207

Youth and Other Special Populations

Motor Vehicle Crashes and Alcohol
Among American Indians and
      Alaska Natives

Philip A. May, Ph.D.

University of New Mexico

The American Indian population, made up of well over 300 tribes, now numbers more
than 1.5 million or over 0.6 percent of the U.S. population. Throughout the recent past,
it has been a rapidly growing population that has consistently had a birth rate twice that
of the rest of the U.S. population (IHS 1988; May 1988; Broudy and May 1983). Because
of this high fertility, the median age of the Indian population was 22.9 in 1980, compared
to 30.3 for the overaIl U.S. population. The median age of the population living on
reservation was 19 years in 1980 (U.S. Congress 1986). The young age composition has
definite implications for the study of both motor vehicle injuries and alcohol.

Some other general considerations of the U.S. Indian population are also vital here.
While Indians and Alaska Natives live in every State of the Union, most live in 32
"reservation States" (see exhibit l), the vast majority (over 1 million) in Western States
(IHS 1988). Many Indians live in rural areas (46 percent) or other urbanized settings
such as small towns (32 percent), while 22percent live in central cities. In 1980,37 percent
lived on reservations or in Indian communities. Many who live in cities or off reservations
are characterized as highly mobile (U.S: Congress 1986). Average economic indicators
for Indians as a group remain poor. The 1980 Census indicated unemployment rates
twice the national average, and the median family income for Indians was about half the
average for the entire U.S. population (U.S. Congress 1986; U.S. Bureau of Census
1984q b). Finally, educational attainment of many Indians remains lower than the
national averages (Brod and McQuiston 1983).

Overview of Accident Statistics

When reviewing accident data for Indians, one must first consider accidents as they
affect the overall Indian population and then move to specific considerations of gender,
age, and local and regional data, Only recently have accidents fallen to second place
among causes of mortality. Accidents were the leading cause of death throughout the
195Os, 196Os, and 1970s for Indians and Alaska Natives in the 32 reservation States (IHS
1988). In 1983-85? accidents caused 3,218 deaths or 16 percent of all mortality (see table
1). Of these deaths, 1,753 or 54.5 percent were caused by motor vehicles. When measured
by crude rates, accidents are the fourth leading cause of death among other U.S.
residents. Motor vehicle accidents take a higher toll among Indian males than females,
and this is even more true of other accidents.

Table 2 presents age-adjusted death rates that allow comparisons between Indians
and other groups in the United States. When age-adjusted rates are considered, accident


208

BACKGROUND PAPERS

Exhibit 1

Indian Health Service (IHS) reservation States numbered L?4 from 1969 to 1974. Prior
to that, IHS calculated rates on SO-percent samples of U.S. records. Since 1974, eight
more States have heen added. The current 32 stateslisted by administrative area and the
year added for the most recent additions are:
Nashville Area:  Alabama (added in 1984),.Connecticut (added in 1983), Florida,
         Louisiana, Maine (added in 1979), Mississippi, New York
        (added in 1979), North Carolina, Pennsylvania (added in 1979),
         Rhode Island (added in 1983).
Bemidji Area:   Michigan, Minnesota, Wisconsin
Oklahoma Area:  Oklahoma, Texas (added in 1983), Kansas
Aberdeen Area:   Iowa, Nebraska, North Dakota, South Dakota.
Billings Area:    Montana, Wyoming
Albuquerque Area: Colorado, New Mexico
Navajo Area:    Main Navajo reservation (parts of Arizona,NewMexico and Utah)
Phoenix Area:   Arizona (most), Nevada, Utah
Tucson Area:    Southern Ariina (Papago reservation)
Portland Area:   Idaho, Oregon, Washington
Alaska Area:     Alaska

mortality becomes the third leading cause of death for aU Indians and Alaska Natives.
The rate of 42.2 per 100,000 for motor vehicle accidents is 2.3 times the rate for alI races
combined. Other accidents, which in the distant and relatively recent past have played
a major role in mortality among Indians (Kunitz 1983) and particularly Alaska Natives
(Boyd et al. 1968), are 2.2 times higher than U.S. averages.

The trend in accident mortality rates for Indians and Alaska Natives has been down
over the years that accurate, Indian-specific rates have been kept, but the exact mag-
nitude of this drop is difficult to determine . Many procedural changes have affected the
calculation of Indian mortality rates, confusing the interpretation of trends. Some of
these changes include: alterations in census enumeration methodologies for American
Indians and Alaska Natives; changes in methodologies for estimating the Indian popula-
tion (which was necessary to correct suspected undercounts;); debate over whether tribal
enrollment or resident population figures were the most appropriate for use as denom-
inators; and, most importantly, the addition of Indians from States such as Pennsylvania,
Rhode Island, and Connecticut to Indian Health Service "reservation States" (see U.S.
Congress 1986, pp. 59-82; IHS 1988; Passe11 1976; PasseII and Berman 1986, May 1988).

Taken at face value the Indian Health Service (IHS) rates indicate that accident
mortality has fallen dramatically. The age-adjusted rate of motor vehicle accident
mortality declined from a high of 106.2 in 1956 to 42.6 in 1985 (IHS 19@3), a drop of 59.8
percent. However, a more realistic trend figure might be obtained by using m-year
figures from 1956 through 1976, when the major reshaping of the II-IS denominator
began. From 1956 to 1976, the Indian rate of motor vehicle accident death dropped from
106.2 to 74.5 or 29.8 percent. This is quite comparable to the overall U.S. drop of 14.7
percent from 1956 to 1976 or 34.0 percent from 1956 to 1985. Therefore, it is safe to
conclude that the American Indian rates have dropped, probably in a magnitude similar
to or slightly greater than the drop for the overall U.S. population. 1 One  positive
reason for this drop could certainly be the upgrading of emergency medical services
begun in the middle 1970s on many reservations.

1  Indian vital statistics in many areas tend to parallel U.S. statistics, although some rates usually remain
higher. For example, most tribes experienced a baby boom similar to the total U.S. population, only the birth
rates were substantially higher and the peak was several years later (see Broudyand May 1983). Also, motor
vehicle accident rates were reduced in 1974 on the Navajo reservation when the oil embargo forced the
lowering of the national speed limit (Katz and May 1979).


YOUTH AND OTHER SPECIAL POPULATIONS

209

Table I. Leading causes of death for American Indian and Alaska Natives by
   frequency, gender, and rates per 100,000, 1983-85

          Males                    Females
              Mortality                Mortality
Causes of death     Number   rate   Causes of death      Number rate

All causes        11,894
Diseases of the heart   2,727
Accidents        2,385
Motor vehicle     1,263
Other accidents    1,122
Malignant neoplasms   1,424
Chronic liver disease
and cirrhosis       520
Suicide             485
Cerebrovascular diseases 456
Homicide            453
Pneumonia and influenza  387
Diabetes mellitus       284
Chronic obstructive
pulmonary diseases
and allied conditions   254
Certain conditions
originating in the
perinatal period      216
All other causes      2,303

568.4
130.3
114.0
60.4
53.6
68.0

24.8
23.2
21.8
21.6
18.5
13.6

12.1

10.3

All causes
Diseases of the heart
Malignant neoplasms
Accidents
Motor vehicle
Other accidents
Cerebrovascular diseases
Chronic liver disease
and cirrhosis
Diabetes mellitus
Pneumonia and influenza
Certain conditions
originating in the
perinatal period
Nephritis, nephrotic,
and nephrosis
Homicide
All other causes

8,216   382.2
1,958   91.1
1,301   60.5
833   38.7
490   22.8
343   16.0
513   23.9

404   18.8
392   18.2
295   33.7

171    8.0

151
144
2,054

7.0
6.7

Source: Indian Health Service, Chart Book Series, 1988.

The greater magnitude of the rate of inotor vehicle accident death warrants further
discussion here. The overall aggregated data for 1983-85 indicate that Indians and Alaska
Natives die twice (2.3 times) as frequently from motor vehicle crashes. But since these
are overall figures that include both males and females, eastern and western Indians,
Alaska Natives and Indians, rural and urban Indians, and a great diversity of tribes with
differing social and cultural traditions, it is imperative to examine data that are more
specific to local, tribal, and gender variations.

Table 3 gives age- and gender-specific data for U.S. Indians and Alaska Natives.
Indian males' rates of motor vehicle accident mortality are substantially higher than
Indian females, in each age category. Further, Indian males age 15 to 85 years and older
die three times more frequently than Indian females in motor vehicle crashes. Both
Indian males and Indian females have higher rates of death at virtually every age category
than all races combined, the exception being Indian women 75 and over.

This higher rate of accidental death for Indian males, when expressed in years of
potential life lost or life expectancy, is dramatic. Among the Navajo in 1972-74, motor
vehicle deaths reduced the male life expectancy at birth by5.2 years, and other accidents
reduced male longevity by another 3.1 years (Carr and Lee 1978). For Navajo females,
the respective figures were 2.7 years and less than 1 year (Carr and Lee 1978). The
comparable figures for the U.S. population at this time were reductions of less than 1
year for motor vehicle and other accidents for both males and females (Tsai et al. 1978).

An examination of geographical and cultural variations in unintentional injury death
rates (table 4) reveals three items that need to be emphasized. First, the highest rates of


210                                                       BACKGROUND PAPERS

Table 2. Age-adjusted mortality rates (per 100,000 population) for American
   Indians and Alaska Natives in reservation States, 1983-1985, and
   U.S. populations, 1985

Indians         United States     Ratio of
and Alaska                AlI   Indians to
Natives   All races   White   other all US races

All causes         ~ 542.7
Major cardiovascular disease 174.6
Diseases of heart       141.6
Cerebrovascular diseases 26.8
Atherosclerosis         2.5
Hypertension          1.0
Malignant neoplasms       84.9
Accidents             77.7
Motor vehicle         42.6
AII other            35.1
Chronic liver disease
and cirrhosis          29.2
Diabetes mellitus         22.9
Pneumonia and influenza    17.9
Homicide             14.3
Suicide               14.1
Chronic obstructive
pulmonary diseases
and allied conditions     11.5
Tuberculosis, all forms       1.6

546.1     523.1   697.8     1.0
224.0     216.9   273.4     0.8
180.5     176.1   210.4     0.8
32.3     30.1   49.4     0.8
4.0      4.0    3.9     0.6
1.8      1.4    4.7     0.6
133.6     130.7   155.7     0.6
34.7     34.1   39.7     2.2
18.8      19.1   17.4     2.3
16.0     15.0   22.3     2.2

9.6      8.9    14.4     3.0
9.6      8.6   17.7     2.4
13.4      12.8   16.8     1.3
8.3      5.4   24.4     1.7
11.5      12.3    6.7     1.2

18.7     19.2   13.8     0.6
0.5      0.3    1.8     3.2

Source: Indian Health S&vice. Chart Book Series, 1988.

motor vehicle accident deaths occur in the West (Rocky Mountain, Plains, and Upper
Midwest). Indians in the Billings, Aberdeen, Tucson, and Navajo areas have the highest
rates, which are 6.7, 5.4, 4.9, and 4.6 times, respectively, that of the general U.S.
population. Alaska has the lowest rate.

Second, Alaska Natives, while they have lower rates of motor vehicle mortality, have
much higher rates of other accident mortality such as from water transport, firearm
incidents, and air transport. Third, females, particularly those living in Alaska and the
West, are at increased risk for motor vehicle and other injury-related death. In summary,
even though the overall age-adjusted death rates for accidents among Indians seem to
have improved dramatically over the years and are now only 2.2 to 2.3 times the national
averages, many tribes, cultures, and subcultures, particularly in the West, still have
&maIjdy I&her accident mortality rates. The reasons for this are sociocultural (May
1982) as well as geographical and envirqnmental.

Local Mortality Data From the West

Isolated State data confirm, in another way, the extremely high accident mortality
rates for western Indians. From 1982 through 1986 in Montana, the Indian crude rate of
death from motor vehicle accidents was 79.7 per lOO,fKKl, while the non-Indian rate was


YOUTH AND OTHER SPECIAL POPULATIONS

211

Table 3. Age-and gender-specific motor vehicle accident death rates (per
   100,000 population) for American Indians and Alaska Natives in
    reservation States, 1983-85, and U.S. all races, 1984

       MALE             FEMALE

American Indian U.S.  Ratio American Indian -U.S.    Ratio
    and     all Indian to     and      au    Indian to
Alaska Native races U.S. all  Alaska Native races   U.S. all
(1983-1985) (1984) races   (1983-1985) (1984)     races

Under 1 year     19.5      43 4.5       12.0      4.6       2.6
1 to 4 years     23.8      8.0 3.0       18.8      5.7      3.3
5 to 14 years      9.9      8.3 1.2       7.9      4.9       1.6
15 to 24 years     87.7     54.9 1.6      31.9     18.3       1.7
25 to 34 years     99.1     37.0 2.7      30.7     10.7      2.9 /
3.5 to 44 years     78.4     25.2 3.1       29.4      9.2       3.2
45 to 54years     71.0     22.4 3.2       25.7      8.8      2.9
55 to 64 years     59.0     21.9 2.7       22.1      10.1      2.2
65 to 74 years     57.0     24.9 2.3       15.2     12.7       1.2
75 to 84 years     89.4     42.0 2.1       14.4     20.0      0.7
Over 84 years     71.9     53.3 1.3       9.5     13.5      0.7

Source: Indian Health Service, Chart Book Series, 1988.

26.5 (calculated from data in the State of Montana, 1983-88). Even though these wey
not age-adjusted, one can conclude that the Indian rate was approximately 2.5 to 3
times the non-Indian rate in the same State. In New Mexico, similar trends are found. In
both 1976-78 and 1984-86, the age-adjusted motor vehicle accident death rates for
Indians were considerably higher than for the other three major ethnic groups (see table
5). Indian rates in both periods were 2.5 to 5.2 times higher than the other groups, even
though the rates for all groups decreased with time. The rate of decrease was 35.5 percent
for Indians, which was a more substaritial reduction than among Hispanics and blacks,
but not as desirable as the decline among non-Hispanic whites. Among Indian and
non-Indian populations in the same State, Indians have higher rates of motor vehicle
accident death.

Even in the same county, Indians and non-Indians have differential rates of motor
vehicle accident death. For example, in Montana in 1974, a colleague of mine and I
calculated crude accidental death rates for both Indians and non-Indians on a county-by-
county basis. This was facilitated by the fact that reservation boundaries cross several
counties, and each county therefore has a substantial number of both Indian and
non-Indian residents living in a similar natural ecology. Of the 17 counties characterized
by this situation, Indians had higher rates of accidental death (motor vehicle and other)
in 11. The overall mortality rate for Indians in these counties was 253 per 100,000
compared to 70 per 100,000 for non-Indians (May and Morigeau 1976).

Morbidity Statistics

Accidents among Indians put a great burden on the health care system as measured
by hospital discharge data. In fiscal year 1987, injuries and poisonings was the leading
diagnostic category for Indian and Alaska Native males at IHS and contract hospitals,

2  Actually3.6 times, but since the rates are not age-adjusted, too specific acomparison is not appropriate.


Table 4. Age-adjusted death rates (per 100,000 population) by type of Injury, sex, and area for Indians and Alaska Natives, 1980-82

Type of injury

  EASTERN                     WESTERN                    FAR WEST
Nashville Oklahoma Aberdeen Bemidji Billings Albuquerque Navajo   Phoenix  Tucson Portland Alaska

Male

Motor vehicle traffic

Ratio to U.S. all races
Other unintentional injury
Ratio to U.S. all races

Female

Motor vehicle traffic

Ratio to U.S. all races
Other unintentional injury
Ratio to U.S. all races
Total (both sexes)
Motor vehicle traffic

Ratio to U.S. all races
Other unintentional injury
Ratio to U.S. all races

74.4     64.5    160.4    109.9    204.7    104.3    156.8    120.7    162.8    99.5     42.5

2.3     2.0     4.9     3.4     6.3     3.2     4.8     3.7     5.0     3.0     1.3

84.5     36.7    103.0     79.7    149.8     85.6    114.3    106.5    59.7    76.6    277.1

3.1     1.3     3.7     2.9     5.4     3.1      4.2     3.9     2.2     2.8     10.1

22.2     27.8     77.2

2.0     2.5     6.8

4.2     6.7     30.8

0.5     0.7     3.4

46.6

4.1

28.3

3.1

87.2     48.0     51.2     54.1     55.0     49.0    86.7

7.7     4.3     4.5     4.8     4.9     4.3     9.5

35.2     17.6     20.1     24.8     19.2     27.1     11.0

3.9     1.9     2.2     2.7     2.1     3.0     1.0

48.2     45.8    116.8     77.6    145.0     74.8    101.3    85.9    106.2    74.0    27.0

2.2     2.1     5.4     3.6     6.7     3.4     4.6     3.9     4.9     3.4     1.2

42.7     21.1     65.5     53.1     91.1     49.6     64.4    63.9    37.5    51.6    183.5

2.4     1.2     2.3     3.0     5.1     2.8     3.6     3.6     2.1     2.9     10.2

Source: U.S. Congress, Indian Health Care, 1986.


YOUTH AND OTHER SPECIAL POPULATIONS

Table 5. Age-adjusted and crude mortality motor vehicle accident rates (per
   100,000 population) for New Mexico ethnic groups 197878 and
     1984-86

213

Crude
rate

   Age-adjusted rates          Percent
     Ratio            change
Total I&Other Male   Female  1976-86

1976 through 1978
Indian
Hispanic
White non-Hispanic
Black

1984 through 1986
Indian
Hispanic
White non-Hispanic
Black

125.5   350.4     -
44.6   51.2    2.9
39.1   42.6    3.5
23.5   29.2    5.2

85.9   97.0      -     1483
36.3   38.8    2.5      58.6
24.9   25.2    3.8      35.6
23.7   27.7    3.5      43.7

243.5     67.9 -
85.7     22.8 -
61.4     26.2 -
39.7     19.4 -

52.0  -35.5

19.8   -24.2
14.9 a.8
10.3    - 5.1

Source: New Mtico Selected He&h Statistics, 1978 and 1986

accounting for 18.7 percent of ail inpatient stays. Among females, the same category was
the fourth most frequent inpatient diagnosis, accounting for 6.8 percent of all stays.
Within these statistics, motor vehicle-related injuries are the largest category in most
areas of the country, rivaled and/or surpassed only in certain age groups by falls (IHS
1988; unpublished IHS program statistics.).

Available Literature and Explanatory Themes

All the above material raises some interesting questions about why Indians and Alaska
Natives are plagued by high rates of accidental death and injury. Realizing that the word
"accident" is both unpopular and also inaccurate because vehicle crashes have objective,
recognizable, and predictable precursors, it is now expedient to examine the research
literature.

Few major studies are available on motor vehicle accidents among Indians or Alaska
Natives. However, some studies have examin ed all types of accidents combined and also
violent death. Most of these articles include motor vehicle accidents as one of a number
of variables. Schmitt et al. (1966) studied accidental deaths among Indians in British
Columbia (Canada) . In this study, motor vehicle deaths accounted for 24 percent of all
Indian accident deaths as opposed to 35 percent for non-Indians. Drownings and burns
were the most common causes of death.

Boyd et al. (1968) studied accident mortality in Alaska in 1958-62 and found drowning
(water transport) as the leading cause of death (62.7 per 100,000) and motor vehicle
accidents as the third leading cause, behind fires. Brown et al. (1970) also studied all
types of accidents, but used clinic records to examine both morbidity and mortality
among the Navajo. Motor vehicle accident deaths accounted for 48 percent of Navajo
accident mortality in the late 1960s and 19.3 percent of the injuries. Factors related to
motor vehicle crashes were unlicensed drivers, alcohol use, lack of driver education, lax
enforcement of laws, and poor roads.

Omran and Laughlin (1972) also studied injury morbidity and mortality among the


214

Navajo, but focused only on clinic records from an earlier period (1950s and early 1960s)
from a remote, central portion of the reservation. All the studies cited above are rather
descriptive and in many ways serve to place the motor vehicle accident experience in a
historical context (e.g., in relation to horse and wagon-induced injuries) and in the
broader context of all injuries (cuts, falls, etc.).

A more recent study of all types of injury was undertaken by Leon Robertson for the
Indian Health Service (1985). Using national IHS chic data and existing literature,
Robertson reviewed the nature of injury morbidity and mortality as they related to
magnitude in all areas served by IHS. Also, there was an attempt to identify individual
risk factors that relate to injury. Such high-risk diagnoses are venereal diseases, diabetes,
etc. While this was an interesting attempt to identify a general population at risk, the
epidemiological and public health implications of this study were limited by a lack of
focus on local and specific conditions and socio-cultural variables.  i

Four major articles/works have been published about the Papago of Southern
Arizona. Each work examined the total range of injuries from clinic records in various
modern and traditional communities. Hackenberg and Gallagher (1972) found that
injury rates were twice as high in the more modern villages and explained this as a
function of social change correlating with wage labor, Protestant religion, and higher
education. Change produced stress that, coupled with alcohol use, produced more
injury.

Stull(l972,1973) also studied Papago clinic records and found that the highest injury
rates were typical of modern individuals in progressive communities, but that rates of
accident and injury were lower for traditional individuals in progressive communities
and lowest for traditional people in traditional communities. In a later article, Stull
(1977) modified this argument to say that injuries were more prevalent in modern settings
"simply because the environment and associated lifestyle place individuals at a greater
risk for injury." Alcohol was also mentioned as a contributing factor to injury.

One other article that explored the theme of modernization and social stress was
written by James Wills (1969), w h o worked among the Oglala Sioux of Pine Ridge, South
Dakota. Wills states that a comprehensive, baseline self-report survey showed that
accident and injury were higher among fullblood Indians. Further, one half of those
individuals involved in vehicular accidents had been arrested at least once for drinking
and were also prone to other social and legal problems. The bulk of this study, however,
was concerned with brief psychological autopsies of three male Sioux drivers killed in
motor vehicle crashes. These drivers were characterized as having problems of adjust-
ment, low self-esteem, failure to achieve, and feelings of a lack of control over their own
lives.

Another study among the Navajo focused solely on motor vehicle accidents. Using
police data from three States and from tribal police, this project produced three
documents - one monograph (Katz and May 1979) and two article/pamphlets (May and
Katz 1979u, b) -that described and analyzed the multivariate nature and epidemiologic
features of both Indian and non-Indian fatal (n = 500) and nonfatal crashes (n = 2,347).
Data were collected on both the Navajo reservation and roads leading to it in 1973-75
Some of the key findings regarding fatal crashes in this study include:

o  Mortality rates per 100 million miles traveled (which control for driving ex-
posure) were higher for Navajos (12.6 per 100 million) than for the State of
Arizona (5.0), New Mexico (6.1), or the U.S. population (3.8).

o  Of all the fatal Indian crashes, 51 percent were single vehicle, 29 percent were
multiple vehicle, and 20 percent were pedestrian.

o  In fatal single vehicle crashes, Navajos were significantly more likely than
non-Indians to be driving a pickup truck, have an invalid license, be younger,
and have been drinking.


YOUTH AND OTHER SPECIAL POPULATIONS

215

o  When comparing Navajo fatal single versus multiple vehicle crashes, single
vehicle drivers were significantly more likely to have been drinking (41 percent
versus 28 percent), less likely to have a valid license, were younger, and single
vehicle fatalities were more likely to happen at any time of day and in the
daylight.

o  Regarding multiple vehicle crashes, the only signifitit difference between
Navajo and non-Indian experience was that Navajos were more likely to be
driving a pickup.

No differences were found between fatal Indian .and non-Indian crashes regarding
number of persons in the vehicle, condition of vehicle, or environmental conditions
(weather, light, hour of day, weekend, or season).

In nonfatal crashes, weather, road, and environment were more important. Therefore,
this study pointed heavily, but not exclusively, to the individual characteristics (e.g.,
youth, alcohol, license) of the Indian driver. Local belief at the time of the study
maintained that the roads, environmental conditions, vehicles in poor condition, and
driving greater distances were the major determinants of serious crashes. In the study,
however, the rates per hundred million miles traveled and other comparisons did not
support these beliefs, but rather showed that most fatal crashes were related to driver
characteristics.

In addition to the specific findings of the Katz and May (1979) Navajo studies, general
conclusions were reached as to why Indians have a higher rate of motor vehicle death
than others in the United States or surrounding areas.

First of all rurality is a key factor. As Waller (1967) and Wailer et al. (1964)
have shown, accidents in rural areas produce four times the amount of death
than urban accidents of similar severity. Since the Navajo reservation is
possibly the most remote area in the U.S. with a very sparse population
(150,000 to an area the size of West Virginia), high rates of death are to be
expected. The U.S. in general is about 70 percent urban and had a rate of
death of 4.20 per 100 million miles traveled in 1973. One would, then, expect
the total rate for the Navajo reservation (approximately lo-20 percent urban)
to be approximately 12 per 100 million overall and 16 or higher on many
roads. Thus lack of access to medical care due to remoteness and time and
distance to medical care influence the fatalities greatly. . . .

A second major factor in the high rates is the age of the population. Young
persons in the U.S. are frequently involved in and killed in accidents. To a
similar extent Navajo under 30 years of age are also highly involved in
accidents, particularly, single car accidents. The difference, which has the
effect of raising Navajo rates, is the sheer number of people who are under
30 years old. While only 50 percent of the U.S. population is under 30, 70
percent of the Navajo population is under 30. Thus, unless age specific rates
are calculated, crude rates and rates per 100 million miles will be higher for
the Navajo population. The preponderance of young Navajo results in a high
risk population.

A third factor in the high rates is alcohol and the drinking patterns. Younger
persons are more likely to be experimenters with alcohol in the U.S. in
general and this is also true with the Navajo. Most Navajo who drink are
under 45 years of age (Levy and Kunitz 1974) and the modal drinking style
of those who do is sporadic, binge drinking (Ferguson 1968). This style of
drinking, coupled with prohibition, is a factor in high accident rates. Under
prohibition, with most cultural and ethnic groups, drinking styles emphasize
hurried drinking and intoxication (see May 1976). The Navajo are no excep-
tion and drinking in border areas such as Gallup, Farmington, Flagstaff, etc.,


216                                                        BACKGROUND PAPERS

takes this form. After drinking, however, a long drive or walk home of 10 to
over 100 miles becomes a more difficult task, especially on two-lane roads.
Thus, the higher rates of motor vehicle and pedestrian accidents and alcohol
relatedness among the Navajo are influenced by alcohol and particularly the
laws of prohibition on the reservation.

A final variable in explaining high accident rates is culture. As many authors
have pointed out, cultural variables are important in many areas of deviance
or "social pathology" (Levy and Kunitz 1974), and for accidents this is true
(Hackenberg and Gallagher 1972; Selzer and Viokur 1974). Nevertheless
the nature of Navajo acculturation and assimilation should not be ignored.
Acculturation and assimilation of cultural items are slow processes and are
never uniform. Presently in Navajo society, acculturation has occurred in that
the motor vehicle (particularly the pickup truck) has been adopted and is
used with great vigor. Assimilation, on the other hand, the internalizing of
values from another culture, is a much slower process and has not occurred
among many Navajo with regard to motor vehicle use. The Navajo use
pickups in a fashion which is strongly based in traditional values. One very
prominent value surrounding accidents is fatalism. . . . Related to this is a
lack of adoption of safe or defensive driving, many people disregard licensing
procedures and laws, and seat belts are rarely used. This is not to deny that
overall U.S. and European populations could be accused of these behaviors,
but the degree is different. Due to differences in culture and world view,
fewer Navajo have adopted safe practices for motor vehicles than some other
groups in the U.S. population. (Katz and May 1979)

Alcohol Involvement

Because of drunk-Indian stereotypes and other folk beliefs about the West, a strong
relationship between alcohol and motor vehicle accidents among Indians has been
assumed by many (see May and Smith 1988; May 1982). The fact is, however, that there
is little concrete evidence in print to document the true extent of alcohol involvement in
motor vehicle accidents involving Indians and Alaska Natives. There is, however, enough
evidence to generalize here.

First of all, a little known fact is that Indian drinking behavior is highly variable from
one tribe to the next. In some tribes, more youth and adults drink than the general
population but in others, fewer individuals drink. For example, among the Navajo in 1970
only 31 percent of adults drank at all, and many individuals in the over-40 age categories
were abstainers (Levy and Kunitz 1974). By 1985, some increase had been registered in
Navajo drinking prevalence, which was then believed to be as high as 52 percent, but the
prevalence was still lower than the 67 percent reported in the overall U.S. population
(May and Smith 1988). The point here is that Indian drinking patterns arehighlyvariable
from one tribe to the next, and drinking styles are also unique and may not always
conform to popular notions put forth by mainstream stereotypes. Particular drinking
styles, however, are important to consider when studying and intervening with the
unintentional injury complex.

Going back to earlier accident studies, Schmitt et al. (1966) in British Columbia used
hospital insurance data to find that 28 percent of the 300 accidental (of all types) native
deaths in their study were alcohol-related. Further, they found that among those over 20
years of age, 39 percent of the male accident deaths and 49 percent of the female deaths
were alcohol-related. Alcohol intoxication, they concluded, was an important factor in
native driving and transport accidents.


YOUTH AND OTHER SPECIAL POPULATIONS

217

Other studies dealing with all types of accidents have found and/or speculated upon
a native alcohol and injury relationship. Boyd et al. (1968) found that 12 percent of all
motor vehicle accidents and drownings in Alaska were alcohol-related. Wii (1969)
found a significant correlation between Sioux accident victims and alcohol arrest. Brown
et al. (1970) listed alcohol as the most influential factor in Navajo motor vehicle
accidents, but provided no data. Omran and Laughlin (1972) reported that of 10 motor
vehicle accident deaths studied among the Navajo, 5 were alcohol-related. Among the
Papago, both Hackenberg and Gallagher (1972) and Stull(l973,1977) related alcohol
consumption to modernization and acculturation stress, and these in turn combined to
increase injury rates. Katz and May (1979) found that police records baked alcohol to
41 percent of the Indian drivers in single vehicle crashes, 46 percent  of multiple
vehicle crashes, and driver or pedestrians in 44 percent 4 of pedestrian fatalities.

With all of these studies, however, the role of alcohol was, no doubt, underestimated,
for police reports in the 197Os, hospital and clinic records, and death records seldom  .,
reported the true magnitude of the problem (Zylman and Bacon 1968). Further, police
data might be biased in that Indians might be tested more frequently than others as
Westermeyer and Brantner (1972) found, or recording of alcohol involvement on Indians
may be more common or acceptable in terms of societal norms. For example, in the
Navajo studies (Katz and May 1979), the Indian alcohol involvement was 2.8 times higher
in single vehicle crashes, 1.7 times higher in multiplevehicle crashes, and 1.3 times higher
in pedestrian fatalities than non-Indian events. Maybe this was the actual magnitude, but
underreporting and selective reporting of all alcohol involvement must be considered as
a possibility with all these studies.

Some investigators used more accurate or valid data sources. In an intensive autopsy
study of sudden death in British Columbia, 43 of the subjects were Native (Cutler and
Morrison 1971). Of the accidents, suicides, and homicides of these Indians, 54.8 percent
involved BACs at or above to the legal intoxication limit (0.08) in Canada. The authors
concluded that the "high rate of Indian sudden death is primarily the result of occasional,
but intense intoxication in high risk situations" (Cutler and Morrison 1971).

In another study of sudden death, `the Kenora (Ontario) Planning Council found,
through inquiry of knowledgeable parties, that alcohol was a factor in more than 70
percent of the nearly 200 sudden Indian deaths, including even 50 percent of the victims
of homicide. This report concluded that the 70 percent may be an underestimate. In
Manitoba, Trott et al. (1981) found sudden death to be more common among Native
Indians, with 52.5 to 54.3 percent of the accidental deaths alcohol- and/or drug-related.
These data, however, included many non-Indians as well as Indians. Jarvis and Boldt
(1982) studied the deaths of Alberta Province Indians in a prospective fashion, using
interviewers in 35 native communities. Alcohol was involved in 70.6 percent of all motor
vehicle accident deaths as reported by informants immediately following a death. The
four Canadian studies have increased our knowledge considerably, but the question
remains, what about Indians in the United States?

In New Mexico, the medical investigator system and the State laboratories are
centralized in both authority and in operation. Blood and breath testing are strictly
overseen by these centralized bureaus, so the quality of information is good. Since more
than 8 percent of the State is populated by American Indians, and several counties are
heavily Indian, one might closely examine the alcohol and accident situation among
Indians using routine data. Realizing the real risk of committing the ecological correla-
tion fallacy in examining county data without linking it to individuals (Robinson 1950),

3  Includes data on all drivers of both vehicles, so that if one or the other or both were cited as intoxicated,
it was counted as an alcohol-related crash.

4  The pedestrian involvement included 22 percent of the drivers (excluding the 255percent hit-and-run
who maywell have been intoxicated) and 22 percent of the pedestrians.


218

Table 6. Motor vehicle accidents and alcohol in three selected counties in
    New Mexico, 1982-84

          Percent Indian      Alcohol involvement (percent)
County      (major tribe)       Fatal accidents    Severe accidents*

A          66 (Navajo)           78.0            33.1

B          33 (Navajo)           78.0            28.8

C          27 (Pueblo)           73.7            24.2

Entire State      8                 63.7            21.2

*Severe accidents are those that involve injury or death.
Source: New Mexico Traffic Safety Bureau 1984 and New Medco vital Statistics, 1984.

table 6 shows that serious accidents are slightly more alcohol-related in those counties
with a substantial Indian population. County A, which is 66 percent Indian, is probabl!
the best comparison. In the 3 years covered, 1982 through 1984,78 percent of all fatal
accidents and 33 percent of all serious accidents were alcohol-involved as measured by
blood or breath alcohol.

One final statistic from New Mexico is also available. Several studies, particularly in
Canada, referred to one particular Indian pattern or style of drinking-binge drinking-
that is characterized by rapid consumption and leads to high blood alcohol levels.
Autopsy data examining alcohol levels in blood and vitreous fluid samples from 253
accidental deaths in New Mexico indicated that Indian crash victims had high blood-
alcohol levels. The 68 Indian crash victims autopsied in 1986 who were positive for
alcohol had a mean blood alcohol level of 0.201, compared to 0.183 for Hispanic positives
and 0.126 for comparable non-Hispanic whites `(Guerin, in process).

Solutions and Partial Solutions

Given all the data that indicate that alcohol and driving are tragically linked in
American Indian populations, with more severe consequences than among other groups
in the United States, a comprehensive, multivariate prevention strategy must be planned
and launched. Because the available information is not as complete as public health
professionals might desire, more research to further specify the relationship between
alcohol, injury, and Indians is needed in the future. However, current knowledge is
clearly adequate for a solid beginning in prevention and intervention.

Below, general trends and/or ideas in prevention are highlighted, using as a guide the
usual scheme of primary, secondary, and tertiary levels of prevention. Primary preven-
tion attacks root causes of a problem in its basic environmental, social, cultural, and
political structure. Secondary prevention is directed at eliminating the onset of a problem
and/or taking action in the early stages of manifestation. Tertiary prevention seeks to
provide curative and remedial action to deal with and minimize the illness, injury, and
other negative outcomes of a major health problem.

5  The legal intoxication level in New Mexico is 0.10.


YOUTH AND OTHER SPECIAL POPULATIONS

Primary Prevention

219

The so&I, economic, and educational status of many American Indians can undoubt-
edlybe improved to the overall benefit of many tribes and individuals alike (Dozier 1966).
As several authors have pointed out, many Indian groups are undergoing epidemiologic
transition (Omran 1971; Kunitz 1983; Broudy and May 1983), and this movement from
traditional to modern is related to the high accident rates now prevalent, particularly on
Western reservations (Hackenberg and Gallagher 1972; Stulll972,1977,1973; Omran
and Laughlin 1972). As Omran and Laughlin (1972) pointed out, people in transition
"exhibit many insecurities and inabilities to cope with their changing way of life," and
this results in the accident and violence complex among particular segments of Indian
societies. Therefore, assisting Indian groups and individuals in their efforts at economic,
social and educational enhancement will ultimately benefit many areas, including alcohol
abuse and accident and violence rates.

In the Native American Adolescent Injury Prevention Program (unpublished data)   :
run in the rural areas of New Mexico, rural Indian youth were found to have the lowest
scores on social psychological scales, such as locus of control and self-esteem, that are
predictive of accident susceptibility. However, these scores are highly influenced by the
educational level of the parents of the Indian children (see also Liban and Smart 1982).
Indian children from families of high educational attainment not only score better on
social psychological scales, but they aIso report less substance abuse and risk-taking
behavior common to accidents. Therefore, broad social enhancement, such as education,
which may strengthen the family, also enhances the individual in ways that should reduce
the accident rate over an extended period (Mail 1985; Dozier 1966).

Other primary prevention is being, and can be further, pursued. The HIS, Office of
Environmental Health, is now working at national, State, and local levels to improve
roads, encourage seatbelt use, and promote injury control and state-of-the-art highway
safety all over the Indian lands of the Nation. It appears likely that some of this road
improFment has already begun to reduce the accident fatality rates in some reservation
areas.

A final area of primary prevention concerns tribal and community law and policy.
Tribes have great lega power to control alcohol policy, taxation, and enforcement on
their reservations and communities. More than 60 percent have retained prohibition but
are reluctant to enforce strong penalties to support it (May 1975,1976,1977; May and
Smith 1988). Tribes need to strictly examine and change alcohol and social policies so
that they influence new norms and guidelines of behavior regarding alcohol and sub-
stance use, particularly for the minority who abuse alcohol. Whether the policy adopted
is a more strict, comprehensive, and effective approach to prohibition, or whether it is
legalization that is comprehensive and specific in its prescriptive qualities, a new, more
explicit set of policies is needed to guide behavior (see May and Smith 1988; May 1986).

Secondary Prevention

Alcohol and heahh education with youth must continue and be further expanded.
Recent years have seen a great increase in this area, but more has yet to be done. Youth
need to be educated, not only about alcohol abuse, but also taught in a social learning
mode that emphasizes self-esteem enhancement, values clarification, coping, and prob-
lem-solving skills (Bach and Bornstein 1981; Winfree and Griffiths 1983; May 1986).

6  For example, the motorvehicle accident death rate for the Crow and Northern Cheyenne Indians appears
to have declined in 19f31-8.5 (IHS unpublished statistics) from what it was in 1959-75 (see May 1976). Some
of this reduction may be due to the construction of Interstate Highway 25 from Crow Agency to Billings,
Montana, for the old road was a notoriously narrow, hilly, winding, and dangerous stretch of more than 60
miles.


220

BACKGROUND PAPERS

Health education with adult Indians should take a different approach. Most adult
Indians are well aware of the health implications of alcohol abuse but could benefit
greatly from education and exposure to public health principles and the possibilities of
public policy for alcohol-abuse and accident prevention (May and Smith 1988).

A continuing and open forum on alcohol policy needs to be pursued, and widespread
public education will feed this. Policies, laws, and ~paigns that are specific to accident
and alcohol abuse hold great promise for a tribe. Positive action in this area is now
beginning with safety campaigns, but routiniig the dialog and concern regarding these
issues is necessary. Recently, for example, the Navajo Tribe took a major step in this
direction by passing a mandatory seatbelt law for theii reservation, the largest in the
United States (Landon 1988). The enforcement of such laws and the perception of sure
and swift penalties must be emphasized as well (Ross 1982).

Safety programs such as infant car-seat purchase and rental have been promoted by
the IHS and a number of tribes. Generally, these programs seem to be well received, for
most Indians are particularly responsive to child health and weifare issues. The
programs, however, need to be expanded to all babies of all tribes. Targeting youth in
safety programs may produce a whole new generation of Indian seatbelt users. Currently,
surveys of the New Mexico Native American Adolescent Injury Prevention Program
(unpublished data) indicate that young Indian males have the lowest seatbelt use of any
group in New Mexico. But these data also indicate that increasing seatbelt use is the most
common and significant change in behavior of the injury prevention program.

Tertiary Prevention

Until the middle 197Os, few reservations had any emergency medical resources such
as ambulances and trained and employed emergency medical technicians. Now, most
reservations and many rural Indian communities have some level of emergency medical
services, and these small programs may well have had an influence on the drop in Indian
motor vehicle crash fatality rates registered since 1976. However, these services greatly
need to be continually upgraded, improved, and expanded so that more accident victims
can be saved and/or their injuries minimized, and the high disability rate of Indians can
be lowered. Further, emergency room capabilities need to be enhanced, so that accident
victims receive state-of-the-art trauma care whenever possible. New Mexico has only one
level-one trauma center and some western States have none.

The most desirable tertiary prevention would be improved interdiction of drunk
drivers before they cause crashes and expanded alcohol treatment capabilities. Tribal,
Bureau of Indian Affairs, local sheriff, and police forces in Indian country are notoriously
understaffed and in need of further assistance of all kinds. Increasing their training and,
particularly, their manpower and resources should be a priority. Further, if the laws and
policies regarding alcohol and driving under the influence (primary and secondary
prevention) were improved so that the police efforts were facilitated, then enforcement
would be greatly aided. For example, on many "dry" reservations, bootlegging is so
common and institutionalized that the tribal police can tell you who sells and how much
it costs, and can even estimate their income. But to eliminate the practice would require
considerably more manpower, time, and new, stronger,
currently exist on reservations and in most western States. yd more explicit laws than

Alcohol treatment programs in Indian country are characterized by too few resources
and capabilities of all kinds (manpower, money, level of training for the counselors, and

7  On the Naajo reservation, for example, the maximum penally for bootlegging is 6 months in jail and a
SXlOfine.Policereport, however, that tochargeapersonwith bootleggingtakesanumberofofficermanpower
days to build a case, search, collect evidence, and bring it to court. Seldom, however, is any major jail time
spent by the accused, and the maximum fine for conviction ($500) is little more than an overhead expense in
the cost of doing a profitable business.


YOUTH AND OTHER SPECIAL POPULATIONS

221

treatment regimens). A total upgrading and new commitment is needed in this arena, so
that all first-time driving-under-the-influence offenders can be screened and placed in
an appropriate treatment modality (May 1986).

Conclusion

In summary, then, the problem of alcohol abuse and accidents exists in many Indian
communities. It takes a tremendously large toll in terms of injury and lives lost. Since it
has multiple causes and related factors, its solution must also be multivariate. Any
program designed to reduce alcohol-related motor vehicle accidents among Indians
must be comprehensive and must address both general conditions and specific preven-
tion and intervention tasks.

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Passell, J.S., and Berman, PA. Quality of 1980 census data for American Indians. Social BioZogv
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Robertson, L.S. "Epidemiological Assessment of the Contributing Factors of Injury Mortality and
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Ross, H.L. Deterring the Drinking Driver. Lexington, MA Heath, 1982.
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