COVID-19 Risk Factors and Mortality among Native Americans

Leggat-Barr, K.; Uchikoshi, F.; Goldman, N.

BACKGROUND: Academic research on the disproportionate impact of COVID-19 among Native Americans has largely been restricted to particular indigenous groups or reservations. OBJECTIVE: We estimate COVID-19 mortality for Native Americans relative to other racial/ethnic groups and explore how state-level mortality is associated with known risk factors. METHODS: We use the Standard Mortality Ratio (SMR), adjusted for age and county, to estimate COVID-19 mortality by racial/ethnic groups for the U.S. and 10 selected states. The prevalence of risk factors is derived from the American Community Survey and the Behavioral Risk Factor Surveillance System. RESULTS: The SMR for Native Americans greatly exceeds those for Black and Latino populations and varies enormously across states. There is a strong correlation between the share of Native Americans living on a reservation and the SMR. The SMR for Native Americans is also highly correlated with the income-poverty ratio and the prevalence of multigenerational families, crowded housing, frontline worker status, and health insurance (excluding the Indian Health Service). Risk factors associated with socioeconomic status and co-morbidities are generally more prevalent for Native Americans living on homelands, a proxy for reservation status, than for those living elsewhere. CONCLUSIONS: Most risk factors for COVID-19 are disproportionately high among Native Americans, particularly for those living on homelands. Reservation life appears to increase the risk of COVID-19 mortality. CONTRIBUTION: We assemble and analyze a broader set of COVID-19-related risk factors for Native Americans than previous studies, a critical step toward understanding the exceptionally high COVID-19 death rates in this population.