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COVID-19 Risk Factors and Mortality among Native Americans

Our take —

The study, available as a preprint and thus not yet peer-reviewed, sought to describe the COVID-19-related mortality disparity among Native Americans in the US. The study found a standardized mortality ratio of 2.77 compared to white populations, and this was even higher in some states, with South Dakota having a mortality ratio of 9.7 as compared to the white population. They found that the standardized mortality ratio was highly correlated with cthe perent of Native Americans living on reservations. The study had many limitations due to its ecological study design, including use of data collected as far back as 2014, and potential underreporting of Native American race/ethnicity. Regardless, results show a high level of disparity in Native American mortality from COVID-19 compared to other racial/ethnic populations in the US.

Study design

Cross-Sectional, Ecological

Study population and setting

The study sought to describe risk factors for COVID-19 infection and related mortality among Native American/American Indian communities in the US. COVID-19-related death counts from the National Center for Health Statistics from January 1, 2020, through January 16, 2021 were used. Midyear population estimates of 2019 were drawn from the US Census Bureau data from 10 states: Arizona, California, Oklahoma, New Mexico, Washington, New York, South Dakota, Minnesota, Utah, and Mississippi. The American Community Survey (ACS) and the Behavioral Risk Factor Surveillance System (BRFSS) were used to estimate potential risk factors that may impact transmission and mortality. For the ACS, the analysis used 2014 – 2018 data to estimate the type of health insurance, income-poverty ratio, and household living arrangements. They also extracted data on frontline worker status using data from 2018. They used the BRFSS from 2011 to 2018 to estimate smoking status and health conditions including asthma, chronic obstructive pulmonary disease (COPD), kidney disease, cancer, heart disease, diabetes, and obesity. More recent ACS or BRFSS versions were not yet available. Finally, they utilized data from MultiState, which generates a rating of open-ness during the pandemic based on state policies and capacity/industry restrictions. They categorized race as non-Latino Native American (including American Indian and Alaskan Native), non-Latino white, non-Latino Black, and Latino, and using the My Tribal Area tool, integrated 2014 – 2018 ACS estimates of Native Americans living on- vs. off-reservation. They generated standardized mortality ratios compared to the 3 other racial categories overall and by state. They disaggregated this based on reservation living status, occupation, and chronic health conditions and behavioral risk factors, generating correlation estimates for each.

Summary of Main Findings

In this study, 2,789 COVID-19-related deaths were estimated from January 1, 2020 to January 16, 2021 among Native Americans. They estimated a crude death rate of 1.63 times that among the US white population, and a standardized mortality ratio of 2.77. This was greater than the standardized mortality ratio within the Black population (1.64) and the Latino population (1.81). Stratifying by state, they found geographic differences as well, with South Dakota having the highest standardized mortality ratio at 9.7 compared to the state’s White population, while California had the lowest at 1.6 times the mortality to the state’s White population. The standardized mortality ratios for the 10 states were correlated with increasing percentages of Native Americans living on reservations (correlation = 0.8). In their sociodemographic and behavioral correlations, they found the income-poverty ratio was highly negatively correlated with the standardized mortality ratio (-0.86).

Study Strengths

The study made use of a wide range of data to describe the health disparities impacting Native Americans, an often underreported population. They disaggregated by meaningful variables indicative of structural risks of disease, such as living on a reservation which may impact access to health services, and living in multigenerational or crowded households, and having insurance. They also examined individual-level factors, such as clinical risks through COPD and diabetes.


The study’s primary limitation was that they used many different data sources which may have different reporting guidelines and criteria. Therefore, these results paint an overall picture of Native American health and health disparities, but do not generate individual-level estimates of risk factors and are limited to standardization by age and place alone.. They also limited their analysis to individuals reporting Native American as their only race, which likely underreports the true number of Native American people in the US. This standardization does not reflect differences in the underlying clinical health between white and Native American populations likely due to differences in access to health services and clinical care, and may be biased. They also used data from prior years going as far back as 2014 which may not reflect more recent trends in disease and social factors.

Value added

This is a large study of Native American people in the US, reflecting the health disparities they face compared to white and other racial/ethnic groups.

This review was posted on: 8 April 2021