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Spring 2024

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A Call to Improve Upon the Health Disparities Affecting Native American and Alaskan Native Populations

Benjamin Brown MD, MPH1; Aantaki Raisa PhD2; Richard Moser PhD, FSBM3

Approximately 9.7 million people in the United States (3% of the total population) identified as American Indian or Alaskan Native (AI/AN) in 2020.1 There are over 550 federally recognized Indian tribes with many others not formally recognized.2 Though many from these groups have contributed to medical and healthcare advances, such as inventing baby bottles, syringes, and vaccines, these groups also experience numerous health disparities.3 The factors that have led to the development of these disparities are complex and likely rooted in decades of marginalization, discrimination, racism, and forced displacement and relocation. The goal of this article is to inform and educate across several areas in which AI/AN populations experience disparate health outcomes compared to other races.

Socioeconomic Disparities

Compared to White individuals, those who are AI/AN are “twice as likely to live in poverty”.1 Poverty affected 29.4% of individuals living on reservations which is almost double the United States (U.S.) national average of 15.3%.2 Median household income for the AI/AN population is $35,310 which is far below the U.S. national average of $51,371.2 Health insurance rates are also lower among AI/AN populations with the uninsured rate being 2.7 times the uninsured rate of White individuals (27% vs 10%).1

Health Behavior Disparities

Tobacco use is more prevalent among AI/AN populations (27.1%) compared to other races (White 13.3%, non-Hispanic (NH) Black 14.4%, NH Asian 8%, Hispanic 8%).4 Among high school students, watching 3 or more hours of television per day was more common among AI/AN youth compared to White youth (33.2% vs 16.5%).4

Health Outcome Disparities

There are numerous health outcome disparities that affect the AI/AN population. In 2017, the prevalence of youth onset type 2 diabetes was more than 8 times higher among AI youth compared to White youth (1.63/1,000 vs 0.20/1,000).5 Compared to White individuals, AI/AN individuals have higher overall cancer incidence rates among all cancer types and several specific cancers including colon/rectum, kidney/renal pelvis, liver/intrahepatic bile duct, lung/bronchus, pancreas, stomach, and uterine/cervical.1  Breast cancer screening rates are also lower in AI/AN individuals.6 Routine mammography was completed by 64.4% of AI/AN individuals compared to 73.1% NH White individuals.6 Cancer survival rates are also lower than Whites for most cancer types1.  The AI/AN population had worse outcomes related to COVID-19 infections with a higher likelihood of being hospitalized or dying from the infection compared to White individuals.1

Mental Health Related Disparities

AI/AN populations have elevated PTSD rates compared to the U.S. population in general (16%-24% vs. 4.8%-6.4%).7 AI/AN adults face a 20% higher death rate from suicide compared to NH Whites and suicide was the second leading cause of death among AI/AN individuals aged 10 – 34 in 2019.8 In addition, clinically significant depressive symptoms are higher among AI/AN adult individuals compared to the general U.S. population (25% vs 8.1%).9

Why it is Imperative to Improve AI/AN Health?

AI/AN individuals face a 50% higher mortality rate compared to non-AI/AN individuals.9 AI/AN peoples are not only a vulnerable group in terms of health outcomes, but this is also a historically vulnerable group who have been victims of genocide, forced displacement, colonization, and racism.10 There is growing evidence supporting the idea that populations who have experienced significant trauma may pass down intergenerational effects genetically through epigenetic changes which may impact health, stress, disease risk, and reduced quality of life and longevity.11 To make significant and lasting changes for the health and well-being of AI/AN populations, the efforts of academic, community, and political groups need be united to counteract, uproot, and resolve the issues that have led to persisting and worsening disparities among the AI/AN population.

Despite resilience and communal support mechanisms, systemic issues persist, such as, air pollution reduction patterns in AI/AN-populated counties.12 For example, a 2022 study found that while air pollution decreased between the years 2000 and 2018, the rate of decrease was higher in counties with non-AI/AN populations compared to those counties populated by AI/AN peoples.12 Healthy People 2030 defines health equity as “the attainment of the highest level of health for all people” and it “requires valuing everyone equally”.13(p2) Addressing AI/AN health disparities is a matter of justice and moral responsibility.

What Needs to be Done?

Efforts for culturally sensitive healthcare in the U.S. can enhance AI/AN health outcomes.14–16 Health research must prioritize community-based interventions integrating AI/AN individuals and perspectives, honoring their values for sustained engagement as researchers and as participants. Researchers who are building and implementing interventions for AI/NA populations should incorporate community participatory research methods as they improve relevance and quality of research, allow for complex problems to be addressed, build bridges, and help heal distrust.17 To tackle disparities, upstream changes like policy enhancements and healthcare access improvements are vital, possibly more than downstream interventions. Yet, data scarcity and underrepresentation in research and national datasets hinder policy-making for diverse AI/AN groups.18 Past disregard to ethical research standards, as seen in the case affecting the Havasupai Tribe of northern Arizona, must never recur; ethical representation of AI/AN data in research is imperative to build and maintain trust and to improve important collaborations.19 Science needs to embrace indigenous methodologies, grant indigenous communities access to their data for self-empowerment, and innovate solutions from within.20 If we work together as researchers, scientists, community members, community leaders, politicians, and health care providers, we will have greater power to improve upon and resolve the negative health disparities experienced by AI/AN populations.

Affiliations:

  1. Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah.
  2. Department of Surgery, Division of Public Health, Washington University in St. Louis, Saint Louis, Missouri.
  3. Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland.

References:

  1. American Cancer Society. Cancer Facts & Figures 2022. Published online 2022. Accessed November 18, 2023. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2022/2022-special-section-aian.pdf
  2. American Indians and Alaska Natives - By the Numbers. Administration for Native Americans. Accessed November 18, 2023. https://www.acf.hhs.gov/ana/fact-sheet/american-indians-and-alaska-natives-numbers
  3. AdventHealth. 8 Medical Contributions by Native Americans That Are Used Every Day. Published November 3, 2022. Accessed February 2, 2024. https://www.adventhealth.com/blog/8-medical-contributions-native-americans-are-used-every-day
  4. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association. Circulation. 2023;147(8). doi:10.1161/CIR.0000000000001123
  5. Lawrence JM, Divers J, Isom S, et al. Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001-2017. JAMA. 2021;326(8):717-727. doi:10.1001/jama.2021.11165
  6. Roubidoux MA, Kaur JS, Rhoades DA. Health Disparities in Cancer Among American Indians and Alaska Natives. Acad Radiol. 2022;29(7):1013-1021. doi:10.1016/j.acra.2021.10.011
  7. Emerson MA, Moore RS, Caetano R. Association Between Lifetime Posttraumatic Stress Disorder and Past Year Alcohol Use Disorder Among American Indians/Alaska Natives and Non-Hispanic Whites. Alcohol Clin Exp Res. 2017;41(3):576-584. doi:10.1111/acer.13322
  8. Mental and Behavioral Health - American Indians/Alaska Natives | U.S. Department of Health and Human Services Office of Minority Health. Accessed January 8, 2024. https://minorityhealth.hhs.gov/mental-and-behavioral-health-american-indiansalaska-natives
  9. McKinley CE, Boel-Studt S, Renner LM, Figley CR. Risk and protective factors for symptoms of depression and anxiety among American Indians: Understanding the roles of resilience and trauma. Psychol Trauma Theory Res Pract Policy. 2021;13(1):16-25. doi:10.1037/tra0000950
  10. Edwards TS, Kelton P. Germs, Genocides, and America’s Indigenous Peoples. J Am Hist. 2020;107(1):52-76. doi:10.1093/jahist/jaaa008
  11. Lehrner A, Yehuda R. Cultural trauma and epigenetic inheritance. Dev Psychopathol. 2018;30(5):1763-1777. doi:10.1017/S0954579418001153
  12. Li M, Hilpert M, Goldsmith J, et al. Air Pollution in American Indian Versus Non-American Indian Communities, 2000-2018. Am J Public Health. 2022;112(4):615-623. doi:10.2105/AJPH.2021.306650
  13. Health Equity in Healthy People 2030 | U.S. Department of Health and Human Services. Accessed February 2, 2024. https://health.gov/healthypeople/priority-areas/health-equity-healthy-people-2030
  14. Fleischhacker S, Roberts E, Camplain R, Evenson KR, Gittelsohn J. Promoting Physical Activity Among Native American Youth: a Systematic Review of the Methodology and Current Evidence of Physical Activity Interventions and Community-wide Initiatives. J Racial Ethn Health Disparities. 2016;3(4):608-624. doi:10.1007/s40615-015-0180-1
  15. Baldwin JA, Lowe J, Brooks J, et al. Formative Research and Cultural Tailoring of a Substance Abuse Prevention Program for American Indian Youth: Findings From the Intertribal Talking Circle Intervention. Health Promot Pract. 2021;22(6):778-785. doi:10.1177/1524839920918551
  16. Walters KL, Johnson-Jennings M, Stroud S, et al. Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian, Alaska Native, and Native Hawaiian Communities. Prev Sci. 2020;21(S1):54-64. doi:10.1007/s11121-018-0952-z
  17. Israel BA, Schulz AJ, Parker EA, Becker AB. REVIEW OF COMMUNITY-BASED RESEARCH: Assessing Partnership Approaches to Improve Public Health. Annu Rev Public Health. 1998;19(1):173-202. doi:10.1146/annurev.publhealth.19.1.173
  18. Improving Health Outcomes for American Indian and Alaska Native People with Disabilities: A Law and Policy Perspective. Health.gov | Office of Disease Prevention and Health Promotion | U.S. Department of Health and Human Services. Published April 15, 2020. Accessed January 8, 2024. https://health.gov/news/202004/improving-health-outcomes-american-indian-and-alaska-native-people-disabilities-law-and-policy-perspective
  19. Garrison NA. Genomic Justice for Native Americans: Impact of the Havasupai Case on Genetic Research. Sci Technol Hum Values. 2013;38(2):201-223. doi:10.1177/0162243912470009
  20. Walter M, Suina M. Indigenous data, indigenous methodologies and indigenous data sovereignty. Int J Soc Res Methodol. 2019;22(3):233-243. doi:10.1080/13645579.2018.1531228