Epidemiology Public Health

The Overlooked U.S. Health Disparity That We Aren’t Talking About

Last month, I was giving the annual lung cancer lecture to our first year medical students. As part of that lecture, I discussed the demographics of cigarette smoking. American Indians have by far the highest rate of smoking and in 25 years, that will translate into the highest rate of lung cancer in the United States. As the medical director of an urban community hospital, I saw the results of racial healthcare disparities first hand. Our hospital’s demographic has a high percentage of Black and immigrant patients. These populations have a low rate of cancer screening, high infant mortality rate, and high rate of insufficiently treated chronic diseases. But the health disparities between Black and White Americans often get more public attention than the disparities between Indian and other Americans. We need to broaden the discussion on health disparities to include what is in many ways our greatest national health disparity.

Summary Points:

  • The greatest health disparities in the U.S. currently exist among American Indians
  • The prevalence of cigarette smoking is twice as high among American Indians compared to other racial/ethnic groups
  • Higher rates of cigarette smoking today will amplify health disparities in the future
  • We have the opportunity to reduce health disparities in the future by reducing cigarette smoking among American Indians today


When we talk about health disparities, we usually are talking about differences between the big 4 racial/ethnic groups in the United States: White, Black, Hispanic, and Asian. The group that gets less public attention is American Indian. For the purposes of this post, I will use “Indian” as a term of simplicity for Native American, Alaskan Native, and American Indian peoples. This demographic group is often lost in our discussions of American health disparities. A minority among minorities, American Indians comprise 1.3% of the U.S. population versus White (59.3%), Hispanic (18.9%), Black (13.6%), and Asian (6.1%) Americans (Native Hawaiian/Pacific Islanders comprise 0.3%). What disparities exist between American Indian and these other racial/ethnic groups?

Life expectancy

The United States has a relatively poor life expectancy compared to other developed countries. The OECD reports that in 2021 the average American life expectancy from birth was 77.0 years – slightly better than Mexico but slightly worse than China.

Within the U.S., there is considerable variation in life expectancy by race/ethnicity. The National Institutes of Health reports that the U.S. Asian population has the longest life expectancy at 85.7 years, followed by the Latino population (82.2 years), White population (78.9 years), and Black population (75.3 years). The lowest life expectancy is in the American Indian population at 73.1 years.

Chronic health conditions

The National Health Interview Survey has been conducted by the Centers for Disease Control annually since 1957. The most recent data is through 2021 and consists of interviews with 30,000 adults and 9,000 children. The Survey is one of the most comprehensive assessments of the current health status of Americans. Once again, we find that health and healthcare disparities disproportionately affect American Indians in the United States.

American Indians are much more likely to report having chronic medical conditions and chronic psychologic conditions than any other racial/ethnic group in the U.S. In addition, American Indians are more likely to report that they have overall poor health and to have some form of disability. They are more likely to have had at least one emergency department visit in the past year and are a close second to Hispanics in high percentages lacking health insurance. Suicide rates are also higher among American Indians than any other racial/ethnic group in the U.S.

COVID has uncovered preventative care disparities affecting American Indians. The vaccination rate (receipt of at least 1 dose of a COVID vaccine) is lowest among American Indians (77%) compared to White (87%), Hispanic (88%), Black (89%), and Asian (98%) Americans. Not surprisingly, the COVID death rate among American Indians (yellow curve in the graph below) is also higher than other American racial/ethnic groups:

Not only were American Indians more likely to die of COVID during the pandemic, but they were also more likely to be diagnosed with COVID and more likely to be hospitalized with COVID, according to a report from the CDC:

Smoking as a forecast of future health problems

As a pulmonologist, one of the public health metrics that concerns me the most is the prevalence of cigarette smoking. The health effects of smoking can be divided into those that affect people now and those that affect people 25 years from now. If a person starts smoking today, the main short-term health effects that they will experience are cough, bronchitis, and wheezing. For most smokers, these are minor problems and are consequently ignored so they continue to smoke. The greater health problems are those that occur decades later, namely lung cancer, COPD, and heart disease. The best reflection of this can be seen in the graph below that compares per-capita cigarette consumption to the death rate from lung cancer in the United States. Annual cigarette consumption peaked in 1965 at about 4,300 cigarettes per person in the U.S. The lung cancer death rate peaked 25 years later in 1990.

Smoking can kill people in a lot of ways other than lung cancer: heart disease, COPD, stroke, esophageal cancer, kidney cancer, and other cancers. Overall, about 1 out of every 5 deaths in the U.S. is related to smoking. Because of this, a woman who smokes a pack of cigarettes a day can expect to live 11 years less than a woman who does not smoke. Men who smoke a pack a day will live 12 years less than men who do not smoke. Overall, this works out to about 14 minutes of life lost for every cigarette smoked.

What this means is that people who smoke today will be dying from lung cancer, COPD, and heart disease 25 years from now. So, we can use today’s smoking demographics to predict the future’s health disparities. Today’s smokers are more likely to have a lower income and lower education level than non-smokers. Americans who have the lowest income are nearly 4-times more likely to smoke than those who make over $100,000 per year. Those whose education is limited to a GED are 10-times more likely to smoke than those who have a graduate degree:

The good news is that we have made great headway in reducing the percentage of cigarette smokers in the United States. Because 90% of smokers start smoking before age 18, much of the reduction in smoking prevalence can be attributed to preventing adolescents from starting to smoke in the first place. Currently, 14.1% of U.S. men smoke and 11.0% of U.S women smoke. This is a vast improvement from the 1960’s when approximately half of all American adults smoked.

However, smoking cessation and prevention efforts have not been uniform across all racial and ethnic groups. Here is where one of the most glaring health disparities exist with American Indians. The CDC reports that they are twice as likely to smoke as Black Americans and White Americans. They are three and a half times more like to smoke the Hispanic Americans and Asian Americans:

The implication of this is that 25 years from now, there will be even greater health disparities among American Indians, with much higher rates of lung cancer, COPD, stroke, heart disease, and other cancers compared to all other U.S. racial/ethnic groups. Furthermore, the life expectancy for Indian Americans (which is already considerably shorter than for White, Black, Hispanic, and Asian Americans) will be even shorter.

Why have we failed American Indian populations?

For many years, we’ve known that American Indian populations have a higher incidence of cirrhosis than other racial/ethnic groups and this has been attributed to a higher rate of alcohol abuse among American Indians. We now must face that the rate of other chronic health problems will also be higher in American Indians in the near future. How did these disparities come to exist?

As the first European immigrants arrived at our Eastern shores, they brought with them European diseases, such as smallpox and measles. An estimated 90% of Native Americans subsequently died of these diseases. Those who survived were pushed westward. As a consequence, most tribal reservations are located west of the Mississippi River and in the northern part of Alaska. These are largely remote, rural areas that distant from large cities. This also means being distant from higher paying urban jobs, distant from tertiary care hospitals, and distant from institutions of higher learning. Data from the 2021 U.S. census shows that the median annual household income for all Americans was $69,717. American Indians had a median annual household income of only $53,148. In contrast, Asian Americans had the highest median income at $100, 572. The U.S. Department of Eduction reports that American Indians also have the lowest college enrollment rate of all U.S. racial/ethnic groups at 19%. Asians had the highest college enrollment rate at 58%, followed by White (42%), Hispanic (39%), and Black (36%) Americans.

Health disparities in the U.S. are usually a consequence of discrimination. Discrimination against Blacks has its roots in slavery. Discrimination against Indians has its roots in geographic displacement. Discrimination against Asians backfired as I outlined in a previous post – the restriction of immigration to only Asian merchants and teachers in the 19th and early 20th century in the U.S. had the unintended consequence of an Asian American demographic that had a higher education level and higher income than other Americans (the intention of the Chinese Exclusion Act of 1882 was to prevent unskilled Chinese workers from competing with American-born U.S. citizens for labor jobs). The Indian Health Service is an attempt to overcome healthcare disparities but this has by necessity resulted in a “separate but equal” healthcare delivery system. Separate but equal did not work in the education of Black Americans in the 1950’s and it wasn’t working in 1913 when my grandmother became the first non-white child to attend Atlanta public schools.

So, what can we do?

Last month, at the end of my lecture to the medical students on lung cancer, I challenged them to address disparities in lung cancer. Specifically, I challenged them to address the high prevalence of cigarette smoking in the American Indian population. If we can reduce smoking now, we can reduce health disparities in the future.

On December 20, 2019, the United States Congress passed legislation amending the Family Smoking Prevention and Tobacco Control Act of 2009. This amendment raised the age that anyone can buy cigarettes to 21 years old in all U.S. states and on all tribal lands. This will help reduce the number of American Indians who start to smoke as teenagers. But cigarette smoking is often a symptom of employment and educational disparities so another way of reducing health disparities in the future is by improving employment and education today.

Historically, tribal lands were geographically distant from high-paying urban jobs. A silver lining of the COVID pandemic has been the normalization of working remotely and so we need to promote remote-working jobs to those living on tribal lands. An implication of this is that we need to prioritize high-speed internet access to these areas. Because many of the jobs that are amenable to remote work require education beyond a high school level, we need to eliminate barriers to higher education. Educational debt forgiveness is fiercely debated in political circles but if there is any one group that could really benefit by reducing the cost to attend 2-year community colleges and 4-year universities, it is those living on tribal lands. An 18-year old growing up in a U.S. city can live with his/her parents and commute across town to attend a public university at minimal cost but a 100-mile commute from a family home on tribal lands to an urban university is unrealistic. In addition, sustainable change has to come from within and effective reduction in smoking prevalence also requires engagement and advocation by tribal leaders.

All too often, public health is reactive, we wait until there is a health problem and then we react to that problem. We have a rare opportunity to make public health proactive… by reducing American Indian smoking rates today we can reduce health disparities in the future. When the ocean waters recede from the beach just before a tsunami, there are two kinds of people: those who walk around picking up newly uncovered seashells and those who run to high ground. There is a public health tsunami coming for American Indians, let’s not act like people on the beach picking up seashells.

February 25, 2023

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital