A year ago, the federal Indian Health Service posted dozens of flyers on Facebook advertising flu and COVID-19 vaccination clinics across the Navajo Nation, which suffered a staggering toll from the pandemic just a few years ago.
The notices featured photos of smiling families and elders in traditional costumes and made a clear case for getting vaccinated, linking vaccination to tribal values such as community responsibility. “Vaccines are effective in preventing severe disease and hospitalization,” one of them said.
But this year, the IHS’s public message about the vaccine changed dramatically as Health and Human Services Secretary Robert F. Kennedy Jr., a vaccine critic, gave his stamp of approval for federal vaccination policy.
In internal emails obtained by ProPublica, IHS officials deemed terms such as “immunization” and “vaccine” dangerous “buzzwords” and flagged them for further scrutiny, and their use in social media posts, brochures and patient presentations would require approval from an agency spokesperson.
By mid-October, IHS had published far fewer posts promoting vaccine clinics on Facebook this year than last year, according to ProPublica. These posts and other notices replaced language touting the benefits of vaccination with language making both routine childhood immunizations and annual influenza and COVID-19 vaccinations personal choices, advising patients to talk to their health care providers about their “vaccine options.”
Current and former IHS physicians told ProPublica that the changes threaten vaccine access in Navajo communities and that health care workers serving the population feel censored.
“It seems to me that they’re trying to put up barriers,” said Harry Brown, a physician and epidemiologist who retired from IHS in 2016 and now works at a tribally run health facility in North Carolina. In his 26-year career at IHS, he said he has never encountered an effort to stifle a public health campaign or restrict health care providers from speaking publicly about vaccines.
Other than Brown, the health care workers who spoke to ProPublica did not want their names used because they feared their jobs could be at risk. One doctor said IHS’s new restrictions on vaccine-related speech were a factor in his decision to leave IHS this year.
“I can’t keep people safe,” she said in an interview shortly before her resignation. “I don’t have any more words to say what I want to say.”
Two 2024 Facebook posts from the Navajo Territory Indian Health Service emphasize the importance of vaccination. Navajo Indian Health Service via Facebook Recent posts from the Navajo Indian Health Service about COVID-19 vaccine availability use more subdued language and no color or appealing images. Navajo Indian Health Service via Facebook
The changes in vaccine messaging by IHS were not previously reported, but are consistent with widely publicized changes within the Department of Health and Human Services under President Kennedy’s leadership. Over the past 10 months, as measles cases have reached their highest levels in decades, President Kennedy has been tepid in supporting vaccines to prevent the disease, taking several steps that critics predict will undermine public confidence in the shot.
He launched a federal investigation into the scientific link between vaccinations and autism and canceled nearly $500 million in mRNA vaccine contracts and research grants. This technology was central to the rapid development of a COVID-19 vaccine.
In June, he fired all 17 members of the Advisory Committee on Immunization Practices, which advises the Centers for Disease Control and Prevention on vaccine policy, and replaced them with his own appointees, including several vaccine skeptics. Kennedy also supports the founders of the Idaho Health Freedom Movement, which helped persuade the state to ban vaccine mandates this year.
At IHS, the only branch of HHS that operates its own network of hospitals and clinics, clinicians said changes in federal policy on vaccine policy are having a more direct impact on patient care.
An HHS spokesperson said in a statement that the revised IHS public messaging materials are intended to encourage “shared decision-making” between patients and health care providers.
“The Indian Health Service continues to provide accurate, evidence-based information on vaccines and infectious disease prevention,” it said in a statement. “We remain focused on providing clear, trustworthy guidance to tribal communities and ensuring they have access to the care of their choice.”
The statement did not say what prompted the message refresh or concerns doctors had raised about the potential impact.
In a separate statement, Matthew Clark, IHS’ deputy chief medical officer, insisted that the agency’s approach to vaccinations remains consistent, even as messages about vaccinations have changed.
“We continue to advocate for every patient to receive the full range of FDA-approved and ACIP-recommended vaccines as appropriate,” Clark’s statement said.
It is not yet clear what impact this change will have. There are no publicly available data on Navajo Nation vaccination rates for influenza and COVID-19 this season. Through September, coverage of measles, mumps and rubella vaccine (known as MMR) for 2-year-olds remained stable at about 95%, the level of herd immunity needed to prevent an outbreak, according to IHS data.
Still, IHS clinicians say the agency’s lack of public messaging about vaccines was especially evident during the winter and spring, when a measles outbreak broke out in Texas and then neared the reservation border in New Mexico.
The outbreak has raised alarm. Tribal health facilities, which operate independently from IHS, posted a mass message on Facebook in late February about MMR vaccinations, urging residents to get themselves and their children vaccinated.
But two IHS physicians said the agency placed new restrictions on vaccine-related speech around the same time.
According to a March 13 email from Navajo Nation Hospital Public Information Officer Ryan Goldtooth to colleagues, members of the group were instructed to remove social media posts and flyers that included the terms “vaccine (i.e., measles)” and “immunization” from the agency’s Facebook page. The email said it “may not be forwarded or posted publicly.”
The email also states that the terms “immunization” and “vaccine” have been reclassified as “low to moderate risk.” As a result, if clinicians want to use these words in public presentations or printed materials, they must first get permission from a spokesperson, Goldtooth wrote.
The email listed several other topics and types of information that can no longer be freely shared or discussed publicly. The email said that starting the day President Donald Trump returned to office, all information shared by state health departments, for example, must be removed from Facebook, without giving a reason. All posts related to the executive order also had to be deleted.
Mr. Goldtooth, who still works for IHS, did not respond to requests for comment on the email.
Laura Hammitt, director of the Infectious Disease Program at the Center for Indigenous Health at the Johns Hopkins Bloomberg School of Public Health, has been working closely with IHS officials on vaccination efforts. Restricting what can be said about vaccines could hurt the ability to respond to future outbreaks, he said.
“People are trying to adhere to the changes mandated by the administration, but they also have a responsibility to care for patients,” Hammit said. “These two may seem contradictory.”
The Navajo Nation, the nation’s largest tribal jurisdiction with approximately 170,000 people, has long been a focus and challenge for IHS. The reservation is served by four of the agency’s 22 hospitals, but the 27,000-square-mile area, surrounded by mountains and high desert, lacks cell phone service, internet access, and electricity, creating obstacles for clinicians in communicating information and providing care.
These structural issues had a devastating impact early in the pandemic, when the reservation had the highest rates of COVID-19 infections, hospitalizations, and deaths in the country. The virus has claimed the lives of at least 2,300 Navajo people.
Over the past decade, Navajo vaccination rates, particularly MMR and influenza vaccination rates, have regularly exceeded national numbers. That rate also exceeds that of tribal communities in other areas served by IHS, which generally lags behind the national average, according to the agency’s data. When COVID-19 vaccines arrived in 2021, vaccination rates among Native Americans exceeded 60%, and IHS public service messaging and outreach strengthened that effort.
On the Navajo Nation, IHS hospitals posted messages on their Facebook page and distributed flyers urging community members to get vaccinated. “Protect yourself, protect your family, protect your elders,” the leaflet read. Tribal members arrived in droves and lined up in cars to get vaccinated at hospitals and clinics.
For people unable to travel to large towns on reservations with medical facilities, teams from IHS, tribes, and Johns Hopkins University set up mobile clinics and conducted home visits, especially in remote communities.
After the pandemic, IHS and Navajo tribal teams sought to extend the success of COVID-19 vaccinations to routine vaccines. MMR immunization rates for 2-year-olds have fallen to 85%, but another concerted effort has restored reservation communities to pre-pandemic levels.
Dr. Hammit of Johns Hopkins University said the IHS was the driving force behind the campaign. Government agency flyers and Facebook posts modified appeals used to promote COVID-19 vaccinations to support the MMR vaccine, calling on people to protect “future generations.”
But in the first months of this year, the message started to change again, with references to “measles” and “coronavirus” disappearing from IHS’ social media pages.
The weeks leading up to flu season and back-to-school season typically mark the beginning of a robust vaccination campaign at IHS hospitals. But this year, doctors noted little notice, as New Mexico continues to battle a measles outbreak that started in Texas and the Navajo Nation saw a spike in COVID-19 cases in late summer.
One exception was in May, when IHS officials shared on Facebook a New Mexico Department of Health alert that measles had reached Sandoval County, which overlaps the eastern side of the Navajo Reservation. Such was the case that same month, when IHS Hospital in the town of Gallup, New Mexico, announced a clinic for people seeking measles vaccinations.
IHS Hospital in Shiprock, New Mexico, was the only facility to post a public service announcement regarding back-to-school vaccine clinics for children. It includes language asking patients to talk to their doctors about their options and did not specifically mention measles, COVID-19 or other infectious diseases, as in previous announcements.
In mid-August, another measles outbreak surfaced in the Southwest, this time just west of the Navajo Nation along the Arizona-Utah border. In early November, the number of cases had increased to at least 200, according to health officials in Arizona and Utah. IHS did not issue any advisories or notifications on Facebook regarding this outbreak. Clinicians who spoke to ProPublica said the new approval process for green-lighting public health warnings has slowed the response of local governments and hospitals.
Several clinicians said the restrictions on vaccine-related speech would change the IHS doctor-patient relationship, even though it only applied to public communications and not one-on-one consultations.
“This is what we do for a living, and the most important thing we do is explain to patients what’s going on,” one doctor said. “When you have external agencies interfering with that, as we do now, you are creating a fundamental trust between patients and the people who are trying to provide care for them.”
