American Indians and Alaska Natives in the United States live nearly four years less than official statistics would have you believe. In fact, their life expectancy (72.7 years) is closer to that of a typical citizen of El Salvador (72) than the U.S. (78).
That is according to a new study published in JAMA on Monday. The difference, the authors show, is a result of race and ethnicity data being misreported on death certificates.
Typically, American Indian and Alaska Native (AI/AN) mortality rates — and life expectancy — are calculated using race reported on the death certificate. In the sample that the authors analyzed, race and ethnicity data in 41% of AI/AN deaths were erroneously marked as “white.”
“What you have is the statistical equivalent of unmarked graves for thousands of American Indians who have died but are not observed in vital statistics as having died as American Indians,” said Jacob Bor, an associate professor of global health and epidemiology at Boston University School of Public Health and the study’s lead author.
The study analyzed data from the U.S. Census Bureau and the Centers for Disease Control’s mortality data spanning from 2008 to 2019. Bor and his co-authors paired the mortality data, with respondents’ self-identification of race, the gold standard for racial classification. Bor described the study as “work that seeks to make the invisible, visible.”
The study adds new insights to a long-standing field of research that seeks to better understand health disparities in the U.S. AI/AN populations have been subjected to centuries of oppression — from forced assimilation, being pushed off their land, cultural genocide, and now “statistical erasure” — a term the authors coin in the study.
Accounting for deaths that were mislabeled, the authors uncovered a widening of the gap between life expectancy for the AI/AN population and the broader U.S. population. From 2008 to 2010, the gap was 4.1 years, whereas between 2017 and 2019, the life expectancy gap grew to eight years. Although not a focus of the study, the authors acknowledged that beyond misclassification of race on death certificates, part of the gap may be explained by the rise in deaths from drug overdoses, diabetes, heart disease, and other causes.
The census data the team analyzed contained 3,100 deaths of individuals who self-identified as American Indian or Alaska Native, but only 2,600 of those were marked as AI/AN on their death certificates. There was a higher rate of misclassification for those who were older, lived in urban areas and outside a reservation, and had higher education levels. Similarly, those who died from heart disease were misclassified at the highest rate, while those who died from assault and what authors called “legal intervention” were least likely to be misclassified.
Siobhan Wescott, who directs the American Indian Health Program at the University of Nebraska Medical Center’s College of Public Health, told STAT that the study, which she was not part of, “was a breath of fresh air. It’s very good science on a topic that those who work in Indigenous health have been aware has been a problem for a long time.”
By utilizing self-identification data, the authors said, the power of defining a person’s race is placed back into the hands of the individual, rather than the funeral directors or coroners who typically fill out the paperwork. Although the data is disheartening, now “we have the study to help us make sure that we are really accounting for these problems with the reporting,” Wescott told STAT.
The authors point out that the self-identification of race — a social construct rather than a biological one — can fluctuate based on individuals joining and leaving tribes, for example. Bor called for more mortality linkages of national surveys — such as the American Community Surveys, which collect self-identified race data — and research that looks at specific tribes to better understand those more specific experiences.
Michael Bird, past president of the American Public Health Association, a member of the Kewa Pueblo tribe in New Mexico, and a study co-author, emphasized the importance of understanding the historical and cultural determinants of health, and not just the social determinants of health so many researchers focus on.
Bird has dedicated his life to bringing attention to the AI/AN communities through his work. He hopes that the study will spark conversation and answer his enduring question about why Indigenous people remain invisible: “Why are the first Americans the last Americans?”
