Challenges, inequalities and COVID-19: Examples from indigenous Oaxaca, Mexico

In early 2020, a novel coronavirus (SARS-CoV-2) began to trickle through global communities, resulting in a pandemic of proportions not seen since 1918. In the US, while the disease caused by SARS-CoV-2, COVID-19, initially affected international travelers and their close contacts, it is now ravaging many disadvantaged communities. As in past pandemics, social and economic determinants will strongly influence susceptibility to and health outcomes of COVID-19; thus, it is predictable that low-income and vulnerable US populations will be disproportionately affected. Certain “hot spots” have already demonstrated high rates of COVID-19–related mortality in minority populations, particularly those of impoverished communities, likely due to increased prevalence of comorbid conditions as a result of unequal socioeconomic factors and inadequate access to timely healthcare [1–5]. We can anticipate similar outcomes in other vulnerable populations, particularly in immigrant communities, which have similar socioeconomic status and rates of comorbidities. With over 46.7 million immigrants currently living in the US, of which 11 million are undocumented [6], a socioeconomic perspective of the ongoing COVID-19 pandemic within the US immigrant community is necessary. Here, we will focus on the potential impact of COVID-19 on immigrant communities in the US, particularly those in Texas. Why is the COVID-19 pandemic likely to disproportionately affect US immigrants? The intricacies of poverty, limited access to healthcare, and fear of legal repercussions place vulnerable immigrant communities within the US at high risk for acquiring SARS-CoV-2 and developing severe COVID-19 (Fig 1). Houston is an excellent example of a large, prosperous US city that is made up of (and depends upon) immigrants. Currently, there are an estimated 1.6 million immigrants (23.3% of the population) living in Houston, the majority of whom are from Mexico (40.2%), El Salvador (7.6%), Vietnam (5.9%), India (5.5%), and Honduras (3.6%). More than 500,000 of these immigrants (37.2%) are undocumented [7,8]. In Texas as a whole, an estimated 32% of undocumented immigrants live below the poverty level, and 64% are uninsured with limited options to meet their medical needs [8]. 10.1371/journal.pntd.0008484.g001 Fig 1 Risk factors and anticipated socioeconomic outcomes for the COVID-19 pandemic in vulnerable immigrant communities. The lack of readily accessible, affordable healthcare [9,10] is particularly consequential during the COVID-19 pandemic. First, early diagnosis and monitoring of persons with COVID-19 is critical both to optimize the individual patient’s outcome and to prevent further community transmission. Many vulnerable immigrants are under- or uninsured [11] and thus depend upon Federally Qualified Health Centers (FQHCs), safety-net public health systems, or free clinics. These organizations are often underfunded, limiting their ability to provide testing, management, and follow-up services to their patients. Second, lack of access to preventive medicine leads to increased risk of underlying health conditions such as obesity, hypertension, and diabetes-—comorbidities that have been linked to more severe COVID-19 manifestations [9,12–15]. In a national evaluation of health conditions in immigrant populations, nearly a third (27.7%) of those from Mexico, the Caribbean, and Central America had hypertension, 71.5% had obesity, and 9.6% had diabetes [15], compared with the age-adjusted prevalence of 45.4%, 42.4%, and 8.2%, respectively, in the US general population [16]. However, within the US general population, these comorbidities tend to be higher in minority groups compared to whites; for instance, while the prevalence of diabetes in the US general population was 8.2% overall, it was 12.5% for people of Hispanic origin, 11.7% for non-Hispanic Blacks, and 7.5% for non-Hispanic Whites [17]. Third, depending on their mode of entry into the US, many immigrants may be at risk for excessive stress related to poverty, trauma, and poor social support, which leads to mental health conditions such as post-traumatic stress disorder, depression, and anxiety [18]. These psychological stressors may be worsened during a pandemic, certainly for those with limited healthcare resources, high risk of job loss, or high risk of SARS-CoV-2 exposure. Regarding risk of SARS-CoV-2 exposure, many immigrants are at increased risk both because their economic situation requires continuation of work despite “social distancing” and “stay-at-home” recommendations and because the types of jobs most commonly worked by immigrants often require face-to-face interactions. Immigrants make up more than 20% of the Texas work force and are employed most commonly in construction, accommodation, food services, healthcare, and manufacturing industries [8,19]; these are “essential” professions that do not lend themselves to working from home [20]. In addition, immigrants who continue working are more likely to use public mass transit to get to their jobs, which further increases their risk of SARS-CoV-2 exposure [21]. In the home, immigrants are more likely to live in large, multigenerational family groups or with multiple roommates. Nearly 29% of Asian, 27% of Hispanic, and 26% of Black Americans live in multigenerational households, a practice that is particularly common in those who are foreign-born [22]. Logically, if one person living in a crowded home is infected with SARS-CoV-2, their cohabitants, including elderly and immunosuppressed ones, will likely be exposed as well. Finally, recent immigrants and their families are less likely to have cell phones or internet access [23] and to speak and read English; in Texas, for example, approximately 50% of undocumented immigrants lack English proficiency [8]. Consequently, immigrant communities with limited English skills may be less likely to receive and understand public health messages, warnings, and updates. What is the potential socioeconomic impact of the COVID-19 pandemic on US immigrants? One of the ways US immigrants play a significant role in the US economy is by paying federal, state, and local taxes. In 2018, immigrants in Texas paid 38.6 billion dollars in taxes, of which undocumented immigrants assigned Individual Taxpayer Identification Numbers (ITINs) contributed an estimated $4.2 billion [24]. Despite this, ITIN holders do not qualify for COVID-19 federal economic relief through the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Families with mixed immigration status who file jointly, such as undocumented adults with children or spouses who are US citizens, are also excluded because all individuals included in a tax return must have valid Social Security numbers to be eligible [25]. As such, despite paying into the US economy and experiencing equal, if not more severe, consequences from the COVID-19 pandemic, many immigrants will not receive any COVID-19–related economic relief from the US government. Thus, there is much concern that the COVID-19 pandemic will result in particularly high rates of unemployment and financial strain within immigrant communities [26]. Between February 2020 and April 2020, the unemployment rate for immigrant women increased from 4.3% to 18% and for immigrant men from 3% to 15.3%, while for US-born women, it changed from 3.3% to 15.3%, and for US-born men, it increased from 4.3% to 12.8% [27]. Because undocumented immigrants are ineligible for national unemployment benefits in addition to CARES Act benefits, job loss or reduced work hours due to the COVID-19 pandemic may lead to significantly decreased financial reserve in immigrant households. For the 57% of immigrants who have private insurance [1], loss of a job could also mean loss of health insurance for the employee and their family, leading to further difficulty accessing healthcare. Those who are able to retain their jobs, as discussed above, may work in sectors not amenable to working from home or that do not permit sick leave [20,28]. Higher numbers of uninsured immigrants combined with those working in high SARS-CoV-2 exposure risk jobs will undoubtably result in increased COVID-19–related morbidity and mortality in immigrant communities. Additionally, in the context of extended school closing as a result of COVID-19, many parents have limited childcare options, putting additional financial, health, and social pressure on families. As the COVID-19 pandemic causes instability in global supply chains, concern for worsening food insecurity is growing in many disadvantaged communities. Immigrants are at particularly high risk, especially those who have resided in the US for less than 5 years [29]. This may be because immigrant families newly arrived in the US have more significant language barriers and less exposure to a stable education system and jobs than those who have lived in the US for longer periods of time. However, even immigrant families who have lived in the US for more than 10 years are at higher risk of food insecurity than US-born households. According to one study, more than 30% of children born to Mexican and Central American immigrants are already subject to food insecurity [29]. Additionally, the federal government stipulates that adults (with some exceptions) with legal permanent resident status (i.e., green card holders) must wait 5 years before they can apply for the Supplemental Nutrition Assistance Program (SNAP) [30]. Furthermore, despite being eligible for SNAP, low-income US citizen children with immigrant parents have decreased utilization of this benefit in recent years [31]. Although children with green cards are not subject to the 5-year waiting period and may qualify for SNAP along with low-income US citizen children, studies have shown that eligible children of ineligible parents are less likely to participate in assistance programs [32]. This has become increasingly apparent in recent years because of concern over the “Public Charge” rule (implemented on February 24, 2020), which limits the ability of immigrants to adjust to legal permanent resident status if they have used certain public benefits. The fear of deportation and chilling effect of this rule have led many immigrant families to forgo participation in all federal assistance programs, including nutrition assistance, even if they are eligible and not subject to a public charge determination. The factors driving this downward trend will likely also prevent many eligible immigrant families from applying for Pandemic Electronic Benefit Transfer (EBT), a provision of the Families First Coronavirus Response Act allowing states to provide money to families whose children were receiving free or reduced cost meals through their schools. This would have a far-reaching impact because, unlike SNAP, Pandemic EBT is available to children regardless of immigration status. Expansion of “food deserts” as a result of limited transportation options and restaurant restrictions, reduced grocery store supply, and diminished resources in food banks may further limit food availability in at-risk immigrant communities [33–35]. Finally, due to the implementation of recent immigration policies such as the “Public Charge” rule, the utilization of available health resources among immigrants and their families has effectively decreased as a result of widespread fear of immigration enforcement and/or concern that using these services would impair their success of future naturalization. In addition, mounting health, psychosocial, and financial concerns—together with fears of legal exposure—may inhibit immigrant participation in the ongoing 2020 census data collection [25]. In the long term, inadequate enumeration of the US immigrant populations will manifest as decreased funding for sorely needed health, education, and socioeconomic programs in many disadvantaged communities. Déjà vu: Comparing COVID-19 to H1N1 The COVID-19 pandemic is certainly not the first pandemic to reveal underlying health disparities. Most recently, the 2009 H1N1 influenza pandemic provided opportunity to understand health inequalities in vulnerable US populations that parallel those emerging in the current COVID-19 pandemic (Fig 2). Both suggest poor health and economic outcomes in disadvantaged populations such as at-risk immigrants. 10.1371/journal.pntd.0008484.g002 Fig 2 Comparison of COVID-19 and 2009 H1N1 influenza pandemic timelines in the context of events affecting vulnerable immigrant communities in the US. CDC, US Centers for Disease Control and Prevention; EUA, emergency use authorization; FDA, US Food and Drug Administration; ICE, US Immigration and Customs Enforcement; USCIS, US Citizenship and Immigration Services; WHO, World Health Organization. In the spring of 2009, Mexico reported a number of cases of influenza-like illness caused by a novel H1N1 virus. This virus disseminated rapidly, and the World Health Organization (WHO) declared H1N1 influenza a pandemic in June 2009 [36]. The final burden of H1N1 disease in the US was estimated to be approximately 60.8 million cases, with more than 274,000 hospitalizations and more than 12,000 deaths [37]. Like SARS-CoV-2, H1N1 frequently caused severe lung injury [38]. Specific risk factors for severe H1N1 disease included obesity, pregnancy, immunosuppression, lung disease, HIV infection, poverty, and lack of access to healthcare [39–41]. Additionally, factors such as limited access to and use of preventive medical care [42], large household sizes [28], difficulties complying with work-from-home directives (even when ill) because of the need to work [20,28], and reliance on public transportation [21] placed immigrants at high risk of H1N1. Surveillance case reports during the 2009 H1N1 pandemic were disproportionately high among all disadvantaged groups, and the Hispanic population specifically was noted to have increased influenza-associated hospitalization and pediatric mortality [43]. The disproportionate effect of the H1N1 pandemic on Spanish-speaking Hispanics may have occurred because of increased risk of H1N1 exposure and greater disparity in access to healthcare compared with other disadvantaged groups [28]. However, there are sparse data on outcomes for other immigrant populations during the H1N1 pandemic because of limited surveillance. In addition to clinical outcome inequalities, the H1N1 pandemic exemplified the disparities in pandemic preparedness, response, and recovery for disadvantaged populations, including immigrant communities [21]. Unfortunately, since the H1N1 pandemic, health disaster preparedness for immigrant communities has largely remained inadequate. Conclusions and next steps SARS-CoV-2 has severely impacted our global community, placing marginalized populations at high risk of contracting the virus and of developing severe COVID-19. As we learned from the H1N1 pandemic, it is imperative that we act urgently to support disadvantaged communities during this COVID-19 health and economic crisis. Taking action at local, state, and national levels to improve healthcare access as well as economic and legal protections for immigrant communities is critical [44]. Acutely, healthcare facilities should be designated as locations where immigration enforcement is prohibited. Such action will decrease the fear of seeking healthcare services. For those states that have not already done so, opting into Medicaid expansion would increase health insurance coverage for more low-income adults, including documented immigrants. Additionally, states should change their eligibility criteria for the Children’s Health Insurance Program (CHIP) to allow all children—regardless of immigration status—to be considered, thus increasing the number of immigrant children with healthcare coverage. Future COVID-19–related relief packages should include vulnerable immigrant groups and improve the availability of health services through the expansion of safety-net health systems in all disadvantaged communities [45]. Testing for SARS-CoV-2 should be made widely available, easily accessible, and free. Policy changes to prevent or mitigate devastating healthcare costs for uninsured patients with COVID-19 must be instituted. In the long term, improving primary care resources to diagnose, treat, and control comorbidities in high-risk populations may reduce poor outcomes in vulnerable immigrant communities during future pandemics. Additionally, measures to create and maintain safe employment opportunities would help to relieve immigrants’ economic burden while not increasing their exposure risk. Further, developing tools to rapidly disperse culturally and linguistically appropriate public health messages to at-risk immigrant communities will improve health education, preparedness, and response time. The care of disadvantaged communities—including immigrant populations—in the US must be prioritized to reduce the devastating, inequitable health and financial costs repeatedly and predictably accrued by immigrant populations during epidemic disease outbreaks. Policy recommendations to lessen the impact of the SARS-CoV-2 pandemic on US immigrants Expand Medicaid in every state to cover more low-income adults. Eliminate immigration status requirements for children when assessing their eligibility for the Children’s Health Insurance Program (CHIP). Pass legislation stating that Immigration and Customs Enforcement (ICE) cannot conduct any operations at or near healthcare facilities. Fund SARS-CoV-2 testing and COVID-19 treatment for all uninsured individuals, regardless of immigration status. Include immigrants who have an Individual Taxpayer Identification Number (ITIN) and their families in economic relief packages (not just those with a Social Security number).

1 We acknowledge the traditional custodians of Country across the world, and their continuing relationship to culture, community, land, waters and sky. We honour children born and yet to be, and pay our respects to Elders, past, present and future. 2 INTRODUCTION Every person on Earth has been affected in some way by the coronavirus disease (COVID‐19) pandemic. However, there is a marked inequity in the impact and threat of the disease for the 370 million Indigenous Peoples worldwide. While honouring diversity in Peoples and cultures, this editorial (written by a collaborative of Indigenous nurses from Australia, Aotearoa (New Zealand), Canada, the United States of America and Central America) explores contemporary issues raised for Indigenous communities by this latest public health emergency. Please note, while we may describe a situation about a specific Indigenous group, readers can be assured that the issues we raise are endemic across colonised Indigenous communities globally. During pandemics, Indigenous Peoples suffer higher infection rates, and more severe symptoms and death than the general population because of the powerful forces of the social and cultural determinants of health and lack of political power. During the 1918 Spanish Influenza pandemic, Māori died at a rate of seven times that of the European population, which is likely an underestimation because of undocumented Māori deaths (Summers, Baker, & Wilson, 2018). First Nations people in Canada were eight times more likely to die compared with non‐First Nations (Kelm, 1999). Although COVID‐19 infection rates are currently low, in the 2009 H1N1 influenza pandemic, Aboriginal people in central Australia experienced rates five times higher than the nonindigenous population (Mousseau, 2013). Pacific Island and Māori people were seven times more likely to be hospitalised than Europeans and three and a half times more likely to die (Mousseau, 2013). Mortality for American Indian and Alaska Natives from H1N1 was four times higher than people from all other ethnicities combined (Centers for Disease Control & Prevention, 2009). In Canada, First Nations people were three times more likely to be hospitalised, and six and a half times more likely to be admitted to an intensive care unit (Boggild, Yuan, Low, & McGeer, 2011). Indigenous Peoples experience a more significant burden of noncommunicable and infectious diseases generally, and this is related to social and health inequities stemming from invasion and subsequent colonisation. Colonisation's legacy for Indigenous Peoples includes intergenerational and concentrated poverty, poor physical and mental health, transport and housing issues, increased rates of domestic and family violence, shorter life expectancy and inadequate access to culturally safe care (Allan & Smylie, 2015; Braveman et al., 2011). Colonisation is known to have a negative effect on the social determinants of health (Greenwood, de Leeuw, & Lindsay, 2018; Sherwood, 2018) and cultural determinants of health (Salmon et al., 2019). In Canada, Australia, New Zealand and the Americas, invasion and subsequent colonisation have brought about disproportionate inequities that detrimentally affect Indigenous Peoples compared with other groups in their respective countries. Indigenous Peoples in colonised nations share similar histories of invasion, displacement from traditional lands and relocation onto missions or reservations, stolen generations, forced assimilation, genocide, decimation from introduced infectious diseases and the attempted erasure of culture through the banning of languages and cultural practices (Sherwood, 2018). In Central American countries like Guatemala and Panama, Indigenous Peoples have endured centuries of war, internal violence, exile, marginalisation, genocide and other trauma. The existence of imposed trauma and decimation began when Spaniards invaded Panama in the early 16th century (Central Intelligence Agency, 2020). Despite the world class, universal healthcare systems available in Canada and Australia, Indigenous populations continue to experience much poorer health outcomes due to the legacies and intersections of colonialism and racism (Allan & Smylie, 2015). Indigenous People's increased vulnerability to disease is unquestionable, evident not only in shorter life expectancies but also in the lower age we become more vulnerable. In Australia, the Health Department advice is for Australians aged 70 years or over, or those aged 65 years or over with chronic medical conditions to stay at home and avoid all contact with other people. However, for Indigenous Peoples, this recommendation is for those aged over 50 years (Department of Health, 2020b). Regretfully, while they do highlight the danger of comorbidities, several of our governments have neglected to explicitly recognise the premature mortality of Indigenous Peoples in their advice about vulnerability to COVID‐19 (Centers for Disease Control & Prevention, 2020; New Zealand Government, 2020b; Public Health Agency of Canada, 2020). Historical data have demonstrated that poor health and poverty positively correlate with pandemic severity (Clay, Lewis, & Severnini, 2019). Poverty impacts Indigenous Peoples' capacity to respond to COVID‐19 on multiple levels. In this current crisis, health outcomes are determined by levels of secure housing, employment, comorbidities, functional literacy, health insurance, food security, access to running water, access to health care and technology. A one‐size‐fits‐all response to COVID‐19 ignores the roles of privilege, affluence and racism in perpetuating inequities, and therefore the ability to provide culturally safe care (Best, 2018). Globally, many Indigenous Peoples live on missions and reserves. Many of these missions and reserves are geographically rural or remote. Among the 574 tribes in the USA, the Navajo Nation is the third highest population in the nation for per capita infections after New York and New Jersey. As of 22nd May 2020, the Navajo Nation had over 4,253 positive cases and 146 deaths from COVID‐19 (Navajo Department of Health, 2020a). Older age, multigenerational housing, lack of running water, communal wells, increased chronic disease and poverty have increased the impact of COVID‐19. Forty per cent of Navajo households do not have access to running water, and thirty per cent do not have electricity (DigDeep & US Water Alliance, 2020). Lack of access to running water makes it difficult to comply with handwashing recommendations. Additionally, many Native American tribes, such as the Lumbee Tribe of North Carolina, are not eligible to receive federal funds to provide health care (Maynor Lowery, 2009, 2018). The marginalisation, segregation and discrimination of these tribes are negatively impacting their health and wellbeing during the COVID‐19 situation. These tribes are relying upon their own resources to address their tribal community needs. Likewise, in Central America, many Indigenous groups live in low‐ or middle‐income countries lacking fundamental basic human needs such as clean water and environment to live in, resulting in higher rates of infectious disease such as COVID‐19 (Babyar, 2019). To help curb the spread of COVID‐19, the Navajo Department of Health ordered all members within their 17‐million‐acre reservation/jurisdiction, over the age of 2 years to wear masks in public and have instituted isolation measures including weekend curfews. Unnecessary travel is punishable by up to 30 days incarceration or a $1,000 (USD) fine (Navajo Department of Health, 2020b). Similar lockdowns are evident across the globe. In Australia, enactment of the Biosecurity Act 2015 has given the Federal Minister of Health extraordinary powers (Maclean & Elphick, 2020). On the 26th March 2020, the Minister invoked biosecurity travel restrictions for remote areas. People wishing to enter remote communities must self‐isolate for 14 days prior to entry (National Indigenous Australians Agency (NIAA), 2020). Assurances that “Governments will support people who do not have appropriate alternate arrangements to self‐isolate” are not trusted (NIAA, 2020). Some communities are hundreds of kilometres and many hours away from regional centres, and where people would be accommodated is not clear. Furthermore, this support has not been evident for other Aboriginal people, with media reports of rough sleepers having camps broken up by police, and possessions thrown into garbage trucks (Hirini, 2020). A central tension exists between food security and affordability and the closing of missions, reservations, and communities to keep Indigenous Peoples safe from the virus. Prepandemic, one in three adult Aboriginal people who lived remotely in Australia reported running out of food and being unable to afford more (Rogers, Ferguson, Ritchie, Van Den Boogaard, & Brimblecombe, 2018). In many remote communities, there is only one store to buy food from, and prices are exorbitant due to transport and access issues (Rogers et al., 2018). In some cases, price‐gouging is evident (Central Land Council, 2020). Because of food costing up to sixty per cent more in remote communities, many Aboriginal people prefer to travel to regional towns to do their shopping (Central Land Council, 2020). With biosecurity lockdowns in effect, this is no longer possible. COVID‐19 exacerbates food insecurity by unexpected increases in unemployment, halts in tourism and people being unable to leave their communities to hunt and participate in cultural determinants of health. This also demonstrates one of the unique differences globally among Indigenous populations in locking down communities. Within Australia, Indigenous Peoples have a history of being confined to designated areas called missions and reserves. This was government policy from approximately the 1890s to 1970s (Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS), 2019). In other global Indigenous populations, locking down has been a self‐determined process. Within Australia, the question of triggering episodes of post‐traumatic stress has arisen for those older Indigenous Peoples who still live on the missions and reserves. Being locked down again due to government intervention and legislation as they were up until the early 1970s in the state of Queensland is still in the lived experiences of a number of Indigenous Australians. Characteristics of crises like pandemics include a rapid increase in rape, sexual assault and violence (Peterman et al., 2020). Indigenous people worldwide are already at increased risk of family violence, a consequence of colonisation and historical trauma, (Wilson, Mikahere‐Hall, Sherwood, Cootes, & Jackson, 2019), with "prevalence rates of 57% and 80% found for lifetime violence among wāhine Māori" (women; Wilson et al., 2019, p. 15). “Aboriginal women [in Australia] are 32 times more likely to be hospitalised for family violence as non‐Aboriginal women” (Andrews, 2020, para. 3). In Canada, First Nations, Inuit and Métis women are two and half times more likely to experience violence than nonindigenous women (Klingspohn, 2018). In the National Inquiry into Missing and Murdered Indigenous Women and Girls (NIMMIWG) (2019) in Canada, the sexual and physical abuse and murder of Indigenous women and girls that have been ongoing for generations have been labelled genocide. Native American women sustain rates of violent victimisation (rape, sexual assault, robbery, aggravated assault and simple assault) at rates that are two times higher than African Americans, two and a half times that of Hispanics, two and a half times that of Caucasians, and four times that of Asians (Morgan & Oudekerk, 2019). The current COVID‐19 crisis has seen “reports from Australia, Brazil, China and the United States suggesting a sudden rise in violence against women and children” (Peterman et al., 2020, p. 3). Compounding the sudden increase in violence during a pandemic is the intersecting forms of stressors stemming from a sudden rise in economic, emotional and physical pressures; enforced proximity from lockdowns; and, reduced access to support systems, health care and first responders (Peterman et al., 2020). Pre‐existing trauma and stress are triggered during disasters, so there will also be a corresponding rise in harmful alcohol and substance abuse (Macauley, 2020). Families faced with the stressors associated with COVID‐19 may see violence occurring for the first time. These factors all culminate in Indigenous women and children affected by violence, no longer being able to enact the strategies they could take to keep themselves and their children safe. It will also be very difficult to seek help outside of their homes. The COVID‐19 crisis has seen unprecedented disruption to cultural practices and the normal relational and collective practices of Indigenous Peoples. This is detrimental as it has been empirically proven that the cultural determinants of health have an overwhelmingly positive impact on the health of Indigenous Peoples (Bourke et al., 2018). Many Aboriginal and Torres Strait Islander people in Australia travel frequently between communities to attend to Sorry Business (funerals and grieving; Department of Health, 2020a, 2020b). In the current environment of lockdowns and social distancing, Indigenous people are having difficulties reconciling coronavirus restrictions with their relationally based cultural obligations, with mourning taking precedence (Wainwright, 2020). Māori in Aotearoa have also been forced to reconsider how they undertake the cultural practices involved to farewell someone who passed away and how they support older people and those with high needs. Traditional greetings of hongi (pressing noses when greeting) and harirū (shaking hands) have a rāhui (temporary prohibition) suspending such practices that breach social distancing regulations (New Zealand Government, 2020a). Prepandemic, governments were already failing in their efforts to reduce the inequities in social determinants and health outcomes between Indigenous and nonindigenous citizens, and Indigenous Peoples are generally under‐resourced for responding to the current crisis. A 2019 report on health security across 195 countries found that the majority of countries were ill‐equipped to prevent, detect and respond to health emergencies (Nalabandian et al., 2019). For instance, it is estimated that there are only 100 ventilators available from Guatemala to Haiti (Burki, 2020). Furthermore, algorithms triaging access to intensive care facilities are likely to exclude Indigenous Peoples because of the co‐morbid conditions they may have. Indigenous Peoples are known to survive historical and contemporary adversities, demonstrating resourcefulness and resilience in adversity. Despite the marginalisation of Indigenous Peoples in countries’ COVID‐19 responses, Indigenous communities are instituting their own measures in the presence of universal approaches to managing not only the spread of COVID‐19 but in addressing the needs borne out of poverty, housing and food insecurity. In Aotearoa, Iwi (tribal nations) are distributing food parcels to older people who cannot leave their homes and whanau (Family) rather than expecting people to make their way to a food bank. In some more remote areas, Iwi are monitoring who comes and goes out of their rohe (Iwi region) with roadblocks. In Canada, First Nation populations are gathering their bundles for medicine, food, birthing and death, while developing innovative ways to protect themselves such as making their own protective facemasks (Wright, 2020). Although we and some allied media are reporting on these initiatives, information on strategies Indigenous Peoples have implemented during pandemics is not routinely collected or acknowledged (Zavaleta, 2020). To this date, despite known vulnerability and high mortality rates, little information related to the rates of COVID‐19 in Indigenous Peoples is obtainable. Even where testing is available, data are rarely disaggregated by ethnicity (United Nations, 2020). Yet data will be essential to understand the true impact of COVID‐19 on our communities, justify the demand for resources like food and personal protection equipment (PPE) and allow service access and delivery to ensure already existing inequities do not worsen further (Phelan, 2020). Indigenous communities across Canada are urging provincial and federal health leaders to disclose COVID statistics to their nations, reporting that these numbers will help nations prepare and respond appropriately to potential outbreaks. In Central America, statistical transparency among Indigenous groups related to previous pandemics and other health outcomes is lacking, further perpetuating the lack of Indigenous voice and increasing the health disparity gap (Babyar, 2019). Failure to recognise the differences in morbidity and mortality among Indigenous Peoples contributes to inequities. There is not only a lack of information sharing but the delay in funding to support nations, and the growing jurisdictional disputes over who will provide these services has once again been intensified in the response to COVID pandemic planning. If ever there was a time to acknowledge the need to collect accurate ethnicity data and disseminate adequate resources to address health disparities among Indigenous people globally, now is that time. The needs of Indigenous Peoples must be made visible and not subsumed instead, in generalised universal response strategies. In this editorial, we have drawn attention to the existing health and social justice inequities stemming from colonisation. We have discussed the devastating effects pandemics have on our health and capacity to practice culture which is our medicine. We have asked the reader to consider the desperate situation our Peoples face, but recognise the Indigenous‐led solutions that are being enacted. We demand our governments recognise that the harm and hurt and drastically increased morbidity and mortality in our communities during this pandemic are their legacies of failing to address historical and ongoing inequities. The cultural determinants of health must be recognised as the remedy and be built into health policy, practice and research. Going forward, data need to meticulously document the damage, naming us by our countries, our communities, our clans and our tribes. So that the next time disease sweeps our planet, we know our weaknesses, we know our strengths, and if more informed and empowered, we will prevail against the next neo colonial wave.

The objective of this study was to conduct a critical analysis of the social, environmental and health risk factors in the Mexican indigenous population in the context of the COVID-19 disease pandemic, and to propose strategies to mitigate the impacts on these communities. Regarding social factors, we identified the return of indigenous people to their communities, poor access to water, language barriers, and limited access to the Internet, as factors that will not allow them to take the minimum preventive measures against the disease. Additionally, environmental risk factors associated with pollutants from biomass burning were identified. In health, the lack of coverage in these areas and comorbidities such as diabetes mellitus, hypertension, respiratory tract infections, and chronic pulmonary diseases were identified. Some existing government programmes were identified that could be supported to address these social, environmental and health gaps. We believe that the best way to address these issues is to strengthen the health system with a community-based approach. Health is the best element of cohesion for inserting development and progress proposals in indigenous communities, given the vulnerability to which they are exposed in the face of the COVID-19 pandemic. In this review, all information is provided (as possible) on risk factors and potential solutions in indigenous communities in the hope of providing solutions to this pandemic and providing a reference for future studies.