Indigenous peoples and the COVID-19 pandemic: a systematic scoping review

There is no universal definition of Indigenous peoples. The concept of Indigenous peoples emerged in response to the process of colonization by European forces that saw the subjugation of some, but not all aboriginal peoples (Secretariat of the Permanent Forum on Indigenous Issues 2009). The United Nations Permanent Forum on Indigenous Issues provides the following criteria, that we used to determine 'Indigenous': 'identify themselves and are recognized and accepted by their communities as indigenous; demonstrate historical continuity with pre-colonial and or pre-settler societies; have strong links to territories and surrounding natural resources; have distinct social, economic or political systems; maintain distinct languages, cultures and beliefs, form non-dominant groups of society, resolve to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities' (Secretariat of the Permanent Forum on Indigenous Issues 2009).

The COVID-19 pandemic is a rapidly evolving situation with articles and evidence being published in peer reviewed journals and by organizations including the United Nations. Hence this review includes grey literature from UN agencies. Relevant publications for this review were identified by using a systematic search strategy for electronic databases and by manually searching select UN agency websites. The strategy (S1 table) was applied to Web of Science, Scopus, PubMed databases and UN agencies. All databases and UN agencies were searched on 1 March 2021, to identify publications from 1 January 2020 to 31 January 2021; then again on 4 July 2021 from 1 February 2021 to 4 July 2021. The inclusion and exclusion criteria employed are shown in table 1.

Our search identified a total of 7119 publications between 1 January 2020 and 4 July 2021 in the mentioned databases and UN agencies. The titles and abstracts were exported to Microsoft Excel and 590 duplicates were removed. Two reviewers, who had completed a training workshop on implementing the screening protocol and had completed two blind trials of screening papers with a 90% agreement, independently screened titles and abstracts to determine which publications would be included. Any disagreements or discrepancies were resolved by discussion between the reviewers. A total of 6359 articles were excluded because the focus was not on Indigenous peoples and COVID-19. The remaining 170 publications were downloaded for a full text screening conducted by four reviewers (who are co-authors based in Canada, Australia, and India). A further 17 articles were removed: Indigenous peoples were not the focus in nine and COVID-19 was not the focus in eight. In total 153 publications (140 peer-reviewed articles and 13 from UN agencies) were retained for final review (figure 1). Additional quality control occurred via bi-weekly meeting with Kerrie Pickering (KP) and Eranga Galappaththi (EG) to verify steps and process. Monthly progress meetings were held with all the authors for high level feedback. The unit of analysis was each article, the quality of each article was not assessed.

Zoom In Zoom Out Reset image size

From our initial analysis four themes evolved: COVID-19 virus and Indigenous peoples; impacts of pandemic restrictions on livelihoods and food security; system level challenges; responses by Indigenous peoples, government and organizations. Within these four themes, we designed 12 coding questions to answer the research questions (S2 table). The answers to the coding questions were analyzed using content analysis (Downe-Wamboldt 1992). Themes that emerged from the content analysis were: testing/incidence/hospitalization/mortality of COVID-19 in Indigenous peoples compared to the non-Indigenous population and pre-existing health conditions; effects of pandemic restrictions upon cultural practices, livelihoods and income; social and ecological challenges; government, organization, community and cultural responses. Microsoft Excel 2019 was used for descriptive statistics.

Our study identified 153 publications discussing Indigenous peoples and COVID-19 from 1 January 2020 to 4 July 2021 of which, 140 were peer reviewed and 13 were grey literature from UN agencies (S3 Table). The pandemic was declared on 11 March 2020 and three weeks later on 1 April, UN Women (2020) released a report and on 7 April the journal Nature published the first article, a correspondence by Zavaleta (2020) on the pre-existing lack of Indigenous peoples data. The peer reviewed publications were spread across 101 unique journals, most (95%) of the journals published one or two articles. The three journals with the greatest publications were Morbidity and Mortality Weekly Report (n = 8), Alternative—An International Journal of Indigenous Peoples (n = 7), and Mundo Amazonico (n= 5). The most (43%) frequent type of articles were editorial/commentaries followed by original research (38%) with fewer publications being conceptual (7%), literature reviews (6%) or policy briefs (6%) (figure 2). The majority (80%) of editorials were published in 2020, while original research remained constant at three publications per month since April 2020. In 2020, there was an average of 10 publications (of all types) per month. The greatest publications were in October 2020 (n = 17), then December (n = 16). In 2021, publications dropped to an average of six per month.

Zoom In Zoom Out Reset image size

Of the peer reviewed articles, the three countries with the highest first author affiliation were the US 29% (n = 40), Brazil 18% (n = 25), and Canada 15% (n = 21). Twenty-two per cent of authors identified receiving funding, this was largely (79%) by government agencies, the US National Institute of Health, funded most (29%) of these publications. Analysis identified publications focused on Indigenous peoples from 19 different countries (figure 3). The most (23%) articles focused on Indigenous peoples in Brazil, then American Indians/Alaska Natives (17%) in the US, followed by First Nations, Inuit and Métis (16%) in Canada. The majority (90%) of articles focused on the general adult population. Four articles looked at youth, while two applied a gender lens, demonstrating a gap in how the pandemic has had gendered and intersectional impacts. Of the peer reviewed articles, 29% had authors who self-identified as Indigenous. For the grey literature, six UN agencies had publications, Department of Economic and Social Affairs (DESA), Food and Agriculture Organization (FAO), International Labor Organization (ILO), Pan American Health Organization (PAHO), WHO, United Nations Children's Fund (UNICEF) and UN Women. The PAHO/WHO had the most (n = 4) publications followed by ILO (n = 3) then UNICEF (n = 2).

Zoom In Zoom Out Reset image size

To answer the first research question on how COVID-19 is affecting Indigenous peoples, we split the question into two separate (but interacting) themes: the COVID-19 virus and pandemic restrictions. The next two sections discuss these themes sequentially.

3.2.1. COVID-19 virus and Indigenous peoples

3.2.2. Impacts of pandemic restrictions on livelihoods and food security

Pre-existing structural inequities mediated Indigenous peoples capacity to respond to the COVID-19 virus and pandemic restrictions. Our second research question sought to identify these challenges. Five types of challenges emerged from our analysis: ecological, poverty, communication, education and health care services. Ecological challenges were the least prominent, identified by 39% of articles. Most (33%) articles identified a lack of adequate water and sanitation prevented hand hygiene, a first line of defense in the transmission of many other diseases that can make people more susceptible to contracting COVID-19. Other ecological challenges included deforestation (11%), followed by climate change (6%) then pollution (3%). Authors documented ecological factors are compounding other structural factors potentially increasing risks of COVID-19. For example, de León-martínez et al (2020) explains in Mexico many Indigenous households use solid fuel indoor cooking stoves which reduce indoor air quality and are associated with pulmonary diseases such as lung cancer, and acute respiratory infections, making these populations more susceptible to contracting COVID-19. At a broader scale, Haas et al (2021) identify that in Chaco Province, Argentina, widespread deforestation has altered the local climate and driven water scarcity, making actives such as wild food gathering (e.g. picking berries, hunting) and hand-washing more difficult.

A range of social challenges were identified in 59% of the reviewed documents. Of these articles, the impacts of factors linked to structural inequity from colonialism, racism, loss of land rights, and violations of human rights were cited most frequently (93%). Racism caused some Indigenous peoples to be stigmatized as sources of COVID-19 causing severe movement restrictions to be enforced. For example, Haas et al (2021) describe during an outbreak in May 2020, lasting several weeks the Gran Toba, in Chaco Province, Argentina, were singled out by the regional government, who physically isolated the settlement with earth barriers and fences preventing people and goods from entering and leaving the community. In Brazil, Menton et al (2021) reports the mayor of Pau D'Arco decreed a lockdown to prevent members of a nearby village from entering the city, yet many Indigenous peoples in Brazil are increasingly being exposed to COVID-19 as they encounter individuals involved in illegal mining and land grabbing actions on their traditional lands.

Poverty, employment and overcrowding were reported as significant challenges as well. Indigenous peoples are three times more likely to live in extreme poverty compared to non-Indigenous people (ILO 2020). Poverty was most often (57%) identified as increasing the incidence and poor outcomes of COVID-19, across the Americas, Africa, India and Asia, and was associated with food insecurity and malnutrition (FAO 2021, Hoover 2020, Leite et al 2020, Rodriguez-Lonebear et al 2020, Teixeira 2020). One of the most important ways in which poverty increases vulnerability to COVID-19 is that it requires people to go out to work increasing their risk of exposure. Globally, more than 86% of Indigenous peoples work in the informal sector where the low pay and lack of social protection has forced them to keep working (ILO 2020). Those in the formal sector are largely in service occupations that further increase their risk of exposure such as domestic work, health care, transportation and construction (ILO 2020). COVID-19 spreads quickly when people are close together. Overcrowding due to inadequate housing was found to be a challenge for many (43%) Indigenous peoples.

A lack of communication strategies about COVID-19 prevention in Indigenous languages that were also culturally appropriate was another challenge identified by several articles (9%). To improve access to information about COVID-19, some governments have translated information into local languages and made culturally appropriate flyers. The FAO (2020) notes in Columbia the government issued COVID-19 messages in Indigenous languages and in Peru the government developed informational posters and radio spots. In New Zealand, Māori organizations collaborated to create their own culturally appropriate flyer (Te One and Clifford 2021). Digital platforms have also been useful for communicating health information. For example, in Gran Toba, Argentina members of a bilingual school created and shared a digital video in three Indigenous languages (Haas et al 2021). Additionally, social media platforms have provided a tool for activism by youth and young adults to increase local and global awareness of the struggles Indigenous peoples are facing. For example, in Brazil Franco and da Silva (2021) describe the use of Instagram by Indigenous peoples to create awareness of Indigenous rights violations and to mobilize organized forms of resistance. Menton et al (2021) explains in Brazil social media platforms have enabled Indigenous peoples to access crowdfunding to support their efforts to take the government to court for a lack of support. However, Haas et al (2021) also notes these platforms have been used as a vehicle for hate speech against Indigenous peoples. Communication strategies will need further evaluation to understand the effectiveness and cultural adequacy in preventing COVID-19 and or promoting vaccination among Indigenous peoples.

A challenge for many Indigenous children and youth has been the disruption to their education. Many countries have taken classes online and as UNICEF (2020) explains, this disadvantages Indigenous children and youth, as many communities lack digital coverage, equipment, technical expertise, and programming in their languages. For example, in Mexico, 54% of Indigenous children (7–17 years) lack access to a radio.(UNICEF 2020). Beyond the logistics, Dietz and Cortés (2021) raise concerns that in Mexico the return to a Spanish only curriculum will undo the years of work to include Indigenous languages and cultures with the goal of making education more relevant to students and keeping them attending school longer. However, the closure of schools has been beneficial for some groups providing an opportunity to recover indigenous knowledges. For example, in Canada, Neeganagwedgin (2020) describes how some First Nations children are now being taught on the land by elders. While in northern Russia, Potravnaya and Sleptcov (2020) found the closure of schools allowed reindeer farmers to take their children with them to summer pastures.

The prevention and treatment of COVID-19 require access and trust in health care services. Yet, across all 19 countries, authors (37%) identified inadequate access to health care was a chronic challenge for Indigenous peoples. For example, Ferrante and Fearnside (2020) explain in Brazil the lack of access to health care has intensified, as prior to the pandemic, the Bolsonaro administration had dismissed 8000 doctors, who served mostly Indigenous peoples in the interior. Authors (Curtice and Choo 2020, Teixeira 2020, Mosby and Swidrovich 2021, Pratt et al 2021, Speers 2021) have stressed given their greater risk of contracting COVID-19 Indigenous peoples need to be prioritized for early vaccination. However, other authors caution due to past involuntary medical treatment and experimentation, many Indigenous peoples may be hesitant to be vaccinated. For example Mosby and Swidrovich (2021) explain in Canada some First Nations, Métis and Inuit elders remember having vaccines tested on them as children at residential school and are weary of the new vaccines. Adding to this concern is the federal governments prioritizing of First Nations, Métis and Inuit for vaccinations, with some feeling these populations were again being used to test these new vaccines (Mosby and Swidrovich 2021).

Our analysis identified responses to the pandemic are being generated from two types of actors: national and sub-national governments and Indigenous peoples themselves at the individual, community and organizational scale. We found governments were implementing a range of short- and longer-term, largely reactive responses. Government in Ecuador (Tuaza Castro 2020), India (Kasi and Saha 2021), Peru (Reinders et al 2020), and Bolivia (Kaplan et al 2020), provided intermittent food rations and vouchers to those in need when food supplies became limited, although in some regions those receiving government assistance prior to the pandemic were excluded from these initiatives (Reinders et al 2020). Other governments chose to bolster current programs with additional funding over a period. For example, the US federal government provided an additional US$2.4B to the Indian Health Service (Burki 2021) and US$100 M to the Food Distribution Program on Indian Reservations (Hoover 2020). While the Australian government chose to direct US$11 M toward Indigenous suicide prevention (Walker et al 2021). In contrast to these programs, the federal government of Canada gave funds directly to communities to use as they saw fit (Hillier et al 2020). In response to lesson learnt from the H1N1 pandemic, the Australian Government also took a pre-emptive approach, convening the Aboriginal and Torres Strait Islander Advisory Group on COVID-19 soon after the pandemic was declared, to ensure the Indigenous population were actively involved in all phases of national planning (Crooks et al 2020). However, not all government assistance came willingly; federal governments in the US (Yellow Horse and Huyser 2021) and Brazil (Charlier and Varison 2020) were ordered by their respective supreme courts to provide relief funds for Indigenous peoples. Overall, during the first 18 months it was governments who were working with Indigenous population prior to the pandemic that implemented policies that were most helpful.

There is also significant evidence to suggest that many Indigenous communities and organizations proactively took action to protect their communities. Roadblocks and checkpoints were most (31%) frequently used to prevent people from entering the communities and to assess for symptoms of COVID-19 (Kaplan et al 2020, Goha et al 2021, Menton et al 2021). Although the Yanomami, Brazil chose to isolated by moving into the forest (Goncalves et al 2020). In several Pacific Island communities, mandatory quarantine areas were set up for those returning to the community (Davila et al 2021). However, isolation measures were not always successful, Ortiz-Prado et al (2021) show in the Amazon regions of Ecuador such isolation measures failed to contain the spread of COVID-19.

Isolation measures slowed the flow of goods and services into a community. To ensure people had adequate access to water, food and medication during the isolation periods, some communities built upon existing networks and programs. For example, in New Zealand Māori organizations Te Pūtahitanga and Whānau Ora navigators collaborated to respond to lockdown needs of Māori by supplying food and hygiene packs, grants for home heating and digital devices (McMeeking et al 2020). In North Western Ontario, Canada, the Red Rock Indian Band began ordering directly from bulk food suppliers and partnered with local businesses to get a constant supply of fresh fruit and vegetables (Levkoe et al 2021). Others, including First Nations in Canada (Banning 2020a) and the US (Hoover 2020) returned to traditional communal practices of sharing and caring for one another. To boost the local food supply in Pacific Island communities, farmers focused on producing local foods instead of cash crops (Davila et al 2021). Similarly, in Mexico Indigenous Oaxaca, increasingly sourced food from their home gardens (Cohen and Mata-Sánchez 2021).

Other responses by Indigenous peoples included using Indigenous knowledge and medicines, as identified in 13% of the articles. For example, da Silva et al (2021) found in the Alto Rio Solimões Special Indigenous Sanitary District, over half (54%) of the patients who attended a medical clinic with symptoms of COVID-19 had sought treatment using local Indigenous medicines. Similarly, in Brazil, Mondardo (2020) identified Indigenous herbal preparations that were used to treat COVID-19 symptoms. However, this traditional medicine was not always welcomed. Beyers (2020) explains in South Africa, although traditional healers are legally recognised the government has not included them in strategies to manage the pandemic.