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Health Disparities Among American Indian/Alaska Native

Populations

“Addressing Health Inequalities in the US”

by

Dean S. Seneca, MPH, MCURPDirector, Office of Tribal Affairs

Agency for Toxic Substances and Disease Registry



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2

1492Arrival of Columbus

1790ForcedInland

1830IndianCountry

1860ImmigrationStampede

1890Vanquished

2090Indian Country?

= ReservationLands



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Why is it Important to have Diversity in Public Health?

• Ensures that everyone understands the problems and are asking the right questions.

• Ensures that we are producing trustworthy data.

• Ensure that bias does not creep into the analysis and interpretation of results.

CDC & ATSDR



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Ten Leading Causes of Death in the U.S. in 2002 for American Indians & Alaska Natives

1. Heart disease2. Cancer3. Unintentional injuries4. Diabetes5. Stroke6. Chronic liver disease and Cirrhosis7. Chronic lower respiratory disease8. Suicide9. Influenza and Pneumonia10. Homicide

Source: Health, United States, 2004, Table 31.

http://www.cdc.gov/nchs/data/hus/hus04trend.pdf



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Purpose of Discussion

• This presentation is to inform you of the Leading cause of Death Among AI/AN populations

• Present comparisons of AI/AN Health mortality/morbidity compared to other ethnic groups

• Discuss the need for Diversity in Public Health

CDC & ATSDR



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Ten Leading Causes of Death in the U.S. in 2002 for AI/AN as Compared to the Nation

AI/AN

1. Heart disease2. Cancer3. Unintentional injuries4. Diabetes5. Stroke6. Chronic liver disease & Cirrhosis7. Chronic lower respiratory

disease8. Suicide9. Influenza and Pneumonia10. Homicide

U.S.

• Heart disease• Cancer• Stroke• Chronic lower respiratory disease• Unintentional injuries• Diabetes• Influenza and Pneumonia• Alzheimer’s Disease• Nephritis, nephrotic syndrome, &

nephrosis• Septicemia

Source: Health, United States, 2004, Table 31.

http://www.cdc.gov/nchs/data/hus/hus04trend.pdf



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AI/AN Population

• 2000 Census– AI/AN alone: 2,475,956– AI/AN alone or in combination: 4,119,301

• Mostly urban – 36% live on reservations – 64% live in urban areas



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AI/AN Population

• 2000 Census*– AI/AN alone: 2,475,956– AI/AN alone or in combination: 4,119,301

• Mostly urban** – 14% live on reservations – 57% live in urban areas

Sources: *http://www.census.gov/prod/2002pubs/c2kbr01-15.pdf**http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/002950.html

http://www.census.gov/prod/2002pubs/c2kbr01-15.pdf

http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/002950.html



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American Indian and Alaska Native Population By State

AI/AN Populationby State, 2000

100,00 to 333,400

50,000 to 99,999

10,000 to 49,999

1,713 to 9,999

* Census 2000, One race (AI/AN) alone

WA

OR

CANV

ID

MT

WY

UTCO

AZ NM

TX

OK

ND

KS

NE

SD

AR

MO

IA

MN

GA

TN

MSAL

LA

MI

OHINIL

WI

FL

PA

VA

ME

NY

WV

NCKY

SC

AK

NH

MA

NJ

DEMD

HI

VT

RI

CT



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American Indian and Alaska Native Percent Population By State

AI/AN Percent Populationby State, 2000

15.6

5.0 to 12.4

0.9 to 4.9

0.1 to 0.8

WA

OR

CANV

ID

MT

WY

UTCO

AZ NM

TX

OK

ND

KS

NE

SD

AR

MO

IA

MN

GA

TN

MSAL

LA

MI

OHINIL

WI

FL

PA

VA

ME

NY

WV

NCKY

SC

AK

NH

MA

NJ

DEMD

HI

VT

RI

CT

* Census 2000, One race (AI/AN) alone



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Demographics*

12.5%20%Living in Poverty**

$43,318$35,441Median Income**

36 years29 yearsMedian Age*U.S. All racesAI/AN

Sources:U.S. Census 2000: * Table 2 Age, July 2003: http://www.census.gov/Press-Release/www/releases/img/cb04-98-table2.pdf

**Census News, Thursday, AUG. 26, 2004 http://www.census.gov/Press-Release/www/releases/archives/income_wealth/002484.html

http://www.census.gov/Press-Release/www/releases/img/cb04-98-table2.pdf

http://www.census.gov/Press-Release/www/releases/archives/income_wealth/002484.html



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2001 IHS Service Population* by AreaTotal Population: 1,540,129

Albuquerque82,818

Portland158,892

Billings58,794

California132,740 Phoenix

150,540

Oklahoma318,691

Nashville78,745

Navajo223,029

Tucson28,980

Alaska109,780

Aberdeen102,758

Bemidji94,362

IHS Epidemiology *Projected from 1990 Census

Source: Health, United States, 2004. Table 29.http://www.cdc.gov/nchs/data/hus/hus04trend.pdf#topic

Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for All Causes: U.S. - 2002

845.3 829.0

1083.3

677.4

474.4

629.3

0

200

400

600

800

1000

1200

All Races White AfricanAmerican

AmericanIndian/Alaska

Native

Asian/PacificIslander

Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons

Sources: HUS = Health, United States, 1999. Table 30.IHS=Trends in Indian Health, 200-2001, General Mortality Stats, Part 4, Table 4.11 Age-Adjusted Death Rates, p69.

*Adjusted to compensate for misreporting of AI/AN race on state death certificates.

Age-Adjusted Death Rates per 100,000 Persons by Race for All Causes: U.S. & IHS Service Area - 1997

479.1 456.5 465.3

620.7

715.2

0

150

300

450

600

750

All Races (HUS) White (HUS) American Indian/Alaska Native AI/AN

(HUS)

AI/AN UnAdjustedIHS Service Area

(IHS)

AI/AN Adjusted * IHSService Area (IHS)

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



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IHS Trends in Indian Health 1998-1999

Age-Adjusted Death Rate

0

250

500

750

1,000

1972-74 (1973) 1983-85 (1984) 1994-96 (1995)

Calendar Year(s)

Rate Per 1,000 Population

American Indians & AlaskaNatives, Actual (3-Year)

U.S. White (1-Year)U.S. All Races (1-Year)

American Indians & AlaskaNatives, Adjusted (3-Year)



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IHS Regional Differences in Indian Health1998 – 1999

Age-Adjusted Death RatesCY 1994-1996

0 300 600 900 1,200

Bemidji

Aberdeen

BillingsTucson

Phoenix

AlaskaPortland

Nashville

AlbuquerqueNavajo

Oklahoma

California

Rate per 100,000 Population

IHS Adjusted Total - All Areas = 699.3U.S. All Races (1995) = 503.9

Actual

Adjusted forRace Miscoding



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Age-Specific Death RatesRatio of American Indians ('94-'96) to U.S. All Races ('95)

Ratio

Under 1

35-44

5-14

65-74

1-4

15-24

25-34

55-64

45-54

85+

75-84

0 1 2 3

Age



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Deaths by Age and Race

0

10

20

30

40

50

60

70

80

Under 5 5-24 25-44 45-64 65+

Age

Percent Distribution

American Indians & AlaskaNatives (1994-1996), Adjusted

U.S. White (1995)U.S. Black (1995)



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IHS Trends in Indian Health 2000-2001 Table 4.11 p.69 age adjusted

Death Rates for Leading CausesAmerican Indians and Alaska Natives (1997)

31.7

44.4

82.2

107.5

132.9

0 50 100 150

Age-Adjusted Death Rate per 100,000 Population

Diseases of the Heart

Chronic Liver Disease& Cirrhosis

Unintentional Injuries

Diabetes Mellitus

Malignant Neoplasms



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IHS Regional Differences in Indian Health1998-1999

Leading Causes of DeathAll IHS Areas, CY 1994-1996

4.7

5.9

14.1

15.3

21.7

0 10 20 30

Percent of Total Deaths


Chronic Liver Dis.& Cirrhosis

Accidents &Adverse Effects

Diabetes Mellitus

Malignant Neoplasms



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Leading Causes of DeathU.S. All Races, CY 1995

4.0

4.5

6.8

23.3

31.9

0 10 20 30 40



Chronic ObstructivePulmonary Diseases

Accidents &Adverse Effects

CerebrovascularDiseases

Malignant Neoplasms



Age-Adjusted Death Rates per 100,000 Persons by Race for Cerebrovascular Diseases: U.S. & IHS Service Area - 1997

25.924.0

19.9

26.7

29.5

0

5

10

15

20

25

30


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



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IHS Trends in Indian Health 2000-2001 Chart 4.9 p. 66

Death Rates, Leading Causes: MalesAmerican Indians and Alaska Natives (1996-1998)

31.9

37.5

101.7

120.4

158.2

0 50 100 150 200

Deaths per 100,000 Population


Diabetes Mellitus



Malignant Neoplasms



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IHS Trends in Indian Health 2000-2001 Chart 4.10 p. 66

Death Rates, Leading Causes: FemalesAmerican Indians and Alaska Natives (1994-1996)

31.6

45.3

55.8

98.2

113.2

0 25 50 75 100 125

Deaths per 100,000 Population


Diabetes Mellitus


CerebrovascularDiseases

Malignant Neoplasms



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Selected Age-Adjusted Death RatesRatio of American Indians ('94-'96) to U.S. All Races ('95)

Ratio

0 1 2 3 4 5 6 7

HIV Infection

Suicide

Malignant Neoplasms

Accidents

Chron. Obs. Pulm. Dis.

Major Cardiovascular Dis.Homicide

Diabetes Mellitus

Pneumonia & Influenza

Tuberculosis, All FormsChron. Liver Dis. & Cirrhosis

Alzheimer’s Disease



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IHS Regional Differences in Indian Health2000-2001 Chart 4.5 p. 53

Leading Causes of DeathAberdeen Area, CY 1996-1998

6.3

7.5

14.4

15.0

21.1

0 10 20 30



Diabetes Mellitus



Malignant Neoplasms



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IHS Regional Differences in Indian Health2000-2001 Chart 4.7, p. 54

Leading Causes of DeathAlbuquerque Area, CY 1996-1998

7.5

9.5

10.7

13.7

16.2

0 10 20



Diabetes Mellitus


Chronic Liver Dis.& Cirrhosis

Malignant Neoplasms



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IHS Regional Differences in Indian Health2000-2001 Chart 4.11, p.56

Leading Causes of DeathNashville Area, CY 1994-1996

4.4

8.9

10.6

15.8

28.6

0 10 20 30




Diabetes Mellitus

Malignant Neoplasms



Age-Adjusted Death Rates per 100,000 Persons by Race, and Hispanic Origin for Unintentional Injuries: U.S. - 2002

36.9 37.5 36.9

53.8

17.9

30.7

0

10

20

30

40

50

60



Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



Age-Adjusted Death Rates per 100,000 Persons by Race for Unintentional Injuries: U.S. & IHS Service Area - 1997

30.1 29.6

58.5

82.2

94.7

0

10

20

30

40

50

60

70

80

90

100


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



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Unintentional Injuries Age-Adjusted Death Rates, per 100,000 Persons

U.S. and Selected States, 1995-1997

30.336.7

33.029.8 30.033.736.7

0.0

33.5

57.4

133.1

11.016.4

0.0

17.8

28.8

0.0

31.4

0

20

40

60

80

100

120

140

US SD TX

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns

TotalWhiteBlackAI/ANAsian/PIHispanic



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Unintentional Injuries Age-Adjusted Death Rates per 100,000 Persons U.S. and Selected States

1995-1997

30.3

51.4

23.029.8

48.2

22.2

36.731.1

26.8

57.4

99.1

0.0

16.4

0.0

13.1

28.8

60.4

9.0

0

20

40

60

80

100

120

US NM MD

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns



Age-Adjusted Death Rates per 100,000 Persons by Race, and Hispanic Origin for Motor Vehicle-Related Injuries: U.S. - 2002

15.7 16.0 15.0

28.8

8.4

15.2

0

5

10

15

20

25

30



Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



Age-Adjusted Death Rates per 100,000 Persons by Race forMotor Vehicle-related Injuries: U.S. & IHS Service Area - 1997

15.9 15.9

32.3

46.6

54.8

0

10

20

30

40

50

60


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons


Age-Adjusted Death Rates per 100,000 Persons by Race, and Hispanic Origin for Suicide: U.S. - 2002

10.912.0

5.3

10.2

5.4 5.7

0

5

10

15



Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



Age-Adjusted Death Rates per 100,000 Persons by Race for Suicide: U.S. & IHS Service Area - 1997

10.6 11.312.9

17.6

20.2

0

5

10

15

20

25


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



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Suicide Age-Adjusted Death Rates per 100,000 Persons, U.S. and Selected States¹ 1995-1997

10.8

19.7

10.311.6

16.0

11.3

6.6

0.0

6.9

12.7

41.2

6.26.2

0.0

6.16.7

0.0

5.2

0

5

10

15

20

25

30

35

40

45

US AK CA

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns




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Suicide Age-Adjusted Death Rates per 100,000 Persons, U.S. and Selected States , 1995-1997

10.8

14.8

6.7

11.6

15.0

7.26.6

0.0

4.7

12.7

0.0 0.0

6.2

0.0

3.9

6.7

16.3

4.1

0

2

4

6

8

10

12

14

16

18

US UT NJ

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns




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Suicide Death Rates for Males Ages 15-24 Per 100,000 Persons by Racial/Ethnic Group

1990-1997

0

10

20

30

40

50

60

1990

1991

1992

1993

1994

1995

1996

1997

Age

-Adj

uste

d D

eath

Rat

e pe

r 10

0,00

0 Pe

rson

s


CDC, ADMH, GHRSource: Health United States, 1999



Age-Adjusted Death Rates per 100,000 Persons by Race for Malignant Neoplasms: U.S. & IHS Service Area - 1997

125.6 122.9

86.6

107.5

124.0

0

25

50

75

100

125

150


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



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Age-Adjusted Malignant Neoplasm Death RatesCY 1994-1996

0 50 100 150 200 250

Bemidji

Billings

AberdeenAlaska

Portland

OklahomaNashville

Tucson

AlbuquerquePhoenix

Navajo

California



Actual




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All Cancer Age-Adjusted Death Rates per 100,000 Persons U.S. and Selected States¹

1995-1997

112.4121.5

167.9

0.0

172.5

83.6

205.0

20.2

76.1

0.0

58.6

77.4

0.0

89.4

125.1113.9

127.6124.9

0

50

100

150

200

250

US ND TX

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns




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Age-Adjusted Malignant NeoplasmDeath Rates

60

80

100

120

140

Per 100,000 Population

1973 ‘75 ‘80 ‘85 ‘90 ‘95Calendar Year

American Indians &Alaska Natives, Actual

U.S. All Races

American Indians & Alaska Natives, Adjusted


Age-Adjusted Death Rates per 100,000 Persons by Race, & Hispanic Origin for Diabetes Mellitus: U.S. - 2002

25.423.1

49.5

43.2

17.4

35.6

05

101520253035404550



Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



Age-Adjusted Death Rates per 100,000 Persons by Race for Diabetes Mellitus: U.S. & IHS Service Area - 1997

13.5 11.9

30.4

44.4

52.8

0

10

20

30

40

50

60


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



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Age-Adjusted Diabetes Mellitus Death RatesCY 1994-1996

0 20 40 60 80

Tucson

Bemidji

AlbuquerquePhoenix

Aberdeen

BillingsNashville

Navajo

OklahomaPortland

California

Alaska



ActualAdjusted forRace Miscoding



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AGE-ADJUSTED DIABETES DEATH RATESAmerican Indians and Alaska Natives, IHS Service Area

0

10

20

30

40

50

60

70

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Per 100,000 population(single-year rates)

Calendar Year

U.S. All Races

American Indians and AlaskaNatives, Actual

American Indians and AlaskaNatives, Adjusted



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Diabetes as Underlying Cause Age-Adjusted Death Rate per 100,000 Persons by

Racial/Ethnic Group – 1990-1997

0

5

10

15

20

25

30

35

1990 1991 1992 1993 1994 1995 1996 1997

Age

-adj

uste

d D

eath

Rat

e pe

r 10

0,00

0 Pe

rson

s




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Diabetes as Underlying CauseAge-Adjusted Death Rates

per 100,000 Persons in Michigan1989-1997

0

10

20

30

40

50

60

1990-92 1991-93 1992-94 1993-95 1994-96 1995-97

Age

-Adj

uste

d D

eath

Rat

es p

er 1

00,0

00 P

erso

ns




Age-Adjusted Death Rates per 100,000 Persons by Race for Diseases of the Heart: U.S. & IHS Service Area - 1997

130.5 125.9

102.6

132.9

157.1

0

25

50

75

100

125

150

175


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



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51


Age-Adjusted Diseases of the Heart Death RatesCY 1994-1996

0 50 100 150 200 250 300

Bemidji

Aberdeen

BillingsNashville

Oklahoma

AlaskaPhoenix

Portland

TucsonCalifornia

Navajo

Albuquerque



Actual




52



52


Age-Adjusted Heart Disease Death Rates

0

100

200

300


1973 ‘75 ‘80 ‘85 ‘90 ‘95

Calendar Year

American Indians & Alaska Natives, ActualU.S. All RacesAmerican Indians & Alaska Natives, Adjusted



53



53


Heart Disease Death Rates by Age and SexAmerican Indians and Alaska Natives (1994-1996)

0

1,000

2,000

3,000

4,000

5,000

<1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age


Male, AdjustedFemale, Adjusted



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Age-Adjusted Lung Cancer Death RatesCY 1994-1996

0 20 40 60 80

Bemidji

Billings

AlaskaAberdeen

Portland

OklahomaCalifornia

Nashville

PhoenixTucson

Albuquerque

Navajo


U.S. All Races (1995) = 38.3

Actual


IHS Adjusted Total - All Areas = 31.7



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55


Age-Adjusted Lung Cancer Death Rates

0

10

20

30

40


1973 ‘75 ‘80 ‘85 ‘90 ‘95Calendar Year

American Indians& Alaska Natives, Actual

U.S. All Races

American Indians & Alaska Natives, Adjusted



56



56


Life Expectancy at Birth, Both SexesCY 1994-1996

0 20 40 60 80

California

Oklahoma

NashvilleAlbuquerque

Navajo

PortlandAlaska

Phoenix

BillingsTucson

Bemidji

Aberdeen

Years

IHS Adjusted Total - All Areas= 71.1 (73.2)

65.1 (67.8)

66.9 (67.4)

67.2 (68.1)69.0 (69.7)

69.1 (70.0)71.0 (72.6)72.5 (72.7)

72.6 (73.5)72.7 (74.8)74.3 (79.5)

76.4 (81.7)

U.S. All Races (1995) = 75

64.8 (65.2)


NOTE: Actual life expectancies (i.e., not adjusted for miscoding of Indian race) are shown in parentheses.



57



57


Life Expectancy at Birth, MalesCY 1994-1996

0 20 40 60 80

California

Oklahoma

AlbuquerqueNashville

Portland

NavajoPhoenix

Alaska

BillingsBemidji

Tucson

Aberdeen

Years


62.2 (62.6)62.4 (65.1)

63.6 (64.5)

65.6 (66.5)65.8 (66.6)

68.3 (68.5)

68.6 (70.3)

69.4 (71.7)69.9 (70.2)70.8 (75.9)72.5 (78.2)

U.S. All Races (1995) = 72.5

60.6 (61.0)





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58


Life Expectancy at Birth, FemalesCY 1994-1996

0 20 40 60 80

California

Oklahoma

NavajoNashville

Albuquerque

PortlandAlaska

Phoenix

TucsonBillings

Aberdeen

Bemidji

Years


70.0 (70.4)

70.8 (71.7)

72.0 (72.5)72.3 (73.0)

73.0 (73.8)73.4 (74.8)

75.8 (76.6)76.0 (77.9)

76.7 (76.8)

77.5 (82.6)80.2 (84.9)

U.S. All Races (1995) =

67.8 (70.5)





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59


Life Expectancy at Birth, FemalesCY 1994-1996

0 20 40 60 80

California

Oklahoma

NavajoNashville

Albuquerque

PortlandAlaska

Phoenix

TucsonBillings

Aberdeen

Bemidji

Years


70.0 (70.4)

70.8 (71.7)

72.0 (72.5)72.3 (73.0)

73.0 (73.8)73.4 (74.8)

75.8 (76.6)76.0 (77.9)

76.7 (76.8)

77.5 (82.6)80.2 (84.9)

U.S. All Races (1995) =

67.8 (70.5)





60



60


Years of Potential Life Lost RatesCY 1994-1996

0 50 100 150

Aberdeen

Tucson

BemidjiPhoenix

Alaska

BillingsNavajo

Albuquerque

PortlandNashville

Oklahoma

California

Rate per 1,000 Population Under 65 Years of Age


Actual




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Infant Health• What goes into ensuring a healthy infant?

– Prenatal care– Nutrition

• Breastfeeding– Freedom from poverty– Adequate child care– Health insurance– Preconception care



62



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Fetal death definitions

• Spontaneous abortions or miscarriages –early loss of pregnancy during first few weeks of gestation

• Fetal deaths – death between 20-27 weeks gestation

• Late fetal death – stillbirth 28+ weeks gestation



63



63

Infant Mortality Definitions

• Infant mortality – number of infant deaths per 1,000 live births

• Neonatal mortality – deaths in the first 27 days of life per 1,000 live births

• Postneonatal mortality – deaths from 28 to 364 days per 1,000 live births


Infant Mortality Rates per 1,000 Live Births by Race, and Hispanic Origin of the Mother: U.S. - 2002

7.05.8

13.8

8.6

4.85.6

0

5

10

15



Native


Hispanic

Infa

nt M

orta

lity

Rat

e pe

r 1,0

00 L

ive

Birt

hs



65



65

Infant Mortality Rates: 1972-94

0

5

10

15

20

25

72-74

73-75

74-76

75-77

76-78

77-79

78-80

79-81

80-82

81-83

82-84

83-85

84-86

85-87

86-88

87-89

88-90

89-91

90-92

91-93

92-94

Rat

e p

er 1

,00

0 L

ive

Bir

ths

American Indian US All races White

Source: Trends in Indian Health 1997



66



66

Postneonatal mortality rates: 1972-94

02468

101214

72-7473-7574-7675-7776-7877-7978-8079-8180-8281-8382-8483-8584-8685-8786-8887-8988-9089-9190-9291-9392-94

per

1,00

0 liv

e bi

rths

A/AN US all races White

*

Source: Trends in Indian Health 1997* after adjusting for racial miscoding



67



67

Postneonatal Mortality Rates: 1972-96

0

2

4

6

8

10

12

90-92

91-93

92-94

93-95

94-96

Rat

e p

er 1

,00

0 L

ive

Bir

ths

AI/AN US All races White

***

Source: Trends 1998*Adjusted for Miscoding



68



68

IMR declines• Congenital anomalies declined 39% from 1979

to 1997

• SIDS fell by 42% from 1992

• RDS declined by 64% since 1989 due to new medical treatments

• largest difference in birth weight specific IMRsbetween black and white has been infants over 2500 g (2.5 & 4.2)

Source: Guyer, B et al, Pediatrics 12-98



69



69

American Indian and Alaska Native Infant Mortality and SIDS

• Infant mortality has declined dramatically since the 1950’s

• The gap between the White and AI/AN rates has increased

• AI/AN have the highest post neonatal mortality rate

• SIDS rate 3 times the White rate

Source: Trends in Indian Health 1997



70



70

Leading causes of AI/AN infant death (1995-1996)

0.4

0.4

0.6

2

2

0.1

0.2

1

1.7

0.9

0.1

0.2

0.7

1.6

0.7

0 0.5 1 1.5 2 2.5

Pneumonia

Accidents

Disorders-short gest./LBW

Congenital Anomalies

SIDS

Rate per 1,000 live births

AI/AN US all races White

Source: Trends in Indian Health 1998after adjusting for racial miscoding



71



71

LBW causes• Prematurity – infant born too soon

– 36 weeks or less– Less than 32 weeks for extreme prematurity

• Intrauterine growths retardation – born too small– Small for Gestational Age (SGA) rank in

lowest 10th percentile– Developmental problems



72



72

Birth weight

6

12.7

7.3

10.3

6.2

11.5

02468

101214

<2500 g >4000

wt grams

perc

ent

AIAN US all races White

Source: Trends 1998



73



73

AI/AN (1992-1994) Age-Adjusted Mortality Rates Compared to U.S. All Races (1993)

Source: Trends in Indian Health, 1997

1.11.61.7

3.13.3

4.45.3

0 1 2 3 4 5 6

Cardiovascular Diseases

Pneumonia & Influenza

Suicide

Accidents

Diabetes Mellitus

Chron. Liver Disease & Cirrhosis

Tuberculosis, All Forms

Ratio



74



74

TB Case Rates* among American Indians/Alaska Natives, and the U.S.,

1986-2001

0

5

10

15

20

25

TB C

ase

Rat

e*

1986

AI/AN

U.S.

2001

Year

*TB Case Rate = TB cases per 100,000 population



75



75

Percentage TB Cases in AI/AN,U.S.-Born Patients Only,United States, 1993-1999

D.C.

81%81%

24%24%

11%11%

16%16%55%55% 30%30%

8%8%

43%43% 24%24%

7%7%79%79%

23%23%

11%11%

5%5%12%12%

Average percentage posted if at least 5% for 1993 -1999

Source:Trends in Indian Health, 200-2001, General Mortality Stats, Part 4, Table 4.11 Age-Adjusted Death Rates, p69.


Age-Adjusted Death Rates per 100,000 Persons by Race for Tuberculosis (TB): U.S. & IHS Service Area - 1997

0.30.2

1.5 1.5

0

1

2

All Races (US) White (US) AI/AN UnAdjusted IHSService Area (IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons


Age-Adjusted Death Rates per 100,000 Persons by Race, and Hispanic Origin for

Chronic Liver Disease and Cirrhosis: U.S. - 2002

9.4 9.68.5

22.8

3.2

15.4

0

5

10

15

20

25



Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



Age-Adjusted Death Rates per 100,000 Persons by Race for Chronic Liver Disease and Cirrhosis:

U.S. & IHS Service Area - 1997

7.4 7.3

20.6

31.7

36.4

0

5

10

15

20

25

30

35

40


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons


Age-Adjusted Death Rates per 100,000 Persons by Race, & Hispanic Origin for Influenza & Pneumonia: U.S. - 2002

22.6 22.624.0

20.4

17.519.2

0

5

10

15

20

25



Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



Age-Adjusted Death Rates per 100,000 Persons by Race for Influenza & Pneumonia: U.S. & IHS Service Area - 1997

12.9 12.413.4

19.821.5

0

5

10

15

20

25


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



81



81

Pneumonia and Influenza Age-Adjusted Death Rate per 100,000 Persons by

Racial/Ethnic Group 1990-1997

0

5

10

15

20

25

1990 1991 1992 1993 1994 1995 1996 1997

Age

-Adj

uste

d D

eath

Rat

e pe

r 10

0,00

0 Pe

rson

s


Source: Health United States, 1999 CDC, ADMH, GHR


Age-Adjusted Death Rates per 100,000 Persons by Race, and Hispanic Origin for

Human Immunodeficiency Virus (HIV) Disease: U.S. - 2002

4.9

2.6

22.5

2.20.8

5.8

0

5

10

15

20

25



Native


Hispanic

Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



Age-Adjusted Death Rates per 100,000 Persons by Race for Human Immunodeficiency Virus (HIV) Disease:

U.S. & IHS Service Area - 1997

5.8

3.3

2.42.9

3.3

0

1

2

3

4

5

6

7

8


(HUS)


(IHS)


Age

-Adj

uste

d D

eath

Rat

e pe

r 100

,000

Per

sons



84



84

Human Immunodeficiency Virus Infection Age-Adjusted Death Rates per 100,000 Persons by

Racial/Ethnic Group 1994-1997

0

10

20

30

40

50

60

1994

1995

1996

1997

Age

-Adj

uste

d D

eath

Rat

e pe

r 10

0,00

0 Pe

rson

s



Total Enrollment of Minorities in Schoolsfor Selected Health Occupations: Nursing, Registered

According to Detailed Race, and Hispanic Origin: U.S. 2001-2002

100.0

78.4

11.8

1.1 3.8 4.9

0102030405060708090

100

All Races White Non-Hispanic

AfricanAmerican

Non-Hispanic

AmericanIndian

Asian Hispanic /Latino

Perc

ent D

istri

butio

n of

Stu

dent

s


Total Enrollment of Minorities in Schoolsfor Selected Health Occupations: Dentistry


100.0

65.3

4.90.4

23.5

5.9

0102030405060708090

100


AfricanAmerican

Non-Hispanic

AmericanIndian


Perc

ent D

istri

butio

n of

Stu

dent

s


Total Enrollment of Minorities in Schoolsfor Selected Health Occupations: Medicine (Allopathic)


100.0

63.2

7.20.8

19.9

6.4

0102030405060708090

100


AfricanAmerican

Non-Hispanic

AmericanIndian


Perc

ent D

istri

butio

n of

Stu

dent

s


Total Enrollment of Minorities in Schoolsfor Selected Health Occupations: Medicine (Osteopathic)


100.0

75.9

3.7 0.6

16.4

3.50

102030405060708090

100


AfricanAmerican

Non-Hispanic

AmericanIndian


Perc

ent D

istri

butio

n of

Stu

dent

s


Percent Distribution of Enrollment of Minoritiesin Medical, Dental, and Nursing Schools

by Race/Ethnicity 2001-2002

63.2 65.3

78.4

7.2 4.9

11.8

0.8 0.4 1.1

19.923.5

3.86.4 5.9 4.9

0

10

20

30

40

50

60

70

80

Medicine (Allopathic) Dentistry Nursing

WhiteBlackAI/ANAsianHispanic



90



90

Indian Health Service (IHS)



91



91

Indian Health Service

• Part of the Dept. of Health and Human Services since 1955

• Federal health care provider for eligible AI/AN– Member of federally recognized tribes

(560)– Not an entitlement program



92



92

Indian Health Service

• 2001 IHS Service Population:1,540,000

• ~200 facilities in 35 states–Mostly on reservation lands–36 urban programs in 20 states



93



93

IHS Per Capita AppropriationsIHS Appropriations Per Capita Compared to Other Federal Health Expenditure

Benchmarks

$0

$1,000

$2,000

$3,000$4,000

$5,000

$6,000

$7,000

MedicareExpendituresper Enrollee

Medical Carefor Veterans

AdministrationUsers

US Per CapitaExpendituresfor Personal

MedicalServices

Acute MedicalCare for

MedicaidEnrollees

Medical Carefor Federal

Prison Inmates

FEHB MedicalCare

Benchmark perIHS User

IHSAppropriations& Collections

Per User

5,915

1999

5,214 5,065

1999

3,879

1998

3,803

1999

3,725

1999 1,914619Med

IHS20022001

Non-Med



94



94

Tribal Sovereignty &Self-Determination



95



95

Tribal Sovereignty

• Government to government relationship– Sovereign Nations

• Relationship is unique– Different from other communities – Different from other minority groups

IHS Epidemiology



96



96

1975 Indian Self-Determination Act (PL - 638)

• Gives tribes option to manage health care services in their communities

• Diminishes IHS presence in tribal affairs– Decentralizes IHS role in health services

delivery



97



97

Contracts and CompactsThree ways to manage health care services

1. IHS provides all health care services2. Contracts between IHS and Tribes

• Health care services are contracted3. Compacts

• Health care services are tribally run• 53% of IHS budget goes directly to Tribes• California and Alaska Areas are completely

compacted



98



98

Challenges in Indian Health I

• Under-funded– 1996 per capita healthcare expenditures

• U.S. - $3046• IHS - $1200

• Multiple jurisdictions– Tribal, state, federal– Quality of state and tribal relationships is variable

• Incomplete data– Racial misclassification– Data collection difficult

• Multiple jurisdictions• Limited technology & resources



99



99

Challenges in Indian Health II

Fragmented health care delivery systemsIHS Areas cross state boundariesUrban Indian programs, tribal programs

Limited access to services 1.5 million of 2.4 million AI/ANLimited urban programshigh staff turnover rates and vacancies



100



100

Why do Disparities Continue to Exist?• Multiple Causes; Social, Economic, Service.

• Disparities vary by state, region and causes vary by characteristics.

• Causes also vary for each racial/ethnic group and for subgroups of these groups.

• Many different persons and disciplines are involved in responding to health needs and not all understand the culture and needs of the population group they are working with.

• Language barriers exist.



101



101

Why do Disparities continue to Exist?(continued)

• States may not have the same resources and commitment.

• When many agencies are involved and/or accountable it may mean no one is accountable.

• Pervasive effects of poverty on health.• Access to health care varies for different age

groups and for different states.

• Differences in health care received.

• Health policy and the political arena.



102



102

Why Do We Need Natives (Ethnic Groups) in Public Health?

• Need to ensure that we ask the right questions, collect, analyze the data and interpret/disseminate the results to the public, especially those at greatest risk.

• Need to develop and evaluate interventions that are culturally appropriate and specific to the communities we are trying to serve.



103



103

Note:From the National Vital Statistics Report (NCHS), Deaths: Final Data for 1997, Volume 47, number 19, page 95, it is stated that:"Estimates of the approximate effects of the combine bias due torace misclassification on death certificates and under enumeration on the 1990 census areas follows:

White - 1.0 percent; Black - 5.0 percent; American Indian + 20.6; Asian or Pacific Islander, =10.7 (23)."

This indicates that these figures presented are seriously underestimated and the health problems could be seriously worse than indicated.



104



104

Tribal Sovereignty

Treaty Tribes have a Nation to Nation

relationship with the US. Government

Tribes are Sovereign Nations

States do not have jurisdiction on tribal lands

Movement towards Tribal Self-Governance

Tribes make and enforce your own Laws



105



105

Trust ResponsibilityThe general component of the Trust Responsibility relates to the United States unique legal and political relationship with federal–recognized Indians as part of treaties, statutes and executive orders.

The Supreme Court has noted that the federal government, as trustee, is “charged with moral obligations of the highest responsibility and trust.”

This responsibility provides a basis for the legal principle that ambiguities or doubts in statutes must be construed in favor of the Indians.

The Indian Tribal Justice Act, noted, that the general Trust Responsibility “includes the protection of the Sovereignty of each Tribal Government.”



106



106

Federal Indian Policy• 1608-1830, “Treaties” – The Marshall Trilogy

historic cases Johnson v. McIntosh, Cherokee Nation v. Georgia, and Worcester v. Georgia all recognized Indian Nations as Sovereign Entities.

The Supreme Court found that Tribes were no longer territorially separate from the United States.

Tribes (a) could not transfer lands to or sign treaties with any other colonizing power and (b) had placed themselves under the protection of the United States.



107



107

Federal Indian Policy (continued)• 1830-1850, “Removal Policy” – Indian

Removal Act policies moved the Tribes west of the Mississippi into the Louisiana and Northwest Territories.

• 1850-1871, “Removal Shifts to Reservation System” – Over 100 treaties created moving Tribes to new, smaller territories or confined them to smaller territories reserved from there aboriginal territory.



108



108

Federal Indian Policy (continued)• 1871-1928, “Assimilation and

Allotment Era” – The United States sold or gave Indian Land to non Indians to make Indians Assimilate into non-Indian communities. Resulted in (a) the loss of 90 out of 138 million acres of land and (b) the displacement of thousands of Indians.

• “Indian Reorganization Act of 1934” –The Act reaffirmed that tribal governments had inherent powers.



109



109

Federal Indian Policy (continued)• 1943 – 1968, “Termination” – Reversed many of

the reforms made in the 1930’s by terminating many federal state tribal relationships. Promoted assimilation of Indians into mainstream society.

• 1968 – Present – “Self Determination” – In 1968, PL 280 was amended to require the consent of Indian Nations before state could assume jurisdiction. This era of various presidential policy statements and legislative acts that benefited Indians, strengthened tribal governments, reaffirmed tribal sovereignty and ended the termination period.



110



110

Presidential Memorandum on Government-to-Government Relations with AI/AN Tribal Governments

• Operate within a government-to-government relationship with federally-recognized Tribes

• Consult, to the greatest extent practicable and to the extent permitted by law, with Indian tribal governments before taking actions that affect federally recognized tribes.

• Assess the impact of executive department and agency activities on tribal trust resources and assure that tribal rights and concerns are considered.

• Take appropriate steps to remove procedural impediments to working directly and effectively with tribal governments on activities that affect the trust responsibility and/or governmental rights of tribes.



111



111

Treat all men alike. Give them all the same law. Give them all an even chance to live and grow. All men were made by the same Great Spirit Chief. They are all brothers. The earth is the mother of all people, and all people have equal rights upon it.

Chief Joseph, Nez Perce

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