In the U.S., American Indian and Alaska Native populations experience some of the worst health outcome disparities. Indigenous populations have the lowest life expectancy of all racial groups and experience disproportionate burdens for chronic conditions like cardiovascular disease—a term that encompasses several diseases of the heart and blood vessels. 

To evaluate these disparities, LDI Senior Fellows  Lauren A. Eberly,  Sameed Ahmed M. Khatana, Judy A. Shea, Peter W. Groeneveld, and colleagues used Medicare administrative data and the Distressed Communities Index to assess trends in the incidence and prevalence of cardiovascular disease among American Indian and Alaska Native Medicare beneficiaries from 2015 to 2019.

Investigators found evidence for significant levels of cardiovascular disease and risk burden for these Medicare beneficiaries. These results suggest an urgent need to implement strategies that reduce disparities and prioritize this population’s cardiovascular health.

To learn more, we asked first author Lauren A. Eberly, a cardiologist at the University of Pennsylvania as well as a staff cardiologist for the Indian Health Service (IHS) at Gallup Indian Medical Center, about the significance of their research and how it can inform our commitments to health equity and justice.

What motivated you and your colleagues to conduct this research? 

Eberly: While we know that structural racism pervades our health care system, and cardiovascular disparities are in many cases worsening, the cardiovascular health of American Indians and Alaska Natives has been severely understudied. Efforts to improve health have not been prioritized. Given this, we wanted to better understand the state of cardiovascular health in these groups to help inform future equity efforts. 

This work is meaningful for me, as I am originally from New Mexico and now work as a cardiologist with IHS in the Eastern Navajo Nation in New Mexico. I have seen first-hand the impacts of settler colonialism on cardiovascular health and continue to be struck daily by the incredible level of cardiometabolic risk factors such as obesity and diabetes, and subsequent cardiovascular disease.  

While we continue to reckon with a legacy of racial injustice in the U.S., the topic of settler colonialism and its ongoing impacts on health are not often part of mainstream academic discourse. In this study, I wanted to call attention to the larger sociopolitical context in which settler colonialism serves as a principal upstream driver of Indigenous health inequities. Our work, while focusing on cardiovascular health, shows how settler colonialism serves not only as a foundation, but as an ongoing, oppressive system of power that fuels poverty and poor health in Indigenous communities.

What are the study’s most important findings? How does it stand out from other studies? 

Eberly: In the 1990s, before our work, there were landmark studies from the Strong Heart Study, which previously had provided the largest population-based cohort of American Indian patients. From this, we learned that American Indian patients had double the incidence of coronary heart disease compared with other racial groups. However, these findings are now over two decades old, and before our work, there were no large cohort studies in the current era investigating the burden and outcomes of cardiovascular disease among Indigenous patients. 

Our paper—unfortunately but not surprisingly—confirmed a significant burden of cardiovascular disease and cardiometabolic risk factors. In fact, half of the patients carried a diagnosis of severe cardiovascular conditions (either coronary artery disease, heart failure, or atrial fibrillation). The prevalence of these three illnesses was high, with over 40% of patients having a diagnosis of coronary artery disease and 27% with heart failure during the study period. While we did not examine other racial groups in our study, these rates exceeded previously reported rates of other racial groups in the U.S. 

Furthermore, we found the incidence of heart failure is rising in this population, as is the incidence of acute myocardial infarction—or heart attacks. The rising incidence of heart failure in the study population is alarming and stands in clear contrast to prior evidence of a declining incidence of heart failure among all other Medicare beneficiaries.  

The prevalence of cardiovascular risk factors was also striking, with 45% having a diagnosis of diabetes, 61% hyperlipidemia (high cholesterol), and 72% with hypertension (high blood pressure) during the study period. These results call for action, as inequities in cardiovascular disease and outcomes will keep worsening without immediate strategies to reverse them.

What is the clinical, social, economic, and political significance of your study?

Eberly: It’s critical to acknowledge the underlying sociopolitical, environmental, and economic drivers of these findings, all rooted in settler colonialism. Academic discourse often has been dominated by settler academics erroneously attributing native biological differences as a main driver of Indigenous health inequities. However, settler colonial determinants of health are the root cause of the disease burden in our study. We have to contextualize these findings within a history of broken treaty obligations, forced displacement, land theft, exclusionary governmental policies, and Indigenous genocide, which have all concentrated poverty and fueled health inequities. 

Settler colonialism, however, is not a thing of the past, but an enduring structure of oppression that continues to drive inequitable health outcomes. We hope that our studies will push those in our academic and public health community to acknowledge these contemporary impacts. We are long overdue for a reckoning to rectify the historical and ongoing harm within Indigenous communities.

What are common limitations to studying disease burden in Indigenous groups?

Eberly: Many clinical and administrative databases are problematic for evaluating for racial inequities because of  how race is coded. Often the gold standard of self-identified race is not used. Therefore, many databases have low validity for certain racial groups, particularly for American Indian people. Furthermore, American Indian or Alaska Native people are often not even included in many clinical or administrative databases as a unique racial category or are assigned to an “other category.” Furthermore, the American Indian population represents a heterogeneous and diverse group. Due to limitations of the database (and many administrative databases), we could not evaluate differences based on tribal affiliations, which have been linked to differential disease risk (i.e., when risk factors and  symptoms match more than one condition).

The IHS and tribal entities have robust data that enable a more reliable study of disease burden. However, access to this data is protected and strictly regulated, as it should be. There is appropriately a lot of mistrust when it comes to conducting research in Indigenous communities due to a long history of exploitative practices, with high rates of neocolonial (i.e., helicopter) research. Community-based and tribal partnerships are critical not only to access data and understand the health of this population, but also to ensure that the work benefits the subjects. In addition, accurate population-based estimates of disease burden are challenging to obtain; American Indians and Alaska Natives have severely worse access to care for 62% of access measures, so their burden of diseases is often underestimated.

What are some potential strategies that could advance health equity and justice for Indigenous populations?

Eberly: Our team presented some of our work at the Navajo Nation research conference on October 18, and Kim Russell, Executive Director of the Navajo Department of Health, shared these important words: “The solutions to Native health inequities lies within Indigenous communities.” 

Strategies in Native communities must be community-designed, and led, while promoting decolonization and tribal sovereignty. Strategies that integrate traditional healing into Western medicine, such as the Navajo Wellness Model, have proven more effective in improving health in these groups. Strategies incorporating promotion of Indigenous knowledge and traditional cultural practices have reduced chronic diseases and cardiometabolic risk factors, and should be expanded on a broader scale. 

These strategies must be coupled with pathways that center decolonization and targeted investment in Native communities to address the upstream drivers of health. 

For example, poverty and food insecurity are endemic in any Indigenous community—as a direct result of land theft, broken treaty obligations, forced displacement, and ongoing exclusionary governmental policies. The key to addressing upstream sociopolitical drivers of health must include strategies that center reparative justice frameworks in order to rectify legacies of injustice, which includes repatriation of Indigenous land as a central tenet. 

What work do you or others plan to do next? 

Eberly: As part of an Indian Health Service Innovations Project award, we are evaluating the burden of heart failure in the Navajo Nation and are now implementing a community-designed care delivery program to improve care at IHS sites in the Navajo Nation. We are also partnering with tribal entities, and will be traveling to Navajo Chapter Houses throughout the Eastern Navajo Nation to expand our stakeholder taskforce to members throughout remote parts of the Navajo reservation. This will allow us not only to understand the barriers of assessing cardiac care, but also to co-design strategies to overcome such barriers and improve care delivery in the Navajo Nation, as well as throughout the IHS.  

Disclaimer: These responses reflect the personal views of Dr. Eberly, not the Indian Health Service.

---

The study, “Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries,” was published on September 22, 2023 in JAMA Network Open. Authors include Lauren A. Eberly, Kaitlyn Shultz, Maricruz Merino, Maria Ynes Brueckner, Ernest Benally, Ada Tennison, Sabor Biggs, Lakotah Hardie, Ye Tian, Ashwin S. Nathan, Sameed Ahmed M. Khatana, Judy A. Shea, Eldrin Lewis, Gene Bukhman, Sonya Shin, and Peter W. Groeneveld.

---

Author

---