How the Navajo Nation slowed one of the worst Covid-19 outbreaks in the US

When the Navajo Nation reported its first Covid-19 case on March 17, tribal officials quickly declared a public health emergency and a shelter-in-place order. As the virus spread, doctors scrambled to increase the reservation’s health care capacity for the sickest patients.

“We knew this was just the beginning, and we would have to be very aggressive,” says Loretta Christensen, the chief medical officer for the Navajo Area Indian Health Service.

The Navajo Nation (Dine’é in Navajo language) spans Utah, Arizona, and New Mexico, and with over 300,000 members, it’s the largest tribe in the United States. Despite having an infection rate higher than New York City this spring, the Navajo Nation — under the leadership of its President Jonathan Nez — has since successfully flattened its curve. Daily new cases have fallen from a high of 240 in May to 54 on July 26.

Courtesy of Navajo Times

Jeanne Noble is an associate professor of emergency medicine and an ER physician at the University of California San Francisco who joined a medical mission to the Navajo Nation in May. “It was incredible to see what they did with overwhelming patients and limited resources,” essentially doubling the emergency room capacity, she told Vox.

The Nation also faces social and economic disparities that make its population particularly vulnerable during the pandemic. This includes a high rate of preexisting conditions that increase the risk for severe Covid-19, including diabetes, which affects more than one-fifth of its residents.

“We have 13 supermarkets for 27,000 square miles, so people have to travel a long way to get food,” Christensen says. “It has a lot to do with the high rate of diabetes, heart disease, and high autoimmune disorders,” she says.

Additionally, access to clean, safe water is challenging: One in three households doesn’t have indoor plumbing, and decades of uranium mining has contaminated existing water supplies, adding to health problems. Families are also more likely to live in multigenerational homes, making quarantining more difficult.

These disparities have worsened the pandemic’s impacts. For example, although Native Americans are only 9 percent of New Mexico’s population, they account for 57 percent of its Covid-19 deaths.

Many of these inequities stem from the US government’s breaking of treaty obligations: The Indian Health Service is chronically underfunded, with an annual budget about six times less than it actually requires to meet its needs.

The Navajo Area Indian Health Service Hospitals only have 15 ICU beds: Even in normal times, it relies on transferring critical care patients out to tertiary facilities in Albuquerque, Phoenix, Flagstaff, and Tucson. With cases surging in the southwest — Arizona’s hospital capacity has become so limited that the state has activated crisis standards of care — finding beds for transfer patients has become much harder. Christensen is also worried about spillover viral transmission onto the reservation.

While it’s still possible that the Navajo Nation will see cases rebound in the coming months, both Noble and Nathan Teismann, another visiting emergency doctor from UCSF, say that the rest of the country has a lot to learn from its response. “The thing that keeps coming back to me is how important it is for a community to come together around a problem, and not just be worried about their own personal liberty or business or children,” Teismann says. “There, the health of the community at large was primary.”

Christensen adds, “The loss of elders [to Covid-19] and that history has been very hard, but the bottom line is we stood up — we’re strong.”

Central to the success is clear messaging from Navajo Nation President Jonathan Nez on masks and curfews; his leadership, she says, played a key role in reducing Covid-19 transmission. To learn more, Vox called Nez to discuss the lessons he’s learned about controlling the virus — and leading the Navajo Nation through this difficult time. The following interview has been edited and condensed for clarity.

Lois Parshley

How has the Navajo Nation responded to Covid-19?

Jonathan Nez

The Navajo Nation is locked down — we’re telling residents to please stay home, and visitors to pass through. We have travel advisories against leaving the Navajo Nation, and we’ve told citizens living off the reservation that now’s not the time to come visit relatives.

We’re asking everyone to wear a mask, social distance, wash their hands, and stay home. Since early April, we mandated mask use in public.

It’s concerning that Arizona still doesn’t mandate masks, although New Mexico has. Data shows that wearing masks slows the spread of Covid-19. If the Navajo Nation is to be a case study, we had a fast increase in cases — we have multiple generations of family living under one roof, so Covid spread like wildfire — but wearing masks has flattened our numbers.

The Indian Health Service did a surge projection in March where they suggested that our peak of hospital use would be in mid-May. We went door to door on a public health campaign, and the numbers show we beat that projection by a whole month — the peak of our cases actually happened in mid-April. Since then, we’ve been on a downward trend.

Navajo Nation Office of the President and Vice President

Lois Parshley

Obviously, Covid-19 has required a lot of changes, but what new policies do you think have been most important in controlling transmission?

Jonathan Nez

Our message has to be repeated. I’ve been saying, “Wear your mask, masks save lives, masks slow the spread.”

We’ve gone door to door. We have a database of high-risk patients and when we saw the virus coming in February we started reaching out to them.

We framed it within our cultural teaching: We teach that we have fought monsters, but today we also have modern monsters, like alcoholism, depression, suicide, and disease.

In our society, we value our elders and we let people know they are warriors, and they are supposed to protect their families — in this case, to shield their elders, who have traditional and cultural knowledge for the future of our people. We’re also doing daily updates on Facebook, and you can watch a town hall meetings online every Tuesday and Thursday.

There’s always a fear of catching the virus. I’m out there [working in the community], so I had to move into a different room in my home — like a lot of first responders, I’m isolating away from my family, just in case.

Lois Parshley

What have been some of the biggest challenges you’ve faced during this crisis?

Jonathan Nez

At the beginning, there was a lot of media attention, making us look like the “poor, poor Navajo people.” But we are proud and resilient.

We overcame the Long Walk of the Navajo in the 1860s, when we signed a treaty with the federal government that said we would be in partnership together. To this day, the Navajo people still honor that treaty — which stated the federal government would help us with education, health care, and infrastructure. We have contributed greatly to this country and its freedom, and there have been so many broken promises.

It took a pandemic to educate US citizens about the failure of the US government in honoring those promises.

During the pandemic, because of the failure and slowness of the federal government to give us our share of the Cares Act [federal funding to tribal governments was delayed over a lawsuit concerning whether Alaska Native corporations were eligible], so we had to use our sovereign ability to govern ourselves and keep our people safe.

A lot of people donated while we were waiting for funding from Washington, DC, and friends of all nationalities came to the aid of the tribes. I appreciate their donations — it helped get us through — but these [Cares] dollars are not handouts, they were supposed to be given as relief. While all states got money right away, we had no federal money until long after we hit our surge.

Of course we’re grateful, but this money was intended for US citizens. Tribal people are US citizens, and we had to wait and wait for our fair share.

We are doing our best to get all the protection equipment we need, but we need the federal government to step up.

Lois Parshley

Christensen, the chief medical officer for the Navajo Area Indian Health Service, told me the pandemic has highlighted many existing problems. She said, “A meaningful lesson from Covid-19 is that when you have resources, use them to improve the infrastructure — this is essential to move toward health equity.”

What have you learned as president during this time?

Jonathan Nez

We have incorporated stringent public health orders. Of course you’ll get pushback if you try to put restrictions on citizens, but we’ve showed how the data backs it up.

For example, we had 57-hour weekend curfews — so from 8:00 pm Friday to 5:00 am Monday — until we saw a reduction in cases. Then we ended the curfews for two weeks, but we saw new spikes in the states around the Navajo Nation, so we reinstated the curfews. We’ve learned it’s important to be proactive. Now, the Navajo people see the curfews worked, now the people themselves are saying they’re right.

For people who have been asking how they can help — please contact your congressional representatives. Let them know there needs to be a change in this relationship between the federal government and the tribes.

Now is the time to reshape Indian Country, to bring us equal to the rest of the US citizens. And that means changing federal policies, so we can be truly self-reliant and self-sufficient.

Lois Parshley is a freelance investigative journalist. Follow her Covid-19 reporting on Twitter @loisparshley.

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