Why the Navajo Nation was hit so hard by coronavirus: Understanding the disproportionate impact of the COVID-19 pandemic

Abstract

The COVID-19 (SARS-CoV-2) pandemic of 2019–2020 has incurred astonishing social and economic costs in the United States (US) and worldwide. Native American reservations, representing a unique geography, have been hit much harder than other parts of the country. This study seeks to understand the reasons for the disproportionate impact of the pandemic on Native American communities by focusing on the Navajo Nation – the largest Native American reservation in the US. I first reviewed the historical pandemics experienced by Native Americans. Guided by the literature review, an institutional analysis focusing on the Navajo Nation suggests a lack of both institutional resilience and healthcare preparation. The analysis further identified four factors that could help explain the Navajo's slow response to the COVID-19 pandemic: prevalence of underlying chronic health conditions, lack of institutional resilience, the relationship between the federal government and tribal governments, and lack of social trust. Relevant policy implications are discussed. For instance, to better prepare Native American communities for shocking events like the COVID-19 pandemic in the future, policymaking should integrate informal institutions to build efficient formal institutions for self-governance. Promoting public health education and establishing collaborations between Native and non-Native communities are also necessary long-run strategies.

1. Introduction

Since March 2020, the coronavirus SARS-CoV-2 (COVID-19) has quickly spread across the United States (US) and the world. By the end of summer 2020, several regions had been hit particularly hard as the pandemic expanded, including Washington, New York, California, and Florida in terms of the total positive cases reported. By early December 2020, many states across the country saw an escalating number of positive cases. The total number of coronavirus cases in the US reached 15 million, with a death toll of close to 300,000. As several vaccines became available from the beginning of 2021, both the daily new positive cases and deaths have been declining as the vaccination rolls out across the country. As of this writing (July 2021), the COVID-19 pandemic has not been under effective control due to new coronavirus variants (e.g., Delta variant) and stagnating vaccination rates (Bekiempis, 2021). Both the total positive cases and deaths doubled from the December 2020 statistics. Based on some preliminary estimates, the total economic cost of the COVID-19 pandemic can be as high as US$16 trillion, which is more than three-quarters of the US annual GDP (Cutler & Summers, 2020). According to a more recent study by Chen et al. (2021), published in late May 2021, the total burden of the pandemic will be between US$17 and 94 trillion over the next decade in the US. Behind all the shocking numbers and estimates, there seem to be very few questions asked about one unique geography – the Native American reservations. According to the 2010 US Decennial Census, 5.2 million people (1.7 % of the US population) self-identified as American Indian or Alaska Native scattered across over 500 federally recognized tribes. Steckel and Prince (2001) once commented in their economic history study: “… … Fortunately for European-Americans, they rarely had to test their system of production and distribution against the kinds of demographic disasters faced by Plains tribes.” The COVID-19 pandemic has put the system under a tough test.

In spite of their low-density population and remoteness, Native Americans have been hit much harder by the COVID-19 pandemic than the US white population, according to a US CDC (Centers for Disease Control and Prevention) report (Hatcher et al., 2020). Based on data collected from 23 states, the cumulative COVID-19 incidence rate among American Indians (and Alaska Natives) was 3.5 times that among non-Hispanic white persons. According to the statistics compiled by Johns Hopkins University (https://coronavirus.jhu.edu/us-map), McKinley County (New Mexico) had 5515 positive cases per 100,000 residents as of July 14, 2020. It was the highest per-capita cases in the country. By the first week of December 2020, the number nearly doubled. Neighboring Navajo County and Apache County in Arizona were also among the top 10 counties nationwide in terms of per-capita cases. All three counties are mostly located in the Navajo Nation (with the Hopi reservation in the middle) – the largest Native American reservation in the US. The reservation covers approximately 70,000 square km² (more than the states of Connecticut, Massachusetts, New Hampshire, and Rhode Island combined), but only with a population of 156,823 living on the reservation as of the 2010 US Census.1 As Fig. 1 shows, the reported positive COVID-19 cases were already more than 10 % of the Navajo Nation residents by the end of November 2020, which is significantly higher than the US national average (about 4 % at the same time). Based on our common knowledge of epidemic diseases, a low-density population is more resistant to disease spread. So why has the Navajo Nation been hit so hard by the pandemic? The existing research focuses mainly on documenting the epidemic facts and studying the general population (e.g., Dyer, 2020; Laurencin & McClinton, 2020, van Dorn et al., 2020). No in-depth analysis has explored the pandemic situation and its causes and impacts in Native American communities. This study seeks to understand the disproportionate impact of the COVID-19 pandemic by looking into the Navajo Nation and its healthcare system, institutions, and related factors.

Fig. 1.

The reported COVID-19 positive cases on the Navajo Nation from March 2020 to November 2020 (the first two waves of the pandemic)

Data source: Compiled from the data reported by the Navajo Nation Department of Health; https://www.ndoh.navajo-nsn.gov/COVID-19/Data, accessed on Jul 23, 2021. Note: The highest daily case count was reached on Nov 21, 2020 (401 cases), based on data up to Jul 21, 2021.

The literature has found that health disparities between indigenous and non-indigenous people persist worldwide (e.g., Leeuw et al., 2012). In this study, I ask the specific question of what is causing the severity of the COVID-19 pandemic in the Navajo Nation. Is it the lack of institutional resilience and healthcare resources, or other factors?2 The Navajo Nation sits around the four-corner region and is located mainly in the state of New Mexico and Arizona's remote areas (Fig. 2 ). There is no metropolitan area inside the reservation. As Fig. 2 shows, several small to medium-size cities are around the reservation. Large metropolitan areas like Albuquerque and Phoenix are hundreds of miles away. Its location and geographical layout give rise to the first hypothesis that the inadequacy of healthcare resources has resulted in slow responses to the pandemic. As early as April 2020, the Navajo Nation instituted the country's most extensive and restrictive lockdown orders, but underfunded infrastructure and lack of access to basic needs have worked against the efforts (Baek, 2020). It leads to questions about the unique legal relationship between the US federal government and Native American tribes. The federal-tribal relationship is a complicated result of history, culture, and traditions. This suggests another hypothesis that the lack of institutional resilience explains the situation, which requires us to examine the institutional environment (formal and informal institutions and their interactions, see footnote 5 for definitions of formal and informal institutions) of the Navajo Nation. Or simply, people are not following public health recommendations due to social norms? In the following sections, I first review the history of public health pandemics with a focus on Native American tribes. I then analyze the institutional environment of the Navajo Nation and explore factors behind the severity of the pandemic. Methodologically, I synthesize a multi-disciplinary literature review, anecdotal evidence, and conversations with Navajo scholars.3 The choice of the methodology considers the limitations of collecting individual/household-level data on the reservation. I conclude the paper by discussing the policy implications of my findings and highlighting the suggestions for moving forward. This study contributes to the broad literature on indigenous geography (Butzer, 1992; Larsen & Johnson, 2012).

Fig. 2.

The map of Navajo Nation agencies and major nearby cities. Data sources: GIS shapefiles are provided by the Navajo Nation Land Department. All city locations indicate the coordinates of the city hall or city council based on Google Maps.

2. Background and literature review

The COVID-19 pandemic is not the first pandemic that the Navajo Nation and other Native American tribes have faced. And it is unlikely to be the last one. If we look through the history of pandemic shocks by exploring the literature, the pandemics that Native Americans have survived since the first contact with Europeans can be broadly categorized into two: internally emerged pandemics and exogenously imported pandemics. The difference between the two is not always clear. In general, internally emerged pandemics are more likely to be chronic pandemics, such as opioid addiction and obesity. Of course, certain external factors can influence the spread and severity of these chronic pandemics. Exogenously imported pandemics, on the other hand, tend to be more swift, such as the diphtheria pandemic of 1801 in California, the Influenza pandemics, and the COVID-19 pandemic.

Among Native American communities, the most consequential chronic pandemics include drug disorder (opioid pandemic), alcohol problems, obesity, diabetes, and hypertension (e.g., Broussard et al., 1995; Frank et al., 2000; Jernigan et al., 2020; McLaughlin, 2010; Wiedman, 2012). Earlier studies also suggest that HIV/AIDS has been another pandemic faced by some Native American communities (Campbell, 1989; Hamill & Dickey, 2005; Nebelkopf & King, 2003). These chronic pandemics can take a toll on the labor force on top of those already sluggish tribal economies. It also puts additional stress on the underfunded tribal healthcare system.

The reasons for the prevalence of these chronic health problems in Native American communities range from biological reasons to cultural & socio-economic environments (Wiedman, 2012). Several previous studies have explored the biological reasons (e.g., Broussard et al., 1995; Frank et al., 2000; Wiedman, 2012). For instance, one hypothesis related to obesity is that Native Americans have a genetic predisposition to obesity when exposed to the modern environment of high calorie food and low body energy consumption (Broussard et al., 1995). Other research has suggested alternatives to the biological response hypothesis. For instance, studies have shown that physical activities play a significant role in preventing obesity among Native Americans (e.g., Esparza et al., 2000; Stevens et al., 2004). However, socio-economic factors are believed to be more relevant to the prevalence of chronic conditions. First, lagging socio-economic conditions link to “diseases of poverty” (or infections of poverty in some studies). Hotez (2008) summarized some of the common diseases of poverty among tribes in the US West, including Navajo. Second, Native American tribes, including the Navajo Nation, face much higher transaction costs in economic development than their non-Native counterparts (Yonk et al., 2017; Lofthouse, 2019). One of the consequences is the underinvestment in healthcare and lack of employer-sponsored health insurance.4 Meanwhile, the complicated relationship between the federal government and tribal governments leads to underfunded public health facilities and other infrastructure necessary to maintain and improve the quality of life (Tipps 2018). Feir and Akee (2019)'s study of the First Nations in Canada suggests that the nutrition and health conditions of Native Indians have rarely changed in the last several decades.

To prevent and eradicate these internally emerged chronic pandemics, informal and formal institutions need to work integratively.5 The traditional Native American culture and belief systems, which show a great amount of heterogeneity across hundreds of federally recognized tribes, value peoplehood and tend to be receptive to health interventions (Broussard et al., 1995; Plough et al., 2011; Lerma, 2014).6 Castillo (1999) found that Native Americans’ adherence to their traditional belief patterns has been robust. They did not simply abandon their belief systems and become Christian but have maintained their cultural diversity, for instance, through traditional storytelling (Grandbois & Sanders, 2012). It suggests that Native Americans have built-in resilience in terms of informal institutions and culture.7 Institutional resilience is critical in healthcare systems and recovering from a public health pandemic (Carthey et al., 2001; Wu et al., 2020). When designing public health interventions, institutional resilience should be channeled and utilized instead of being suppressed or ignored (Dufrene et al, 1992). One example is the Wellness Courts program adopted by several tribal groups across the US (Tipps et al., 2018). It has been a successful institutional innovation of the healthcare systems for some tribal groups.

Meanwhile, a thorough understanding of these chronic pandemics is essential. As we will further explore in the following sections, an important reason why some Native American communities were hit hard by exogenously imported pandemics is the prevalence of underlying conditions. The current COVID-19 pandemic suggests that this is not a problem unique to Native Americans. People with underlying conditions are more vulnerable to coronavirus. However, it is worth noting that Native American communities usually have a significantly higher prevalence of chronic diseases (La Ruche et al., 2009; McLaughlin, 2010), which makes them more vulnerable to exogenously imported pandemics like H1N1 virus (influenza) and coronavirus (COVID-19). Most Native Americans with chronic illnesses are a collateral result of the prevailing chronic pandemics.

The exogenously imported pandemics in Native American tribes date back to the sixteenth to the seventeenth century. Historically, especially in the pre-Columbian era, most Native Americans had a nutrition advantage (Steckel & Prince, 2001). However, this nutrition advantage has gradually disappeared since the first contact with Europeans. From the sixteenth through the twentieth century, according to Campbell (1989), Native Americans had experienced more than several detrimental epidemics such as smallpox, rubella, influenza, malaria, yellow fever, and cholera. All these diseases appeared after the first contact with Europeans and followed the expansion of the frontier. During the first contact period that lasted over two centuries, many diseases with common cures in Europe became exogenously imported pandemics as the frontier expanded across the American continent. Castillo (1999) presented an in-depth study about the diphtheria pandemic of 1801 among Tongva and Chumash tribes in Southern California. The traditional belief systems and social norms of these tribes played a critical role in their fight against the pandemic. Pre-Columbian historical evidence also suggests that Native Americans are vulnerable to infectious diseases – something that can easily be imported by outsiders (Martin & Goodman, 2002). It is worth noting that such a vulnerability is not unique to American Indians. It has been observed globally as the global transport networks expanded in the past several centuries (Tatem et al., 2006).

Another exogenously imported pandemic that significantly affected Native Americans was the 1918–1920 Influenza pandemic. According to Dahal et al. (2018), there was a significant decline in the number of births occurring 9–11 months after peak pandemic mortality in Northern Arizona counties where Native Americans, including the Navajo people, have lived for centuries. A similar case, but well-documented, was the recent Influenza H1N1 pandemic in 2009. The literature identified two key factors that affected the pandemic interventions: (1) The prevalence of underlying health conditions; (2) the cultural, social, and economic barriers to adoption of pandemic interventions (e.g., Hutchins et al., 2009; La Ruche et al., 2009). A US CDC report indicated that American Indians/Alaska Natives had an H1N1 mortality rate four times higher than all other racial/ethnic populations combined (US CDC 2009).

From the literature on historical pandemics that were exogenously imported into Native American communities, we can seek a better understanding of the disproportionate impact of the COVID-19 pandemic on them. For instance, one thing is clear – pandemic vulnerability directly relates to the institutional environment of Native American reservations and their institutional resilience (Groom et al., 2009; La Ruche et al., 2009; McLafferty, 2010; Tipps et al., 2018; Wiedman, 2012). This study focuses on the Navajo Nation – the largest Native American reservation in North America. In particular, I analyze its institutional environment and related factors to understand how it presents both challenges and opportunities for Navajo people when facing exogenously imported pandemics like the COVID-19. The analysis considers both dimensions of its institutional environment: informal institutions and formal institutions (and their interactions). The goal is to unpack the current public health situation under the COVID-19 pandemic and shed light on how to better prepare for similar shocking events in the future.

3. The institutional environment of the Navajo Nation

3.1. Informal institutions

Before Europeans arrived, Native American tribes lived mainly under the governance of informal institutions. Even though there were certain types of formal institutions established by some tribes (e.g., private property rights, see Miller (2018)), the formal institutions only started playing active roles after the treaty-making between sovereign Indian tribes and the US government.8 Informal institutions have been playing essential roles in the social-economic life of Native Americans, which in turn shapes their public health conditions (Plough et al., 2011). Navajo's informal institutions are notable in social norms and networks. They are passed on to generations mainly through storytelling and ceremonies. Storytelling is an effective and critical way for Navajos to sustain cultural history, language, social customs, and knowledge systems (Iseke, 2013; Sage, 2019). Their informal institutions have two key characteristics: Peoplehood and connection to nature. Holm et al. (2003) argued that peoplehood in Native American culture explains why colonialism failed to destroy the Diné (Navajo People)'s traditional institutions of governance. A qualitative comparative analysis of Navajo history by Lerma (2014) suggests that between the first contact and 1923, the impact of colonial strategies on the elimination of traditional Diné institutions was minimal. Feir and Gillezeau (2018)'s study of unemployment of Native Americans during the Great Recession also suggests that relying on peoplehood is an important social trait of the Navajo people. Language is a good example to contextualize the importance of peoplehood for Navajo. Language is one of the four building elements of peoplehood (Holm et al., 2003). A Navajo member is expected to speak their own language. In practice, not every Navajo member can speak the Navajo language (also known as Diné Bizaad). But it is a shared expectation, which fits the conceptual framework of informal institutions by Helmke and Levitsky (2004). The Navajo language is also the fundamental medium of storytelling that sustains Navajo's cultural history and social norms.

The connection to nature is a common element of Native Americans' culture and belief systems. It was documented in detail by Castillo (1999) when discussing the Tongva and Chumash tribes in Southern California. Even nowadays, the strength of connecting to nature is reflected in the Navajo Nation's Climate Adaptation Plan (Navajo Nation Department of Fish and Wildlife, 2018). Such a robust integrant of their informal institutions is also revealed in their attitude towards energy and natural resources development. For example, Necefer et al. (2015) found that Navajo people attach significant importance to environmental preservation, not only for the sustainability of future generations but also for the viability of their culture and identity that have supported environment and natural resource stewardship for centuries.

However, their informal institutions have faced challenges. For instance, the lack of social trust with the surrounding non-Native communities has been an invisible barrier. Social trust is not necessarily in the realm of informal institutions, but informal institutions affect social trust.9 As an indispensable part of social capital, social trust builds on social norms and expected behaviors (Jensen & Svendsen, 2016). The recent Days Inn incident between Alamo Navajo Reservation (a non-contiguous branch of the Navajo Nation) and the City of Socorro in New Mexico suggests that the lack of social trust with the non-Native communities may have slowed them down in managing the COVID-19 pandemic.10 Such challenges to Navajo's informal institutions have also increased the transaction costs in other aspects of their socio-economic life. For example, Cattaneo and Feir (2019) showed that Native Americans face an average interest rate of nearly two percentage points above the average loan for non-Native Americans in the mortgage loan market. Such an elevated risk premium not only reflects discrimination in the financial markets but also suggests a deeply rooted lack of social trust between Native American communities and the non-Native communities.

Another challenge to the Navajo informal institutions is that many public health recommendations from the federal agencies and local organizations (e.g., large healthcare providers) during the pandemic are not customized. For example, a generic 6 or 12-feet social distancing recommendation may not be consistent with some of the important Navajo social norms like attending seasonal tribal ceremonies. A more customized and balanced (between disease prevention and social norms) social distancing recommendation could prevent people from ignoring the universal social distancing recommendation from the CDC. A related example concerns the face covering recommendation. A generic message like ‘get your mask’ or ‘wear your mask’ does not work for many Navajo residents who already lack public health education. Because it takes them several hours of driving to go to the nearest chain store like Walmart to get supplies, and many do not have internet access to place an online order (and this already assumes that they have a credit/debit card). A customized message like ‘make your own mask and here is how’ is much more effective.

3.2. Formal institutions

Historically, Navajo people have struggled in building effective formal institutions relative to their success in sustaining strong informal institutions. One way to understand this is by looking at the Navajo Nation's path to promoting economic growth. Despite their unique culture and way of life, Navajo people have been seeking changes, if not revolutions, to be part of the modern economy as American Indian history scholar Peter Iverson depicts in his book:

“At the time of the 1970 [Navajo Nation chairman] race, [Peter] MacDonald represented a new face, with the promise of a new way of doing things. Well known throughout the reservation because of his work with the Office of Navajo Economic Opportunity, he obtained the support both of more traditional Navajos and of younger Navajos looking for a chairman who understood the old ways and yet could meet the Anglo world on more equal terms.”

- from <The Navajo Nation> (Iverson, 1981; Page xv)

During this process of seeking change, the role of formal institutions becomes more and more important. In the past several decades, the local governance institutions of the Navajo Nation have become increasingly relevant to its economic development and the improvement of its social safety net. It became even clear after the federal government released much responsibility for reservation governance from the Bureau of Indian Affairs (BIA) to the tribal governments in the 1980s (Dippel, 2014). The process of rebuilding and enhancing self-governance has proved difficult, which affects economic development and has consequences for Navajo's healthcare system today (Spirling, 2012; Dippel, 2014). According to the literature on Native American economic development and entrepreneurship, some of the main weaknesses of Native Americans' formal institutions include ambiguity in property rights, heavy reliance on federal grants and aids, dual bureaucracy, tax complexity, financial discrimination, etc. (Yonk et al., 2017; Lofthouse, 2019; Cattaneo & Feir, 2019). The weaknesses in formal institutions that contribute directly to the poor public health conditions are dual bureaucracy and limited access to financial resources and services. Dual bureaucracy refers to circumstances when the federal and tribal officials, who both have broad authority and discretion regarding tribal public policies, attempt to manage resources that are under their dual jurisdiction (Lofthouse, 2019). A consequence of dual bureaucracy is that, after the 1980s federal-tribal relation reform, some power and responsibilities were given back to the Navajo Nation while necessary formal institutions and infrastructure were not there for the tribal government to make good decisions. Some of the changes concerned Navajo's healthcare system (e.g., S.2728 - Indian Health Care Amendments of 1980).

According to the treaties between Native American tribes and the federal government, the federal government is obligated to provide healthcare services to Native Americans on the reservation as part of the federal trust (Tipps et al., 2018). The federal healthcare services for Native Americans are managed by the Indian Health Service (IHS), established in 1955. However, as Tipps et al. (2018) pointed out, the system has been underfunded in recent years. Some IHS clinics operated on the reservation have suffered from inadequate staffing, out-of-date facilities, failure to implement new programs, etc. Some well-funded reservations, for example, those who have a relatively small population but with significant casino and tourism revenues, can supplement the federal programs or build their own healthcare infrastructure. But this is usually not the case for large reservations like the Navajo Nation. According to recent national news amid the COVID-19 pandemic (e.g., Baek, 2020), 30 % of the Navajo Nation residents do not have access to running water almost 200 years after its invention. It makes critical public health measures, such as frequent hand-washing, difficult to implement on the reservation during a pandemic.

Since the 1980s, there has been a decline in the role of the BIA in Native American communities. Meanwhile, the persistent social divisions lead to fractional politics within some reservations. According to Dippel (2014), a critical institutional and historical reason is the forced coexistence during the formation of Native American reservations in the 19th century. As Dippel (2014) argued, when different tribes or bands (even with a shared cultural identity) were forced to live together, it often did not imply coherent shared governance. The forced coexistence has significantly increased reported cases of internal conflicts and corruption in the policy processes (Dippel, 2014). It is essentially a consequence of the lack of resilience in formal institutions that were never fully functional as expected. Such a consequence becomes more pronounced when tribal self-governance began to matter more after the 1980s (Dippel, 2014). To some extent, it explains the inadequate preparation observed through several recent pandemics, including the COVID-19 pandemic. In the case of the Navajo Nation, there were no forced coexisting bands. For administrative and constitution-related reasons, however, the Navajo Indians were organized into over 100 chapters and five agencies (Fig. 2). They are represented by delegates in the Navajo Nation Council – the legislative body of the Navajo Nation government. All the Navajo chapters share the same culture with little difference in traditions and social norms (e.g., ceremonies). It potentially explains Navajo's strength in informal institutions. We will explore the impact of the exogenously introduced governance structure on its response to the COVID-19 pandemic in the next section.

As discussed before, the intricate relationship between the federal government and tribal governments has resulted in sluggish economic development and scanty employment opportunities. It limits many Native American residents’ ability to supplement their healthcare through employer-sponsored or private insurance. It also keeps potential financial firms away from providing lending and other financial services on or near reservations. The fact that many Native American residents cannot use their real estate property as collateral makes the situation potentially worse. It means that they have limited or only expensive lending opportunities to use as leverage to help with family healthcare. Such a disadvantage also applies to situations like entrepreneurship development and human capital accumulation (e.g., education and professional training). Of course, one potential explanation for the restriction on land titling is the concern that privatization may lead to concentrations of economic power and a worse outcome for tribal members (Holm et al, 2003). But the debate around tribal land privatization does indicate the level of challenge faced by Native Americans. Over time, the challenge has contributed to several chronic pandemics across Native American communities, which we reviewed in the previous section. No matter whether it is the dual bureaucracy or the limited financial resources at their disposal, they all leave many Native Americans unprepared for shocking events like the COVID-19 pandemic, even though research has shown that Native Americans are receptive to health interventions (Dufrene et al., 1992; Broussard et al., 1995; Plough et al., 2011).

4. The COVID-19 pandemic: why the Navajo Nation was hit so hard?

Based on the literature review and the institutional analysis of the Navajo Nation and other Native American reservations in general, we can identify four key factors that could explain why the Navajo Nation was hit hard by the coronavirus from the onset of the pandemic through December 2020 (the first two waves). They are (1) prevalence of underlying chronic health conditions; (2) lack of institutional resilience to external changes and psychosocial stresses; (3) complicated relationship between the federal government and tribal governments; (4) lack of social trust. They are interrelated, but each reflects a distinct aspect of the challenges that the Navajo people have faced. Here we explore them separately in the context of the COVID-19 pandemic.

4.1. Prevalence of underlying health conditions

As we reviewed in the background section, underlying chronic conditions such as drinking problems, obesity, diabetes, and hypertension have frequently exposed Native Americans to abrupt public health risks. The Navajo Nation is not immune to these problems. For example, Dabelea et al. (2009) showed that diabetes has been a critical health problem for Navajo youth. Infectious diseases are another high-risk health burden among communities in the Navajo Nation (Sutcliffe et al., 2019). Such chronic health conditions have already put some Navajo families under financial and psychosocial stresses before an exogenously imported pandemic hits. During the COVID-19 pandemic, affected individuals and families rely mainly on the underfunded IHS clinics to provide treatment and care, at least during the first several months. However, the IHS is not an insurance program, and it does not cover care from external providers. When the tribe-supported supplemental healthcare services cannot meet the gap, the affected individuals and families were trapped by the healthcare system. Despite the extremely low population density, the infection rates in terms of per-capita cases in several Navajo Nation counties were among the highest in the country.

4.2. Lack of institutional resilience

Formal and informal institutions, if operating effectively, can reinforce each other. The interaction and integration of formal and informal institutions have been found as a principal driver of social stability and economic development (Pejovich, 1999). It would be the ideal scenario and socioeconomic path for the Navajo Nation. The reality, on the other hand, has been that despite the traditionally robust informal institutions, the Navajo Nation has not been able to build efficient formal institutions that can advance its social-economic life to a level comparable to the non-Native world.11 Historically, the Navajo Nation relied on informal institutions to guide tribal affairs while depending on the federal government to provide essential services and infrastructure. After the federal government released some of the power back to the tribes, a vacuum of formal institutions appeared. Suddenly, many tribal governments found themselves weak in self-governance institutions. Tribes have to catch up in institutions and infrastructure development to take the new responsibilities. It has resulted in a lack of institutional resilience when facing abrupt changes, especially exogenously imported shocks. Although the Navajo Nation is a very adapting group as Tolan (1989) depicted, the robustness of its informal institutions alone cannot revamp through the collision between the Native world and the non-Native world during a period of rapid social and economic changes. As a passive reaction to the lack of formal institutional resilience, the Navajo Nation has developed a strong dependence on federal support and its natural resources endowment since World War II. According to the Navajo Nation Division of Economic Development, coal, oil, and uranium have been the foundation of the Navajo economy since the 1920s.12 The issue with such a resource-dependent economy is path dependence, similar to that of the dependence on the federal budget. The income and welfare of the Navajo people are directly subject to the fluctuation of the commodity markets. At the reservation level, this limits the supplementary investment in healthcare services. At the individual and household level, frequent disruptions of income affect consumption and health, as well as the ability to prepare for abrupt changes such as a pandemic.

4.3. The relationship between the federal government and tribal governments

Dippel (2014) shows that reservations that combined multiple tribal bands in the 1800s on average are 30 % poorer today. The result does not apply directly to the Navajo Nation. However, it has implications for Navajo Nation's governance structure. As previously mentioned, the Navajo Nation was ‘required’ to organize into over 100 chapters and five agencies for administrative and constitution-related reasons. Each chapter is a sub-governmental entity within the Navajo Nation delegated to address local issues such as land and health of its respective chapter residents (Navajo Nation Government, 2013). Since there are no different bands within the Navajo Nation, the question is that does the Navajo Nation needs this many administrative units to effectively self-govern. In practice, such a widely divided government entity weakens the Navajo Nation's bargaining position during negotiations with the federal government. It may also reduce the efficiency of decision-making processes concerning internal tribal affairs, including public health education and disease prevention.

But the internal organization is not the only factor that prevents the Navajo Nation from working with the federal government effectively. Even if we treat the Navajo Nation as a coherent government entity, it still faces two issues when working with the federal government: (1) A disadvantage in the negotiation because of its small size; (2) the cultural differences. The first issue is easy to see. Although being the largest reservation in the US, the total Navajo population was 332,129 in 2010, according to the 2010 US Census. Only close to half of them lived on the reservation, and others lived in nearby off-reservation towns and other areas (Navajo Nation Government, 2013). The second issue is more implicit, and it often seems esoteric to the non-Native world. However, cultural differences can have significant influences on the Navajo Nation's pursuit of economic prosperity under self-governance. As a 1989 Los Angeles Times article (Jones, 1989) titled: “MacDonald Faces Cultural Conflicts: Embattled Navajo Leader Tries to Straddle 2 Worlds,” tribal leaderships often struggle for a balance between strong traditional social norms (e.g., taking care of families and relatives, or nepotism) and a set of well-established rules to follow (formal institutions).

Given more than 500 federally recognized American Indian and Alaska Native tribes in the US, the federal support for Native Americans is often stretched even without any budget cuts. As far as healthcare services and support are concerned, what happens often is a delayed distribution of funds and/or insufficient funds (Newton, 2020). Such situations can worsen the spread of underlying chronic conditions and, in the case of a pandemic, exacerbate the challenges faced by Native American communities.

4.4. Lack of social trust

Social trust concerns both shared values and shared expectations within a community. Based on Helmke and Levisky (2004)'s conceptual framework, social trust overlaps culture and informal institutions. Lack of social trust can explain some of the challenges faced by the Navajo people. Internally, social trust affects the efficiency of group decision-making processes. Native Americans have a history of making decisions as a group under the dominant institutional environment of traditions and norms (Dufrene et al, 1992). It was also one of the potential reasons that the Navajo people survived the Long Walk between 1863 and 1866 (Denetdale, 2007). As its social & economic environment changes and formal institutions begin to matter, the Navajo Nation has suffered from failures of group decision-making. Although sharing the same culture, group interests overshadow social ties and trust as socio-economic conditions change. It has affected their efficiency of responding to exogenous shocks. One example is the allocation of federal funds. Despite the frequent insufficient federal support, how to timely and effectively allocate federal funds is a common obstacle that the Navajo decision-makers have to deal with. During the 2020 COVID-19 pandemic, the Navajo Nation received $716 million from the federal government through the CARES Act. However, there were different opinions within the tribal government regarding how to spend the fund (Smith, 2020), which potentially delayed the use of the fund and the relief of Navajo residents affected by the pandemic. If the relief fund can be used effectively and assistance programs can be implemented in a timely manner, the risk exposure to the COVID-19 pandemic would have been greatly reduced. Some tribal leaders believed that part of the relief fund should be allocated to improve essential infrastructures such as electricity, water systems, bathroom additions, and telecommunications access (Smith, 2020), which could generate long-term public health benefits and economic benefits.

Externally, social trust is particularly relevant to individual healthcare and public health in the Navajo Nation. Similar to many federally recognized tribes, the Navajo Nation relies on the IHS clinics for primary healthcare. However, a typical issue is the instability of the federally sponsored healthcare system. For instance, doctors who work at the clinics are usually on a short rotation, ranging from several months to a few years. There is little incentive for both doctors and patients to build trust, connection, and stable communication mechanisms. A derivative consequence of the lack of communication and hence social trust is the lack of customized education on nutrition and public health. The latter is critical for pandemic preparation and disease prevention. Understaffing has been another challenge faced by the Navajo healthcare system (Albino et al., 2017; Kim, 2000).

5. Discussion

This study reviewed the background and the literature on previous public health pandemics that Native Americans had faced. In the context of the COVID-19 pandemic, I conducted an institutional analysis of the social & economic environment of the Navajo Nation, incorporating conversations with Navajo scholars, to answer the question of why the Navajo Nation was hit so hard in the first two waves of the pandemic. The policy implications of the analysis can be explored from several aspects.

At the informal institutions level, first, we should realize the values and social norms embedded in the Navajo social-economic life and culture. Such values and social norms are prevailing across Native American communities (Nebelkopf & King, 2003; Miller, 2018), although with variations. The design of federal assistance programs and their implementation should take into account these values and social norms to alleviate poverty and widespread underlying health conditions, which will help Native American communities to prepare for future pandemics in the long run. The same suggestion applies to any cooperative effort between the federal government and tribal governments. Ignoring the existence and value of Native American cultural history and social norms can only make policy implementation less effective and exacerbate any inconsistencies between federal policy and self-governance. In this regard, several programs proposed in the public health arena have proved successful, such as group counseling and wellness courts (Dufrene et al, 1992; Tipps et al., 2018). These programs usually consider a Native individual's cultural identity and traditional values carefully. Besides, giving attention to indigenous rights is an effective way to improve social trust in healthcare systems (Nelson & Wilson, 2021).

Another essential aspect of enhancing Navajo's informal institutions is to build social trust and communication with the non-Native world, especially with the non-Native communities where some Navajo lives. As the 2010 US Census suggests, 10 % of Navajo people live in border towns surrounding the Navajo Nation (Navajo Nation Government, 2013). The social gap between a reservation and its border towns is not necessarily the smallest, but the geographical proximity is something that can be leveraged. Historically, during their decades and centuries of encountering and exchange with the non-Native world, Native American tribes have been able to prosper for most of the time. Setbacks did happen. For example, the incrimination of the unprecedented four-term chairman Peter MacDonald, who was once a popular public figure in the country, was a major setback in the Navajo Nation leadership in 1989 and led to the restructuring of the tribal government in 1991. Between 1989 and 2003, the Navajo Nation had six chairmen, and none of them served more than one term. But a short setback like this should not stop the effort to collaborate with non-Native communities, both nearby and far away. On another note, tribal governments mainly dealt with the federal government in the past. To build social trust and communication with the non-Native communities, it is also worthwhile to collaborate with local state and municipal governments. The recent Days Inn incident in New Mexico (Ihrig, 2020) highlights the importance of such local-level collaborations.

At the formal institutions level, policymakers and tribal leaders should realize the importance of formal institutions and their relationships with culture and informal institutions. First and foremost, the established formal institutions should match the tribal culture. It is one of the four key factors for successful economic development identified by the Harvard Project on American Indian Economic Development (HPAIED, Cornell and Kalt (2000)). For instance, this is essentially the direction of the 1989 Navajo Nation Council reform (i.e., Navajo Nation Local Governance Act; for more discussion, see Morris (1991)). The new Act gave some local Navajo chapters the ability to make their own decisions. Another example is clear property rights. Dippel et al. (2020) showed that fee simple title (a form of freehold ownership, which gives the owner absolute property rights) adds between $4000 and $15,000 in value to an acre of land using allotment data from Native American reservations. The estimate does not necessarily reflect any potential value from the future improvement of lending opportunities with better collateral (the land), as well as any health effect of increased willingness to invest in home improvement. This monetary estimate illustrates the value of formal institutions. It is worth noting that the idea of titling reservation lands has had both successful cases (e.g., Alaska Native village corporations, see Dayo and Kofinas (2009)) and questionable ones (e.g., Hernando de Soto's design, see Otto (2009)). One implication from these mixed outcomes is that it is important to use informal institutions to overcome the shortfalls of formal institutions.

More importantly, building efficient formal institutions is a critical step towards self-governance. Without strong self-governance, the resident health and economic livelihood on the reservation are always subject to the fluctuations of federal grants and funds. Federal support often does not go to residents on the reservation directly. Complaints tend to link such a way of fund distribution to corruption among tribal officials. Strong self-governance can reduce reliance on federal support and create employment opportunities for tribe members, which eradicates the root cause of corruption related to federal funds. It is consistent with Howitt (2012) that “sustainable Indigenous futures cannot arise from policy interventions that rely on creating wealth for state and corporate appropriation and assume enough of this wealth can be redistributed to local Indigenous communities to constitute ‘development.’” In addition, strong self-governance allows tribal governments to strategically utilize federal support. Historically, a lot of federal funds allocated to Native American communities were used for consumptive purposes. With strong self-governance and a strategic relationship with the federal government, much of the federal funds could be diverted to production purposes, such as investment in telecommunication infrastructure (e.g., broadband) and supporting small and medium enterprise development.

Another essential component of building efficient formal institutions is to invest in the education system. As far as pandemic prevention is concerned, promoting public health education in Native American communities is critical. It is an indispensable vehicle for building health equity and eliminating health disparities. Over the last several decades, there has been a trend toward transferring public health programs from the IHS to tribal governments. Noren et al. (1998) argued that for the tribe-sponsored programs to be effective and sustainable, they need to be operated by skilled healthcare professionals and managers to adapt to the changes in the healthcare environment. Promoting public health education can help to address the shortage of nurses and physicians on reservations while managing the burden on their healthcare system in the long run. It is also an effective way to integrate informal institutions and formal institutions. For instance, Dignan et al. (1994) found that the unique cultures and the diversity of Native Americans are critical factors in developing successful health education programs for their communities. It can also help address the high turnover rates of doctors and nurses at the IHS clinics and grow social trust in the healthcare system.

It is worth noting that it may be necessary for tribal governments to work with local state and municipal governments to develop successful public health education programs. First, the already-stretched federal funds and limited tribal resources make it difficult for tribal governments to invest in the needed education infrastructure from scratch. Collaborating with local state and municipal governments may allow them to share the already existing infrastructure. A recent example is a cooperative agreement between Navajo Technical University (a tribally controlled university) and a local public research university in New Mexico to address the drinking water quality issue on the reservation (Davis, 2020). Similar collaborations can be expanded to public health education. Second, working with local state governments on education programs will also help address the poor higher education situation for Native Americans. In that regard, Native American students have been struggling (Pruitt & Flores, 2020).

Overall, it needs to stress that with policies and initiatives integrating both dimensions of tribal institutions, such as the suggested above, institutional resilience can be forged to prepare Native American reservations like the Navajo Nation for pandemics in the future.

6. Concluding remarks

Based on reviewing the pandemic history of Native Americans and analyzing the institutional environment of the largest Native American reservation – the Navajo Nation, this study aims at understanding the disproportionate impact of the COVID-19 pandemic on Native American communities. I use the Navajo Nation as a case study to seek answers for the slow response to the pandemic among some Native American communities, especially during the beginning stage. Exploring its formal and informal institutions provides us a way to identify the critical factors behind the severity of the pandemic on the reservation compared to the non-Native world. The analysis indicates that there is a lack of both institutional resilience and healthcare preparation. They are essentially two intertwined aspects of the same challenge that the Navajo Nation and other Native American reservations have faced. Specifically, four factors can help explain the severity of the pandemic: prevalence of underlying chronic health conditions, lack of institutional resilience, the relationship between the federal government and tribal governments, and lack of social trust. They provide implications for the way to move forward. The Navajo Nation traditionally has robust informal institutions but weak formal institutions, especially institutions necessary for effective self-governance. Taking that into consideration, the study offers several policy suggestions. First, policymaking should balance the traditional culture and social norms of a Native American tribe and the public health needs instead of ignoring or suppressing them. Second, integrating informal institutions to build efficient formal institutions is an essential step towards self-governance. Besides, as a component of building strong self-governance, tribal economic development policy should increase investment in its education system. In particular, promoting public health education could help Native American communities to better prepare for pandemics in the future.

In the long run, to avoid institutional lock-in or institution vacuum, local-level collaboration and cooperation should be promoted to enhance social trust and communication between Native and non-Native communities. One way is through strategically integrating Native American culture and regional economic development. It requires the federal government to work with tribal governments to reduce business transaction costs and improve financial opportunities for entrepreneurial activities. The momentum of economic growth will help to build resilience to, for example, chronic conditions and psychosocial stresses in the long run. Furthermore, addressing policy vacuum and policy ambiguity is as necessary as crafting new policies and agreements. For instance, according to van Dorn et al. (2020), “the IHS support does not cover care [for COVID-19] from external providers. Although there is a provision of the CARES Act stimulus bill that is intended to cover those costs, it is unclear how effective it would be if someone covered by the IHS is transferred to a non-IHS facility.” Hopefully, such policy ambiguity due to dual bureaucracy can be resolved soon in the wake of the COVID-19 pandemic.

CRediT authorship contribution statement

Haoying Wang: Conceptualization, Formal analysis, Literature Review, Visualization, Analysis, Writing – review & editing.