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Abstract
Death investigation on tribal lands and of American Indian/Alaska Native (AIAN) people
is complex and not well documented. An analysis of data from the 2018 Census of Medical
Examiner and Coroner Offices (CMEC) provides a timely update on the extent of medicolegal
death investigations (MDIs) on federal and state-recognized tribal lands. An estimated
150 MEC offices serve tribal lands, however, 44 % of these offices (i.e., 4 % of MEC
offices) do not track cases from tribal lands separately. MEC offices with a population
of 25,000 to 250,000 that serve tribal lands had more resources and access to information
to perform MDIs than all other MEC offices. Analysis also indicates that the median
number of unidentified human remains cases from MECs serving tribal lands is 6 times
higher than that of jurisdictions not serving tribal lands. This analysis begins to
elucidate gaps in the nation's understanding of MDI on tribal lands.
Highlights
•
MEC systems serving US tribal lands are underrepresented among death investigations.
•
Deaths of AIAN people from violent crimes are higher than the general population.
•
Median unidentified human remains cases for MECs serving tribal lands is 6 times higher
than others.
•
MECs serving tribal lands among other jurisdictional regions represent smaller populations.
•
Resources of MECs serving tribal lands are similar to MECs not serving tribal lands.
Structural racism has been and remains a fundamental cause of persistent health disparities in the United States. The coronavirus disease 2019 (COVID-19) pandemic and the police killings of George Floyd, Breonna Taylor, and multiple others have been reminders that structural racism persists and restricts the opportunities for long, healthy lives of Black Americans and other historically disenfranchised groups. The American Heart Association has previously published statements addressing cardiovascular and cerebrovascular risk and disparities among racial and ethnic groups in the United States, but these statements have not adequately recognized structural racism as a fundamental cause of poor health and disparities in cardiovascular disease. This presidential advisory reviews the historical context, current state, and potential solutions to address structural racism in our country. Several principles emerge from our review: racism persists; racism is experienced; and the task of dismantling racism must belong to all of society. It cannot be accomplished by affected individuals alone. The path forward requires our commitment to transforming the conditions of historically marginalized communities, improving the quality of housing and neighborhood environments of these populations, advocating for policies that eliminate inequities in access to economic opportunities, quality education, and health care, and enhancing allyship among racial and ethnic groups. Future research on racism must be accelerated and should investigate the joint effects of multiple domains of racism (structural, interpersonal, cultural, anti-Black). The American Heart Association must look internally to correct its own shortcomings and advance antiracist policies and practices regarding science, public and professional education, and advocacy. With this advisory, the American Heart Association declares its unequivocal support of antiracist principles.
Homicide is one of the leading causes of death for women aged ≤44 years.* In 2015, homicide caused the death of 3,519 girls and women in the United States. Rates of female homicide vary by race/ethnicity ( 1 ), and nearly half of victims are killed by a current or former male intimate partner ( 2 ). To inform homicide and intimate partner violence (IPV) prevention efforts, CDC analyzed homicide data from the National Violent Death Reporting System (NVDRS) among 10,018 women aged ≥18 years in 18 states during 2003–2014. The frequency of homicide by race/ethnicity and precipitating circumstances of homicides associated with and without IPV were examined. Non-Hispanic black and American Indian/Alaska Native women experienced the highest rates of homicide (4.4 and 4.3 per 100,000 population, respectively). Over half of all homicides (55.3%) were IPV-related; 11.2% of victims of IPV-related homicide experienced some form of violence in the month preceding their deaths, and argument and jealousy were common precipitating circumstances. Targeted IPV prevention programs for populations at disproportionate risk and enhanced access to intervention services for persons experiencing IPV are needed to reduce homicides among women. CDC’s NVDRS is an active state-based surveillance system that monitors characteristics of violent deaths, including homicides. The system links three data sources (death certificates, coroner/medical examiner reports, and law enforcement reports) to create a comprehensive depiction of who dies from violence, where and when victims die, and factors perceived to contribute to the victim’s death ( 3 ). This report includes NVDRS data from 18 states during 2003–2014 (all available years). † Five racial/ethnic categories § were used for this analysis: white, black, American Indian/Alaska Native (AI/AN), Asian/Pacific Islander (A/PI), and Hispanic. Persons categorized as Hispanic might have been of any race. Persons categorized as one of the four racial populations were all non-Hispanic. Analyses were limited to female decedents aged ≥18 years. IPV-related deaths were defined as those involving intimate partner homicides (i.e., the victim was an intimate partner [e.g., current, former, or unspecified spouse or girlfriend] of the suspect), other deaths associated with IPV, including victims who were not the intimate partner (i.e., family, friends, others who intervened in IPV, first responders, or bystanders), or jealousy. Deaths where jealousy, such as in a lovers’ triangle, was noted as a factor were included only when they involved an actual relationship (versus unrequited interest). Violence experienced in the preceding month refers to all types of violence (e.g., robbery, assault, or IPV) that was distinct and occurred before the violence that killed the victim; there did not need to be any causal link between the earlier violence and the death itself (e.g., victim could have experienced a robbery by a stranger 2 weeks before being killed by her spouse). Rates were calculated using intercensal and postcensal bridged–race population estimates compiled by CDC’s National Center for Health Statistics and were age-adjusted to the 2010 standard U.S. population of women aged ≥18 years ( 4 ). Sociodemographic characteristics and precipitating circumstances across racial/ethnic groups were examined using chi-square and Fisher’s exact tests. Two-sided p-values 90% of these women being killed by their current or former intimate partner. Strategies to prevent IPV-related homicides range from protecting women from immediate harm and intervening in current IPV, to developing and implementing programs and policies to prevent IPV from occurring ( 5 ). IPV lethality risk assessments conducted by first responders have shown high sensitivity in identifying victims at risk for future violence and homicide ( 6 ). These assessments might be used to facilitate immediate safety planning and to connect women with other services, such as crisis intervention and counseling, housing, medical and legal advocacy, and access to other community resources ( 6 ). State statutes limiting access to firearms for persons under a domestic violence restraining order can serve as another preventive measure associated with reduced risk for intimate partner homicide and firearm intimate partner homicide ( 7 ). Approximately one in 10 victims of IPV-related homicide experienced some form of violence in the preceding month, which could have provided opportunities for intervention. Bystander programs, such as Green Dot, ¶ teach participants how to recognize situations or behaviors that might become violent and safely and effectively intervene to reduce the likelihood of assault ( 8 ). In health care settings, the U.S. Preventive Services Task Force recommends screening women of childbearing age for IPV and referring women who screen positive for intervention services.** Approximately 15% of female homicide victims of reproductive age (18–44 years) were pregnant or postpartum, which might or might not be higher than estimates in the general U.S. female population, requiring further examination. Approximately 40% of non-Hispanic black, AI/AN, and Hispanic female homicide victims were aged 18–29 years. Argument and jealousy were common precipitating factors for IPV-related homicides. Teaching safe and healthy relationship skills is an important primary prevention strategy with evidence of effectiveness in reducing IPV by helping young persons manage emotions and relationship conflicts and improve their problem-solving and communication skills ( 5 ). Preventing IPV also requires addressing the community- and system-level factors that increase the risk for IPV; neighborhoods with high disorder, disadvantage, and poverty, and low social cohesion are associated with increased risk of IPV ( 5 ), and underlying health inequities caused by barriers in language, geography, and cultural familiarity might contribute to homicides, particularly among racial/ethnic minority women ( 9 ). The findings in this report are subject to at least five limitations. First, NVDRS data are available from a limited number of states and are therefore not nationally representative. Second, race/ethnicity data on death certificates might be misclassified, particularly for Hispanics, A/PI, and AI/AN ( 10 ). Third, the female homicide victims in this dataset were more likely to be never married or single and less likely to have attended college than the general U.S. female population †† ; although this is likely attributable to the relatively younger age distribution of homicide victims in general, §§ this requires further examination. Fourth, not all homicide cases include detailed suspect information; in this analysis, 85.3% of cases included information on the suspect. Finally, information about male corollary victims of IPV-related homicide (i.e., other deaths associated with IPV, including male victims who were not the intimate partner) were not included in this analysis. Therefore, the full scope of IPV-related homicides involving women is not captured. The racial/ethnic differences in female homicide underscore the importance of targeting prevention and intervention efforts to populations at disproportionately high risk. Addressing violence will require an integrated response that considers the influence of larger community and societal factors that make violence more likely to occur. Summary What is already known about this topic? Homicide is one of the leading causes of death for women aged ≤44 years, and rates vary by race/ethnicity. Nearly half of female victims are killed by a current or former male intimate partner. What is added by this report? Homicides occur in women of all ages and among all races/ethnicities, but young, racial/ethnic minority women are disproportionately affected. Over half of female homicides for which circumstances were known were related to intimate partner violence (IPV). Arguments and jealousy were common precipitating circumstances among IPV-related homicides. One in 10 victims of IPV-related homicide were reported to have experienced violence in the month preceding their deaths. What are the implications for public health practice? Racial/ethnic differences in female homicide underscore the importance of targeting intervention efforts to populations at risk and the conditions that increase the risk for violence. IPV lethality risk assessments might be useful tools for first responders to identify women at risk for future violence and connect them with life-saving safety planning and services. Teaching young persons safe and healthy relationship skills as well as how to recognize situations or behaviors that might become violent are effective IPV primary prevention measures.
Objectives This report presents the findings of an updated study of the validity of race and Hispanic-origin reporting on death certificates in the United States, and its impact on race- and Hispanic origin-specific death rates. Methods The latest version of the National Longitudinal Mortality Study (NLMS) was used to evaluate the classification of race and Hispanic origin on death certificates for deaths occurring in 1999–2011 to decedents in NLMS. To evaluate change over time, these results were compared with those of a study based on an earlier version of NLMS that evaluated the quality of race and ethnicity classification on death certificates for 1979–1989 and 1990–1998. NLMS consists of a series of annual Current Population Survey files (1973 and 1978–2011) and a sample of the 1980 decennial census linked to death certificates for 1979–2011. Pooled 2009–2011 vital statistics mortality data and 2010 decennial census population data were used to estimate and compare observed and corrected race- and Hispanic origin-specific death rates. Results Race and ethnicity reporting on death certificates continued to be highly accurate for both white and black populations during the 1999–2011 period. Misclassification remained high at 40% for the American Indian or Alaska Native (AIAN) population. It improved, from 5% to 3%, for the Hispanic population, and from 7% to 3% for the Asian or Pacific Islander (API) population. Decedent characteristics such as place of residence and nativity affected the quality of reporting on the death certificate. Effects of misclassification on death rates were large for the AIAN population but not significant for the Hispanic or API populations.
[a
]RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC, 27709, USA
[b
]University of North Carolina at Chapel Hill, Division of Pharmaceutical Outcomes and
Policy, Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, USA, 27599
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