Shocking disparities: American Indians in North Dakota die 22.5 years younger than white residents

COVID-19, to be clear, has nothing to do with it. The study focuses on pre-pandemic mortality in North Dakota from 2010 to 2019 through analysis of death certificates. The data reveals significant differences in age-specific mortality rates and leading causes of death between American Indians and white residents.

Key findings:

• Median age at death: American Indian males die at a median age of 55, while white males die at 77. American Indian females die at a median age of 62, compared to 85 for white females. Overall, American Indians die 22.5 years younger than white residents in North Dakota.
• Leading causes of death: The top three causes of death for American Indians are diseases of the heart (21.7%), cancer (18.5%) and accidents (15.2%). For white residents, they are diseases of the heart (27.1%), cancer (25.9%) and Alzheimer’s disease (9.1%).
• Both young and old are affected: American Indians experience higher mortality rates across all age and sex groups for nearly all common causes of death.
• Influenza and pneumonia: American Indians have significantly higher rates, with rate ratios up to 15 times higher than white residents.
• Septicemia: American Indians experience rate ratios up to 38 times higher than white residents.
• Suicide: American Indians have rate ratios up to 15 times higher than white residents, particularly among young females (ages 5-14).
• Homicide: American Indians experience rate ratios up to 18 times higher than white residents, especially among those aged 25-34. Social implications: Lack of education, lack of health insurance and poverty contribute to health disparities. American Indians in North Dakota are less likely to have health insurance and experience higher poverty rates compared to white residents.
• It’s not just a Native issue, but in large part something tied to the specific situation of American Indians living in North Dakota or, more generally, in the Northern Plains region. There are key differences when compared to the rest of the United States, where mortality rates vary significantly for American Indians and Alaska Natives. Age-adjusted mortality rates for Native residents in Illinois, New Jersey and Texas are lower than other groups in those states. In states like North Dakota, South Dakota and Montana, mortality rates are significantly higher.

Geography plays a role: across the United States, 87% of the American Indian/Alaska Native population lives in urban areas. In North Dakota, less than 40% of American Indians live in urban areas, with over 60% residing on reservations.

Then there’s poverty. From 2015 to 2019, North Dakota as a whole had a poverty rate of 10.6%, the 10th lowest in the country. But American Indians in the state experience a higher poverty rate of 31.0%. Counties with the highest poverty rates in North Dakota include Sioux County, Rolette County and Benson County, which include all or part of the Standing Rock, Turtle Mountain and Spirit Lake Indian Reservations, respectively.

When you factor in COVID-19, the situation gets worse. American Indian and Alaska Native populations had the biggest drop in life expectancy in 2021, of 1.9 years, and that is across the entire country, not just the Northern Plains. American Indians had a life expectancy at birth of 65.2 years in 2021, equal to the life expectancy of the total U.S. population in 1944. The life expectancy for American Indian and Alaska Native populations has declined 6.6 years from 2019 to 2021.

Why trust this research? Beyond the credibility of the institutions that conducted the study, the research uses official data, publicly available population mortality data from the North Dakota Department of Health & Human Services Division of Vital Records and data from the U.S. Census Bureau. The methodology is fairly straightforward: the study uses standard statistical methods to calculate rates and rate ratios. The study has been funded by the National Institute of General Medical Sciences of the National Institutes of Health and a research seed grant from the School of Medicine & Health Sciences at University of North Dakota. The goal of the study is to inform and guide communities and providers on prevention, planning and policy efforts.

What don’t we know?

The authors acknowledge uncertainties that could affect the data. Misclassification of race and ethnicity on death certificates is a known challenge affecting public health data for American Indians. If individuals are incorrectly identified as white instead of American Indian (or vice versa), the mortality statistics are skewed.

The same is true for inaccuracies in census data, which can affect the population estimates used to calculate mortality rates. If the American Indian population is undercounted, mortality rates could be overestimated. Conversely, if the white population is undercounted, the mortality rates could be underestimated.

Potential errors go in one direction only, though. When data are adjusted to account for misclassification, American Indian mortality rates are even higher. This means that the unadjusted data presented in the study may underestimate the mortality disparities.

The social impact may be even more significant when factors beyond economics, education and healthcare access are considered, such as discrimination, historical trauma or cultural barriers to healthcare. These are more difficult to measure and quantify.

The most important unknown, however, is the current picture, meaning the disparity in North Dakota when COVID-19 pandemic data is factored in.