A demonstrator stands outside the Wisconsin State Capitol in Madison, Wisc., in 2022 to commemorate missing and murdered Indigenous women and girls. Researchers have launched a new survey to determine the prevalence of brain injuries in Native survivors of sexual assault and domestic violence. (Photo by Stacy Revere/Getty Images)

Abigail Echo-Hawk, director of the Urban Indian Health Institute, recalled a Native mother in her 30s who started having memory loss and other dementia-like symptoms.

The woman had suffered multiple blows to her head and falls at the hands of her husband over the years. He had wanted to disable her, to make it more difficult for her to keep her children if she tried to leave him, Echo-Hawk said.

Many Native women have traumatic brain injury symptoms as a direct result of abuse, Echo-Hawk said. Tribal health advocates and groups serving survivors have long been aware of the problem, she said, but there has been little national research documenting the extent of it.

“It’s a very difficult thing to see,” said Echo-Hawk, of the Pawnee Nation of Oklahoma. “This is a pressing concern.”

The Urban Indian Health Institute, an Indigenous health research group, this month launched a first-of-its-kind national survey of American Indian, Alaska Native and Native Hawaiian women to determine the prevalence of brain injuries in Native survivors of sexual assault and domestic violence. The goal is to illuminate the extent of the problem, guide clinicians, raise public awareness and direct resources.

A 2015 study in Arizona found a higher incidence of traumatic brain injuries in Native women in that state, but the new survey is the first national, Indigenous-led study of its kind, according to the institute.

It comes as domestic violence groups across the nation are struggling with federal funding delays caused by the government shutdown. As the impasse continues, the Trump administration has furloughed grant workers at the Office on Violence Against Women, which is part of the U.S. Department of Justice.

Traumatic brain injuries can cause memory loss, confusion and long-term behavioral changes and raise the risk of dementia. Some abusers intentionally inflict traumatic brain injuries on their victims because it doesn’t leave visible bruises, according to the Brain Injury Association of America.

The link between domestic violence and traumatic brain injuries has been documented in women generally, and the effects of such injuries have been studied in former football players and veterans. But research on Native communities is lacking. Even when victims show up in ERs, their cases can go underreported.

In a previous survey of survivors, some Native women reported broken teeth, evidence of blows to the head, Echo-Hawk said. But pushing and strangulation also can cause traumatic brain injuries.

Violence is a public health crisis among American Indian, Alaska Native and Native Hawaiian women, who are overrepresented in intimate partner violence statistics. Fifty-five percent report experiencing intimate partner violence, and a disproportionate number of Native women and girls are murdered or go missing.

In a 2020 survey by the federal Centers for Disease Control and Prevention, nearly 44% of American Indian and Alaska Native women reported being raped in their lifetime.

“People are losing their children because of memory loss and dementia,” Echo-Hawk said. “When people are experiencing intimate partner violence, they end up in ERs. Their children suffer. The whole community suffers as a direct result. And the same with the crisis of missing and murdered Indigenous women and girls.”

Doctors and other hospital staff should receive more training on brain injuries and should know which communities are most likely to experience violence, said Nikki Cristobal, policy and research specialist for Pouhana ʻO Nā Wāhine, a nonprofit domestic violence resource center for Native Hawaiians.

Cristobal said one survivor told her clinicians hadn’t performed a brain scan or traumatic brain injury assessment on her, despite her ongoing psychological and cognitive symptoms. “It never occurred to anybody,” she said.

“We have to talk more about it,” said Cristobal, who worked with Echo-Hawk on developing the survey and is the principal investigator for the Missing and Murdered Native Hawaiian Women, Girls and Mahu state task force.

Native communities, including Native Hawaiians, have endured long-term, intergenerational traumas during colonization and forced assimilation that can’t be ignored when targeting the disproportionate rates of violence, Cristobal said.

“It’s the undercurrent,” Cristobal said. “It’s the precursor.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

An emergency room nurse tends to a patient at Houston Methodist The Woodlands Hospital in Texas. States, counties and nonprofits are striving to continue their work to close racial health disparity gaps but are struggling amid a loss of federal dollars. (Photo by Brandon Bell/Getty Images)

Racial health disparities may widen as states, universities and nonprofits grapple with federal funding cuts to programs that were aimed at filling gaps in care, public health experts say.

As part of its federal restructuring and crackdown on diversity, equity and inclusion (DEI) programs, the Trump administration has been shuttering federal offices and rescinding grants dedicated to addressing worse health care access and outcomes for racial minorities.

The shake-up has caused some state agencies and nonprofits to pause programs and some groups and universities to apply for foundation grants instead.

Hundreds of grants have been terminated for state, local and territorial health departments as well as nonprofits and universities, many of which addressed health equity across rural, low-income and communities of color.

The nation’s racial health disparities were laid bare during the COVID-19 pandemic, when the virus killed Black, Hispanic and Indigenous people at higher rates than white people. The police murder of George Floyd in May 2020 also fueled a racial reckoning across the nation, prompting efforts by states, universities, health systems and the federal government to address racial health disparities.

Those approaches ranged from targeted vaccine campaigns and efforts to enroll more people of color in clinical trials to corrections of diagnostic tests that relied on inaccurate information about race and biology.

Communities of color have long had less access to health care, increased exposure to environmental pollutants and higher rates of certain chronic illnesses and cancer deaths. They also have more diabetes-related amputations because of a lack of access to care. And specific genetic diseases, such as sickle cell disease, disproportionately affect Black people.

“COVID revealed the impact of health disparities to individual health — as well as how not addressing these disparities undermines the health system for everyone,” said Dr. Georges Benjamin, executive director of the American Public Health Association.

Now, many of the programs trying to address health disparities are being rolled back.

As a result, health policy experts, clinicians and researchers fear those disparities will widen as states, universities and nonprofits grapple with lost federal dollars while the administration continues to limit federal funding for DEI programs. In July, the U.S. Department of Justice released guidance saying such initiatives should not receive federal funding, alleging they are “discriminatory.”

Entities that receive federal funds “must ensure that their programs and activities comply with federal law and do not discriminate on the basis of race, color, national origin, sex, religion, or other protected characteristics—no matter the program’s labels, objectives, or intentions,” the news release said.

Several state and local health officials were reluctant to speak with Stateline on the record about how the federal administration’s DEI crackdown has left them in a bind, fearing retaliation or targeting by the federal government. The White House did not respond to Stateline’s request for comment.

“My concern about what the administration is doing is that they are, in effect, making these disparities worse,” Benjamin said. “Everybody’s health is not the same. … It’s important to know that the disparities are really profound.”

Benjamin added that the cumulative effect of disparities means more late-stage disease — costing both patients and health systems more.

“There’s a trope or misunderstanding out there that DEI is a ‘woke’-related agenda. DEI is not a ‘woke’ agenda. DEI is an American agenda, because it’s really one that is the same thing as ‘rising tides lift all boats,’” said Brandon Wilson, senior director of Health Innovation and Public Health at Community Catalyst, a health equity advocacy organization. “When you cut [resources] off, you’re actually disproportionately impacting those who are already impacted.”

‘Increasing need’

The administration canceled billions of dollars in grants from the National Institutes of Health (NIH), the Centers for Disease Control and Prevention, the Environmental Protection Agency and the Department of Health and Human Services.

Many of the grants helped recipients create solutions tailored to their communities’ needs and strengths.

At least three dozen state, local and territorial health departments have had pandemic-era grants that addressed health equity terminated. While originally focused on COVID-19, agencies have since used that grant money for other public health efforts: testing and contact tracing for a wide range of diseases, better data reporting, and community partnerships that address social and environmental effects on health.

The money was part of a $2.2 billion national health equity initiative that aimed to address vulnerabilities and protect those communities ahead of the next outbreak.

The Department of Health and Human Services told media such cancellations were due to the pandemic emergency ending in 2023.

At NIH, the administration terminated more than 5,400 NIH research grants, although about 2,800 were reinstated. Canceled grants included research toward illnesses like HIV and AIDS, which disproportionately affect Black and Hispanic people as well as gay and transgender people.

The Trump administration has also gutted federal offices dedicated to fighting disparities, including the Offices of Minority Health under the Centers for Medicare & Medicaid Services and the Department of Health and Human Services.

At the state level, the Arkansas Department of Health recently shut down its own minority health-focused office. Ashley Whitlow, a spokesperson for the department, said in a statement that it “relies on federal grant funding to support a variety of public health programs.”

“The recent reduction in program staff reflects the Arkansas Department of Health’s ongoing efforts to operate more efficiently with the resources available. Despite these changes, ADH remains fully committed to serving communities across the state,” the statement said.

Meanwhile, Maryland’s Department of Health said its minority health office is funded through state general funds and not directly impacted by the federal cuts.

The nation has seen a spike in congenital syphilis cases, which disproportionately occur among Black and Indigenous families.

“Regardless of whether you’re at the highest risk, any outbreak that’s not controlled can spread widely and broadly, and you can see that that’s what’s happening with measles,” said Dr. Julie Morita, former executive vice president of the Robert Wood Johnson Foundation and former health commissioner Chicago Department of Public Health.

But states likely can’t replace all the lost federal dollars.

“You’ve got declining capacity, and increasing need — which is a formula for problems,” said Richard Frank, director of the Brookings Institution Center on Health Policy.

“It’s impossible to make all that up with state and local dollars,” he continued. “You’re going to see programs that serve real people getting pulled back.”

Frank and Wilson also expressed concern about the Medicaid changes included in the broad tax and spending law President Donald Trump signed in July. The law is projected to cut federal Medicaid spending by an estimated $911 billion over the next decade, largely because new work requirements will push people off the rolls. Data shows the majority of Medicaid enrollees already work, and experts say many will be kicked off the rolls due to difficulties in states’ reporting processes. Black and Hispanic people are disproportionately represented on the Medicaid rolls.

OB-GYN Dr. Versha Pleasant, a clinical assistant professor at the University of Michigan, directs the Cancer Genetics and Breast Health Clinic at Von Voigtlander Women’s Hospital. She treats patients at high risk for breast and ovarian cancers. Black women have an almost 40% higher risk of death from breast cancer than white women.

“That, to me, is unacceptable,” she said, adding that such disparities speak to the need for ongoing programs to “provide everyone with a fair chance at leading a long and healthy life.”

“If we don’t make a special effort to save the most vulnerable lives … where does that leave us?” she continued. “The changes that we’re seeing are only going to magnify preexisting challenges.”

Data and dollars

Dr. Sarah Rudman, acting public health officer at the Santa Clara County Public Health Department in California, and others have told Stateline that federal officials are informing health agencies that race and ethnicity data are no longer required to be reported.

“We are being asked to change the way we collect our own data here and report it,” Rudman said, adding that her county is going to continue collecting data to “understand who is here, who’s experiencing what health outcome and what they need.”

Many families, in the shadow of the county’s Silicon Valley, still struggle with poverty — more than 27,000 children suffer food insecurity, United Way Bay Area says.

“It is sometimes surprising and striking to people to understand how much poverty and other types of vulnerability are hidden among the more visible wealth of Silicon Valley, and that’s where we’ve dedicated our resources,” Rudman said.

“It’s hard to even imagine what my colleagues in smaller areas of California or in other parts of the country are experiencing,” she added about lower-income counties. “We are feeling extremely strained and already in our second round of layoffs, knowing that many more are likely. So I think that the hits are going to be that much more significant in areas who have less resources than we do.”

Federal officials also canceled the county’s $5.7 million grant to address COVID-19-related disparities, used to shore up vulnerable communities ahead of the next disease outbreak, natural disaster or heat wave, Rudman said. The money helped the county conduct basic laboratory testing and vaccine outreach for a wide range of diseases, not just COVID-19.

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.