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American Indians and Alaska Natives (AI/ANs) experienced some of the highest rates of COVID-19 disease and death in the United States1,2: an estimated 1 in 475 AI/ANs have died from COVID-19, in contrast to 1 in 825 White Americans.3 Infectious diseases have caused catastrophic losses among Indigenous populations since the first contact with Europeans; the distribution of smallpox-infected blankets by colonizers and federal officials is the earliest documentation of germ warfare and remains a devastating memory.4,5 The disproportionate impact of COVID-19 in AI/AN communities is a result of historically rooted systems of colonization, oppression, and marginalization.6 High rates of poverty, lack of running water, inadequate access to healthy food and transportation, poor indoor air quality, and overcrowded housing have all contributed to increased risk from COVID-19, especially on tribal reservations. Lack of electricity, Internet, and cell service, and inadequate infrastructure also created barriers to sharing prevention guidance, access to telemedicine, and health education. Chronic underfunding of the Indian Health Service resulted in insufficient resources and capacity to care for COVID-19 patients; many had to be transported off reservations to regional hospitals. High rates of underlying chronic health conditions, particularly those that contribute to more severe outcomes-including diabetes, heart disease, and lung disease, which are driven by these same social determinants-exacerbated the effects of COVID-19. Public health surveillance during COVID-19 has also failed at times to appropriately count and consider AI/ANs, an issue deemed \"data genocide.\" Despite these challenges, the COVID-19 vaccination efforts in many AI/AN communities have been major successes; AI/ANs have the highest COVID-19 vaccination rate of any racial or ethnic group in the country (Figure 1). How can this success inform the ongoing implementation of vaccination efforts elsewhere? We draw from four decades of work in partnership with tribes to outline several key lessons. Ultimately, we argue that the COVID-19 vaccination effort in AI/AN communities has been successful because it was nurtured at its roots by a deep well of community strength and by respect for tribal sovereignty.

The Indian Health Service (IHS) faces severe workforce shortages due to underfunding and underdevelopment of clinical training programs. Unlike other direct federal health care systems that have implemented clinical training paradigms as central parts of their success, the IHS has no formalized process for developing such programs internally or in partnership with academic institutions. While the Indian Health Care Improvement Act (IHCIA) authorizes mechanisms by which the IHS can support overall workforce development, a critical portion of the act (U.S. Code 1616p) intended for developing clinical training programs within the agency remains unfunded. Here, we review the funding challenges of the IHCIA, as well as its authorized and funded workforce development programs that have only partially addressed workforce shortages. We propose that through additional funding to 1616p, the IHS could implement clinical training programs needed to prepare a larger workforce more capable of meeting the needs of American Indian/Alaska Native communities.

The state attorney general's office said it is illegal to use taxpayer money to pay these legal fees. There is no money in the budget for home health care for the aged; no money for services to handicapped children; no money for services to taxpayers who are paying legal fees of over $$@$!100,000 so far.