Barriers to Telemedicine Implementation in Southwest Tribal Communities During COVID‐19

Abstract

Tribal communities across the United States face significant health and mental health disparities, including rates of suicide that far exceed those of nontribal communities.1 Timely access to health care is limited across most rural areas in the United States, particularly in remote tribal communities.2, 3 It is likely that the COVID-19 pandemic will exacerbate disparities among American Indian tribes, particularly when coupled with existing barriers to access health services.4 In their commentary, Kakol et al (18 April 2020)5 summarized historical and ongoing ramifications of colonization on Southwestern American Indian tribes from an infectious disease perspective, including challenges confronting those communities amidst the COVID-19 pandemic. They comment on the need to expand telehealth to rural Southwest American Indian communities, adding to the burgeoning literature on COVID-19 that emphasizes telehealth approaches, namely telemedicine, as a means of improving access to physical and mental health care, while maintaining social distancing.6-10 Yet, Kakol et al omit the important consideration that broadband Internet access—required to deliver care to patients from a distance—is a barrier to rural patients, no matter how quickly providers are upskilled to deliver it. This is of particular concern in tribal communities. To illustrate this concern, we summarized broadband Internet service data from the 2018 American Community Survey estimates11 for census tracts within the Navajo Nation, the largest American Indian tribe in the United States. We found that 58.1%-87.7% of households in Navajo Nation census tracts reported not having broadband Internet service, compared to 19.6% nationally (Figure 1). Access to broadband Internet service is not only a concern for the Navajo Nation; it is a challenge facing most tribal communities in the United States.12, 13 Even if tribal members can access the Internet at public spaces (eg, local library or school), these locations are far from ideal for telemedicine visits, especially telemental health. The Navajo Nation spans approximately 17,544,500 acres, occupying portions of Arizona, Utah, and New Mexico in the United States (left); and percent of households in Navajo census tracts reporting no access to broadband Internet service (right). Source: Authors’ analysis of data from 2018 American Community Survey 5-year estimates. Without access to technology needed for telemedicine, members of rural American Indian communities are distinctly disadvantaged. Aside from barriers to access, the acceptability and effectiveness of telemedicine among tribal communities must be considered.14 With this in mind, we agree with Kakol et al that telehealth expansion has the potential to improve access to care. However, substantial progress must be made toward increasing broadband Internet service on tribal lands before the potential of telemedicine to serve geographically dispersed but tightly woven communities, such as the Navajo Nation, can be realized.