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Mortality disparities: A comparison with 

the Haudenosaunee in New York State 

Rodney C. Haring1, Melissa A. Jim2, Deborah Erwin3, Judith Kaur4, Whitney Ann E. Henry5, Marissa L. 

Haring6, Dean S. Seneca7 

1 
Office of Community Outreach and Engagement , Department of Cancer Prevention and Control, Roswell Park 

Comprehensive Cancer Center, Buffalo, NY 
2 
Division of Cancer Prevention and Control, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Albuquerque, NM 
3
 Office of 

Community Outreach and Engagement, Department of Cancer Prevention and Control, Roswell Park Comprensive 

Cancer Center, Buffalo, NY 
4 
Mayo Clinic, Jacksonville, FL 

5
 Office of Community Outreach and Engagement, 

Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY 
6
 Student 

Research Experience Program in Cancer Science, Department of Educational Affairs, Roswell Park Comprehensive 

Cancer Center, Buffalo, NY 
7 
Partnership Support Unit, Office for State, Tribal, Local and Territorial Support, Centers 

for Disease Control and Prevention, Atlanta, GA 

*Corresponding author email: rodney.haring@roswellpark.org 

 

ABSTRACT: Identifying health status and disparities for Indigenous populations is the first logical step 

toward better health. We compare the mortality profile of the American Indian and Alaska Native 

(AI/AN) population with that of non-Hispanic whites in the Haudenosaunee Nations in New York State, 

the Indian Health Service (IHS) East region (Nashville Area) and the United States. Data from the linkage 

of IHS registration records with decedents from the National Death Index (1990-2009) were used to 

identify AI/AN deaths misclassified as non-AI/AN. Analyses were limited to persons of non-Hispanic 

origin. We analyzed trends for 1990-2009 and compared AI/AN and white persons in the 

Haudenosaunee Nations in New York State, IHS East region and the United States. All-cause death rates 

over the past two decades for Haudenosaunee men declined at a greater percentage per year than for 

AI/AN men in the East region and United States. This decrease was not observed for Haudenosaunee 

women with all-cause death rates appearing to be stable over the past two decades. Haudenosaunee 

all-cause death rates were 16% greater than that for whites in the Haudenosaunee Nations. The most 

prominent disparities between Haudenosaunee and whites are concentrated in the 25-44 year age 

group (Risk Ratio=1.85). Chronic liver disease, diabetes, unintentional injury, and kidney disease death 

rates were higher in Haudenosaunee than in whites in the Haudenosaunee Nations. The 

Haudenosaunee cancer death rate (180.8 per 100,000) was higher than that reported for AI/AN in the 

East (161.5 per 100,000).Haudenosaunee experienced higher rates for the majority of the leading causes 

of death than East AI/AN. These results highlight the importance of Haudenosaunee-specific data to 

target prevention efforts to address health disparities and inequalities in health. 

KEYWORDS: cancer, diabetes, health disparities, obesity, Native American, American Indian, 

Haudenosaunee, Iroquois, New York, minority health. 

Citation: Haring RC et al (2018) Mortality disparities: A comparison with the Haudenosaunee in New 

York State. Cancer Health Disparities 2:e1-e20, doi:10.9777/chd.2018.10009 

mailto:rodney.haring@roswellpark.org


 
 
 
 
 

 

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BACKGROUND 

Health disparities are health differences that are 

closely linked with social, economic, or 

environmentally disadvantaged communities or 

populations (U.S. Department of Health and 

Human Services, 2008). Health disparities 

adversely affect groups of people who have 

systematically experienced greater obstacles to 

health based on characteristics historically linked to 

discrimination or exclusion. Health disparities are 

measured by tracking rates of illness, death, 

chronic conditions, and behaviors related to socio-

demographic features such as race and ethnicity 

(U.S. Department of Health and Human Services, 

2008) –as well as income and education. 

American Indians and Alaska Natives (AI/ANs)—

Native Americans—experience excesses of a 

number of diseases that may be linked to 

environmental obstacles, health behaviors, or 

lifestyles attributed to the possible epigenetic 

factors of trauma or stress (Brown et al., 2010; 

Shonkoff, Boyce, & McEwen, 2009; Cobb, Espey, & 

King, 2014; Warne, 2006). The most common 

causes of death for AI/AN populations are heart 

disease, cancer, unintentional injuries, diabetes, 

stroke, chronic liver disease and cirrhosis, chronic 

lower respiratory disease, suicide, influenza, 

pneumonia, and kidney diseases. Health disparities 

in Indian Country (Natural Resources Conservation 

Science, n.d.) vary regionally and correspond to 

similar trends in mortality rates (Espey et al., 2014a; 

White et al., 2014; Li et al., 2014; Murphy et al., 

2014; Indian Health Services, 2016). Obesity is likely 

a contributing factor to many of these diseases 

with AI/AN men and women having a higher 

prevalence of obesity than their white counterparts 

(Cobb et al., 2014; Moore, Chadid, Singer, Kreger, 

& Denis, 2014; Haring et al. 2016). 

Cancer Health Disparities 

Kilbourne and colleagues define health disparities 

for public health as the “observed clinically and 

statistically significant differences in health 

outcomes or health care use between socially 

distinct vulnerable and less vulnerable populations 

that are not explained by the effects of selection 

bias,” (Kilbourne, Switzer, Hyman, Crowley-Matoka, 

& Fine, 2006). The National Cancer Institute (NCI) 

has further defined cancer-related health 

disparities as “adverse differences in new and 

existing cancer incidence (new cases), morbidity 

(cancer related health complications), cancer 

mortalities (death), cancer survivorship and burden 

of cancer or related health conditions that exist 

among specific population groups in the United 

States” (NCI, n.d.). 

Cancer is the second leading cause of death in 

New York State (NYS). In 2009, the age-adjusted 

cancer incidence rate for all cancers was 484.2 

cases per 100,000 New Yorkers, which is the ninth 

highest in the United States (U.S.). The NYS age-

adjusted mortality rate for all cancer sites is 164.3 

per 100,000 population, which is almost 6% lower 

than the U.S. rate (173.8); the state’s overall cancer 

mortality rate decreased by an average of 2% 

each year across all ages and races between 2005- 

2009. Notably for this report, only cancers of the 

uterus and liver/bile duct had increases in annual 

mortality rates when looking at 5-year rate 

changes (NYS Cancer Consortium, 2012). 

Incidence and mortality rates in NYS by 

race/ethnicity are reported highest among black 

men (NYS Cancer Consortium, 2012); however, 

incidence and mortality rates for AI/AN 

populations in NYS are not available for 

comparison from the State Cancer Profiles on 

Cancer Control P.L.A.N.E.T. (https://ccplanet. 



 
 
 
 
 

 

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cancer.gov/) or the latest NYS Comprehensive 

Cancer Control Plan, possibly due to the 

challenges of reporting smaller case counts from 

identifiable areas and possible data-reporting 

errors. However, the 2012-2017 NYS 

Comprehensive Cancer Control Plan text states 

that AI/AN populations were one of several 

populations identified by New York’s Medicaid 

Redesign Team Health Disparities Workgroup “that 

may experience greater health disparities,” (NYS 

Cancer Consortium, 2012). This team further states 

that “AI/AN groups face greater socioeconomic 

barriers than many other racial/ethnic groups” and 

“…should receive priority consideration when 

intervention strategies are being developed and 

implemented” (NYS Cancer Consortium, 2012). 

Haudenosaunee & Indian Health Service East 

Region 

To address race misclassification in death records 

and cancer surveillance data, efforts have been 

made to better characterize and track the health 

status of AI/AN populations (Espey et al., 2014b; 

Espey et al., 2008). Mortality data provide essential 

information for measuring the health of a 

population. AI/AN mortality data are often 

presented for 12 Indian Health Service (IHS) Areas 

(Indian Health Service, n.d.) and six IHS regions 

(Northern Plains, Alaska, Southern Plains, 

Southwest, Pacific Coast, and East) (Espey et al., 

2014b; Espey et al., 2008; Espey et al., 2007). Our 

interest lies in the IHS East region, which contains 

the same states as those in the IHS Nashville Area. 

This catchment includes a mixture of tribes with 

varying degrees of “first contact” with Europeans; 

varying levels of Nation-to-Nation relationships 

with the United States; differences in culture, 

customs, and language; and vast geographic 

distances between states from the Northeast to 

the Southeast. 

Previous studies have worked with individual 

Northeast Native Nations to look at tribal data on 

matrilineal enrolled members only (Mahoney, Va, 

Stevens, Kahn, & Michalek, 2009). Others have 

used Nation-specific health center data for review 

(Schulz, Lalicata, Carnes, & Rith-Najarian, 1997) or 

obtained data from school systems for community 

health information (Botash, Kavey, Emm, & Jones, 

1992). Specific tribal data are useful for each 

Nation individually and helpful when looking at 

enrolled citizens, non-enrolled membership 

populations, or school-aged children. There is also 

a need to look at population health from both 

enrolled and non-enrolled tribal members to paint 

an inclusive picture of global tribal wellness and its 

relation to disparities. Therefore, the IHS East 

region lacks an aggregated picture of health 

disparities from the largest Confederacy of Tribes 

in NYS, whose bloodlines are distinctly related 

through clan systems, language, and traditional 

practices. The Haudenosaunee have land 

throughout a majority of NYS (Figure 1). The 

Haudenosaunee Confederacy tribes include the 

Mohawk, Oneida, Onondaga, Tuscarora, Cayuga, 

and Seneca. The Mohawk are known as the 

“Keepers of the Eastern Door” and are responsible 

for protecting and defending the eastern 

boundaries of Haudenosaunee territory 

(Smithsonian NMAI, n.d.). The Onondaga are the 

“Keepers of the Central Fire” since the Onondaga 

Nation is considered the capital of the 

Confederacy (Smithsonian NMAI, n.d.). The Seneca 

are the “Keepers of the Western Door” and are 

responsible for protecting and defending the 

western boundaries of Haudenosaunee territory 

(Smithsonian NMAI, n.d.). 



 
 
 
 
 

 

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Figure 1. Haudenosaunee – Iroquois Confederacy 

 

In this article, we provide an overview of leading 

causes of death and all-cause mortality trends for 

AI/ANs and whites in the Haudenosaunee Nations, 

the East region, and the United States. We utilize 

national mortality data that have been linked to the 

IHS patient registration data to improve race/ethnicity 

classification. Results will provide guiding information 

that can help shape solutions for health care needs for 

the Haudenosaunee in NYS. 

METHODS 

Detailed methods for generating the analytic 

mortality files are described elsewhere (Espey et 

al., 2014b). An abbreviated description follows. 

Data sources 

Population estimates. We used county-level 

population estimates produced by the U.S. Census 

Bureau as denominators in the rate calculations. 

To manage multiple race/ethnicity data collected 

since 2000, we used the National Center for Health 

Statistics (NCHS)/Census Bureau method of 

bridging race/ethnicity categories into single-

race/ethnicity (Ingram et al., 2003). The NCI made 

further refinements regarding race/ethnicity, 

county geographic codes, and adjustments for 

population shifts because of Hurricanes Katrina 

and Rita in 2005, and provided public access to 

these estimates at the Surveillance, Epidemiology, 

and End Results (SEER) website (NCI SEER, n.d.). 

During preliminary analyses, we discovered that 

the updated bridged intercensal populations 

estimates significantly overestimated AI/AN 

persons of Hispanic origin (Edwards et al., 2013). 

Therefore, to avoid underestimating mortality in 

AI/AN populations, we limited analyses to non-



 
 
 
 
 

 

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Hispanic AI/AN persons. Non-Hispanic white was 

chosen as the most homogeneous referent group. 

For conciseness, the term “non-Hispanic” is 

henceforth omitted when discussing both groups. 

Death records. Each state compiles death 

certificate data and sends them to the NCHS, 

where they are edited for consistency. The NCHS 

makes this information available to researchers as 

part of the National Vital Statistics System (NVSS), 

and includes underlying and multiple cause of 

death fields, state of residence, age, sex, race, and 

ethnicity (National Center for Health Statistics, 

n.d.). NCHS and the Census Bureau use the same 

bridging algorithm to assign a single race to 

decedents with multiple races reported on the 

death certificate (National Center for Health 

Statistics, 2004). 

The IHS patient registration database was linked to 

the National Death Index (NDI) to identify IHS 

decedents who had received health care in IHS or 

tribal facilities and were misclassified as non-AI/AN 

(Espey et al., 2014b). Following this linkage, IHS 

records for persons identified as deceased were 

then linked to 1990 to 2009 annual NVSS mortality 

files as an additional indicator of AI/AN ancestry. 

These files were combined with corresponding 

annual bridged race intercensal population 

estimates to create an analytic file, the AI/AN 

Mortality Database (AMD), in SEER*Stat software 

version 8.0.4 (Surveillance Research Program, n.d.). 

Race for AI/AN deaths is assigned as reported 

elsewhere (Espey et al., 2014b). In short, the AMD 

combines race classification by NCHS on the basis 

of the death certificate and information derived 

from data linkages between the IHS patient 

registration database and the National Death 

Index. 

For the years 1990-1998, the underlying cause of 

death was coded according to the International 

Classification of Diseases, Ninth Revision (ICD-9) 

(World Health Organization, 1980). For 1999-2009, 

the International Classification of Diseases, 10th 

Revision (ICD-10) was used (World Health 

Organization, 1999). Trend analyses spanning ICD-

9 and ICD-10 reporting years took into account 

comparability of cause of death recodes between 

the two revisions (Anderson, Minino, Hoyert, & 

Rosenberg, 2001). To present the leading cause of 

death in rank order, as established by death 

counts, we used the method developed by NCHS 

based on the recode for 113 selected causes of 

death (Anderson et al., 2001; Heron, 2012). 

Geographic Coverage. The analyses in this article 

are restricted to IHS Contract Health Service 

Delivery Area (CHSDA) counties, which follow 

county boundaries and are established by IHS for 

each federally recognized tribe. The CHSDA 

consists of counties that include all or part of a 

reservation, and any county or counties that have 

a common boundary with the reservation (Indian 

Health Service, 2016). Linkage studies have 

indicated less misclassification of race/ethnicity for 

AI/AN persons in these counties (Jim et al., 2014). 

The analyses were completed for AI/AN and white 

persons in the Haudenosaunee Nations, East 

region, and the United States. The 

Haudenosaunee Nations are situated in nine NYS 

counties: Allegany, Cattaraugus, Chautauqua, Erie, 

Franklin, Genesee, Madison, Niagara, and 

Onondaga. Only counties that touched one of the 

Haudenosaunee Nations were included in the 

analyses (Figure 1). The East region consists of 

Alabama, Arkansas, Connecticut, Delaware, 

Florida, Georgia, Kentucky, Louisiana, Maine, 

Maryland, Massachusetts, Mississippi, Missouri, 



 
 
 
 
 

 

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New Hampshire, New Jersey, New York, North 

Carolina, Ohio, Pennsylvania, Rhode Island, South 

Carolina, Tennessee, Vermont, Virginia, West 

Virginia, and Washington, D.C. Identical or similar 

regional analyses have been used for other health-

related publications focusing on AI/AN 

populations (Espey et al., 2014a; Denny & Taylor, 

1999; Espey, Paisano, & Cobb, 2005; Wiggins et al., 

2008). 

Statistical methods. All rates, expressed per 

100,000 population, were directly age-adjusted, 

using SEER*Stat software (Surveillance Research 

Program, n.d.), to the 2000 U.S. standard 

population and using 11 age groups (<1 year, 1-4 

years, 5-14 years, 15-24 years, 25-34 years, 35-44 

years, 45-54 years, 55-64 years, 65-74 years, 75-

84 years, and ≥ 85 years) in accordance with a 

1998 Department of Health and Human Services 

recommendation (Anderson, 1998a; Anderson, 

1998b). Readers should avoid comparison of these 

data with published death rates adjusted using a 

different standard population. 

Using the age-adjusted, all-cause death rates, 

standardized rate ratios (RRs) were calculated for 

AI/AN using white rates for comparison. Ninety-

five percent confidence intervals (CI) for age-

adjusted rates and standardized RRs were 

calculated based on methods described by Tiwari, 

Clegg, & Zou (2006) using SEER*Stat and were 

rounded to two decimal places. 

We conducted trend analyses and comparability 

tests for age-standardized death rates using 

Joinpoint software, version 4.0.3 (Joinpoint 

Regression Program, 2017). We calculated annual 

percent change (APC) for each of the trend 

segments and average annual percent change 

(AAPC) for 1990-2009 to quantify the average 

trend over this period. We conducted tests to 

assess pairwise differences between AI/ANs and 

whites to determine whether the trends lines were 

parallel or coincident (Kim, Fay, Feuer, & 

Midthune, 2000), then we tested the average 

annual percentage change for the two groups to 

determine whether they were statistically different. 

Statistical significance was set at P<.05. 

RESULTS 

All-cause death rates and leading causes of death 

for the Haudenosaunee Nations, East, and United 

States comparing AI/AN with white persons in 

CHSDA counties are presented in Table 1. In 

subsequent results as well as in the discussion, 

“death rates” refers to analyses restricted to 

CHSDA counties only and for conciseness, the 

term “Haudenosaunee” will be used when 

discussing “Haudenosaunee Nations AI/AN”. 

Comparisons of all-cause death rates in 

Haudenosaunee with those of whites in the 

Haudenosaunee Nations (RR=1.16) were greater 

than those in the East (RR=1.03) but not as high as 

those in the U.S. (RR=1.41). 

Table 1 also ranks the leading causes of death for 

AI/AN compared to white persons by sex for the 

Haudenosaunee Nations, East, and United States 

for 1990-2009. The ten leading causes of death 

among the Haudenosaunee, in order, were heart 

disease, cancer, unintentional injury, diabetes, 

stroke, chronic liver disease, chronic lower 

respiratory disease, influenza and pneumonia, 

kidney disease, and septicemia. Rates for 

Haudenosaunee were significantly higher than 

whites for all causes (RR=1.16), heart disease 

(RR=1.12), unintentional injury (RR=2.08), diabetes 

(RR=3.46), chronic liver disease (RR=4.06), kidney 

disease (RR=3.31), and septicemia (RR=1.85); and 

significantly lower for cancer (RR=0.89). Rates for 



 
 
 
 
 

 

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stroke, chronic lower respiratory disease, suicide, and influenza and pneumonia were similar for Haudenosaunee and whites in the Haudenosaunee 

Nations. 

Table 1. Death rates for All Causes for American Indians and Alaska Natives compared with whites, Males and Females, All Ages: CHSDA counties, United States, 1990-2009. 

 Haudenosaunee Nations East United States 

 AI/AN White AI/AN:White AI/AN White AI/AN:White AI/AN White AI/AN:White 

Cause of Deatha Rank Count Rate Rank Count Rate Rate Ratio Rank Count Rate Rank Count Rate Rate Ratio Rank Count Rate Rank Count Rate Rate Ratio 

Males and Females 

All Causes ... 2,419 975.9 ... 376,422 844.6 1.16* ... 9,833 847.1 ... 2,787,191 824.1 1.03* ... 184,633 1,158.4 ... 8,298,817 823.7 1.41* 

Heart disease 1 688 306.2 1 124,096 272.6 1.12* 1 2,396 232.4 1 851,677 246.3 0.94* 1 36,199 265.0 1 2,401,219 234.6 1.13* 

Cancer 2 442 180.8 2 89,832 203.6 0.89* 2 1,827 161.5 2 666,908 197.6 0.82* 2 30,837 205.5 2 1,961,477 193.3 1.06* 

Unintentional Injury 3 182 53.5 6 10,196 25.7 2.08* 3 939 55.2 5 103,959 35.2 1.57* 3 24,299 102.9 5 349,035 38.3 2.69* 

Diabetes mellitus 4 151 61.1 7 7,865 17.6 3.46* 4 684 59.4 7 60,945 17.9 3.31* 4 10,549 71.0 8 194,187 19.1 3.71* 

Stroke 5 109 48.7 3 24,581 53.4 0.91 5 504 51.9 3 176,518 50.6 1.03 6 7,816 61.5 3 557,403 54.3 1.13* 

Chronic liver disease 6 105 34.5 11 3,529 8.5 4.06* 6 402 26.9 12 29,969 9.4 2.86* 5 8,547 42.0 11 93,030 9.6 4.39* 

Chronic Lower Respiratory Disease 7 104 46.2 4 19,761 43.3 1.07 7 313 30.1 4 144,806 41.8 0.72* 7 6,348 47.9 4 483,387 47.0 1.02 

Influenza and pneumonia 8 55 27.2 5 12,132 26.4 1.03 8 230 25.5 6 84,987 24.3 1.05 9 5,455 42.3 6 253,216 24.7 1.71* 

Kidney disease 9 51 21.8 8 5,384 11.8 3.31* 12 138 7.3 22 8,736 3.2 2.29* 10 3,540 13.1 21 28,058 3.3 4.01* 

Septicemia 10 50 20.9 9 5,256 11.7 1.85* 9 199 18.2 9 40,278 11.6 1.57* 11 3,137 22.6 10 99,171 9.7 2.34* 

Suicide 11 30 8.1 12 3,156 8.5 0.95 11 158 8.7 11 33,398 11.7 0.75* 8 5,582 20.9 9 128,794 14.3 1.46* 

Males 

All Causes ... 1,251 1,184.1 ... 178,253 1,040.7 1.14* ... 5,215 995.9 ... 1,357,842 1,012.6 0.98 ... 101,696 1,390.9 ... 4,140,089 997.3 1.39* 

Heart disease 1 360 395.0 1 59,191 348.5 1.13* 1 1,279 283.0 1 417,231 313.8 0.90* 1 20,488 337.1 1 1,215,776 296.0 1.14* 

Cancer 2 200 199.2 2 45,076 251.6 0.79* 2 932 196.2 2 343,655 245.4 0.80* 3 15,503 242.1 2 1,025,335 236.3 1.02* 

Unintentional injury 3 124 81.9 5 6,183 36.3 2.26* 3 628 76.2 5 65,649 49.5 1.54* 2 16,673 146.7 4 222,193 53.0 2.77* 

Diabetes mellitus 4 74 69.1 7 3,700 21.0 3.29* 4 316 59.5 7 29,582 21.5 2.77* 5 4,830 71.3 8 94,905 22.3 3.20* 

Chronic liver disease 5 64 44.3 11 2,180 11.8 3.77* 5 235 33.6 10 19,146 13.2 2.54* 4 4,836 50.3 10 59,327 13.0 3.86* 

Stroke 6 48 50.6 4 9,094 55.0 0.92 6 222 53.4 4 66,913 51.6 1.03 7 3,350 61.8 5 216,472 54.6 1.13* 

Chronic Lower Respiratory Disease 7 47 51.9 3 9,441 54.9 0.95 7 145 34.2 3 69,171 51.2 0.67* 8 3,182 58.8 3 238,332 57.1 1.03 

Influenza and pneumonia 8 27 38.2 6 5,353 33.6 1.14 9 113 33.0 6 37,341 29.8 1.11 9 2,794 52.6 6 113,846 29.7 1.77* 

Suicide 9 27 15.5 8 2,671 15.3 1.01 8 123 14.0 8 26,340 19.3 0.72* 6 4,452 34.6 7 102,346 23.7 1.46* 



 
 
 
 
 

 

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Kidney disease 10 24 26.7 9 2,500 15.3 1.74* 11 91 19.6 9 19,719 15.4 1.28 11 1,370 23.7 11 49,475 12.5 1.89* 

Assault (homicide) 11 20 10.9 23 399 2.3 4.68* 10 110 12.0 19 5,902 4.4 2.73* 10 2,663 20.1 20 18,832 4.4 4.56* 

Females 

All Causes ... 1,168 827.9 ... 198,169 708.5 1.17* ... 4,618 730.9 ... 1,429,349 683.9 1.07* ... 82,937 970.8 ... 4,158,728 688.3 1.41* 

Heart disease 1 328 248.5 1 64,905 218.9 1.14* 1 1,117 194.6 1 434,446 196.0 0.99 1 15,711 209.2 1 1,185,443 186.7 1.12* 

Cancer 2 242 169.3 2 44,756 174.4 0.97 2 895 139.5 2 323,253 166.5 0.84* 2 15,334 180.2 2 936,142 164.1 1.10* 

Diabetes mellitus 3 77 54.8 6 4,165 15.3 3.58* 3 368 58.4 8 31,363 15.3 3.81* 4 5,719 70.2 8 99,282 16.7 4.20* 

Stroke 4 61 46.2 3 15,487 51.7 0.89 5 282 50.0 3 109,605 49.1 1.02 5 4,466 60.8 3 340,931 53.3 1.14* 

Unintentional injury 5 58 31.7 7 4,013 16.9 1.87* 4 311 36.2 7 38,310 22.4 1.62* 3 7,626 63.4 7 126,842 24.8 2.56* 

Chronic Lower Respiratory Disease 6 57 42.5 4 10,320 37.0 1.15 6 168 27.8 4 75,635 36.2 0.77* 7 3,166 40.9 4 245,055 40.7 1.01 

Chronic liver disease 7 41 25.5 12 1,349 5.7 4.47* 7 167 21.3 12 10,823 6.1 3.49* 6 3,711 34.7 13 33,703 6.5 5.37* 

Septicemia 8 33 23.8 9 2,890 10.3 2.30* 10 99 15.6 10 20,222 9.5 1.64* 10 1,396 16.7 10 41,899 6.9 2.41* 

Influenza and pneumonia 9 28 21.6 5 6,779 22.3 0.97 8 117 21.2 5 47,646 21.0 1.01 8 2,661 35.5 6 139,370 21.6 1.65* 

Kidney disease 10 27 19.2 10 2,884 9.9 1.94* 9 108 17.5 9 20,559 9.5 1.85* 9 1,767 22.2 9 49,696 8.0 2.79* 

 

Note: AI/AN indicates: American Indian/Alaska Native; CHSDA: Contract Health Service Delivery Area. All analyses were limited to decedents of non-Hispanic origin. AI/AN race is reported from death 

certificates or through linkage with the IHS patient registration database. Rates are per 100,000 people and were age-adjusted to the 2000 US standard population (11 age groups; Census P25-1130). Rate ratios 

were calculated in SEER*Stat (version 8.3.2) before rounding of rates and may not equal RRs calculated from rates presented in the table. States and years data excluded because Hispanic origin was not 

collected on the death certificate: LA: 1990; NH: 1990-1992; OK: 1990-1996. East region is defined as: AL†, AR, CT†, DE, FL†, GA, KY, LA†, ME†, MD, MA†, MS†, MO, NH, NJ, NY†, NC†, OH, PA†, RI†, SC†, TN, VT, VA, 

WV, DC. Percentage regional coverage of AI/AN persons in CHSDA counties to AI/AN persons in all counties: East = 18.4%; total US = 64.2%. 

Source: AI/AN Mortality Supplement Database (1990-2009). 

† Identifies states with ≥ 1 county designated as CHSDA. 

*P<0.05 

 



 
 
 
 
 

 

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In men, all cause death rates in the 

Haudenosaunee Nations (1,184.1 per 100,000) were 

higher than those in the East (995.9) but not as 

high as those in the U.S. (1,390.9). The leading 

cause of death was heart disease for both AI/AN 

and white men, with rates that ranged from 283.0 

in East AI/AN to 395.0 for Haudenosaunee. The 

next ten leading causes of death for 

Haudenosaunee men were cancer, unintentional 

injury, diabetes, chronic liver disease, stroke, 

chronic lower respiratory disease, influenza and 

pneumonia, suicide, kidney disease, and homicide. 

Rates for Haudenosaunee males were significantly 

higher than whites for all causes (RR=1.14), heart 

disease (RR=1.13), unintentional injury (RR=2.26), 

diabetes mellitus (RR=3.29), chronic liver disease 

(RR=3.77), kidney disease (RR=1.74) and homicide 

(RR=4.68); and significantly lower for cancer 

(RR=0.79). Rates for suicide, stroke, chronic lower 

respiratory disease, and influenza and pneumonia 

were similar for Haudenosaunee and whites in the 

Haudenosaunee Nations. 

In women, all cause death rates in the 

Haudenosaunee Nations (827.9 per 100,000) were 

greater than those in the East (730.9) but not as 

high as those in the United States (970.8). For 

AI/AN and white populations, all-cause death rates 

were substantially lower for women than for men 

in the Haudenosaunee Nations, East, and United 

States. The two leading causes of death for both 

AI/AN and white women were heart disease and 

cancer with heart disease death rates that ranged 

from 186.7 for U.S. whites to 248.5 for 

Haudenosaunee and cancer death rates that 

ranged from 139.5 for East AI/AN to 180.2 for U.S. 

AI/AN. The remaining leading causes of death for 

Haudenosaunee women are diabetes mellitus, 

stroke, unintentional injury, chronic lower 

respiratory disease, chronic liver disease, 

septicemia, influenza and pneumonia, and kidney 

disease. Rates for Haudenosaunee women were 

significantly higher than whites for all causes 

(RR=1.17), heart disease (RR=1.14), unintentional 

injury (RR=1.87), diabetes mellitus (RR=3.58), 

chronic liver disease (RR=4.47), kidney disease 

(RR=1.94), and septicemia (RR=2.30). Rates for 

cancer, stroke, chronic lower respiratory disease, 

and influenza and pneumonia were similar for 

Haudenosaunee and whites in the 

Haudenosaunee Nations. 

Cancer death rates and leading cancer causes of 

death for the Haudenosaunee Nations, East, and 

U.S. comparing AI/AN with white persons by sex 

for 1990-2009 are presented in Table 2. The six 

leading causes of cancer death among the 

Haudenosaunee were lung and bronchus (lung), 

colon and rectum (colorectal), liver and 

intrahepatic bile duct (liver), pancreas, kidney and 

renal pelvis (kidney), and stomach cancer. The 

Haudenosaunee all malignant cancers death rates 

was 180.8, which was higher than the East AI/AN 

death rates (161.5) but not as high as those for U.S. 

AI/AN (205.5). Rates for Haudenosaunee were 

significantly higher than whites for liver cancer 

(RR=2.58) and significantly lower for all malignant 

cancers (RR=0.89). The rates for lung, colorectal, 

pancreas, stomach and kidney cancer were similar 

for Haudenosaunee and whites in the 

Haudenosaunee Nations. Comparisons of liver 

cancer mortality in AI/AN with white populations 

were greatest in the Haudenosaunee Nations 

(RR=2.58) than those in the East region (RR=1.57) 

and the United States (RR=2.40). Very large 

differences in liver cancer mortality were observed 

with higher rates among Haudenosaunee men 

(RR=2.69) and Haudenosaunee women (RR=2.84 

– data not shown) when compared to whites. 



 
 
 
 
 

 

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Table 2. Death rates for Cancer Causes for American Indians and Alaska Natives compared with whites, Males and Females, All Ages: CHSDA counties, United States, 1990-2009. 

 Haudenosaunee Nations East United States 

 AI/AN White AI/AN:White AI/AN White AI/AN:White AI/AN White AI/AN:White 

Cause of Deatha Rank Count Rate Rank Count Rate Rate Ratio Rank Count Rate Rank Count Rate Rate Ratio Rank Count Rate Rank Count Rate Rate Ratio 

Males and Females 

All Malignant Cancers ... 442 180.8 ... 89,837 203.6 0.89* ... 1,827 161.5 ... 666,932 197.6 0.82* ... 30,838 205.5 ... 1,961,554 193.3 1.06* 

Lung and bronchus 1 135 54.0 1 25,949 58.8 0.92 1 497 43.2 1 194,011 57.3 0.75* 1 7,906 53.1 1 563,590 55.2 0.96* 

Colon and rectum 2 49 21.4 2 9,554 21.3 1.01 2 189 17.5 2 67,629 19.8 0.89 2 3,137 21.5 2 193,141 18.9 1.14* 

Liver and intrahepatic bile duct 3 21 9.1 11 1,558 3.5 2.58* 4 79 6.6 9 14,036 4.2 1.57* 4 1,463 9.7 9 40,715 4.0 2.40* 

Pancreas 4 19 8.1 3 5,044 11.3 0.71 3 90 8.3 3 37,287 11.0 0.76* 3 1,479 10.0 3 107,762 10.6 0.95* 

Kidney and renal pelvis 5 15 6.0 9 1,837 4.2 1.44 6 59 5.1 10 13,800 4.1 1.24 6 1,215 7.8 8 41,953 4.1 1.88* 

Stomach 6 13 5.3 8 1,906 4.3 1.24 5 59 5.0 8 14,393 4.2 1.19 5 1,237 8.2 10 37,171 3.7 2.23* 

Males 

All Malignant Cancers ... 200 199.2 ... 45,081 251.6 0.79* ... 932 196.2 ... 343,674 245.4 0.80* ... 15,503 242.1 ... 1,025,385 236.4 1.02* 

Lung and bronchus 1 59 52.6 1 14,513 78.9 0.67* 1 287 57.9 1 110,650 76.9 0.75* 1 4,354 67.6 1 320,431 71.8 0.94* 

Colon and rectum 2 21 21.6 3 4,623 26.1 0.83 2 86 17.9 3 33,390 24.1 0.74* 2 1,586 24.7 3 97,516 22.7 1.09* 

Prostate 3 21 28.5 2 4,690 28.2 1.01 3 86 27.5 2 35,587 27.3 1.01 3 1,319 27.7 2 114,978 28.7 0.97 

Liver and intrahepatic bile duct 4 12 13.9 11 937 5.2 2.69* 4 51 9.3 8 8,966 6.3 1.47* 4 878 12.7 10 25,830 5.8 2.19* 

Females 

All Malignant Cancers ... 242 169.3 ... 44,756 174.4 0.97 ... 895 139.5 ... 323,258 166.5 0.84* ... 15,335 180.2 ... 936,169 164.1 1.10* 

Lung and bronchus 1 76 53.4 1 11,436 45.2 1.18 1 210 32.8 1 83,361 43.4 0.76* 1 3,552 42.4 1 243,159 42.8 0.99 

Colon and rectum 2 28 20.6 3 4,931 18.1 1.14 3 103 17.0 3 34,239 16.8 1.02 3 1,551 19.1 3 95,625 16.1 1.19* 

Breast 3 27 17.9 2 7,255 29.5 0.61* 2 124 17.6 2 50,154 26.9 0.65* 2 1,970 21.6 2 146,357 26.5 0.82* 

Pancreas 4 12 8.8 4 2,658 10.0 0.88 4 54 9.3 4 19,256 9.6 0.98 4 771 9.4 4 54,284 9.3 1.02 

Note: AI/AN: American Indian/Alaska Native; CHSDA: Contract Health Service Delivery Area. All analyses were limited to decedents of non-Hispanic origin. AI/AN race is reported from death certificates or 

through linkage with the IHS patient registration database. Rates are per 100,000 people and were age-adjusted to the 2000 US standard population (11 age groups; Census P25-1130). Rate ratios were 

calculated in SEER*Stat (version 8.3.2) before rounding of rates and may not equal RRs calculated from rates presented in the table. States and years data excluded because Hispanic origin was not collected on 

the death certificate: LA: 1990; NH: 1990-1992; OK: 1990-1996. East region is defined as: AL†, AR, CT†, DE, FL†, GA, KY, LA†, ME†, MD, MA†, MS†, MO, NH, NJ, NY†, NC†, OH, PA†, RI†, SC†, TN, VT, VA, WV, DC. 

Percentage regional coverage of AI/AN persons in CHSDA counties to AI/AN persons in all counties: East = 18.4%; total US = 64.2%. 

Source: AI/AN Mortality Supplement Database (1990-2009). 

† Identifies states with ≥ 1 county designated as CHSDA. 

*P<0.05 



 
 
 
 
 

 

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In men, the all malignant cancers death rates 

range from 196.2 for East AI/AN to 251.6 for 

Haudenosaunee Nations whites. For all AI/AN 

males, the leading cancer causes of death are 

lung, colorectal, prostate, and liver. With the 

exception of lung cancer, Haudenosaunee men 

have higher cancer death rates for the leading 

cancer causes of death than the East AI/AN men. 

Rates for Haudenosaunee males were significantly 

higher than whites for liver cancer (RR=2.69); and 

significantly lower for all malignant cancers 

(RR=0.79) and lung cancer (RR=0.67). Rates for 

colorectal and prostate cancer were similar for 

Haudenosaunee and whites in the 

Haudenosaunee Nations. 

In women, the all malignant cancers death rates 

range from 139.5 for East AI/AN to 180.2 U.S. 

AI/AN. Haudenosaunee cancer mortality rates in 

women were 169.3 compared to 139.5 for the East 

AI/AN. The Haudenosaunee reflected rates that 

were lower than those of whites, but this new data 

showed all malignant cancer death rates for 

Haudenosaunee women to be higher than those 

reported for the East AI/AN. For females in the 

Haudenosaunee Nations, the leading cancer 

causes of death were lung, colorectal, breast, and 

pancreatic cancer. With the exception of 

pancreatic cancer, Haudenosaunee women had 

higher cancer death rates for the leading cancer 

causes of death than the East AI/AN women. Rates 

for Haudenosaunee females were significantly 

lower than whites for breast cancer (RR=0.61). 

Rates for all malignant cancers, lung, colorectal 

and pancreatic cancer were similar for 

Haudenosaunee and whites in the 

Haudenosaunee Nations. 

Death rates for all causes by age for AI/AN 

compared to whites for 1990-2009 are shown in 

Table 3. When examined by age, disparities in all-

cause mortality were most evident in younger age 

groups, particularly ages 25 to 44 years. This 

pattern was apparent for the Haudenosaunee 

Nations, East, and United States. It was particularly 

prominent in the United States, where all-cause 

death rates in this age group for AI/AN were 2.6 

times higher than that for whites, and the 

Haudenosaunee Nations, where all-cause death 

rates for Haudenosaunee were 1.9 times higher 

than that for whites. The disparities in all-cause 

mortality were higher in the Haudenosaunee 

Nations than in the East and were statistically 

significantly different for all age groups. 

 

Table 3. Death Rates for All Causes by Age for American Indians and Alaska Natives Compared with 

whites, Males and Females: CHSDA Counties, United States, 1990-2009. 

  AI/AN White AI/AN:White 

Region Age Group Count Rate Count Rate Rate Ratio 95% CI 

Haudenosaunee 

Nations 

0-24 years 148 89.7 6,330 56.5 1.59* 1.34-1.87 

25-44 years 247 225.3 12,065 121.6 1.85* 1.63-2.10 

45-64 years 711 964.2 53,480 602.2 1.60* 1.48-1.72 

65-84 years 1,047 4273.9 191,781 3770.6 1.13* 1.06-1.21 

85+ years 266 12190.7 112,766 15251.0 0.80* 0.71-0.90 



 
 
 
 
 

 

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East 0-24 years 737 95.1 51,632 61.9 1.54* 1.43-1.65 

25-44 years 1,239 228.9 116,623 148.7 1.54* 1.45-1.63 

45-64 years 2,959 790.2 426,452 613.3 1.29* 1.24-1.34 

65-84 years 3,813 3617.8 1,358,821 3528.4 1.03 0.99-1.06 

85+ years 1,085 10875.0 833,663 14863.3 0.73* 0.69-0.78 

US 0-24 years 18,394 144.2 177,184 65.1 2.22* 2.18-2.25 

25-44 years 28,658 386.3 367,061 149.4 2.59* 2.55-2.62 

45-64 years 50,735 1063.7 1,319,759 606.0 1.76* 1.74-1.77 

65-84 years 64,931 4638.5 4,019,450 3511.5 1.32* 1.31-1.33 

85+ years 21,915 15583.2 2,415,363 14974.6 1.04* 1.03-1.05 

 

Note: AI/AN: American Indian/Alaska Native; CHSDA: Contract Health Service Delivery Area. All analyses 

were limited to decedents of non-Hispanic origin. AI/AN race is reported from death certificates or 

through linkage with the IHS patient registration database. Rates are per 100,000 people and were age-

adjusted to the 2000 US standard population (11 age groups; Census P25-1130). Rate ratios were calculated 

in SEER*Stat (version 8.3.2) before rounding of rates and may not equal RRs calculated from rates 

presented in the table. States and years data excluded because Hispanic origin was not collected on the 

death certificate: LA: 1990; NH: 1990-1992; OK: 1990-1996. East region is defined as: AL†, AR, CT†, DE, FL†, 

GA, KY, LA†, ME†, MD, MA†, MS†, MO, NH, NJ, NY†, NC†, OH, PA†, RI†, SC†, TN, VT, VA, WV, DC. 

Percentage regional coverage of AI/AN persons in CHSDA counties to AI/AN persons in all counties: East 

= 18.4%; total US = 64.2%. 

Source: AI/AN Mortality Supplement Database (1990-2009). 

† Identifies states with ≥ 1 county designated as CHSDA. 

*P<0.05 

 

Figure 2 summarizes trends in all-cause mortality 

in CHSDA counties from 1990-2009 for 

Haudenosaunee, East AI/AN, U.S. AI/AN, and U.S. 

whites by sex. All-cause death rates for 

Haudenosaunee males declined 2.2% per year, 

whereas for East AI/AN males death rates declined 

1.6% per year. Nationally, all-cause death rates 

remained stable for AI/AN males, whereas for 

white males, death rates declined 1.3% per year.  

 

Haudenosaunee females and East AI/AN females 

remained stable. Nationally, all-cause death rates 

for AI/AN females significantly increased 0.5% per 

year, whereas white female death rates were 

stable. 

  

 

 

 



 
 
 
 
 

 

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Note. AI/AN = American Indian/Alaska Native; CHSDA: Contract Health Service Delivery Area. Analyses 

are limited to persons of non-Hispanic origin. AI/AN race is reported from death certificates or through 

linkage with the IHS patient registration database. * α = 0.05.  

Figure 2. Annual age-adjusted all-cause death rates and Joinpoint trend lines for males and females: 

CHSDA counties, US, 1990-2009 

0

200

400

600

800

1000

1200

1400

1600

1800

2000

R
a
te

 p
e
r 

1
0

0
,0

0
0

 

Year 

Males 

Haudenosaunee rate Haudenosaunee trend East AI/AN rate East AI/AN trend

US AI/AN rate US AI/AN trend US NHW rate US NHW trend

Annual Percent Change  Average Annual Percent Change 
Haudenosaunee (-2.2*)  Haudenosaunee (-2.2*) 
East AI/AN (-1.6*)   East AI/AN (-1.6*) 
US AI/AN (-0.2)   US AI/AN (-0.2) 
US NHW (1990-2002: -1.0*; 2002-2009: -1.8*) US NHW (-1.3*) 

0

200

400

600

800

1000

1200

R
a
te

 p
e
r 

1
0

0
,0

0
0

 

Year 

Females 
Haudenosaunee rate Haudenosaunee trend East AI/AN rate East AI/AN trend

US AI/AN rate US AI/AN trend US NHW rate US NHW trend

Annual Percent Change   Average Annual Percent 
Change 
Haudenosaunee (0.1)   Haudenosaunee (0.1) 
East AI/AN (1990-2004: 1.4*; 2004-2009: -5.4*) East AI/AN (-0.4) 
US AI/AN (1990-2003: 1.1*; 2003-2009: -0.7)  US AI/AN (0.5*) 
US NHW (1990-2002: 0.1; 2002-2009: -1.5*)  US NHW (-0.5) 



 
 
 
 
 

 

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DISCUSSION 

Haudenosaunee all-cause death rates were 

substantially greater than those for East AI/AN but 

not as great as those for U.S. AI/AN. The most 

prominent disparities for all-cause death rates of 

Haudenosaunee are concentrated in the younger 

age groups. The significant decrease in all-cause 

death rates over the past two decades for 

Haudenosaunee males is declining at a greater 

percentage per year than East AI/AN, U.S. AI/AN 

and U.S. whites. Unfortunately, this decrease was 

not observed for Haudenosaunee females with all-

cause death rates appearing to be stable over the 

past two decades. Lastly, the leading specific cause 

of death and age at death disparities indicates 

potential areas of intervention that can improve 

mortality among the Haudenosaunee. 

Health disparities 

Among the Haudenosaunee of NYS, the six 

leading causes of death compared to whites for 

both males and females combined between 1990 

and 2009 were heart disease, cancer, unintentional 

injury, diabetes, stroke, and liver disease. 

Statistically significant differences were found 

between Haudenosaunee and whites for deaths 

related to unintentional injury, diabetes, and 

chronic liver disease (see Table 1). Although cancer 

was the second leading cause of death for both 

Haudenosaunee and whites, the Haudenosaunee 

had a lower cancer death rate than whites. 

Cancer 

Deaths related to all malignant cancers were 

higher among the Haudenosaunee than the IHS 

East region as a whole. After IHS linkage, death 

rates for Haudenosaunee men and women were 

higher than the IHS East region. However, these 

numbers were lower than all AI/ANs combined 

and whites which also coincided with previous 

findings (Mahoney et al., 2009; Mahoney, 

Michalek, Cummings, Hanley, & Snyder, 1989). 

The top two leading cancers that caused death 

among the Haudenosaunee were lung and 

colorectal, with death rates nearly equivalent to 

those of whites. These new results were 

comparable to previous studies listing lung cancer 

and colon cancer as the leading causes of 

mortality for tribally enrolled men of one tribe of 

the Haudenosaunee, followed by lung, cervix, and 

breast cancer for enrolled women of the same 

Nation (Mahoney et al., 1989). 

This analysis shares new concerns which were 

difficult to assess in a previous study of one 

Haudenosaunee Nation based on a limited 

number of cases (Mahoney et al., 2009). 

First, liver disease and liver cancer is of significant 

concern in these new findings. Chronic liver 

disease was classified as the fifth leading cause of 

death in AI/ANs, with alcoholic liver disease, 

Hepatitis C Virus (HCV) infection and non-alcoholic 

fatty liver disease as the most common 

contributors (Suryaprasad et al., 2014). Non-

alcoholic fatty liver disease or NASH, sometimes 

referred to as diabetes hepatitis, is an increasingly 

recognized condition that may progress to end-

stage liver disease and cancer (Batman & Scheuer, 

1985; Nagore & Scheuer, 1988; Picardi & D’Avola, 

2006). Obesity, type 2 diabetes, and 

hyperlipidemia are also coexisting conditions 

frequently associated with this disease 

(Suryaprasad et al., 2014; Than & Newsome, 2015; 

Aleksandrova, Stelmach-Mardas, & Schlesinger, 

2016). Further, there are data that suggest that 

steatosis with other liver disease, such as the HCV 



 
 
 
 
 

 

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infection, could increase the risk of liver disease 

(Angulo, 2002). 

Diabetes 

Type 2 diabetes is often related to obesity and 

both often co-occur with other conditions and 

chronic diseases (Bril & Cusi, 2017; Rice et al., 2016; 

Vigneri, P., Frasca, Sciacca, Pandini, & Vigneri, R., 

2009). These include fatty liver disease and certain 

types of cancer. Both chronic liver disease and liver 

cancer were concerns for both males and females 

of the Haudenosaunee compared to whites. 

Regionally, diabetes mortality for the 

Haudenosaunee nearly mirrored that found in the 

East region and among other AI/AN populations 

in NYS (data not shown) (Cho et al., 2014). 

However, mirroring nationwide findings, 

Haudenosaunee men and women die nearly 3.5 

times more than whites from diabetes. 

In regards to sex, diabetes rates in 

Haudenosaunee men were higher than those 

reported for East AI/AN, and closely mirrored rates 

for US AI/AN men. Mortality associated with 

diabetes for Haudenosaunee women was slightly 

lower than previous statistics shown for all AI/AN 

women in the East. These findings are similar to 

recent national data that indicated that age-

adjusted diabetes prevalence rates among AI/AN 

persons were at least twice those of whites or the 

total U.S. population and ranked as the fourth 

leading cause of death for AI/AN persons (Cho et 

al., 2014). 

LIMITATIONS 

These results have several limitations. First, 

although linkage with the IHS patient registration 

database improves the classification of race for 

many AI/AN decedents, the issue is not completely 

resolved. AI/AN who are not members of federally 

recognized tribes are not eligible for IHS services 

and are therefore not represented in the IHS 

patient registration database. Additionally, some 

eligible decedents may have never used IHS 

services and were therefore not included in the 

IHS patient registration database. Second, the 

findings from CHSDA counties do not represent all 

AI/AN populations in the US or the East region, 

which includes only 18.2% of the total AI/AN 

population (Espey et al., 2014b). Furthermore, the 

analyses based on CHSDA designation exclude 

many AI/AN decedents in urban areas that are not 

part of a CHSDA county. AI/AN residents of urban 

areas differ from other AI/AN persons in poverty 

level, health care access, and other factors that 

may influence mortality trends (Jacobs-Wingo et 

al., 2016; Urban Indian Health Institute, 2008). 

Third, federally recognized tribes vary substantially 

in the proportion of native ancestry required for 

tribal membership and therefore for eligibility for 

IHS services. Whether or how this discrepancy in 

tribal membership requirements may influence 

some of our findings is unclear, although our 

findings are consistent with prior reports. Fourth, 

to capture enrolled and non-enrolled 

Haudenosaunee, analyses were restricted to the 

nine counties that comprise most of the 

Haudenosaunee Nations. The nine county 

restriction may have excluded Haudenosaunee 

that that do not live in these counties and included 

AI/ANs that belong to other tribes. Finally, 

although the exclusion of Hispanic AI/AN persons 

from the analyses reduces the overall US AI/AN 

deaths by less than 5%, it may disproportionately 

exclude some tribal members. For instance, tribal 

members in states along the US-Mexico border 

and possibly elsewhere who have Hispanic 



 
 
 
 
 

 

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surnames and may be coded as Hispanic on the 

death certificate. 

FUTURE RESEARCH 

More research is needed to investigate what is 

causing the high mortality of liver disease and 

associated cancers affecting the Haudenosaunee. 

The relationship between mortality and obesity has 

been further supported in previous research from 

a member tribe of the Haudenosaunee. The 

research showed that, during a 30-year study 

period, 8.3 percent of years of potential life loss 

were due to digestive disorders that may be 

related to obesity and dietary practices (Mahoney 

et al. 1989). Further, in another tribe of the 

Haudenosaunee, six cardiovascular disease risk 

factors were evaluated. Of 95 school children, 55 

represented 39 interrelated families. Seventy-two 

percent of the family histories included diabetes 

mellitus and 42% of the children’s physical 

examinations revealed obesity (weight/height 

greater than 90th percentile) (Botash et al., 1992). 

Future investigation is needed to discover if 

variables causing liver disease differ among the 

Haudenosaunee. These include specific variances 

between fatty liver disease, HCV, and the role of 

both alcoholic and non-alcoholic cirrhosis. 

Potential co-occurring conditions of concern 

related to liver disease and liver cancer are 

common among the Haudenosaunee and may be 

additive or synergistic in the development of 

disease. Hepatitis C infection rates should be 

evaluated. Otherwise, the stereotype of assuming 

the problems are all related to alcoholism might 

delay a more complete understanding of the 

health risks within this population. The impact of 

historical trauma, inducing adverse childhood 

experiences, among AI/ANs is just now being 

evaluated for its relationship to cancer (Brown et 

al., 2010; Shonkoff et al., 2009). 

This is an initial paper and comparisons to 

ethnically and racially diverse populations that may 

be facing similar social determinants of health in 

the same geographic regions should be explored. 

Recent updated cancer incidence and mortality 

evaluations have clearly identified the importance 

of regional differences across AI/AN populations 

(Espey et al., 2014a; Plescia, Henley, Pate, 

Underwood, & Rhodes, 2014). Disparities in cancer 

and other diseases are due to inequalities in 

socioeconomic status, sexual orientation, gender, 

disability status, geographic location, 

discriminatory practices, or some combination of 

factors (Brennan Ramirez, Baker, & Metzler, 2008; 

Krieger, Emmons, & Williams, 2009). Further, 

future studies could also include the review of 

other Haudenosaunee populations outside of NYS 

(i.e., Haudenosaunee located in Canada, 

Wisconsin, and Oklahoma). 

For the Haudenosaunee and other AI/AN 

populations, chronic diseases, such as diabetes, 

heart disease and cancer, are now the norm (Cobb 

et al., 2014; Acton et al., 2002; Burrows, Geiss, 

Engelgau, & Acton, 2000; Go et al., 2013). There 

was a time when infectious diseases were the 

major health focus. Cancer was previously 

reported for whites and blacks only in the SEER 

Cancer Statistics Review. Now we know that all 

segments of the population, large and small, 

should have data that will guide resources and 

appropriate interventions in reducing cancer 

(Wallerstein & Duran, 2010). The definitions of 

population data are also very important, as shown 

here, so that the limitations can be understood 

and data of higher quality can be collected going 

forward. Understanding factors affecting small 



 
 
 
 
 

 

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population groups is crucial to overcoming 

disparities and will likely require new research 

designs with community-based participatory 

research as the guiding principle (Srinivasan et al., 

2015). The community should be heard and their 

feedback incorporated into the way in which 

questions are asked and data used to develop 

culturally appropriate interventions (Cochran et al., 

2008). 

Overall, these new findings provide a crucial 

framework for tribal health centers, AI/AN urban 

centers, and those who work with the 

Haudenosaunee in NYS. These new data identify 

health disparity rates higher for the 

Haudenosaunee than previously published or in 

comparison to aggregate data for all Native 

Nations in the IHS East region. There should be a 

realization of cultural and traditional views of the 

Haudenosaunee and understanding of what is 

important to future generations, including the 

integration or enhancement of interventions and 

prevention programs. Such programs could also 

include the philosophies and traditional viewpoints 

of the people of the confederacy wrapped in a 

framework of resiliency and courage. Lastly, it is 

also important to be cognizant of historical factors 

related to environmental shifts, and generational 

stress, and how these may contribute to current 

health disparities (Brown et al., 2010; Shonkoff et 

al., 2009; Warne, 2005; Anda, Butchart, Felitti, & 

Brown, 2010; Felitti et al., 1998; Mehta et al., 2013). 

Acknowledgements 

The study used shared resources supported by 

Roswell Park Comprehensive Cancer Center 

Support Grant from the NCI (P30CA016056). The 

authors also wish to thank the Kanatsiohareke 

Mohawk Community’s Indigenous Writing Retreat, 

Paula Jones, and Dr. Brenda Battleson-White (copy 

editors). 

Disclaimer 
The findings and conclusions in this report are 

those of the authors and do not necessarily 

represent the official position of the Centers for 

Disease Control and Prevention. 

Conflict of interest 
The authors declare that no competing or conflict of 

interests exists. The funders had no role in study 

design, writing of the manuscript, or decision to 

publish. 

Authors’ contributions 
Dr. Rodney Haring, Dean Seneca, and Melissa Jim 

worked collaboratively on conceptualization, project 

aims, goals, methods, and results. Melissa Jim was 

the primary statistician and epidemiological reviewer. 

Dr. Deborah Erwin focused on health disparities 

overview and manuscript structuring and Dr. Judith 

Kaur assisted with discussion items. Whitney Ann 

Henry and Marissa Haring provided literature review 

support and assistance with manuscript writing and 

review. 

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