This is the second in a two-part series about the vaccine rollout in Indian Country. Part one looks at the success of the rollout on rural reservations.
The Indian Health Service has delivered coronavirus vaccine doses to the most far-flung corners of the country. From remote villages in Alaska to the bottom of the Grand Canyon, Indigenous Americans as young as 16 have had access to the shot for weeks.
But some urban Native people haven't been so lucky. Count 55-year-old Jonathan Concha of Albuquerque among them.
"For the most part, everybody else in my family has been vaccinated already. So, I'm the last one," he said just after receiving his first shot in mid-March.
Concha scored a spot at a mass-vaccination event co-hosted by New Mexico's Indian Affairs Department, Albuquerque's urban Indian health clinic, and several other partners . But this came after two months of "roadblocks."
Concha's search started when vaccines became available at his tribal clinic at Taos Pueblo. He was willing to make the two-and-a-half-hour drive from the city, but his Pueblo was on strict lockdown.
"I had called, and they said since I live outside of [Taos County] that I wasn't eligible to get it," Concha said.
Next, he tried for an appointment at the city's two urban Indian health care providers: a direct-service IHS hospital and First Nations Community Healthsource, an independently run urban Indian clinic.
"But I wasn't able to register for a vaccine. They said it was only eligible to current patients," he said.
But Concha has private health insurance through his job, and he uses it to get his health care outside of the IHS. He said that's a cheaper option for him, since IHS doesn't always provide specialized care or cover it when sending patients outside of the system.
Concha established a patient chart at both the IHS hospital and First Nations Community Healthsource in hopes of getting a vaccine appointment, but said he was never called in.
"If you don't visit IHS, then you're basically out of the loop," he said.
Concha fell between the cracks of IHS's urban and rural tribal health care systems. That's how he was initially left out of a nationwide effort to mass vaccinate Indigenous people - who, according to the CDC, are more vulnerable to serious COVID-19 illness and death than any other group in America.
Abigail Echo-Hawk, director of the Urban Indian Health Institute, says he's not alone.
"For urban Indians living in cities that don't have urban Indian health programs that have accessible vaccines, they're going to the same hospital systems, same clinics, same grocery store pharmacies that other people are going to to try to get the vaccine, and they're not getting it. Even though they are the most at risk," Echo-Hawk said.
And even though the federal government has a legal responsibility to provide health care to Native people regardless of their zip code.
According to the IHS, more than 70% of Indigenous Americans live away from tribal land. But the agency's 41 urban Indian health centers in 33 cities are funded through a single line item that constitutes less than 1% of the IHS's already stretched annual budget.
At small urban Indian clinics, resources are stretched thin
One of those small, independently run urban Indian health programs is Denver Indian Health and Family Services. Director Adrianne Maddux said the clinic provides quality and culturally appropriate care, but that decades of underfunding has given it a negative reputation.
"Historically, our Native population in the Denver area has always thought of our clinic as the clinic that takes care of people that can't afford to go anywhere else," Maddux said. "We have really tried to change that and say, 'We are here to take care of our Native population.'"
Still, the clinic's share of federal funding is based partially on how many Indigenous patients actually use it. And typically, many who have private insurance choose to go elsewhere.
But during the pandemic, an influx of urban Natives who previously opted out have been seeking coronavirus testing and vaccines at DIHFS. Maddux said it's been difficult to keep up with the surge.
"We have a lot, actually. And I would be thrilled if we were able to retain a lot of these patients. But probably the majority of who we're vaccinating will not come back," she said.
DIHFS has been vaccinating about 300 urban Native people per week. In order to match the pace of rural tribal clinics, Maddux said DIHFS would need more than a bigger vaccine supply from IHS.
"We could do an outside [mass vaccination] event, but we need the staff and we need the storage of these vaccines," Maddux said. "A lot of it has to do with what we're able to do within our infrastructure."
DIHF employs two nurse practitioners, one registered nurse, one part-time medical doctor and a small behavioral health team. Maddux said she's sought out medical temps, but that they're in high demand in the Denver area amid the pandemic.
"Our staff are tired," Maddux said. "And if we try to push them harder, they probably would do it. But it's just a matter of the small size of our clinic."
In some other American cities, there are no urban Indian health facilities at all, as Ani Auld can attest. She's a citizen of the Navajo Nation who lives in the Washington, D.C. area.
"The IHS and the Bureau of Indian Affairs are headquartered here, and still there's nothing available for us," Auld said.
Native American Lifelines, the urban Indian public health center that serves the D.C. and Baltimore metro area, provides outreach and referral services, but not patient care.
Auld said many urban Indigenous people in her circles have traveled hundreds of miles to their reservations to get the shot, and that she has weighed flying home to the Navajo Nation.
"But then you put yourself and your community at risk of exposure for having to travel," Auld said. "That being the only option for urban Natives is pretty ridiculous."
In a hearing last week, Francys Crevier, president of the National Council of Urban Indian Health, told the U.S. House Committee on Natural Resources that she was making the same calculation.
"Myself, I have not been vaccinated, and I keep assessing, is it worth my life to try to travel? Should I stay [in D.C.] and wait and hope?" she said. "That's what a lot of urban Indians are trying to figure out right now."
A partnership model in New Mexico
The initial rural/urban divide in vaccine access for Native people was stark in New Mexico. In late February, as many rural tribal clinics were opening up vaccine eligibility to patients 18 and older, New Mexico's two urban IHS hospitals in Albuquerque and Santa Fe were still working through elders aged 60 and up.
Meanwhile, Albuquerque's small urban Indian clinic was facing the same surge of vaccine-seekers, and the same vaccination bottleneck, as Denver Indian Health and Family Services.
"We don't have enough vaccines to vaccinate the urban Indian population in Albuquerque," said Linda Son-Stone, CEO of First Nations Community Healthsource. "And if we did request more vaccines, we would need to have more staffing to administer them."
Son-Stone has since worked with state officials to address that. FNCH provided 600 vaccine doses, and the state departments of health and Indian affairs provided enough extra staff to host a drive-through vaccination event.
Lynn Trujillo, secretary of the New Mexico Indian Affairs Department, said the event targeted urban Natives who didn't have the ability to drive home to their reservations to get vaccinated.
"We are definitely hearing that some people are facing that challenge," Trujillo said. "If you can make the trip home, that means you can take the time off work, that you have a vehicle, and that you have the money to pay for gas. For some people, that's hundreds of miles to be able to get back to their reservation."
Trujillo said the state hopes to assist with more urban Indian vaccination events in the future, though none have been announced yet.
With April approaching, the state's urban IHS hospitals have finally started to catch up with their rural counterparts, opening vaccine eligibility to IHS beneficiaries aged 18 and older. And while that's several weeks behind most tribal clinics, they're still moving faster than the state of New Mexico.
This story has been updated to clarify that there are 41 urban Indian health centers in the U.S., operating in 33 metro areas.
This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUNR in Nevada, the O'Connor Center for the Rocky Mountain West in Montana, KUNC in Colorado, KUNM in New Mexico, with support from affiliate stations across the region. Funding for the Mountain West News Bureau is provided in part by the Corporation for Public Broadcasting.