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For more than a decade, Americans have been dying younger than people in other developed countries. Researchers attribute much of this rise in mid-life deaths to what are called "deaths of despair" — that is suicides, drug overdoses and deaths from alcoholic liver disease — among middle-aged white Americans.

But a study published last week in The Lancet shows that these premature deaths have affected American Indian and Alaska Native communities far more than white communities.

"The whole sort of premise of the 'death of despair' idea that this is unique to white communities really didn't stand up when we took a close look at the data," says Dr. Joseph Friedman, a physician and researcher at the University of California Los Angeles.

"The Lancet article underscores a number of things that we've known for a substantial period of time, but have never articulated it in such a sharp fashion," says Spero Manson, director of the University of Colorado's Centers for American Indian and Alaska Native Health who wasn't involved in the new study.

The idea that the rise in deaths of despair was the highest in middle aged white Americans was put forward by two Princeton economists in a study published in 2015. They had looked at death rates for 45-54 year-olds from 1999-2013, and compared the numbers by race and ethnicity.

"Ideally no one should die in that age group, certainly not of overdose, suicide and alcoholic liver disease," says Friedman.

When he and his colleagues analyzed the mortality data more closely, they found that American Indians and Alaska Native people had been completely left out of the analysis in the original study. And the midlife mortality rates for these groups were far higher than among whites.

"In the same period that deaths among white Americans did go up by about 9%, deaths among Native Americans went up by 30%," says Friedman.

"The entire narrative about deaths of despair among white Americans depended on the invisibility, or, we might say, the erasure of indigenous presence, invisibility in those datasets," says psychologist-anthropologist Joseph Gone of Harvard University, a member of the Aaniiih Gros Ventre tribal nation of Montana and a co-author of the Lancet study. "And that's a problem from our vantage point."

Data on Native communities are often missing from public health research, he adds, because "our numbers are small and we often get folded into a category like 'Other' instead of being reported distinctively for indigenous peoples."

While the recent rise in deaths among white Americans is, of course, alarming, Gone says, that the factors driving these deaths have affected Native communities for much longer.

"Indian country problems rise and fall with the economy like everyone else's," he says, "but we're just used to a lack of resources and opportunities for a whole bunch of reasons that go way back."

He adds that "colonial subjugation" by European settlers and historical attacks on the ways of life and livelihoods of indigenous communities have shaped the health and lifespans of Native communities since the early days of this country.

"Part of what I think we're seeing in these [rising rates of] deaths of despair are attacks on livelihoods," he says, "and decline in the ability to have good livelihoods."

"If you look at matters of poverty, education, decreased employment opportunities, restricted access to other kinds of resources that are typically associated with these kinds of health disparities," says Manson, "they're very powerful and widely present in American and Alaska Native communities."

The new study also found that the disparities in midlife mortality have only worsened since 2013, especially exacerbated by the COVID pandemic. In 2020, the death rates among middle-aged Native people due to despair-related causes was twice that among white people.

"This is a sort of astronomical inequality, you know, that should be unthinkable in our society," says Friedman.

But Manson believes that addressing these longstanding disparities in health and mortality will take more than just focusing on deaths of despair.

"The problem is if we only focus on deaths of despair, we ignore and do not have adequate attention paid to the sources that promote health and well-being in Native people," he says.

For example, he says, Native people have one of the highest rates of COVID vaccination compared to other racial and ethnic groups. According to the CDC, as of Jan. 25, 2023, nearly 78% of American Indiana and Alaska Native people have received at least one dose of the vaccine — the highest rate compared to all other racial and ethnic groups. And 64% of this group had completed the primary series of vaccination, second only to Asian Americans.

As NPR reported before, this was in large part because of Native people wanting to protect their elders and being more willing to get vaccinated.

Manson has been studying COVID testing and vaccination in six large urban Indian health organizations and found their efforts to be very successful.

"It has been their coming together across their programs, working not only with their urban partners that are non-native, but also working with reservation-based communities adjacent to their catchment areas," he says.

Reducing deaths of despair, Manson says, will require harnessing the strength and resilience of Native communities and supporting them with resources.

"There are possible solutions," he adds. "Those solutions are often local. They have to do with self-determination and the ability to have access to the necessary resources to mobilize those solutions."