Atlas of Injury Mortality

Among American Indian and Alaska Native Children and Youth,

1989–1998

Injury Prevention

TM

Atlas of Injury Mortality

Among American Indian and Alaska Native Children and Youth,

1989–1998

Reshma N. Patel, MPH

L. J. David Wallace, MSEH

Len Paulozzi, MD

U. S. Department of Health and Human Services

Centers for Disease Control and Prevention (CDC)

National Center for Injury Prevention and Control

March 2005

Acknowledgments

The Atlas of Injury Mortality among American Indians and Alaska Native Children and Youth, 

1989–1998 was prepared by Reshma N. Patel, MPH, L.J. David Wallace, MSEH, and Dr. Len 

Paulozzi, MD, of the Division of Unintentional Injury Prevention (DUIP), National Center for Injury 

Prevention and Control (NCIPC). Robyn Anderson, MPH, and Athalia Christie, MA, drafted the Atlas

during their fellowship at NCIPC and were instrumental in launching the project forward. We thank 

Joseph Lee Annest, PhD, Director, Office of Statistics and Programming (OSP), NCIPC, and Kevin 

Webb, MS, also of OSP, for advising us and responding to our data and programming questions. 

Throughout the process, we benefited from advice provided by NCIPC staff; without their help, 

the Atlas could not have been produced. We thank the following individuals for their ideas and 

recommendations during the conceptual design phase: Lawrence R. Berger, MD, MPH; Richard 

Smith, MS; LeMyra Debruyn PhD; Ann Dellinger PhD; David Grossman, MD, MPH; Jim Mercy, PhD; 

Kyran Quinlan, MD, MPH; Dennis Renville; Richard A. Schieber, MD, MPH; David Sleet PhD; and 

Pete Red Tomahawk.

A special thanks to Marilyn Kirk, Mary Ann Braun, Sandra Emrich, and Sevena Quattlebaum in 

the Office of Communication Resources for the design, layout, and production.

i

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Description of Indian Health Service All-Area Maps . . . . . 

Description of Indian Health Service Area-Specific Maps . . 

Explanation of the Summary Sheet . . . . . . . . . . . . . . . . . . . 

Prevention Implications and Priorities . . . . . . . . . . . . . . . . 

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

All Indian Health Service Area Maps . . . . . . . . . . . . . . . . . . 

Motor Vehicle-Related Deaths . . . . . . . . . . . . . . . . . . 

Pedestrian-Related Deaths . . . . . . . . . . . . . . . . . . . . . 

Firearm-Related Deaths . . . . . . . . . . . . . . . . . . . . . . . 

Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Homicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Fire-Related Deaths . . . .. . . . . . . . . . . . . . . . . . . . . . . 

Suffocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

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Contents

Indian Health Service Area-Specific Maps . . . . . . . . . . . . . .

Aberdeen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Albuquerque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Bemidji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Billings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nashville . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Navajo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Phoenix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Portland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tucson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Additional Sources of Information . . . . . . . . . . . . . . . . . . . . . 

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Foreword

I am pleased to present the Atlas of Injury Mortality among American Indian and Alaska Native 

Children and Youth, 1989–1998. Injury is the leading killer of American children and youth from ages 

1–19 years. Each year in the United States, more than 17,000 children and youth die from 

preventable injuries and violence. About 70% of these deaths are caused by unintentional injury and 

28% are violence related.

The burden of injury falls disproportionately on minority populations, compared to the U.S. as a 

whole, and this is particularly true for American Indians and Alaska Natives (also referred to as Native 

Americans). The Atlas examines the eight leading causes of injury death among Native American 

children and youth and the trends in racial disparity among Native Americans, blacks, and whites. 

For most causes, Native American children and youth had the highest injury mortality rates of all 

racial and ethnic groups. Although it is encouraging that injury mortality rates among Native 

Americans have declined for most causes (i.e., motor vehicle crashes, pedestrian related, drowning, 

fire, and suffocation), other causes have either increased (homicide, firearms) or remained 

unchanged (suicide) over the 10-year study period. 

The Atlas should prove to be a valuable resource for tribes, Indian Health Service (IHS) public 

health staff, and decision makers interested in the health of Native American children and youth. The 

maps visually display the extent of the injury problem by region and offer a comparison with IHS and 

national rates. 

The National Center for Injury Prevention and Control (NCIPC), the “Injury Center,” and IHS have 

had a long-term partnership in an effort to reduce injuries among Native Americans. Hopefully, this 

information will encourage local, regional, and national decision makers to form new partnerships or 

enhance existing ones to further reduce the burden of injury among Native American people.

Christine M. Branche, PhD

Director, Division of Unintentional Injury Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

ii

Injuries, from both unintentional and intentional causes, are 

third behind heart disease and cancer as the leading cause of 

death among all American Indians and Alaska Natives (Native 

1 Americans) . Injuries are the leading cause of death among all 

children in the United States, but Native American children are 

disproportionately affected by injuries, with rates about 2.5 times 

2

the rate for all U.S. children.

In 1993, the Centers for Disease Control and Prevention 

(CDC) and the Indian Health Service (IHS) published the Injury 

Mortality Atlas of Indian Health Service Areas, 1979–1987, which 

summarized the geographic distribution of injury mortality among 

3 Native Americans of all ages by IHS Area. Although similar, the 

current Atlas focuses on the problem of injuries among Native 

American children and youth (ages 0–19 years) residing in IHS 

Areas. The purpose of the Atlas is to provide background 

information and data to public health practitioners and policy 

makers to help identify critical injury problems and set intervention 

priorities for intervention among this vulnerable population. 

The Atlas contains composite maps of all IHS Area rates 

and individual Area maps for eight causes of injury death. It 

includes study results of Native American children and youth (0–19 

years) who live in one of the twelve IHS Areas. The Atlas provides 

information on several causes of injury deaths: motor vehiclerelated, pedestrian-related, firearm-related, suicide, homicide, 

drowning, fire, and suffocation.

The IHS has long recognized the high incidence of 

misclassification of Indian race on state death certificates, 

4, 5 particularly in the California, Oklahoma, and Portland Areas.

Research shows that all IHS Areas have this problem to some 

degree, but it ranges from as low as 1% for the Navajo Nation to a 

4

high of 30% for California. The problem of misclassification is 

Introduction

addressed in this report. Death rates presented are those that have 

been adjusted for misclassification. In Regional Differences in 

Indian Health, the IHS also presents death rates by Area that adjust 

6

for misclassification of American Indian race.

The Atlas is intended for use as a reference tool for public 

health professionals and decision makers who are interested in 

reducing injuries among Native American children and youth. Its 

format allows one to visually recognize injury patterns across IHS 

Areas and to compare rates in IHS Areas with national rates. The 

Atlas is also intended to raise awareness of specific Areas or 

groups at elevated risk of injury death within the IHS and to help 

focus the issue of injuries as a public health problem among Native 

American children and youth. 

Native American children and youth in the IHS Areas are at 

greater risk of preventable injury-related death than other children 

in the United States. The injury maps show how widely this risk 

varies by IHS Area. Although it is promising that death rates from 

motor vehicle crashes, pedestrian events, drowning, and fire 

decreased from 1989 to 1998, the overall injury disparity compared 

7 with rates for white children and youth persists. During this period, 

rates increased for firearm-related death and homicide, but the 

rates remained unchanged for suicide. Given the variation in the 

injury problem and Native American tribal culture, interventions 

need to be tailored to local settings and problems. To ensure 

successful interventions, considerations of local practices and 

cultures should be addressed. Such efforts are needed to help 

reduce or eliminate the injury disparity gap between Native 

American children and other children in America.

1

Unintentional and intentional injuries are the third leading 

cause of death just behind heart disease and cancer among 

American Indians and Alaska Natives (Native Americans); injuries 

are the leading cause of death in the United States among persons 

1

age 1 to 44 years. This Atlas presents injury mortality data from 

1989 through 1998 for Native American children and youth ages 

0 to 19 years residing in the 12 Indian Health Service (IHS) Areas. 

Eight major causes of injury-related death are included: motor 

vehicle crashes, pedestrian-related, firearm-related, suicide, 

homicide, drowning, fire, and suffocation. For each cause of injury, 

composite maps of the IHS Area rates and individual maps are 

shown to allow for rate comparisons among Areas and with national 

rates for all races. In addition, trends in death rates by race, agespecific rates, and subtype distributions of cause are provided for 

each of the eight causes of injury.

From 1989 to 1998, eight major causes of injury resulted in the 

deaths of 3,718 (adjusted for racial misclassification) Native 

Americans age 0 through 19 years in the 12 specified IHS Areas. An 

analysis of these injury deaths revealed the following:

– Injuries are the leading killers of Native American 

children and youth, accounting for 75% of all deaths 

among 1 to 19 year olds.

– Native American males 15 to 19 years of age had the 

highest number of deaths for six causes of injury: motor 

vehicle-related, pedestrian-related, firearm-related, 

homicide, suicide, and drowning.

– The Alaska Area had the highest rates for four causes of 

injury death: firearm-related, suicide, drowning, and 

suffocation.

– Patterns and rates of injury death among Native 

Americans (0–19 years) differed significantly among the 

12 IHS Areas.

– Motor vehicle-related death rates for 9 of the 12 Areas 

were equal to or greater than the top 5% (95th 

percentile) of state injury rates in the United States.

Racial Disparity

! Compared with blacks and whites age 19 or younger, Native 

Americans of the same age had the highest injury death 

rates for motor vehicle crashes, pedestrian-related deaths, 

and suicide.

! Blacks ages 19 or younger had the highest rates for 

homicide and firearms.

! Native Americans and blacks 19 or younger had similar rates 

for fire-related deaths and drowning.

! The death rates for Native Americans were higher than 

those of whites for all injury causes.

Motor Vehicle-Related Deaths

! Motor vehicle crashes were the leading cause of death 

among Native Americans 1 to 19 years of age. Motor vehicle 

crashes were also the leading cause of injury death in all IHS 

Areas—except Alaska—where firearm use was the leading 

cause. 

! From 1989 to 1998, male death rates decreased 21%; 

female death rates decreased by 12%.

! In the Alaska, Navajo, and Tucson Areas, more than 25% of 

the children and youth (0–19 years) killed in motor vehicle 

crashes were pedestrians. 

Pedestrian-Related Deaths

! Native American males were over two times more likely than 

black males and nearly four times more likely than white 

males to be killed as a pedestrian. Likewise, Native 

American female pedestrian death rates were higher than 

those for either black or white males. 

! The majority (74%) of Native American pedestrian-related 

deaths occurred on public roads. However, over half the 

pedestrian-related deaths observed among 1- to 4-year-old 

children occurred in nontraffic locations, such as private 

driveways. 

! Over the ten year period, pedestrian-related death rates 

declined by 56%.

Executive Summary

2
Firearm-Related Deaths

! The majority (78%) of all firearm-related deaths among 

Native American children involved intentional use of the 

weapon. Only 18% of firearm-related deaths were recorded 

as unintentional.

! Firearm-related injury was the second leading cause of 

injury death in five Areas: California, Oklahoma, Phoenix, 

Portland, and Tucson. It was the primary cause of injury 

death in Alaska.

! From 1989 to 1998, firearm-related death rates among 

Native American males increased, while rates among 

females dropped. More recently (1997–1998), firearmrelated death rates among males were over eight times 

greater than those of females.

! Suicides accounted for 46% of the firearm-related deaths.

Suicide

! Suicide rates were highest among those 15 to 19 years of 

age. From 1997 to 1998, Native American males had suicide 

rates almost five times higher than Native American 

females. Rates remained unchanged over the ten year 

period.

! Over half of Native American suicides were committed with a 

firearm, and more than one third were by hanging.

Homicide

! Forty percent of homicides among Native Americans age 19 

or younger involved a firearm. Firearm use was the leading 

cause of homicide among ages 15 to 19 years (52%); child 

maltreatment was the leading cause of homicide among 

those age 0 to 4 years (34%).

! From 1989 to 1998, homicide rates increased for males, but 

remained unchanged for females. Increases in the rate of 

firearm-related homicide accounted for the overall increase 

in the total homicide rate.

! Homicide rates were highest among males 15 to 19 years of 

age, followed by children under 1 year of age. After 

suffocation and choking, homicide was the second leading 

cause of injury death among infants.

Drowning

! Drowning rates were similar among males and females age 

1 to 4 years, but rates for males 15 to 19 years were eleven 

times greater than those for females of comparable age.

! The rate of drowning for Native American males declined by 

about 66% from 1989 to1998; in contrast, the rates for 

females doubled.

! More recently (1997–1998), Native American and black 

males had similar drowning rates. Rates for Native American 

males were two times greater than those for whites. Rates 

for Native American females were higher than black and 

white females. 

Fire-Related Deaths

! Children age 0 to 4 years had the highest fire-related death 

rates. 

! Fire-related death rates increased among males from 1989 

to 1994, but decreased thereafter. Female rates followed a 

similar pattern.

! House fires accounted for 93% of fire-related deaths among 

Native Americans 19 or younger.

Suffocation

! Suffocation, choking, and strangulation were the leading 

causes of infant (less than 12 months of age) injury death. 

Over twice as many infants died from suffocation or choking 

as from motor vehicle crashes. 

! About 58% of all Native American childhood suffocation or 

choking deaths occurred among infants. 

! The highest rates of suffocation occurred in the Billings, 

Bemidji, Tucson, Navajo, Aberdeen, and Alaska Areas, with 

rates approximately three to five times greater than national 

rates.

3

Methods

Cause of Injuries

The causes of death included in this Atlas and the associated 

International Classification of Diseases, Ninth Revision, External 

Cause Codes (ICD9 E-Codes), are shown in Table 1.

Data Files

Data for the Atlas were drawn from two sources:

1. Detailed mortality data files prepared by CDC's National 

Center for Health Statistics (NCHS), based on data from 

state death certificates.

2. NCHS mortality data that Indian Health Service (IHS) has 

categorized by Area.

All data were restricted to children and youth 0–19 years of 

age. The data derived from these sources follows:

Source Type of Data Population

IHS IHS death rates— Native Americans

Area Maps, age, in IHS service Areas

 and sex (1989–1998)

NCHS Death rates—all Entire United States 

other races (1989–1998)

NCHS 10 leading causes All U.S. Native 

of death Americans (1999–2000) 

Indian Health Service Injury Death Data

Each year, NCHS provides IHS with a multiple-cause-of-death 

mortality tape of all U.S. decedents. IHS categorizes these data by 

IHS area offices to create its own mortality data set. The IHS data 

include those Native Americans who lived within an IHS area at the 

time of death and were eligible for IHS services (IHS service 

population). The service population is estimated by counting those 

Native Americans (as identified during the census) who live in the 

geographic areas in which IHS has responsibilities (“on or near” 

reservations). Some individuals who are included in the IHS 

service population do not live on reservations. The IHS service 

population comprises about 60% of all Native Americans who live in 

1

the United States. States that make up the service population have 

been grouped by IHS into twelve administrative Areas, or IHS 

Areas: Aberdeen, Alaska, Albuquerque, Bemidji, Billings, 

California, Nashville, Navajo, Oklahoma City, Phoenix, Portland, 

and Tucson.

Table 1. Underlying causes of death and associated ICD9 Ecodes included in the IHS Childhood Injury Mortality Atlas

Cause of Death ICD9 E-Code

Motor vehicle-related* E810–E825

Pedestrian-related E810–E825 (.7) **

Drowning E830, E832, E910

Fire/burn-related E890–E899, E924

Suffocation E911–E913

Firearm-related*** E922

(intentional, unintentional, E955.0–E955.4,

and undetermined intent) E965.0–E965.4, E970

E985.0–E985.4

Suicide E950–E959

Homicide E960–E969

* Motor vehicle-related coding includes pedestrian-related 

injury deaths. Codes 810–819 indicate traffic-related injury 

deaths. Codes 820–825 indicate nontraffic-related injury 

deaths.

** This parenthetical notation implies that the decimal 

should be applied to each individual three-digit E-code in 

the grouping.

*** Firearm-related coding includes firearm-related 

deaths, homicide, suicide, and unintentional events.

5
Calculation of Rates and Leading Causes

Rates per 100,000 population were calculated using estimates 

of the IHS service population for 1989 to 1998, based on the 

revised 2000 census as denominators. At the time of this project, 

1998 was the most recent year of data available through IHS. Data 

from 1981 to 1988 were used in conjunction with data from 1989 to 

1998 for illustrating injury trends by race group and two-year 

periods. Calculations were based on injury deaths of children and 

youth (0–19 years of age). Native American deaths were adjusted 

using the IHS Area factors outlined in Adjusting for Miscoding of 

4

Indian Race on State Death Certificates. These methods are 

similar to those used by IHS in Regional Differences in Indian 

Health (JoAnn Papalardo, IHS Program Statistics, personal 

communication 2004). All rates specific to IHS Areas, race, and sex 

were age-adjusted by the direct method using the projected 2000 

U.S. population as the standard. Injury death rates based on a 

small number of deaths (< 20) may be unstable and should be 

interpreted with caution. 

Data for the ten leading causes of death charts were taken from 

the compressed mortality file produced by NCHS and include the 

deaths of all U.S. Native Americans. Race-specific data presented 

for white and black children were also taken from the compressed 

mortality file produced by NCHS. 

Both the U.S. national rate and the Area rates were used to 

calculate excess deaths due to injury by Area. 

Description of Indian Health Service All-Area Maps

Each Indian Health Service (IHS) Area is listed with its ageadjusted mortality rate per 100,000 population by specific cause of 

injury. The colors of the maps correspond to where the Area rate 

would fall with relation to the national ranking of state rates for all 

racial groups combined from 1989 to 1998. The Areas colored red 

have the highest injury death rates and rank at or above the 95th 

percentile nationally—a ranking higher than 95% of all state rates. 

Areas colored blue are second highest and have rates that rank 

nationally between the 75th and 94th percentiles. Areas colored 

gray are the third highest, with rates that rank nationally between 

the 50th and 74th percentiles. Areas in white have the lowest rates 

and rank nationally below the 50th percentile. The rates for all U.S. 

races and combined IHS Areas are also listed on each map page. 

Description of Indian Health Service Area-Specific Maps

The composite maps of the United States show all Indian 

Health Service (IHS) Areas and smaller cause-specific multiple 

maps for each Area. Color coding for individual Area maps is the 

same as for the composite maps. Below each Area map is the total 

of injury deaths by cause from 1989 to 1998, the age-adjusted rate 

for the Area and the United States, and the number of excess 

deaths for the Area. For each cause of injury, the total of excess 

deaths (1989–1998) is also estimated. Estimates of excess deaths 

were calculated by subtracting the combined Area rate from the 

national rate and multiplying the excess death rate by the Area’s 

total population. Excess deaths in a specific Area can be 

interpreted as additional Native American deaths because the 

injury mortality rate is higher than the all-races rate for states in that 

Area. Since estimates of excess death depend on an Area’s 

population, two IHS Areas with equal death rates could have 

different estimates of excess deaths. 

Explanation of the Summary Sheet

Graphical summaries of information are presented for each 

cause of death. On each page, a summary of major findings is 

presented. In the top left corner of each summary page is a line 

graph of age-adjusted two-year death rates for the injury being 

highlighted, by race and the two-year period. These graphs show 

trends across an eighteen-year period (1981–1998). At the bottom 

left is a bar graph of American Indian age-specific rates that shows 

the age groups at highest risk of death from the highlighted injury. 

Any rate with an asterisk (*) is based on a small number of deaths 

(< 20) and should be interpreted with caution. The pie chart in the 

bottom right shows the percentage of total deaths attributable to 

subcategories of the cause of injury. 

6
10 Leading Causes of Death, by Age Group

American Indians and Alaska Natives, 1999-2000

1

2

3

4

5

6

7

8

9

10

Rank <1 1-4 5-9 10-14 15-24 25-34 35-44 45-54 55-64 65+ Total

Age Groups

Congenital

Anomalies

135

SIDS

95

Short

Gestation 

72

Unintentional

Injury

33

Maternal

Pregnancy

Comp. 20

Placenta Cord

Membranes 

20

Five 

Tied

15

Five 

Tied

15

Five 

Tied

15

Five 

Tied

15

Unintentional

Injury

76

Homicide

14

Congenital

Anomalies

9

Malignant

Neoplasms

7

Heart

Disease 

6

Septicemia 

4

Influenza

& Pneumonia

3

Acute

Bronchititis 

2

Chronic Lower

Respiratory

Disease 2

Perinatal

Period 

2

Unintentional

Injury

56

Malignant

Neoplasms

7

Congenital

Anomalies

6

Homicide

6

Influenza

& Pneumonia

3

Septicemia 

3

Perinatal

Period 

2

Six 

Tied

1

Six 

Tied

1

Six 

Tied

1

Unintentional

Injury

65

Suicide

8

Heart

Disease 

7

Malignant

Neoplasms

7

Homicide

4

Congenital

Anomalies

3

Influenza

& Pneumonia

3

Cerebrovascular 

2

Three 

Tied

1

Three 

Tied

1

Unintentional

Injury

588

Suicide

184

Homicide

111

Malignant

Neoplasms

26

Heart

Disease 

20

Congenital

Anomalies

10

Influenza

& Pneumonia

7

Septicemia 

6

Benign

Neoplasms

5

Complicated

Pregnancy 

5

Unintentional

Injury

489

Suicide

169

Homicide

132

Liver

Disease 

60

Heart

Disease 

54

Malignant

Neoplasms

52

HIV 

25

Cerebrovascular 

16

Diabetes

Mellitus

15

Influenza

& Pneumonia

9

Unintentional

Injury

508

Liver

Disease 

272

Heart

Disease 

228

Malignant

Neoplasms

190

Suicide

116

Homicide

90

HIV 

58

Cerebrovascular 

52

Diabetes

Mellitus

52

Influenza

& Pneumonia

48

Heart

Disease 

480

Malignant

Neoplasms

437

Unintentional

Injury

360

Liver

Disease 

305

Diabetes

Mellitus

162

Cerebrovascular 

87

Suicide

62

Homicide

51

Influenza

& Pneumonia

47

Septicemia 

47

Malignant

Neoplasms

823

Heart

Disease 

779

Diabetes

Mellitus

299

Liver

Disease 

246

Unintentional

Injury

199

Cerebrovascular 

142

Chronic Lower

Respiratory

Disease 134

Nephritis 

75

Septicemia 

58

Influenza

& Pneumonia

54

Heart

Disease 

3,233

Malignant

Neoplasms

2,198

Cerebrovascular 

813

Diabetes

Mellitus

809

Chronic Lower

Respiratory

Disease 632

Influenza

& Pneumonia

415

Unintentional

Injury

305

Nephritis 

267

Septicemia 

177

Alzheimer's

Disease 

175

Heart

Disease 

4,821

Malignant

Neoplasms

3,750

Unintentional

Injury

2,680

Diabetes

Mellitus

1,341

Cerebrovascular 

1,118

Liver

Disease 

1,047

Chronic Lower

Respiratory

Disease 835

Influenza

& Pneumonia

604

Suicide

588

Homicide

456

US30IT00

Number of deaths during the 2 year period for each cause is shown in the appropriate box.

Includes all American Indians and Alaska Natives in the United States.

Source: National Center for Health Statistics, 2002 

Chart developed by the National Center for Injury Prevention and Control

www.cdc.gov/ncipc

7
Heart Disease 2.0%

All

Other

14.2%

Leading Causes of Death

Native Americans, Ages 1-19, 1997-1998

Injuries

75%

Cancer

4.4%

Congenital Anomalies 2.9%

Pneumonia/Flu 1.5%

8
Figure 1.

Indian Health Service Areas

Portland Billings

California

Tucson

Bemidji

Aberdeen

Oklahoma City

Nashville

Albuquerque

Navajo

Alaska

CA

MN

MI

WI

IN

KS

OK

CO

NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

NV UT

AZ

Phoenix

MA

CT

MT

WY

ND

SD

NE IA

All or parts of 33 States known as Reservation States

9
Motor Vehicle

 Deaths

U.S. 11.5

Area Rate 33.7

Excess Deaths

28

70

Figure 2.

American Indians and Alaskan Natives Injury Deaths per 100,000 

Population for a Hypothetical IHS Area, Ages 0–19 Years, 1989–1998

IHS Areas colored RED have injury mortality rates at 

or above the 95th NATIONAL percentile of all U.S. 

races.

IHS Areas colored BLUE have injury mortality rates 

at or above the 75th but less than the 95th 

NATIONAL percentile.

IHS Areas Colored GRAY have the injury mortality 

rates greater than the 50th percentile but less than 

the 75th NATIONAL percentile.

IHS Areas colored WHITE have injury mortality rates 

below the 50th NATIONAL percentile. 

ç

é

å

å

ç

é

A total of 28 persons died because of motor 

vehicle-related injuries from 1989 through 

1998.

The national motor vehicle-related 

mortality rate for the U.S. was 11.5 

deaths/100,000 population, whereas the 

rate in the Area over the same period was 

33.7 American Indian deaths/100,000 

population.

This IHS Area had a total of 70 deaths more 

than would be expected if the Area had 

experienced the national motor vehiclerelated death rate. Because excess death 

estimates depend on the Area’s population, 

two Areas with equal mortality rates could 

have different estimates for excess deaths. 

The dependence on population size should 

be considered when excess deaths are 

compared among Areas.

10
Prevention Implications

and Priorities

Despite decreases in Native American child and youth death 

rates for motor vehicle crashes, pedestrian events, drowning, and 

fire, the disparity in injury rates between Native Americans and 

whites persists. Native American children and youth have not 

benefited to the same degree as white children in many areas of 

injury prevention practice (i.e., traffic safety, water safety, and 

residential fire safety). However, there are several proven and 

promising injury interventions that could be tailored to local tribal 

settings. Additional information on the circumstances of these 

injuries is needed to effectively target prevention efforts. Some of 

these approaches are discussed below.

Motor Vehicle-Related

Traffic safety can be improved in Native American communities 

where there is a need for increased use of child restraints and seat 

8

belts and for reductions in alcohol-impaired driving. Primary 

enforcement (stopping a driver solely for restraint violation) of seat 

belt laws combined with active enforcement and public awareness 

9

are the most effective strategies for increasing seat belt use. Most 

Native American tribes are considered sovereign nations, which 

pass and enforce their own traffic safety laws. Several tribes have 

passed seat belt laws; however, enforcement of these laws is often 

8

challenging for tribal police departments.

Native Americans have the highest alcohol-related motor 

 10 vehicle death rates of all racial groups, putting their children and 

youth at an elevated risk when they ride with an impaired driver. 

Researchers estimate that in states with American Indian and 

Alaska Native reservations, 65% of motor vehicle-related deaths 

11 among Native Americans involve alcohol. Young drivers are at 

particular risk because of inexperience, nighttime driving, too many 

passengers in the car, and patterns of alcohol use. Many tribes 

have the authority to restrict driving privileges on the reservations, 

conduct sobriety checkpoints, and set curfew ordinances to help 

8

reduce deaths related to motor vehicle crashes among teens.

The highest rates of pedestrian-related death occurred in two 

age groups: 1 to 4 years and 15 to 19 years. Most deaths occurred 

on public roadways, but over half of the 1 to 4 year olds who were 

killed as pedestrians were killed in nontraffic settings, such as 

private driveways. More information is needed about the 

circumstances of these pedestrian-related deaths, but many 

involve young children being backed over by large vehicles such as 

pick-up trucks (Nancy Bill, IHS Headquarters, personal 

communication, 2004). Parents and caregivers of young children 

should be aware of the risk that children face when playing around 

12,13,14 vehicles. Prevention strategies might involve working with 

local housing authorities to install circular driveways in new homes 

to reduce the need to back up, installing fencing to separate play 

areas from vehicle driveways, and increasing the use of audible 

14 back-up warning systems.

Violence

Suicide rates for Native American youth and children did not 

decline over the 10-year period and were especially high in Alaska, 

Aberdeen, and Tucson IHS Areas. Additional research is needed to 

determine the risk factors and reasons for the substantially higher 

rates in the Alaska, Aberdeen, and Tucson Areas and for the 

protective factors in other IHS Areas with lower rates. Native 

Americans 15 to 19 years of age have the highest suicide rates of 

any racial group in the United States. Preliminary work shows many 

15 risks and protective factors related to suicide in this population,

16,17 including access to firearms and alcohol.

The IHS provides technical assistance to suicide prevention 

18 programs and alcohol- and substance-abuse treatment centers.

Individual tribes have launched a number of suicide prevention 

programs that stress cultural relevance and the need for 

19 community involvement, but none have been rigorously 

evaluated. The American Indian and Alaska Native Community 

Suicide Prevention Center and Network in New Mexico has shown 

promising results in the past in reducing Native American youth 

11
Fire

Residential fires account for the majority of fire-related deaths 

(93%) among Native American children and youth in our study. Fire 

death rates were highest for Native American children under five 

years of age. Dramatic improvements have been made in reducing 

fire-related death among Native American children and youth, with 

rates decreasing 64% from 1981 to 1998. Despite this decrease, 

the Aberdeen, Bemidji, and Alaska Areas had substantially higher 

fire-related death rates than all other IHS Areas, with rates more 

than five times the U.S. national rate. Having a working smoke 

alarm in the home is proven to reduce the risk of death from a house 

33 fire by as much as 71%. Some studies find that up to half the 

smoke alarms in Native American homes are inoperable and are 

34 often disconnected due to nuisance alarms. To help prevent such 

alarms, Kuklinski and others recommend installing photoelectric 

34 alarms in place of ionization alarms. One promising intervention 

program is Sleep Safe, which is a smoke alarm distribution and 

education program targeting children and families in Native 

American Headstart Schools. Sleep Safe, supported by the IHS 

and the U.S. Fire Administration, has funded programs in 55 

Headstart schools and distributed over 11,000 smoke alarms to 

Native American families (Harold Cully, Oklahoma City Area IHS, 

personal communication, 2003). 

Drowning

Drowning rates were highest among Native Americans 1–4 

years of age and those 15–19 years. Child and youth drowning 

rates for Native Americans decreased 62% from 1981 to 1998. 

Although this trend is encouraging, Native American drowning 

rates are still high compared to rates for whites. The Alaska IHS 

area had the highest drowning rate and was seven times greater 

than the U.S. national rate. The Phoenix, Billings, Navajo, and 

Bemidji areas also had high drowning rates and were at least two 

times greater than the U.S. national rate. Just under half of the 

Native American drowning occurred in swimming pools or 

quenching tanks, 5% occurred in bath tubs, and 28% were related 

to recreation or water craft.

Four-sided isolation fencing around swimming pools has 

suicide; the organization uses a community-based approach 

involving school-based youth, mental health referral assistance, 

20 and family outreach. 

Native American children and youth have somewhat lower 

homicide than suicide rates, and their rates are well below those for 

blacks. However, in terms of nonfatal violence, results from the 

National Crime Victimization Surveys from 1993 to 1998 indicated 

that Native Americans 12 to 19 years old are assaulted at rates well 

21 above those for any other minority. Programs that show promise 

22 at preventing youth violence have been recently summarized and 

include specific violence-prevention practices in four key areas: 

parents and families, home visitation, social and conflict resolution 

skills, and mentoring. 

Homicide among Native American children (0–4 years) is also 

an important Native American issue. Such homicides are typically 

23 perpetrated by family members . One intervention that has shown 

effectiveness in preventing child maltreatment is the home 

visitation program conducted by nurses or other health 

24 professionals.

Firearms

Over 500 Native American children and youth died from 

firearm-related injuries from 1989 to 1998, including 52% of 

suicides and 40% of homicides. Firearms were also involved in 115 

unintentional deaths. Some proposed measures to reduce the risk 

of a firearm-related death or injury in the home are behavior 

oriented (e.g., education about safe storage and handling of guns 

25,26 or counseling). Other measures are product oriented (e.g., 

changing firearms design or personalization to make firearms more 

difficult to use unintentionally or intentionally if stolen or obtained 

27 illegally). There have also been legislative efforts to reduce the 

potential for firearm-related violence (e.g., licensing requirements, 

28, 29, 30 gun storage laws). Most of these measures have not been 

adequately evaluated making it difficult to determine which 

measures are effective in reducing firearm-related deaths or 

31 injuries. Two Alaska Native villages have piloted a program to 

provide free gun safes to their residents to promote safe firearm 

32 storage. 12
teenagers 

( ). 

Suffocation and Choking

Most suffocation deaths among Native Americans occurred 

among infants due to mechanical airway obstruction rather than 

aspiration of food or other small objects. It is now accepted that 

infants can suffocate if put to sleep on their faces, especially if 

37 38 placed on soft surfaces or loose bedding . Recent survey data

indicate that Native Americans are usually less likely than whites to 

put their infants to sleep on their backs. Bed sharing is another 

39 possible risk factor for infant suffocation. The National Infant 

Sleep Position Study found that parents of other races were more 

40 likely than white parents to share their beds with infants . There is 

anecdotal evidence that in some Native American infant 

suffocation deaths, alcohol intoxication of parents or caregivers 

while sleeping with their infant was a factor (Dr. David Grossman, 

Harborview Injury Prevention Research Center, personal 

communication, 2003). Parental education about safe sleep 

practices for their infants is recommended. The Portland Area 

41 Indian Health Service initiated such a program in 1993.

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

www.chems.alaska.gov/Injury_Prevention/KidsDontFloat.htm

proven to be effective at preventing drowning among young 

children. In-ground pools with four-sided fencing had 60% fewer 

incidents of drowning compared with pools without four-sided 

isolation fencing ( ). Three Tragic Seconds is a 

multimedia drowning prevention education program aimed at 

parents and caregivers of young children. CDC is working with the 

Children's Hospital of Orange County, California, and the National 

SAFE KIDS Campaign to implement the Three Tragic Seconds 

program in two communities in Arizona and Florida 

( ). Once a 

child is in the water, it is very important that a parent or guardian 

provide supervision. Swimmers can further reduce their risk by 

choosing swimming pools with lifeguard services, although this 

35 may not be feasible around natural bodies of water. Proper 

swimming instruction and water-safety training can prepare a 

participant to deal with potentially hazardous aquatic environments 

such as strong currents, waves, and riverbed rocks. Environmental 

modifications can also be made to prevent drowning in natural 

bodies of water (i.e. lakefront slope gradients to prevent sudden, 

35 unseen water drop-offs).

Older children and teenagers are more likely to drown in 

natural bodies of water than in swimming pools. Alcohol is a risk 

factor for drowning and is involved in 25% to 50% of drowning 

incidents among teenageboys 

(www.cdc.gov/ncipc/factsheets/drown.htm). In indigenous 

communities in Canada, alcohol is a factor in half of all drowning 

related to boat travel. In Canada, only about 10% of victims of 

36 boating drowning were wearing a personal flotation device (PFD).

Distribution of PFDs and programs to education and distribute 

float coats have been used to increase boaters' safety in Alaska 

Native villages (Ron Perkins, Alaska Injury Prevention Center, 

personal communication, 2003). These programs involve a public 

awareness campaign combined with sales of low-cost float coats. 

Another promising program being supported by the U.S. Coast 

Guard in Alaska is the Kids Don't Float Program. This is a PFD 

loaner program at village community beaches and boat launching 

areas combined with an educational component for children and 

www.CPSC.gov

www.cdc.gov/ncipc/factsheets/drown-activities.htm

13
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 Rockville (MD): US Public Health Service; 1997.

2. Hartz GJ, Paisano EL, Smith PL, Trujillo MH. Indian

 health focus: injuries, 1998–1999.

3. National Center for Injury Prevention and Control

 (NCIPC). Injury mortality atlas of Indian health service

 areas, 1979–1987. Atlanta (GA): Centers for Disease

 Control and Prevention, NCIPC; 1993.

4. Indian Health Service. Adjusting for miscoding of Indian

 race on state death certificates. Rockville (MD): US Public

 Health Service; 1996. 

5. Sugarman JR, Soderberg R, Gordon JE, Rivara FP.

 Racial misclassification of American Indians: its effect on

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6. Indian Health Service. Regional differences in Indian

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7. Wallace LJD, Patel R, Dellinger A. Centers for Disease

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8. Wallace LJD, Sleet D, James S. Injuries and the 10

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 Natives: opportunities for prevention. IHS Prim Care

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9. Dinn-Zarr TB, Sleet DA, Shults RA, Zaza S, Elder RW,

 Nichold JL, et al. Task Force on Community Preventive

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16
17
All IHS Service Area Maps

18
Motor Vehicle-Related Deaths per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

22.4 Billings

43.9

California

17.0

Tucson

24.5

Bemidji

29.7

Aberdeen

39.5

Oklahoma City

16.7 Nashville

20.5

Albuquerque

33.7

Navajo

37.3

Alaska

12.1

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

KS

OK

NV UT

CO

AZ NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

95–100

75–94

50–74

0–49

Percentile

MA

CT

United States Rate—11.5

All IHS Areas Rate—26.4

Phoenix

32.6

19
Type of Person Killed in Motor Vehicle Crash

1989–1998

Motor Vehicle-Related Death Rates per 100,000 Population

1981–1998

!

!

!

!

!

!

!

Motor vehicle crashes caused the deaths of 1,414 Native 

American children and youth during 1989 to 1998.

All Indian Health Service (IHS) Areas except Alaska had motor 

vehicle-related death rates higher than the U.S. national rate; 

nine Areas had rates higher than 95% of all state rates.

Rates were highest among those 15 to 19 or under 5 years of 

age.

Among Native Americans, 56% of the fatalities were motor 

vehicle occupants; 22% were pedestrians.

Infants died as occupants in 3% of all Native American motor 

vehicle crashes.

During the most recent period, 1997–1998, Native American 

males died in motor vehicle crashes at rates 2.5 times greater 

than those of black or white males. The death rates for Native 

American females were actually higher than rates for black or 

white males. Native American females were 2.8 times more 

likely to die from motor vehicle injuries than black females and 

2 times more likely than white females.

From 1989 to 1998, motor vehicle-related death rates for 

Native Americans declined by 18%.

Motor Vehicle Age-Specific Death Rates

1989–1998

S

U

M

M

A

R

Y

0

10

20

30

40

50

60

70

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

Death Rate per 100,000

0

5

10

15

20

25

30

35

40

45

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

Year

Death Rate per 100,000

White

Native

American

Bicyclist

2.0%

Motorcyclist

1.7%

African

American

Motor Vehicle

Occupant

55.7%

Pedestrian

22.1%

Unspecified/

Other

18.6%

20
Pedestrian-Related Deaths per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

3.1 Billings

7.0

California

3.9

Tucson

8.2

Bemidji

5.4

Aberdeen

7.5

Oklahoma City

2.0 Nashville

3.0

Albuquerque

8.3

Navajo

10.9

Alaska

3.2

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

KS

OK

NV UT

CO

AZ NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

Phoenix

6.3

MA

CT

United States Rate—1.5

All IHS Areas Rate—5.5

95–100

75–94

50–74

0–49

Percentile

21
Pedestrian-Related Age-Specific Death Rates

1989–1998 !

!

!

!

!

!

During 1989 to 1998, 312 Native American children and youth 

were killed in pedestrian-related motor vehicle crashes.

Among Native American pedestrian-related deaths, 94% 

occurred on public roads; however, 54% of 1 to 4 year olds 

were killed in nontraffic locations, such as private driveways.

During the most recent period, 1997–1998, Native American 

males were 2.9 times as likely as white males to die from being 

struck by a motor vehicle. Rates for Native American females 

were 2 and 3.6 times greater than rates for black and white 

females, respectively.

Two infants died from pedestrian-related, nontraffic events 

during the ten year period.

From 1989 to 1998, Native American pedestrian death rates 

decreased by 56%.

Pedestrian death rates in the Aberdeen, Tucson, Albuquerque, 

and Navajo IHS Areas ranged from 5 to 7 times greater than 

U.S. national rates.

S

U

M

M

A

R

Y

Pedestrian-Related Death Rates per 100,000 Population

1981-1998

 * Rates are based on fewer than 20 deaths and should be interpreted with caution. 

Pedestrian-Related Death by Type

1989–1998

0

2

4

6

8

10

12

0

2

4

6

8

10

12

Death Rate per 100,000 Death Rate per 100,000

Year

White

African

American

Native

American

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

*

Traffic

Collision

74.5%

Nontraffic

Collision

25.5%

22
Firearm-Related Deaths per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

9.0 Billings

13.4

California

9.3

Tucson

21.0

Bemidji

6.4

Aberdeen

14.0

Oklahoma City

7.4 Nashville

4.3

Albuquerque

7.9

Navajo

6.4

Alaska

26.5

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

KS

OK

NV UT

CO

AZ NM

PA

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

Phoenix

13.2

MA

CT

United States Rate—6.9

All IHS Areas Rate—10.3

95–100

75–94

50–74

0–49

Percentile

23
!

!

!

!

!

!

!

Firearm-related injuries caused the death of 524 Native 

American children and youth from 1989 to 1998.

Death rates were highest among teens 15 to 19 years of age.

Seventy-eight percent of all firearm-related deaths involved 

intentional use of the weapon.

Suicides accounted for 46% of the firearm-related deaths 

among Native American children and youth.

During the most recent period, 1997–1998, firearm-related 

death rates for black males were 1.5 times greater than rates 

for Native American males. Rates for Native American males 

were 2.7 times greater than rates for white males. Black 

females were 1.5 times more likely to die from firearm-related 

deaths than Native American females. Native American 

females rates were 1.6 greater than white female rates.

From 1989 to 1998, Native American firearm-related death 

rates increased by 13%.

The highest rate of firearm-related deaths among Native 

Americans occurred in the Alaska Area; the lowest occurred 

in Nashville. 

S

U

M

M

A

R

Y

Legal

Intervention

0.6%

Homicide

31.9%

Unintentional

18.4%

Undetermined

Intent/Other

3.2%

Firearm-Related Age-Specific Death Rates

1989–1998

 * Rates are based on fewer than 20 deaths and should be interpreted with caution. 

Firearm-Related Death Rates per 100,000 Population

1981–1998

Native

American

White

Year

Firearm-Related Death by Type

1989–1998

Suicide

45.8%

0

5

10

15

20

25

30

Death Rate per 100,000

African

American

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

0

5

10

15

20

25

30

35

Death Rate per 100,000

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

*

24
Suicides per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

8.5 Billings

8.6

California

5.0

Tucson

18.8

Bemidji

10.7

Aberdeen

19.6

Oklahoma City

4.3 Nashville

2.9

Albuquerque

7.7

Navajo

7.4

Alaska

25.1

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

KS

OK

CO

NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

NV UT

AZ

Phoenix

8.1

MA

CT

United States Rate—3.0

All IHS Areas Rate—9.2

95–100

75–94

50–74

0–49

Percentile

25
!

!

!

!

!

!

Between 1989 and 1998, 462 Native American children and 

youth committed suicide. 

Suicide rates were highest among those age 15 to 19 years.

Among Native American youth who committed suicide, 52% of 

suicides were committed with a firearm, and more than one 

third were by hanging/suffocation.

During the most recent period, 1997–1998, suicide rates for 

Native American males were 5.2 times greater than rates for 

black males and 3.6 times greater than white males. The 

suicide rate for Native American females was 4.7 times greater 

than black females and 3.4 times greater than white females.

Suicide rates for Native American males and females remained 

unchanged from 1989 to 1998.

The highest rates of youth suicide occurred in the Tucson, 

Aberdeen, and Alaska IHS Areas. These Areas had rates that 

were 6 to 8 times greater than U.S. national rates.

S

U

M

M

A

R

Y

Suicide by Method Used

1989–1998

Motor Vehicle

Exhaust Gas

0.5%

Submersion

0.5%

Suicide Age-Specific Rates

1989–1998

Year

Native

American

White

0

2

4

6

8

10

12

Death Rate per 100,000

Suicide Rate per 100,000 Population

1981–1998

Jumping

0.5%

African

American

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

 * Rates are based on fewer than 20 deaths and should be interpreted with caution. 

0

5

10

15

20

25

30

35

Death Rate per 100,000

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

*

Firearms

51.9%

Hanging

37.4%

Poisoning

6.1%

Other Means

3.2%

26
Homicides per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

6.4 Billings

13.6

California

4.4

Tucson

16.2

Bemidji

7.7

Aberdeen

10.7

Oklahoma City

5.4 Nashville

2.7

Albuquerque

7.7

Navajo

8.8

Alaska

6.1

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

KS

OK

CO

NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

NV UT

AZ

Phoenix

12.7

MA

CT

United States Rate—5.9

All IHS Areas Rate—7.8

95–100

75–94

50–74

0–49

Percentile

27
!

!

!

!

!

!

From 1989 to 1998, 427 American Indian and Alaska Native 

children and youth were homicide victims.

Death rates were highest among those age 15 to 19 years, but 

infant homicide rates were almost as high.

Forty percent of Native American homicides involved a firearm.

Thirteen percent of all homicides occurred among Native 

American infants. Homicide was the second leading cause of 

injury death among this group.

During the most recent period, 1997–1998, homicide rates 

among black males were 2.5 times greater than rates for 

Native American males. Rates for Native American males were 

2.5 times greater than rates for white males. Native American 

females rates were almost as high as white males. The rates 

for black females were 1.6 times greater than those for Native 

American females. Native American females were 2.3 times 

more likely to die than white females.

From 1989 to 1998, homicide rates for Native American males 

increased 33%, while the rates for females remained 

unchanged.

S

U

M

M

A

R

Y

Homicide by Method Used

1989–1998

Poison

1.3%

Hanging

3.7%

Submersion

1.3%

Homicide Age-Specific Rates

1989–1998

Homicide Rates per 100,000 Population

1981–1998

0

5

10

15

20

25

30

Death Rate per 100,000

Year

Native

American

White

African

American

0

2

4

6

8

10

12

14

16

18

20

Death Rate per 100,000

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

Unspecified/

Other

28.1%

Firearms

39.1%

Cutting/

Piercing

15.5%

Child

Maltreatment

10.5%

28
Drowning per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

3.7 Billings

4.7

California

2.7

Tucson

3.5

Bemidji

4.8

Aberdeen

3.5

Oklahoma City

1.1 Nashville

4.3

Albuquerque

2.6

Navajo

4.4

Alaska

14.6

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

KS

OK

CO

NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

NV UT

AZ

Phoenix

4.7

MA

CT

United States Rate—2.0

All IHS Areas Rate—4.2

95–100

75–94

50–74

0–49

Percentile

29
!

!

!

!

!

!

!

There were 240 Native American children and youth who 

drowned between 1989 and 1998.

Males in age group 1 to 4 years and 15 to 19 years had the 

highest rates of drowning

Five percent of Native American drowning occurred among 

infants.

About half of all drowning occurred in swimming pools or 

quenching tanks.

During the most recent period, 1997–1998, drowning rates 

were similar for Native American and black males. But these 

drowning rates were 2 times greater than for whites. Drowning 

rates for Native American females were 2 times greater than 

black females and 2.7 times greater than white females.

From 1989 to 1998, drowning rates for Native Americans 

decreased by 34%.

The Alaska IHS Area had the highest drowning rate of all IHS 

Areas. The drowning rate for Alaska Native children and youth 

was 7 times greater than the U.S. national rate.

0

1

2

3

4

5

6

7

8

9

10

S

U

M

M

A

R

Y

Drowning by Type

1989–1998

Drowning Age-Specific Rates

1989–1998

Drowning Rates per 100,000 Population

1981–1998

Year

Death Rate per 100,000

Native

American

White

African

American

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

0

1

2

3

4

5

6

7

Death Rate per 100,000

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

*

Sport/

Recreation

14.5%

Watercraft

Related

13.1%

Bathtub

5.1%

Quenching Tank/

Swimming Pool

45.3% 

Unspecified/

Other

22%

30
Fire- and Burn-Related Deaths per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

2.2 Billings

1.8

California

1.1

Tucson

3.3

Bemidji

9.0

Aberdeen

7.9

Oklahoma City

2.1 Nashville

1.9

Albuquerque

1.6

Navajo

1.9

Alaska

7.3

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

CO

NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

AK

NV UT

AZ

Phoenix

1.3

MA

CT

United States Rate—1.3

All IHS Areas Rate—3.0

KS

OK

TX 95–100

75–94

50–74

0–49

Percentile

31
!

!

!

!

!

!

!

From 1989 to 1998, 184 Native American children and youth 

died from fire-related injuries.

The highest rates occurred among 0 to 4 year olds.

Ninety-three percent of fire-related deaths among Native 

American children and youth were associated with house fires.

Eleven Native American infants died in house fire-related 

incidents.

During the most recent period, 1997–1998, rates among blacks 

were 1.3 times greater than those for Native Americans; rates 

for Native Americans were 2.1 greater than for whites.

From 1989 to 1998, Native American fire-related death rates 

decreased by 49% among children and youth.

Fire-related death rates were highest in the Bemidji, Aberdeen, 

and Alaska IHS Areas. These three Areas had rates 6 times 

greater than U.S. national rates.

S

U

M

M

A

R

Y

Hot Substance

1.2%

Clothing Ignition

1.8%

Non-Building

1.8%

Other/Unspecified

1.8%

Other Building

0.6%

Fire and Burn Age-Specific Death Rates

1989-1998

Fire- and Burn-Related Death Rates per 100,000 Population

1981–1998

Year

0

1

2

3

4

5

6

7

Death Rate per 100,000

Native

American

White

Sources/Locations of Fire

1989–1998

African

American

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

0

1

2

3

4

5

6

7

8

9

10

Death Rate per 100,000

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

*

*

Private Dwelling

92.7%

32
Suffocations per 100,000 Population, Native Americans,

Ages 0–19, IHS Areas, 1989–1998

Portland

1.6 Billings

3.2

California

1.2

Tucson

3.3

Bemidji

3.3

Aberdeen

3.5

Oklahoma City

0.4 Nashville

2.5

Albuquerque

1.2

Navajo

3.3

Alaska

5.3

CA

MT

WY

MN

ND

SD

NE IA

MI

WI

IN

KS

OK

CO

NM

PA

NY

ME

WA

OR

ID

TN NC

MS AL

SC

LA

FL

PA

NY

ME

TX

AK

NV UT

AZ

Phoenix

2.7

MA

CT

United States Rate—1.0

All IHS Areas Rate—2.4

95–100

75–94

50–74

0–49

Percentile

33
!

!

!

!

!

From 1989 to 1998, 155 Native American children and youth 

died from unintentional suffocation, choking, or strangulation.

Suffocation was the leading cause of injury death among 

Native American infants.

Inhalation or ingestion of food or other objects accounted for 

24% of the choking and suffocation deaths. Twenty-five 

percent of children suffocated while in a bed or cradle.

Fifty-eight percent of suffocation deaths occurred among 

infants. Forty percent of these infants suffocated in a bed or 

cradle.

Suffocation rates were highest in the Alaska Area.

S

U

M

M

A

R

Y

Suffocation Age-Specific Rates

1989–1998

Suffocation Rates per 100,000 Population

1981–1998

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Death Rate per 100,000

Year

Suffocation—

Plastic Bag

2.9%

Lack of Air

(in closed place)

2.9%

Cave In

0.7%

Type/Location of Suffocation

1989–1998

Native

American

White

African

American

* * *

0

5

10

15

20

25

30

Death Rate per 100,000

 * Rates are based on fewer than 20 deaths and should be interpreted with caution. 

Age Group (in years)

under 1 1–4 5–9 10–14 15–19

81–82 83–84 85–86 87–88 89–90 91–92 93–94 95–96 97–98

Inhalation/

Ingestion

of Object

23.9%

Suffocation—

Bed,Cradle

25.4%

Unintentional

Hanging

19.6%

Inhalation/

Ingestion

of Food

12.3

Other/

Unspecified

12.3%

34
35
IHS Area Specific Maps

36
Suffocation

 Deaths

U.S. 1.0

Aberdeen 3.5

Excess Deaths

14

9

Fire/Burn

 Deaths

U.S. 1.3

Aberdeen 7.9

Excess Deaths

32

24

Drowning

 Deaths

U.S. 2.0

Aberdeen 3.5

Excess Deaths

13

6

Homicide

 Deaths

U.S. 5.9

Aberdeen 10.7

Excess Deaths

42

18

Suicide

 Deaths

U.S. 3.0

Aberdeen 19.6

Excess Deaths

64

61

Firearm

 Deaths

U.S. 6.9

Aberdeen 14.0

Excess Deaths

46

26

Pedestrian

 Deaths

U.S. 1.5

Aberdeen 7.5

Excess Deaths

28

22

Motor Vehicle

 Deaths

U.S. 11.5

Aberdeen 39.5

Excess Deaths 

137

104

Aberdeen Area

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

Suffocation

 Deaths

U.S. 1.0

Aberdeen 3.5

Excess Deaths

14

9

Fire/Burn

 Deaths

U.S. 1.3

Aberdeen 7.9

Excess Deaths

32

24

Drowning

 Deaths

U.S. 2.0

Aberdeen 3.5

Excess Deaths

13

6

Homicide

 Deaths

U.S. 5.9

Aberdeen 10.7

Excess Deaths

42

18

Suicide

 Deaths

U.S. 3.0

Aberdeen 19.6

Excess Deaths

64

61

Firearm

 Deaths

U.S. 6.9

Aberdeen 14.0

Excess Deaths

46

26

Pedestrian

 Deaths

U.S. 1.5

Aberdeen 7.5

Excess Deaths

28

22

Motor Vehicle

 Deaths

U.S. 11.5

Aberdeen 39.5

Excess Deaths 

137

104

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

ND

SD

NE IA

Percentile 95–100 75–94 50–74 0–49

37
Suffocation

 Deaths

U.S. 1.0

Alaska 5.3

Excess Deaths

25

18

Fire/Burn

 Deaths

U.S. 1.3

Alaska 7.3

Excess Deaths

33

24

Drowning

 Deaths

U.S. 2.0

Alaska 14.6

Excess Deaths

56

51

Homicide

 Deaths

U.S. 5.9

Alaska 6.1

Excess Deaths 

24

1

Suicide

 Deaths

U.S. 3.0

Alaska 25.1

Excess Deaths

90

90

Firearm

 Deaths

U.S. 6.9

Alaska 26.5

Excess Deaths

96

80

Pedestrian

 Deaths

U.S. 1.5

Alaska 3.2

Excess Deaths 

14

7

Motor Vehicle

 Deaths

U.S. 11.5

Alaska 12.1

Excess Deaths

49

2

Alaska Area

AK AK AK AK

AK AK AK AK

Percentile 95–100 75–94 50–74 0–49

38
CO

NM

CO

NM

CO

NM

CO

NM

CO

NM

CO

NM

CO

NM

CO

NM

Suffocation

 Deaths

U.S. 1.0

Albuquerque 1.2

Excess Deaths 

4

1

Fire/Burn

 Deaths

U.S. 1.3

Albuquerque 1.6

Excess Deaths 

5

1

Drowning

 Deaths

U.S. 2.0

Albuquerque 2.6

Excess Deaths 

8

2

Homicide

 Deaths

U.S. 5.9

Albuquerque 7.7

Excess Deaths 

23

6

Suicide

 Deaths

U.S. 3.0

Albuquerque 7.7

Excess Deaths

21

14

Firearm

 Deaths

U.S. 6.9

Albuquerque 7.9

Excess Deaths 

22

3

Pedestrian

 Deaths

U.S. 1.5

Albuquerque 8.3

Excess Deaths

24

21

Motor Vehicle

 Deaths

U.S. 11.5

Albuquerque 33.7

Excess Deaths

98

70

Albuquerque Area

Percentile 95–100 75–94 50–74 0–49

39
MI

WI

IN

MN

MI

WI

IN

MN

MI

WI

IN

MN

MI

WI

IN

MN

MI

WI

IN

MN

MI

WI

IN

MN

Suffocation

 Deaths

U.S. 1.0

Bemidji 3.3

Excess Deaths 

12

7

Fire/Burn

 Deaths

U.S. 1.3

Bemidji 9.0

Excess Deaths

29

23

Drowning

 Deaths

U.S. 2.0

Bemidji 4.8

Excess Deaths 

14

9

Homicide

 Deaths

U.S. 5.9

Bemidji 7.7

Excess Deaths 

23

5

Suicide

 Deaths

U.S. 3.0

Bemidji 10.7

Excess Deaths

29

23

Firearm

 Deaths

U.S. 6.9

Bemidji 6.4

18

Excess Deaths -1

Pedestrian

 Deaths

U.S. 1.5

Bemidji 5.4

Excess Deaths

15

12

Motor Vehicle

 Deaths

U.S. 11.5

Bemidji 29.7

Excess Deaths

83

55

Bemidji Area

Percentile 95–100 75–94 50–74 0–49

40

MI

WI

IN

MN

MI

WI

IN

MN
Suffocation

 Deaths

U.S. 1.0

Billings 3.2

Excess Deaths 

9

5

Fire/Burn

 Deaths

U.S. 1.3

Billings 1.8

Excess Deaths 

4

1

Drowning

 Deaths

U.S. 2.0

Billings 4.7

Excess Deaths 

11

6

Homicide

 Deaths

U.S. 5.9

Billings 13.6

Excess Deaths

29

17

Suicide

 Deaths

U.S. 3.0

Billings 8.6

Excess Deaths

17

12

Firearm

 Deaths

U.S. 6.9

Billings 13.4

Excess Deaths

27

14

Pedestrian

 Deaths

U.S. 1.5

Billings 7.0

Excess Deaths

15

12

Motor Vehicle

 Deaths

U.S. 11.5

Billings 43.9

Excess Deaths

90

71

Billings Area

MT

WY

MT

WY

MT

WY

MT

WY

MT

WY

MT

WY

MT

WY

MT

WY

Percentile 95–100 75–94 50–74 0–49

41
CA CA CA CA

CA CA CA CA

Suffocation

 Deaths

U.S. 1.0

California 1.2

Excess Deaths 

7

1

Fire/Burn

 Deaths

U.S. 1.3

California 1.1

6

Excess Deaths -1

Drowning

 Deaths

U.S. 2.0

California 2.7

Excess Deaths 

14

4

Homicide

 Deaths

U.S. 5.9

California 4.4

20

Excess Deaths -7

Suicide

 Deaths

U.S. 3.0

California 5.0

Excess Deaths

22

10

Firearm

 Deaths

U.S. 6.9

California 9.3

Excess Deaths

40

12

Pedestrian

 Deaths

U.S. 1.5

California 3.9

Excess Deaths

19

12

Motor Vehicle

 Deaths

U.S. 11.5

California 17.0

Excess Deaths

78

27

California Area

Percentile 95–100 75–94 50–74 0–49

42
Suffocation

 Deaths

U.S. 1.0

Nashville 2.5

Excess Deaths 

8

4

Fire/Burn

 Deaths

U.S. 1.3

Nashville 1.9

Excess Deaths 

6

2

Drowning

 Deaths

U.S. 2.0

Nashville 4.3

Excess Deaths 

11

6

Homicide

 Deaths

U.S. 5.9

Nashville 2.7

7

Excess Deaths -8

Suicide

 Deaths

U.S. 3.0

Nashville 2.9

Excess Deaths 

7

0

Firearm

 Deaths

U.S. 6.9

Nashville 4.3

10

Excess Deaths -7

Pedestrian

 Deaths

U.S. 1.5

Nashville 3.0

Excess Deaths 

8

4

Motor Vehicle

 Deaths

U.S. 11.5

Nashville 20.5

Excess Deaths

52

24

Nashville Area

Percentile 95–100 75–94 50–74 0–49

43
Suffocation

 Deaths

U.S. 1.0

Navajo 3.3

Excess Deaths

31

20

Fire/Burn

 Deaths

U.S. 1.3

Navajo 1.9

Excess Deaths 

17

5

Drowning

 Deaths

U.S. 2.0

Navajo 4.4

Excess Deaths

37

20

Homicide

 Deaths

U.S. 5.9

Navajo 8.8

Excess Deaths

72

25

Suicide

 Deaths

U.S. 3.0

Navajo 7.4

Excess Deaths

56

37

Firearm

 Deaths

U.S. 6.9

Navajo 6.4

50

Excess Deaths -4

Pedestrian

 Deaths

U.S. 1.5

Navajo 10.9

Excess Deaths

92

80

Motor Vehicle

 Deaths

U.S. 11.5

Navajo 37.3

Excess Deaths 

302

218

Navajo Area

Percentile 95–100 75–94 50–74 0–49

44
KS

OK

TX

Oklahoma City Area

Suffocation

 Deaths

U.S. 1.0

Oklahoma 0.4

6

Excess Deaths -7

Fire/Burn

 Deaths

U.S. 1.3

Oklahoma 2.1

Excess Deaths 

28

9

Drowning

 Deaths

U.S. 2.0

Oklahoma 1.1

14

Excess Deaths -10

Homicide

 Deaths

U.S. 5.9

Oklahoma 5.4

63

Excess Deaths -6

Suicide

 Deaths

U.S. 3.0

Oklahoma 4.3

Excess Deaths

46

15

Firearm

 Deaths

U.S. 6.9

Oklahoma 7.4

Excess Deaths 

79

6

Pedestrian

 Deaths

U.S. 1.5

Oklahoma 2.0

Excess Deaths 

24

6

Motor Vehicle

 Deaths

U.S. 11.5

Oklahoma 16.7

Excess Deaths

185

63

KS

OK

TX

KS

OK

TX

KS

OK

TX

KS

OK

TX

KS

OK

TX

KS

OK

TX

KS

OK

TX

Percentile 95–100 75–94 50–74 0–49

45
Suffocation

 Deaths

U.S. 1.0

Phoenix 2.7

Excess Deaths

18

10

Fire/Burn

 Deaths

U.S. 1.3

Phoenix 1.3

Excess Deaths 

7

0

Drowning

 Deaths

U.S. 2.0

Phoenix 4.7

Excess Deaths

27

15

Homicide

 Deaths

U.S. 5.9

Phoenix 12.7

Excess Deaths

67

38

Suicide

 Deaths

U.S. 3.0

Phoenix 8.1

Excess Deaths

40

28

Firearm

 Deaths

U.S. 6.9

Phoenix 13.2

Excess Deaths

66

35

Pedestrian

 Deaths

U.S. 1.5

Phoenix 6.3

Excess Deaths

37

27

Motor Vehicle

 Deaths

U.S. 11.5

Phoenix 32.6

Excess Deaths 

173

119

Phoenix Area

NV UT

AZ

NV UT

AZ

NV UT

AZ

NV UT

AZ

NV UT

AZ

NV UT

AZ

NV UT

AZ

NV UT

AZ

Percentile 95–100 75–94 50–74 0–49

46
Portland Area

Suffocation

 Deaths

U.S. 1.0

Portland 1.6

Excess Deaths 

11

4

Fire/Burn

 Deaths

U.S. 1.3

Portland 2.2

Excess Deaths 

13

5

Drowning

 Deaths

U.S. 2.0

Portland 3.7

Excess Deaths

23

10

Homicide

 Deaths

U.S. 5.9

Portland 6.4

Excess Deaths 

35

3

Suicide

 Deaths

U.S. 3.0

Portland 8.5

Excess Deaths

44

32

Firearm

 Deaths

U.S. 6.9

Portland 9.0

Excess Deaths

47

13

Pedestrian

 Deaths

U.S. 1.5

Portland 3.1

Excess Deaths 

18

9

Motor Vehicle

 Deaths

U.S. 11.5

Portland 22.4

Excess Deaths

122

65

WA

OR

ID

WA

OR

ID

WA

OR

ID

WA

OR

ID

WA

OR

ID

WA

OR

ID

WA

OR

ID

WA

OR

ID

Percentile 95–100 75–94 50–74 0–49

47
Suffocation

 Deaths

U.S. 1.0

Tucson 3.3

Excess Deaths 

4

3

Fire/Burn

 Deaths

U.S. 1.3

Tucson 3.3

Excess Deaths 

4

2

Drowning

 Deaths

U.S. 2.0

Tucson 3.5

Excess Deaths 

4

2

Homicide

 Deaths

U.S. 5.9

Tucson 16.2

Excess Deaths

17

12

Suicide

 Deaths

U.S. 3.0

Tucson 18.8

Excess Deaths

18

18

Firearm

 Deaths

U.S. 6.9

Tucson 21.0

Excess Deaths

22

16

Pedestrian

 Deaths

U.S. 1.5

Tucson 8.2

Excess Deaths 

9

7

Motor Vehicle

 Deaths

U.S. 11.5

Tucson 24.5

Excess Deaths

27

15

Tucson Area

AZ

AZ

AZ

AZ

AZ

AZ

AZ

AZ

Percentile 95–100 75–94 50–74 0–49

48

Additional Sources of Information

50
Articles

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and Prevention. Injury mortality among American Indian and 

Alaska Native children and youth—United States, 1989–1998 

[monograph online]. MMWR 2003; 52:697–701. Available from: 

URL: .

The prevention of unintentional injury among American Indian 

and Alaska Native children: a subject review [online]. American 

Academy of Pediatrics, Committee on Native American Child 

Health and Committee on Injury and Poison Prevention, 1999. 

Available from: URL: .

Phelan KJ, Koury J, Grossman DC, et al. Pediatric motor vehicle 

related injuries in the Navajo Nation: the impact of the 1988 Child 

Occupant Restraint Laws [online]. Inj Prev 2002; 8:216–220. 

Available from: URL: .

Quinlan KP, Wallace LJD, Furner SE, et al. Motor vehicle related 

injuries among American Indian and Alaska Native youth, 

1981–1992: analysis of a National Hospital Discharge Database. 

Inj Prev 1998; 4:276–279. Available from: URL: 

.

Grossman DC, Sugarman JR, Fox C, Moran J. Motor vehicle 

crash-injury risk factors among American Indians. Accid Anal 

Prev 1997; 29:313–319. 

Smith ML, Berger LR. Assessing community child passenger 

safety efforts in three northwest tribes [online]. Inj Prev 2002; 

8:289–292. Available from: URL: .

Zaloshnja E, Miller TR, Galbraith MS, et al. Reducing injuries 

among Native Americans: five cost-outcome analyses. Accid 

Anal Prev 2003; 35:631–639.

Brenner RA, Overpeck MD Trumble AC, DerSimonian R, 

Berendes H. Deaths attributable to injuries in infants, United 

States, 1983–1991 [online]. Pediatrics 1999; 103:968–974. 

Available from: URL: 

.

www.cdc.gov/mmwr/

www.aap.org/policy/re9908.html

http://ip.bmjjournals.com/

http://ip.bmjjournals.com/

http://ip.bmjjournals.com/

http://pediatrics.aappublications.org/search.dtl

The guide to community preventive services, reducing injuries to 

motor vehicle occupants, systematic reviews of evidence, 

recommendations from the Task Force on Community Preventive 

Services, and Expert Commentary [online]. Am J Prev Med 2001; 

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childhood home visitation and firearm laws. Findings from the Task 

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www.cdc.gov/mmwr/

51
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.

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.

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.

Harborview Injury Prevention Research Center, Systematic 

Reviews of Childhood Injury: 

Insurance Institute for Highway Safety: 

. 

Injury Control Resource Information Network: 

.

The Children's Safety Network: 

.

The National Safe Kids Campaign: .

The American Academy of Pediatrics: .

The American Academy of Pediatric Committee on Native 

American Child Health: . 

HRSA Office of Maternal and Child Health: .

www.cdc.gov/ncipc/

www.ihs.gov/medicalprograms/injuryprevention/index.cfm

www.nhtsa.dot.gov/

http://depts.washington.edu/hiprc/

www.hwysafety.org/default.htm

www.injurycontrol.com/icrin/index.html#index

www.childrenssafetynetwork.org/

www.safekids.org

www.aap.org

www.aap.org

www.hrsa.gov

Books Websites

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and control for children and youth, 3rd ed. Elks Grove Village 

(IL): American Academy of Pediatrics; 1997.

Christoffel JD, Gallagher SS. Injury prevention and public health: 

practical knowledge, skills, and strategies. Gaithersburg (MD): 

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Atlanta (GA): Centers for Disease Control and Prevention, 

National Center for Injury Prevention and Control; 2000. 

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www.surgeongeneral.gov/library/youthviolence/youvioreport.htm.

www.cdc.gov/ncipc/

52