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.

Characterizing Cancer Burden in the American Indian Population in North Carolina.

BACKGROUND: The American Indian (AI) population in North Carolina has limited access to the Indian Health Service. Consequently, cancer burden and disparities may differ from national estimates. We describe the AI cancer population and examine AI-White disparities in cancer incidence and mortality. METHODS: We identified cancer cases diagnosed among adult AI and White populations between 2014 and 2018 from the North Carolina Central Cancer Registry. We estimated incidence and mortality rate ratios (IRR and MRR) by race. In addition, between the AI and White populations, we estimated the ratio of relative frequency differences [RRF, with 95% confidence limits (CL)] of clinical and sociodemographic characteristics. Finally, we evaluated the geographic distribution of incident diagnoses among AI populations. RESULTS: Our analytic sample included 2,161 AI and 204,613 White individuals with cancer. Compared with the White population, the AI population was more likely to live in rural areas (48% vs. 25%; RRF, 1.89; 95% CL, 1.81-1.97) and to have Medicaid (18% vs. 7%; RRF, 2.49; 95% CL, 2.27-2.71). Among the AI population, the highest age-standardized incidence rates were female breast, followed by prostate and lung and bronchus. Liver cancer incidence was significantly higher among the AI population than White population (IRR, 1.27; 95% CL, 1.01-1.59). AI patients had higher mortality rates for prostate (MRR, 1.72; CL, 1.09-2.70), stomach (MRR, 1.82; 95% CL, 1.15-2.86), and liver (MRR, 1.70; 95% CL, 1.25-2.33) cancers compared with White patients. CONCLUSIONS: To reduce prostate, stomach, and liver cancer disparities among AI populations in North Carolina, multi-modal interventions targeting risk factors and increasing screening and treatment are needed. IMPACT: This study identifies cancer disparities that can inform targeted interventions to improve outcomes among AI populations in North Carolina.

Homicide among Indigenous females in North Carolina: a comparison of publicly generated data and violent death reporting system.

Like other minoritized populations, American Indian/Alaska Native (AI/AN) females experience disparate morbidity and mortality outcomes to that of the general US population. This study identified discrepancies in reporting of AI/AN female decedents between the North Carolina Violent Death Reporting System (NC-VDRS) and an online, user-generated database. Female AI/AN decedent data of all ages were collected from the NC-VDRS and compared against that of the publicly available North Carolina Missing and Murdered Indigenous Women (MMIW NC) database for the study period, 2004-2019. Twenty-four of the 72 cases matched between data systems (33.3%). Substantive differences between the NC-VDRS and the MMIW NC database were found. Future efforts should be directed towards supporting Indigenous communities with the comprehensive data the NC-VDRS can provide. This paper highlights statewide public health systems like the NC-VDRS supporting community efforts to understand, advocate for, and disseminate information on MMIW.

Factors Associated with Delaying and Forgoing Care Due to Cost among Long-term, Appalachian Cancer Survivors in Rural North Carolina.

Background: Little research exists on delayed and forgone health and mental health care due to cost among rural cancer survivors. Methods: We surveyed survivors in 7 primarily rural, Appalachian counties February to May 2020. Univariable analyses examined the distribution and prevalence of delayed/forgone care due to cost in the past year by independent variables. Chi-square or Fisher's tests examined bivariable differences. Logistic regressions assessed the odds of delayed/forgone care due to cost. Results: Respondents (n=428), aged 68.6 years on average (SD: 12.0), were 96.3% non-Hispanic white and 49.8% female; 25.0% reported delayed/forgone care due to cost. The response rate was 18.5%. The proportion of delayed/forgone care for those aged 18-64 years was 46.7% and 15.0% for those aged 65+ years (P<0.0001). Females aged 65+ years (OR: 2.00; CI: 1.02-3.93) had double the odds of delayed/forgone care due to cost compared to males aged 65+ years. Conclusion: About one in four rural cancer survivors reported delayed/forgone care due to cost, with rates approaching 50% in survivors aged <65 years. Impact: Clinical implications indicate the need to: 1) ask about the impact of care costs, and 2) provide supportive services to mitigate effects of treatment costs, particularly for younger and female survivors.

Challenges with misclassification of American Indian/Alaska Native race and Hispanic ethnicity on death records in North Carolina occupational fatalities surveillance.

As frequently segregated and exploitative environments, workplaces are important sites in driving health and mortality disparities by race and ethnicity. Because many worksites are federally regulated, US workplaces also offer opportunities for effectively intervening to mitigate these disparities. Development of policies for worker safety and equity should be informed by evidence, including results from research studies that use death records and other sources of administrative data. North Carolina has a long history of Black/white disparities in work-related mortality and evidence of such disparities is emerging in Hispanic and American Indian/Alaska Native (AI/AN) worker populations. The size of Hispanic and AI/AN worker populations have increased in North Carolina over the last decade, and North Carolina has the largest AI/AN population in the eastern US. Previous research indicates that misidentification of Hispanic and AI/AN identities on death records can lead to underestimation of race/ethnicity-specific mortality rates. In this commentary, we describe problems and complexities involved in determining AI/AN and Hispanic identities from North Carolina death records. We provide specific examples of misidentification that are likely introducing bias to occupational mortality disparity documentation, and offer recommendations for improved data collection, analysis, and interpretation. Our primary recommendation is to build and maintain relationships with local community leadership, so that improvements in the ascertainment of race and ethnicity are grounded in the lived experience of workers from communities of color.