When COVID-19 vaccines first became available in December of 2020, Chuck Hoskin Jr., principal chief of the Cherokee Nation of Oklahoma, knew that he had to do everything he could to get them to the Nation's citizens — especially fluent speakers of the endangered Cherokee language.

Thanks to effective social distancing policies, testing, and contact tracing early in the pandemic, the Cherokee Nation has fared betterin the wake of the virus than other tribes and even the tribe's surrounding areas in Oklahoma. But the Cherokee community was still hit hard.

Of the 140,000 citizens on the reservation, more than 15,000 have tested positive for COVID-19 within the Cherokee Nation health system — comparable to the case load in the state of New York, and more severe than in Massachusetts, although in general, fewer Cherokee Nation citizens on the reservation died of the disease. Around 100 Cherokee citizens have died, more than 50 of whom were fluent speakers of the Cherokee language. With about 2,000 fluent speakers left — and just a couple thousand more citizens with some knowledge of the language or who are proficient speakers — the language is critically endangered.

More widely, Native Americans and Alaska Natives have been infectedwith COVID-19 at 3.5 times the rate of white individuals, and were also more likelyto die from the disease. Compounding the challenges COVID-19 posed to Indigenous communities is a long history of distrust in medical care provided by the United States.

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That distrust isn’t unreasonable — the Indian Health Service, a branch of the U.S. Department of Health and Human Services, is chronically underfundedand often fails to provide adequate care to Native Americans. A lack of testing and protective equipment contributed to the severity of COVID-19 outbreaks in Indigenous communities. And, in the more distant past, American settlers spread devastating infectious diseases to Native Americans.

“We have a real understanding, passed down from generation to generation, of the horrible impacts of infectious disease,” says Hoskin. But with that history, he says, can also come distrust in the system, and therefore a sense of hesitancy about vaccination. “I think it cuts both ways,” he says. To be successful at vaccinating most citizens, he knew that he and other leaders would have to rely on creative ways of reaching them.

Community outreach is an essential part of any mass-vaccination campaign, says Sarah Schaffer DeRoo, a pediatrician at Children’s National Hospital in Washington, D.C. In May 2020, long before there were COVID-19 vaccines, DeRoo published a paperoutlining what an effective COVID-19 vaccination effort might look like, not only in Indigenous communities but across the U.S.

Here’s how Indigenous communities are employing some of these strategies — and how they're working.

Tailoring messaging to the community

Community leaders “can proactively tailor their messaging" — or make the reason for getting a vaccine specific to a particular group's needs, says DeRoo.

Hoskin feels the ability to tailor the Cherokee Nation’s vaccination program to the needs of the tribe was essential in the early vaccination effort. In September 2020, the Indian Health System laid out its plan for which tribal citizens should have first priority for a vaccine, based on Centers for Disease Control and Prevention recommendations, which gave priority to more vulnerable people, like healthcare workers and the elderly. That gave tribes a strong framework to follow right away, but was general enough to give them the freedom to adapt the plan to their communities — for instance, deciding who besides healthcare and older citizens would be first in line to get a shot.

“We took it upon ourselves to put fluent speakers at the front of the line with the health care workers,” says Hoskin, who adds that framing vaccination as a way to preserve and protect Cherokee language and culture was effective in the initial push.

Bringing vaccines to people

In the Rocky Boy’s Reservation in Montana, healthcare workers are getting vaccines to citizens of the Chippewa Cree tribe by meeting them where they are, says Jacy Crowley, the director of nursing at Rocky Boy Health Center, which runs the Chippewa Cree’s COVID-19 vaccination program. Their mobile clinic, a small, converted bus, has allowed them to go out into the reservation freely.

“Our public health department is going out to different spots, twice a week, so that it's a little bit easier to access the vaccine … [for] those who may have transportation barriers,” Crowley says.

The health center has also run vaccination clinics all over the reservation, from the local Stone Child College to an outdoor clinic in a shopping mall parking lot.

Dakota High Hawk, the public information officer for the Oglala Sioux Tribe’s COVID-19 Response Task Force Incident Command Center, says the Oglala Sioux’s vaccination program also runs pop-up clinics all over the reservation, the Pine Ridge Reservation in South Dakota.

“We have nine districts on the reservation. And so we've been trying to get out to all of them where we can coordinate best,” he says. The clinics often take place in local high school or middle school gyms. So far, about a third of the tribe is vaccinated and 40% have received at least one dose.

Using the power of social media

Many programs have also utilized social media to reach out to members of the Indigenous community about where, when, and why they should be vaccinated. High Hawk says the tribe’s COVID-19 task force has been livestreaming COVID-19 updates every Tuesday and Thursday on Facebook; they're also broadcast on a local radio station. Oglala Sioux citizens can ask questions about the virus and vaccine in real time, in addition to hearing updates about vaccination, case numbers, and testing.

“We've been trying to provide more information on the vaccines,” he says. “How they're intended to work, their safety, everything, just to help people and putting out that information for them.”

Hoskin says social media has been a way to engage directly with Cherokee citizens as well. He and other Cherokee leaders have tried to provide information to counter common concerns, like the fear among some young women that the vaccine could impact fertility, though there is no evidence to suggest that it does. Hoskin and the other living principal chiefs of the Cherokee Nation, who Hoskin says are diverse in their political views, also made a joint public service announcement about the vaccine for social media, saying that although they are different, they all believe in the efficacy of the vaccines.

Reaching out person-to-person

Crowley hopes that the relationship the Rocky Boy Health Clinic has with the community will ultimately lead patients to trust their recommendations about COVID-19 and its vaccines.

“Our patients and the community are familiar with us and we have a relationship with them so that they feel they can trust the information that we're giving out,” she says.

Rocky Boy Health Clinic staff also personally called patients who were eligible for the first round of vaccinations, which included many older citizens and those with certain medical conditions, making sure they knew they would have access to the vaccines and transportation.

“We made priority lists and started calling to gauge interest (before we even had vaccine), and then when we did we called to offer if they hadn’t scheduled/received vaccine yet,” Kari Williams, the director of pharmacy at the Rocky Boy Health Clinic, wrote in an email. (Though their clinic runs the Chippewa Cree vaccination program, neither Williams nor Crowley are Chippewa Cree citizens.)

Early success

Because of these early efforts,the Chippewa Cree Tribe experienced early success with their vaccination program, says Crowley. Many older age groups and those at high risk got the vaccine as soon as they could, she says. In March, about a third of the enrolled tribal members in the area had been vaccinated, including Chippewa Cree citizens, double the 15% vaccination rate in Montana as a whole.

Crowley and Williams said the clinic made every effort to keep patients informed on COVID-19 and the vaccines. “I think that with that group, there was a very strong understanding of their risk for illness getting it and the severity of illness if they were to get it,” says Crowley.

Hoskin was worried that Cherokee speakers would be hesitant to get the vaccine. “Speakers are in an older age group, they live in a rural area, many of them sort of have a conservative outlook on life,” he says — all factors that might make them more hesitant to get a COVID-19 vaccine. And yet, in part, Hoskins believes, because of the emphasis on the preservation of language and culture in their outreach, 74% of speakers have received the vaccine.

“I'm convinced one of the reasons we got [here] is because of that early effort, not only to encourage vaccination, but to celebrate publicly people that were vaccinated,” says Hoskin.

DeRoo says there are many reasons why these strategies might work, including that the right person reaching out to the community makes all the difference. “What we know is a recommendation from a trusted member of the community” — a doctor, a religious leader, or a prominent member of the community — ”is really important,” she says.

She also says that education efforts, such as reaching out to people through social media, or personally through an appointment or phone call, are crucial. “We can make sure that [people] have actual information and it’s evidence-based,” she says.

The roadblocks ahead

In spite of their initial success and continued outreach efforts, many Indigenous communities are now struggling with a vaccination slowdown. Since March, Montana’s vaccination rate has risen to 40%, but only about a third of the Chippewa Cree tribe has been fully vaccinated as of mid-June, says Crowley, compared to about 65% of U.S. citizens who have had at least one dose. The health center’s vaccinations are now open to all adults and adolescents ages 12 and up, regardless of tribal affiliation.

“We've gotten to the point where we are vaccinating our younger adults, and we've seen a slowdown [in vaccinations],” says Crowley.

Hoskin agrees. “There's a percentage of people, I think, that were ready, willing, and able to take the vaccine the moment it was available,” he says. He even thinks that a few more people might have been persuaded by the appeal to protect Cherokee culture. But the ones left unvaccinated are the more hesitant ones. “Now is the more difficult time,” he says — especially combined with the sense of hesitation many Indigenous people have about health care delivered by the United States government.

Hoskin is concerned by the tribe’s low vaccination rate, and fears that what will ultimately convince people of the vaccine’s effectiveness are outbreaks affecting only areas with low vaccination rates, including the Cherokee Nation. Although the tribe hasn’t experienced any such outbreaks yet, Hoskin says only around a third of its citizens on the reservation were fully vaccinated as of late May, although about half of the tribe’s workforce is currently vaccinated. He recently signed an executive order to offer $300 to any member of the Cherokee Nation workforce who gets vaccinated, although he's doubtful that the incentive will be what makes the difference.

Hoskin is hopeful that he and other Cherokee leaders can get even more creative with outreach efforts, especially as citizens begin to gather together in person again. Recently, another tribe leader suggested having a pastor at a local church reach out to congregants, and he thinks younger Cherokees, like some athletes, might help sway young people to get the shot.

“I could see them connecting in a way that I could never connect,” he says.

Crowley, too, is thinking about how to get past the slowdown. The health clinic plans to offer vaccines at community events, like a drive-in movie showing at Stone Child College. “We will be there and be available for anybody who's attending that event who wants to get a vaccine,” she says.