A Systematic Review of Environmental Health Outcomes in Selected American Indian and Alaska Native Populations

Trusted partners, community priorities, and data protections: requirements for precision medicine research with Alaska Native peoples

Precision medicine holds promise for improving health care by tailoring disease treatment and prevention efforts to the needs of individual patients. It also raises ethical questions related to equitable distribution of the benefits of precision medicine; data management, including the terms of data ownership, sharing, and security; and, the nature and extent of community engagement in and oversight of research. These questions are particularly salient for minoritized communities that have been harmed by unethical research practices and often deprived the full benefit of advances in medical science. Understanding the perspectives of these communities is essential to the design and conduct of ethical and effective precision medicine research. This study explored perspectives on the acceptability, feasibility, value, and benefits and harms of precision medicine research among Alaska Native and American Indian (ANAI) peoples. We conducted four focus groups with ANAI individuals who receive primary care from a Tribal health organization in Anchorage, Alaska. Participants were willing to engage in precision medicine research provided specific requirements were met. Research must be conducted by the Tribal health organization or another trusted partner, community health priorities must drive the research agenda, and researchers must employ robust data protections to guard against loss of data security and maintain control over data use and access. These requirements work collectively to ensure research benefits and respects Tribal sovereignty. These findings could help inform efforts to design and implement precision medicine research programs tailored to concerns of ANAI peoples.

The Landmark Series: Surgical Oncology Care in Native Americans-The Indian Health Service

American Indian and Alaska Natives (AI/ANs) are a heterogeneous group of people living throughout the USA with some of the highest cancer incidence and highest cancer-related mortality in the country. This landmark series seeks to highlight cancer care in this population by providing a historical context of the largest healthcare delivery system serving AI/ANs, the Indian Health Service (IHS). We will highlight how the dynamic nature of this population creates unique challenges and the need for dedicated resources to help eliminate cancer care disparities.

Mixed contaminant exposure in tapwater and the potential implications for human-health in disadvantaged communities in California

Water is an increasingly precious resource in California as years of drought, climate change, pollution, as well as an expanding population have all stressed the state's drinking water supplies. Currently, there are increasing concerns about whether regulated and unregulated contaminants in drinking water are linked to a variety of human-health outcomes particularly in socially disadvantaged communities with a history of health risks. To begin to address this data gap by broadly assessing contaminant mixture exposures, the current study was designed to collect tapwater samples from communities in Gold Country, the San Francisco Bay Area, two regions of the Central Valley (Merced/Fresno and Kern counties), and southeast Los Angeles for 251 organic chemicals and 32 inorganic constituents. Sampling prioritized low-income areas with suspected water quality challenges and elevated breast cancer rates. Results indicated that mixtures of regulated and unregulated contaminants were observed frequently in tapwater throughout the areas studied and the types and concentrations of detected contaminants varied by region, drinking-water source, and size of the public water system. Multiple exceedances of enforceable maximum contaminant level(s) (MCL), non-enforceable MCL goal(s) (MCLG), and other health advisories combined with frequent exceedances of benchmark-based hazard indices were also observed in samples collected in all five of the study regions. Given the current focus on improving water quality in socially disadvantaged communities, our study highlights the importance of assessing mixed-contaminant exposures in drinking water at the point of consumption to adequately address human-health concerns (e.g., breast cancer risk). Data from this pilot study provide a foundation for future studies across a greater number of communities in California to assess potential linkages between breast cancer rates and tapwater contaminants.

Medicolegal death investigations on tribal lands-underrepresented or underserved?

Death investigation on tribal lands and of American Indian/Alaska Native (AIAN) people is complex and not well documented. An analysis of data from the 2018 Census of Medical Examiner and Coroner Offices (CMEC) provides a timely update on the extent of medicolegal death investigations (MDIs) on federal and state-recognized tribal lands. An estimated 150 MEC offices serve tribal lands, however, 44 % of these offices (i.e., 4 % of MEC offices) do not track cases from tribal lands separately. MEC offices with a population of 25,000 to 250,000 that serve tribal lands had more resources and access to information to perform MDIs than all other MEC offices. Analysis also indicates that the median number of unidentified human remains cases from MECs serving tribal lands is 6 times higher than that of jurisdictions not serving tribal lands. This analysis begins to elucidate gaps in the nation's understanding of MDI on tribal lands.

Incidence of Stomach, Liver, and Colorectal Cancers by Geography and Social Vulnerability Among American Indian and Alaska Native Populations, 2010-2019

Social determinants of health and associated systems, policies, and practices are important drivers of health disparities. American Indian and Alaska Native (AI/AN) populations in the United States have elevated incidence rates of stomach, liver, and colorectal cancers compared with other racial/ethnic groups. In this study, we examined incidence rates of 3 types of gastrointestinal cancer among non-Hispanic AI/AN (NH-AI/AN) and non-Hispanic White (NHW) populations by geographic region and Social Vulnerability Index (SVI) score. Incident cases diagnosed during 2010-2019 were identified from population-based cancer registries linked with the Indian Health Service patient registration databases. Age-adjusted incidence rates (per 100,000 population) for stomach, liver, and colorectal cancers were compared within NH-AI/AN populations and between the NH-AI/AN and NHW populations by SVI score. Rates were higher among NH-AI/AN populations in moderate- and high-SVI-score counties in Alaska, the Southern Plains, and the East than in low-SVI counties. Incidence rates among NH-AI/AN populations were elevated when compared with NHW populations by SVI category. Results indicated that higher social vulnerability may drive elevated cancer incidence among NH-AI/AN populations. Additionally, disparities between NH-AI/AN and NHW populations persist even when accounting for SVI. Exploring social vulnerability can aid in designing more effective interventions to address root causes of cancer disparities among AI/AN populations.

Structural Racism and Lung Cancer Risk: A Scoping Review

Importance

Structural racism is associated with persistent inequities in health and health outcomes in the US for racial and ethnic minority groups. This review summarizes how structural racism contributes to differential population-level exposure to lung cancer risk factors and thus disparate lung cancer risk across different racial and ethnic groups.

Observations

A scoping review was conducted focusing on structural racism and lung cancer risk for racial and ethnic minority groups. The domains of structural racism evaluated included housing and built environment, occupation and employment, health care, economic and educational opportunity, private industry, perceived stress and discrimination, and criminal justice involvement. The PubMed, Embase, and MedNar databases were searched for English-language studies in the US from January 1, 2010, through June 30, 2022. The review demonstrated that racial and ethnic minority groups are more likely to have environmental exposures to air pollution and known carcinogens due to segregation of neighborhoods and poor housing quality. In addition, racial and ethnic minority groups were more likely to have exposures to pesticides, silica, and asbestos secondary to higher employment in manual labor occupations. Furthermore, targeted marketing and advertisement of tobacco products by private industry were more likely to occur in neighborhoods with more racial and ethnic minority groups. In addition, poor access to primary care services and inequities in insurance status were associated with elevated lung cancer risk among racial and ethnic minority groups. Lastly, inequities in tobacco use and cessation services among individuals with criminal justice involvement had important implications for tobacco use among Black and Hispanic populations.

Conclusions and Relevance

The findings suggest that structural racism must be considered as a fundamental contributor to the unequal distribution of lung cancer risk factors and thus disparate lung cancer risk across different racial and ethnic groups. Additional research is needed to better identify mechanisms contributing to inequitable lung cancer risk and tailor preventive interventions.

Land Rights and Health Outcomes in American Indian/Alaska Native Children

American Indian and Alaska Native (AI/AN) land rights, sovereignty conflicts, and health outcomes have been significantly influenced by settler colonialism. This principle has driven the numerous relocations and forced assimilation of AI/AN children as well as the claiming of AI/AN lands across the United States. As tribes across the country begin to reclaim these lands and others continue to struggle for sovereignty, it is imperative to recognize that land rights are a determinant of health in AI/AN children. Aside from the demonstrated biological risks of environmental health injustices including exposure to air pollution, heavy metals, and lack of running water, AI/AN children must also face the challenges of historical trauma, the Missing and Murdered Indigenous Peoples crisis, and health care inequity based on land allocation. Although there is an undeniable relationship between land rights and the health of AI/AN children, there is a need for extensive research into the impacts of land rights and recognition of sovereignty on the health of AI/AN children. In this article we aim to summarize existing evidence describing the impact of these factors on the health of AI/AN children and provide strateg ies that can help pediatricians care and advocate for this population.

The Ramapough Lunaape Nation: Facing Health Impacts Associated with Proximity to a Superfund Site

This study aimed to evaluate self-reported exposure to the Ringwood Mines/Landfill Superfund Site in relation to chronic health outcomes among members of the Ramapough Lunaape Turtle Clan nation and other local residents of Ringwood, New Jersey. Community surveys on personal exposure to the nearby Superfund site, self-reported health conditions, and demographics were conducted with 187 members of the Ramapough Lunaape Turtle Clan Nation and non-Native Americans residing in Ringwood, New Jersey from December 2015 to October 2016. Multiple logistic regression was performed to assess the association between ethnicity and a Superfund site exposure score developed for this study, as well as between exposure score and several chronic health conditions. Native Americans were 13.84 times (OR 13.84; 95% CI 4.32, 44.37) more likely to face exposure opportunities to Superfund sites as compared to non-Native Americans in the same New Jersey borough. For the entire surveyed cohort, increased Superfund site exposure routes was significantly associated with bronchitis (OR 4.10; 95% CI 1.18, 14.23). When the analyses were restricted to Native Americans, the association between self-reported Superfund site exposure and bronchitis remained significant (OR 17.42; 95% CI 1.99, 152.45). Moreover, the association between greater exposure score and asthma in this same population also reached statistical significance (OR 6.16; 95% CI 1.38, 27.49). This pilot study demonstrated a significant association between being a Ringwood resident of Native American ethnicity and self-declared opportunities for Superfund site exposure. It also showed a strong association between self-reported Superfund site exposure and the prevalence of bronchitis and asthma.

Uranium Exposure in American Indian Communities: Health, Policy, and the Way Forward

BACKGROUND

Uranium contamination of drinking-water sources on American Indian (AI) reservations in the United States is a largely ignored and underfunded public health crisis. With an estimated 40% of the headwaters in the western U.S. watershed, home to many AI reservation communities, being contaminated with untreated mine waste, the potential health effects have largely been unexplored. With AI populations already facing continued and progressive economic and social marginalization, higher prevalence of chronic disease, and systemic discrimination, associations between various toxicant exposures, including uranium, and various chronic conditions, need further examination.

OBJECTIVES

Uranium's health effects, in addition to considerations for uranium drinking-water testing, reporting, and mitigation in reference to AI communities through the lens of water quality, is reviewed.

DISCUSSION

A series of environmental health policy recommendations are described with the intent to proactively improve responsiveness to the water quality crisis in AI reservation communities in the United States specific to uranium. There is a serious and immediate need for better coordination of uranium-related drinking-water testing and reporting on reservations in the United States that will better support and guide best practices for uranium mitigation efforts. https://doi.org/10.1289/EHP7537.