摘要：American Indian and Alaska Native (AI/AN) death rates declined over most of the 20th century, even before the Public Health Service became responsible for health care in 1956. Since then, rates have declined further, although they have stagnated since the 1980s. These overall patterns obscure substantial regional differences. Most significant, rates in the Northern and Southern Plains have declined far less since 1949 to 1953 than those in the East, Southwest, or Pacific Coast. Data for Alaska are not available for the earlier period, so its trajectory of mortality cannot be ascertained. Socioeconomic measures do not adequately explain the differences and rates of change, but migration, changes in self-identification as an AI/AN person, interracial marriage, and variations in health care effectiveness all appear to be implicated. When the US Public Health Service (PHS) assumed responsibility for the health care of American Indians and Alaska Native (AI/AN) persons in 1955, it undertook a large study of conditions that, although subject to many of the same reporting and definitional problems with which researchers continue to struggle, remains a useful source of baseline information from which to measure change. 1 Evidence in the 1950s indicated that (1) American Indians had higher mortality than non–American Indians (Alaska Natives were not included in the original study), (2) they were more likely to die from communicable than noncommunicable diseases, and (3) regional differences existed in both socioeconomic and health conditions that were largely explained by regional ecologies and histories of contact with non-Natives and by differences in regional economies. Here, we briefly review some of the results of the original study and subsequent changes. We also consider current regional differences in causes of death amenable to health care interventions, although we do not analyze the overall impact of health care interventions on either change in total mortality or regional differences in mortality decline since 1950. The available evidence indicates, however, that health care has had a beneficial impact, especially on the decline in childhood and infectious diseases. 2–5 “Amenable deaths” are deaths that ought to be avoidable if a health care system is providing adequate and timely services appropriate to the needs of its public. Health services include prevention and primary, secondary, and tertiary care; clinical and public health programs; and care provided by voluntary organizations, ambulance services, and the like. Amenable deaths are sentinel events: they should alert providers and the public to potential problems with the health care system that deserve further scrutiny. 6 Circumstances other than limitations of the health care system may be involved in causing amenable deaths—for example, the reluctance of the public to use services. Nonetheless, these events may well reflect problems in the health care system, and when comparisons among regions and populations reveal large differences in rates, they ought to be investigated with an eye to correcting whatever deficiencies have been found. We describe the different regions in which AI/AN persons live and the ways in which those different contexts appear to have influenced mortality in the 1950s and the changes since then. We argue that variations in socioeconomic conditions across regions do not by themselves adequately explain regional differences in mortality, which require much greater understanding of, among other factors, biases in both reporting of deaths and identification of AI/AN race in the US Census and differences in tribal enrollment criteria, migration, and health care.
