients containing Covid-19 antibodies, thinking she’d have to convince him to take them because the drugs were experimental. Without hesitation, Francis said, “Yes. Just put it in me.” He was discharged five days later.

“Whatever they did at the Indian hospital to take care of me, it worked,” said Francis, calling the physicians and nurses who cared for him “my heroes.”

Back home, Francis quarantined for 22 days at the behest of Cherokee Nation public health workers, who called regularly to monitor him. Francis can’t say enough about the quality of the health care he’s received since getting infected and what an improvement it is over care he received as a youth. Francis grew up in Fort Cobb, Okla., population 634, and still recalls “sitting in folding chairs, outside, all day, to be seen in this itty-bitty clinic.”

“I’ve seen a lot of Indian Country in my lifetime,” said Francis, who is a citizen of the Caddo Nation but was eligible to receive care at Cherokee Nation facilities because he is Native American. “It’s my opinion the Cherokee Nation is doing the best to take care of Native Americans in their area.”

“We don’t want to be at the mercy of the U.S. failure to ensure our people are safe.”

Principal Chief Chuck Hoskin Jr.

While he credits the federal government for making remdesivir available, Francis said he’s disappointed with leadership in his state. He followed Hoskin’s lead instead of state guidance earlier this year when he closed the Blackfox American Legion Post #135 he ran until July. “I followed the Cherokee Nation lead to keep our veterans safe,” he said. “We have a huge number of Native American veterans at our post and so many of them are older.”

Still recovering, Francis is staying mostly at home, following news about the virus closely, and advising people to wear a mask and not make masking a political issue. He’s still unsure how or where he was infected. He’s lost eight people he knows to the virus, including an uncle who died of Covid this weekend. While Francis’ entire nuclear family was infected, they are all now doing well. His daughter recovered at home; his wife had a mild case; and his son, a track athlete and member of the Oklahoma National Guard, was asymptomatic.

Francis said he feels blessed as he continues to read about high death rates in other tribal areas of the U.S., about families who have lost multiple members, and about those found dead in their homes after receiving little medical care or follow up. “Native Americans,” he said, “have a history of not doing well with infections that originate in other continents.”

Dion
“Whatever they did at the Indian hospital to take care of me, it worked,” said Dion Francis, 59, who was treated for Covid-19 at the Cherokee Nation’s W.W. Hastings Hospital. Jeremy Charles for STAT

Holders of history and culture, Cherokee elders are revered; the population of those for whom Cherokee is their first language is shrinking rapidly. “When you’re losing Cherokee speakers and artisans, you’re losing more than your grandparents,” said Bill John Baker, a former Cherokee Nation principal chief. “You’re losing what it means to be Cherokee.”

When it became clear the virus was putting older people at risk, the Cherokee Nation acted swiftly to protect them. In March, Hoskin declared a state of emergency and asked all citizens to help shield elders. The nation set up a Cherokee-language Covid hotline for first language speakers, delivered meals, and offered all citizens over 62 a $400 stipend to help with virus-related expenses. “At Cherokee Nation, putting elders first is simply our way of life,” Hoskin wrote in one of his alerts.

One of those first language speakers is D.J. McCarter, 79, pastor of the Elm Tree Baptist Church, where he teaches Cherokee language through song and Sunday school. McCarter has presided over the funerals of eight coronavirus victims. One was a close relative. Some were designated Cherokee National Treasures for their work in preserving Cherokee art and culture. One was skilled at making bows. Four were Cherokee first language speakers. “They’re dying off,” McCarter said. “And we’re losing that traditional knowledge.”

McCarter, whose wife has been shopping for other elders to keep them safe, said he’s been dismayed to see younger people in the local Walmart, where the Cherokee Nation is unable to enforce its mask mandate, going unmasked, or wearing masks pulled down below their chins. “I just thought to myself, this is idiotic,” he said. “I have emphysema and COPD, so if I get it, it’s going to be goodbye to me.”

McCarter’s done his part at his church. While he says he would be allowed to hold services indoors, he moved services outdoors, even on Easter Sunday. People sit on chairs, socially distanced, to listen via speakers. Now that the weather has turned colder, McCarter has rigged up an FM transmitter, so church members can park and listen to the sermon from the safety of their cars.

“They’re all for it,” he said of his congregation of about 70 people. He thinks the safer outdoor service is also attracting new worshippers. “I don’t know who they are, but I see a lot of cars I don’t recognize,” he said, adding, “We’re not going to go back inside until I get the all clear.”

The coordinated and rapid response of the Cherokee Nation was possible, Pivec said, because it builds on a strong health care system — the nation’s largest tribal health system — that has been decades in the making.

Many credit former Chief Baker for the transformation. One of Baker’s first actions when he took office in 2012 was to sell the tribe’s $1.5 million private jet to help pay for medical services. He also directed hundreds of millions of tribal profits in recent years toward health care projects, upgrading many rural clinics and commissioning a state-of-the-art outpatient facility that opened last year with specialized ventilation and the ability to separate patients, features that have proven extremely useful during the pandemic.

“The facility is breathtaking to look at, and when you get into the logistics, it’s mind blowing,” said Michele Marshall, a nurse manager who oversees nursing staff at the new facility and the hospital. “We have separate clinics with air exchange and negative air pressure. My staff feels very safe.”

The Cherokee Nation’s W.W. Hastings Hospital Jeremy Charles for STAT

The U.S. government is obligated by treaty to provide medical care to members of all federally recognized tribes. But the Indian Health Service annual budget of about $5 billion is far less than the $37 billion the National Indian Health Board estimates is needed; so some tribes, including the Cherokee Nation, supplement IHS funding with their own treasuries.

Marshall said she’s thankful for the abundance of PPE her staff has received. “The team that was responsible for getting PPE, they knocked it out of the park,” she said. Marshall and her nurses are extremely proud of the high survival rate of their Covid patients. “We’re hitting patients with everything we’re able,” she said. “Convalescent plasma, antibiotics, remdesivir, steroids. They get it all.”

Marshall said she’s been stunned to see how differently patients respond to the virus. “We had a 101-year-old man who beat it with flying colors, yet we lost a 39-year-old woman who was scheduled to go home the next day,” she said. She is now facing a new surge of cases with a staff that’s exhausted “mentally, physically, and emotionally”  because they’ve had to not only provide nursing care, but also lend emotional support to patients cut off from their families. Marshall said she’s been juggling schedules and hiring contract nurses so she can get her staff the rest they need. “I tell them it’s not a sprint. It’s a marathon,” she said.

Like many health care workers in the Cherokee Nation, Marshall is a Cherokee citizen. Nationwide, less than 1% of physicians are Native American. At the Cherokee Nation, 27% of physicians are tribally affiliated and the tribe hopes to increase that number further. The Cherokee Nation is erecting a medical school building and launched a partnership with the Oklahoma State University College of Osteopathic Medicine to create the nation’s first tribally affiliated medical school. More than 20% of students in the inaugural class that started this fall are Native American.

“Just as our ancestors grew their own teachers 150 years ago,” Baker said, “we want to grow our own doctors.”

One of those home-grown doctors is Stephn Drywater, who works in the emergency room of W.W. Hastings, the hospital where he was born 34 years ago, and where the virus is keeping him on his toes. “Eight months into this, I’m still surprised daily,” Drywater said. “Some people are critically ill, others have no idea they have it, that’s the scary thing.”

Drywater said the risk he’s personally facing is always a concern, particularly because of his grandparents, and the three young daughters he has at home. But he has plenty of PPE and even more motivation. “I grew up 15 minutes from here,” he said in a telephone interview just as he was leaving an exhausting ER shift. “I basically want to do everything I can to help this community.”

While the tribe faces many challenges as cases rise on and off reservation land — among them asking people who are used to congregating in large family gatherings to stay apart — Pivec said she’s proud to see how much the practices she and her team have put in place have helped.

The Cherokee Nation, it seems, may have lessons for us all. “I hope our response as a nation demonstrates what being in a tribe means,” Pivec said. “It’s collectively caring for one another.”

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