An Under-the-Radar Disparity: Mortality among American Indian and Alaska Native adults.

Today is Indigenous Peoples' Day in the United States. There are many ways to observe this day and I spent some time thinking about what to share with you. (The other context is that I am in the midst of writing a large manuscript about pandemic disparities, along with a team of brilliant experts—so I have been especially thinking about these issues lately.)

Something many people do not “get” is the extent of the mortality disparities endured by American Indian/Alaska Native people in the US. It may not be comfortable, but I think it is important that we confront the reality of the situation, rather than shielding our eyes from the truth. I hope this graph I made helps…

Data: CDC. Image: Inside Medicine .

The graph shows all-cause mortality per capita for adults ages 25-64 by race over a four-year period. I excluded seniors (ages 65 and older) on purpose because I think the American Indian/Alaska Native mortality disparity in younger adults often gets overlooked. (As an aside, my colleagues and I also published a study in the Journal of the American Medical Association this year in which we pointed out the overall disparities that affect Black or African American people in the US; indeed, when you look at all ages—controlling for differences across populations—Black people have the highest mortality of any group. That deserves much attention, and over time, that issue has finally started to receive some).

But we equally cannot afford to ignore a similarly harrowing disparity among younger adults in the American Indian/Alaska Native population. Simply put, the younger (non-geriatric) adult American Indian/Alaska Native population is at risk of having its disparities ignored—including in some major public-facing datasets—because young people die at lower rates than older people who drive the overall composite numbers you’ll often see reported. (Even adjusting for age does not fix this problem, but that’s beyond the scope of what we can cover here.)

Meanwhile, the reason that mortality disparities in seniors are not as apparent in the American Indian/Alaska Native population (and also in the Black and Native Hawaiian, Pacific Islander populations) stems from an insidious epidemiologic phenomenon called the “healthy survivor effect.” In short, disparities among White seniors as compared to the rest of the older population are markedly blunted—and in some groups even reversed—because if you are American Indian/Alaska Native, Black, or Native Hawaiian, Pacific Islander, you might not “get” to survive into retirement age. And the ones that do? They’re damn healthy people. By comparison, if you are White and have a bunch of complicated medical problems, you are far more likely to be able to survive into your 80s and 90s (let alone your 60s or 70s). But as a result, the geriatric White population has a very high mortality rate. Think about it. It’s “better” for a population to have a high mortality rate among 85-year-olds than a low one that resulting from the fact that most people from the parent demographic have already long been dead by then. Growing old is not equally likely in all demographics in this country, despite all of our advances and wealth as a society.

So, as we think about our country on this day, I think it’s appropriate to acknowledge that we could be (and should be) doing a lot better by way of taking care of everyone who is here, whether they are first generation, First Nation, or anything in between.