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

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. •Native Americans are more vulnerable to exogenous shocking events.•The prevalence of underlying conditions contributes to the high incidence rate.•The Navajo Nation has robust informal institutions but weak formal institutions.•Efficient formal institutions are critical for self-governance and Native healthcare.•Balancing traditions and public health needs is essential for pandemic preparation.