White Coat Underground

Swine flu—unequal killer

One of my favorite publications is the Morbidity and Mortality Weekly Report (MMWR). It’s put out weekly by the CDC and allows for rapid communication of emerging or interesting health trends. This week the CDC is reporting an extraordinary death rate from influenza in American Indians/Native Alaskans (AI/NA). Collecting data like this presents several challenges, including under-reporting of AI/NA ethnicity and under-reporting of H1N1 as a cause of death, which makes the data even more sobering.

The death rate from H1N1 among AI/NA is 3.7 per 100,000 population, compared with 0.9 per 100,000 for all other ethnicities combined. This is probably an under-estimate.

Many native populations carry a high burden of high-risk health problems such as diabetes which are associated with complications of influenza. In fact, NA/AI have twice the rate of diabetes as the rest of the population (over 45%). However, the trend of H1N1 mortality is also true for other indigenous populations, such as native Australians. This would seem to implicate poverty, marginalization, and other social factors in the disparity in mortality.

In some ways, this is a good thing. We can’t change genetics, but we can improve social disparities—if we really want to.


  1. #1 Danimal
    December 15, 2009

    “One of my favorite publications is the Morbidity and Mortality Weekly Report”

    Wow, you must be a real hoot at parties, doc!

  2. #2 davidp
    December 15, 2009

    Yeah, real fun social reading. I know the elderly read the death notices, but I thought that was for gossip and keeping score.

    Diabetes, poverty, and poor health services for native Australians not living in towns are important. Another contributing factor for native Australians, American Indians and Native Alaskans may be genetic – Eurasians and Africans co-evolved with influenza. American and Australian natives did not, resulting in serious death rates from these and other eurasian diseases when colonised. How relevent this is must depend on the level of native vs Eurasian genes in the genetics of the individuals’ immune systems.

  3. #3 gmm
    December 16, 2009

    We had the same sorts of figures at the beginning of the h1n1 outbreak- First Nations canadians were being affected at a higher rate. In some responsive fashion, Health Canada sent out kits to reserves with body bags- one chief was pretty upset by this and a whole lotta trouble went on. Lately I have seen very little in the news regarding how the second wave hit our reserve populations, or First Nations in general. Hmm………….you just gave me something else to peek around for.

  4. #4 Mu
    December 16, 2009

    That first line is priceless; you better make sure that PalKid never gets to read your stuff or the “what my father does for a living” homework assignment will get you some really interesting calls from the principals office.

  5. #5 justme
    December 16, 2009

    Don’t let them razz ya, Dr.L … the MMWR can be very interesting reading, especially when truth seems stranger than fiction!

  6. #6 Prometheus
    December 16, 2009

    The last line worries me.

    “This would seem to implicate poverty, marginalization, and other social factors in the disparity in mortality.”

    If you look at the latest comparisons between the U.S. Pima populations and Mexico’s Pima (geographically separated conveniently right at European incursion) prosperity (by European definition) and inclusion in the great American tradition of sitting on your butt seems to be killing off the U.S. tribe.

    Inactivity is a 600 calorie a day difference and something like a 25% greater carbohydrate intake.

    To their credit the Pima are trying everything, from getting the kids to do mandatory laps the moment they get off the bus, to traditional diet school lunches, to volunteering en masse (pardon the expression) for any study, testing protocol, survey etc. that has a remote chance of saving the tribe.

  7. #7 Shay
    December 16, 2009

    I just had my first copy of Morbidity, etc show up in the inbox at work. I wish someone had warned me not to read it over lunch.

  8. #8 alterity
    December 16, 2009

    How can a higher rate of diabetes be due to social disparities? I don’t understand how you jump to that conclusion. IMO, it must be due to other factors, primarily genetic.

  9. #9 PalMD
    December 16, 2009

    There are myriad reasons that SES contributes to mortality. Dr. Tony Iton for example has presented fascinating data on geographic distribution of income, ethnicity, and mortality. For example, markets with healthy foods are very hard to find in many communities, and fresh produce is much more expensive than chef boyardee.

  10. #10 Prometheus
    December 17, 2009

    “IMO, it must be due to other factors, primarily genetic.”

    After 40 years of hunting for the “thrifty gene” I am starting to suspect we are looking at the wrong genome.The metabolic distinction may be in the microbial digestive culture. I don’t base this on anything other than it is becoming the only place we have not looked.

    If you look at the recent revolution in the time periods required to evolve metabolic variation in our bacterial guests it extrapolates out to native americans and others being behind the time curve when slammed with a completely different diet.

    The good news is that if this wild conjecture proves true it is not only correctable but ultimately self correcting.

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