Mexico’s first nations mortality disparities, 2015-2022

Abstract

This article aims to assess overall and cause-specific excess mortality, its cause-specific distribution, and premature mortality in this vulnerable population in 2015-2022. Since 2014, data on the languages of Mexico’s first nations spoken by persons older than 3 years of age have been collected on death certificates. Age-standardized mortality rates (MR) and their ratios (MRR), proportional mortality, and cause-specific mortality rates were calculated. Years of life potentially lost were calculated using age-specific life expectancy. The COVID-19 pandemic reversed the excess mortality observed during pre-pandemic mortality (MRR of 1.1 [95% CI: 1.1, 1.1]). Prior to the pandemic, there was excess cause-specific mortality of highly preventable conditions such as diarrheal diseases, tuberculosis, malnutrition, anemia, alcohol use disorders and alcoholic liver disease, pregnancy-related mortality, which accounted for 40% of excess deaths. In 2015-2019, premature mortality was 20% higher in persons of Mexico’s First Nations. The populations of Mexico’s First Nations have excess mortality. More resources and efforts are needed to eliminate health disparities between the populations of the First Nations and the rest of Mexico.

Key words:
Mortality; Native populations; Health disparities; Mexico

Resumo

O objetivo do artigo é avaliar o excesso de mortalidade geral e por causas específicas e a mortalidade prematura nos povos originários do México (POM) entre 2015-2022. Desde 2014, as certidões de óbito têm coletado dados sobre os idiomas dos POM falados pelos falecidos com mais de 3 anos de idade. Foram calculadas as taxas de mortalidade padronizadas por idade (TM) e suas razões (RTM), a mortalidade proporcional e as taxas de mortalidade por causas específicas. Os anos de vida potencialmente perdidos foram calculados usando a expectativa de vida específica por idade. A pandemia de COVID-19 reverteu o excesso de mortalidade observado entre as POM durante o período pré-pandêmico (RTM de 1,1 [IC95%: 1,1, 1,1]). Antes da pandemia, o excesso na mortalidade por causas específicas para POM foi encontrado em condições altamente evitáveis, como doenças diarreicas, tuberculose, desnutrição, anemias, transtorno por uso de álcool, doença hepática alcoólica e mortalidade relacionada à gravidez, representando 40% do excesso de mortes. Em 2015-2019, a mortalidade prematura foi 20% maior nos mexicanos que falavam idiomas nativos. As populações dos POM apresentam excesso de mortalidade. São necessários mais recursos e esforços para eliminar às disparidades entre os POM e o restante do México.

Palavras-chave:
Mortalidade; Populações nativas; Disparidades de saúde; México

Resumen

El objetivo de este artículo es evaluar la mortalidad en exceso por todas las causas y la distribución por causas específicas y la mortalidad prematura en esta población vulnerable en 2015-2022. Desde el 2014 se recolectan en los certificados de defunción datos sobre las lenguas de pueblos originarios hablados por personas de 3+ años. Se calcularon las tasas estandarizadas de mortalidad (TM) y sus razones (RTM), la mortalidad proporcional y las tasas por causas específicas. Calculamos los años de vida potencial perdidos utilizando esperanza de vida específica por edad. La pandemia de COVID-19 invirtió el exceso de mortalidad observado en el período pre-pandémico (RTM de 1.1 [IC 95%: 1.1, 1.1]). Antes de la pandemia, había un exceso de mortalidad por causas específicas de condiciones altamente prevenibles como enfermedades diarreicas, tuberculosis, desnutrición, anemia, abuso de alcohol y enfermedad hepática alcohólica, mortalidad relacionada con el embarazo, que representaban el 40% de las defunciones en demasía. En 2015-2019, la mortalidad prematura fue 20% mayor en personas de pueblos originarios en México. En los pueblos originarios de México hay un exceso de mortalidad. Se necesitan más recursos y esfuerzos para eliminar las disparidades entre los pueblos originarios y el resto de México.

Palabras clave:
Mortalidad; Poblaciones autóctonas; Disparidades sanitarias; México

Most Mexicans are of mixed ancestry¹, as corroborated by studies indicating that Native, European and African ancestry are found in around 50%, 46% and 4% of Mexicans, respectively². However, most Mexicans consider themselves non-Natives. The term “indio” translated into Indian in English, was coined by Christopher Columbus who believed his expedition had landed in India, and the term has been used to refer to the “other” peoples, that is different from the Spaniards. The nations that existed before the Conquest, had their own identity by the language spoken as Maayas, Náhuatla or Mexicanos, or Náhuatla Tlaxcalteca, Ñuju or Otomíes, Jlumaltik, Tutunáku, Wixáritari, Rarámuri, Hiak-nooki, among 68 nations, but they were lumped together in the term “Indians”. Interestingly, in today’s Mexico, the terms “indio” or “naco” are used as racist slur. The modernization of the country has resulted in the continued extinction of the “other” people. These “other” people are referred hereafter as populations of Mexico’s first nations (MFN).

The will of the people of MFN to continue living in their own ways, according to Bonfil Batalla constitutes the Deep Mexico (México Profundo), the real Mexico, as opposed to an imaginary one, built on the image of and imitating the ways of the Western European metropolis³.

The de-indianization of Mexico and the allure of “whiteness” has retained its role in Mexico, serving as a proxy for socioeconomic status reflecting the history of conquest and colonization of Mexico by European nations. Mexico’s society wealth has been built based on the exploitation and subordination of natives and African slaves^4-5.

By 2023, the population of Native Mexicans was estimated at about 10 million population. In 2000, they were residing mostly in remote mountainous regions of Mexico, except for the Yucatán peninsula among other (Figure 1).

Figure 1
Distribution of linguistic families of Mexico’s first nations by localities, 2010.

Disparities of mortality rates by ethnicity in Mexico if found would be the result of structural racism as a system of beliefs, institutional arrangements, and policies, that perpetuates the inequalities, ranging from employment, housing, income, education, to the health status of the populations of MFN and Mexicans of African descent. The imbalance between MFN and the rest of the population, however, extends to other domains, such as political power, representation, their land and waters, leaving the members of the subordinated casts to be exploited based on their perceived “race” or “ethnic background”, thus limiting the advancement of those individuals, who are indeed discriminated against. Racism, however, also prevents the advancement of the entire society³.

Racism in Mexico had not received the appropriate recognition as a national issue until recent years, when was openly condemned by López Obrador administration (2018-2024): it also strengthened the legal framework and the mandate of the National Institute of Indigenous Peoples⁶.

Ethnic and racial health disparities highlight the need to provide health services that could contribute to the mitigation of such inequalities⁷. However, they reflect wider gaps in the standards of living, the core determinant of health status of populations. Nevertheless, there is a need to recognize and monitor their existence and progress towards the elimination of health disparities.

Starting on 2012, the Mexican death certificate collects data on languages other than Spanish spoken by the decedent⁸, allowing the examination of public health surveillance data during the COVID-19 pandemic to identify the excess risk of morbidity and mortality among persons of MFN, in open data available in the respiratory diseases surveillance system^9-10. During the SARS-CoV-2 pandemic, health services were disrupted and along with a cluster of unusual circumstances that a separate analysis of pre-pandemic and pandemic periods seemed warranted.

Death records are one of the cornerstones of public health surveillance¹¹. Such records are largely incomplete in rural Mexico, particularly among infants, and pregnant women of the MFN^12-15, and for neonatal tetanus¹⁶. To the best of our knowledge there is no previously published report comparing the general mortality nor cause specific mortality of MFN and the rest of the country (Table 1).

Table 1
Sources, terms searched, and publications found in the indexed published literature on this topic.

Sources	MeSH terms entered	Publications
Scopus	Mortality AND indigenous AND Mexico	143
Web of Science	Mortality AND indigenous AND Mexico	193
Biblioteca Virtual de Salud	Mortality AND indigenous AND Mexico	50
Redylac	Mortality AND indigenous AND Mexico	98

• Source: Database search by the author, March 2024, files available upon request.

Mexico is among other countries in the Continent, including Guatemala, Bolivia, Perú, the United States of America, Canada, Paraguay, Chile and Brazil with significant populations of native Americans. Publications on the health status of these native populations outside the USA, Canada and Brazil, are scant.

Objectives

We assessed the death rates and age-adjusted mortality rate ratios comparing the experience of MFN populations and those of the rest of the country age 3+ years considering the last five-year period before the COVID-19 pandemic, that is 2015-2019, and the pandemic period (2020-2022).

Methods

Study design and sources

Descriptive mortality study using de-identified data from death certificates for the years 2015-2022 available to the public from the National Institute for Statistics, and Geography (INEGI). Following the coding rules of the WHO´s ICD -10 system, INEGI staff selected and coded the underlying cause of death¹⁷. After exclusion of deaths that occurred before 2015, decedents of less than 3 years of age, those missing data on age of death and language spoken we included 5,540,404 death records for analysis.

The coverage of death registration by MFN ethnicity is unknown. Collection of data on MFN ethnicity in death certificates started only in 2014. Field research has documented lower certificate coverage in poor rural areas, where MFN populations are largely settled. In one such study, a 23% under-recording of deaths among young children in those settings was found¹².

For the denominator data, we used the 2015-2019 population estimates and the projections for 2021-2022 and imputed the proportion of the 2020 Census population of persons that self-reported speaking languages other than Spanish, available at the INEGI website¹⁸, to mid-year population projections of the National Population Council¹⁹). The age distribution of the index and comparator populations differ substantially (Figure 2). Among the MFN population, 19.3% were 55+ year-olds versus 14.6% in the rest of Mexico’s population. Also, two percent fewer children 3-5 years of age were enumerated in MFN population than in the rest of Mexico.

Figure 2
Age distribution of México’s first nations and the rest of the country population, 2020.

We used the grouping of causes of death in the list 1 of causes of death from the World Health Organization. A comparison on highly preventable and treatable conditions in the two groups was carried out, as the existence of a gap would be important to report. These conditions included: diarrheal diseases (A0), tuberculosis (A15-A18), cervix uteri cancer (C53), pneumonia and other respiratory infections (J15-J18; J20-J22; J40), malnutrition (E40-E44), and anemias (D50-D60), alcohol abuse (F10) and liver cirrhosis related to alcohol abuse (K70), and complications of pregnancy, labor and puerperium (O00-O99).

Analysis

We calculated crude and age-adjusted mortality rates and mortality ratios by ethnicity (MFN and rest of the population) using the age distribution of the 2020 Mexican Census population (3+ years) as the standard (Table 2). The distribution of the main causes of deaths and the proportionate mortality were tabulated by ethnicity, and the proportionate mortality ratio (PMR) calculated for specific causes of death. The 95% confidence interval for the PMR, a ratio of two binomial proportions, was obtained using the estimator of the standard deviation of the natural logarithm of the ratio of two proportions²⁰. We calculated the PMR only if the counts were at least 20 deaths for the index series in the five-year study period. We obtained the life expectancy from the 3^rd year of life for both populations and calculated the years of life lost using the reference life table of the Global Burden of Disease for the year 2015²¹. We also calculated age-adjusted all-cause mortality rates (MRs) and mortality rate ratios (MRRs), cause-specific MRs and MRRs. We obtained 95% confidence intervals around the MRRs using the Robins, Greenland, and Breslow estimator²².

Table 2
2020 Mexico´s Census Standard Population, total and by sex, and imputed value for 3-4-year-olds.

Age group (yrs.)	Total	Males	Females
0-4	10,047,365	5,077,482	4,969,883
3-4	4,018,946	2,030,993	1,987,953
5-9	10,764,379	5,453,091	5,311,288
10-14	10,943,540	5,554,260	5,389,280
15-19	10,806,690	5,462,150	5,344,540
20-24	10,422,095	5,165,884	5,256,211
25-29	9,993,001	4,861,404	5,131,597
30-34	9,420,827	4,527,726	4,893,101
35-39	9,020,276	4,331,530	4,688,746
40-44	8,503,586	4,062,304	4,441,282
45-49	7,942,413	3,812,344	4,130,069
50-54	7,037,532	3,332,163	3,705,369
55-59	5,695,958	2,692,976	3,002,982
60-64	4,821,062	2,257,862	2 563,200
65-69	3 645,077	1,706,850	1,938,227
70-74	2,647,340	1,233,492	1,413,848
75-79	1,814,582	847,898	966,684
80- 84	1,175,364	523,812	651,552
85 +	1,039,551	433,968	605,583

• Source: INEGI, 2020 Census.

The IRB of the investigator´s academic center determined this secondary data analysis was not research on human subjects.

Results

In 2015-2022 there were 455,296 and 5,085,108 recorded deaths among persons 3+ years of age who reportedly spoke a native language of Mexico, and those who did not, respectively. For the entire 2015-2022, the age-adjusted rates were 6.3 and 6.2 per 1,000 3+ year-olds, only a one percent excess of mortality in the population of the MFN in comparison with the rest of Mexico’s population. There was considerable variation by age with the MRR larger in children, with MRR of 2 for those 3-4, then decreasing. However, upon a closer examination of the data by year, we noticed a reversal of the disparity between the pre-pandemic (i.e., 2015-2019 period) and the pandemic period (2020-2022) (Figure 3).

Figure 3
Age-adjusted all-cause maratlity rates among 3+ years-old first nations and the rest of the counstry populations, 2015-2022.

The examination of daily mortality rates from all-cause mortality, and COVID-19 specific mortality suggests the reversal can be pinpointed to the second wave of the pandemic (October 2020 to February 2021), impacting the numbers that yield an overall higher age-adjusted all-cause mortality in 2020 and 2021, in the populations not speaking native languages (Figure 4).

Figure 4
Daily mortality rate from all-causes and COVID-19 among Mexico’s first nations and the rest of the country, 2020-2022.

In 2015-2022, there were no appreciable differences in the distribution by age and gender of MFN decedents and those of the rest of the country, but these two groups were distinctly different with respect to: living in rural communities (i.e., of less than 2,500 persons), reporting less than elementary education if 15+ years of age, dying at home, receiving medical care before their death, and lacking any kind of health insurance program or plan: 50.7% vs. 17.0%, 74.5% vs. 41.1%, 74.4% vs. 51.2%, 24.6% vs. 13.6%, and 40.6% vs. 26.6%, respectively (Table 3).

Table 3
Distribution of decedents by ethnicity and select characteristics, Mexico, 2015-2019.

	Spoke a language other than Spanish			P-value
	Yes (%)	No (%)	Total
Age
3-9	1,961 (0.4)	223,515 (0.5)	25,476	< 0.0001
10-19	5,383 (1.2)	75,930 (1.5)	81,313
20-29	11,868 (2.8)	110,530 (4.2)	117,803
30-39	17,220 (3.8)	256,614 (5.1)	273,834
40-49	29,661 (6.5)	417,721 (8.0)	447,382
50-59	51,042 (11.2)	676,103 (13.3)	727,145
60-69	75,433 (16.6)	933,126 (18.4)	1,008,559
70-79	100,502 (22.1)	1,052,426 (20.7)	1,152,928
80+	162,226 (35.6)	1,453,397 (28.6)	1,615,623
Total	455,296	5,085,108	5,540,404
Sexo*
Masculino	244,717 (53.8)	2,863,999 (56.3)	3,108,116	< 0.0001
Femenino	210,573	2,221,598	2,432,171
Total	455,290	5,084,997	5,540,287*
Living in rural areas (< 2,500 persons)
Yes	225,7531 (50.7)	853,326 (17.0)	1,079,079	< 0.0001
No	219,858	4,171,558	4,391,416
Total	445,611	5,024,884	5,470,495*
<6 years of schooling (15+ years of age only)
Yes	323,318 (74.5)	2,013,170 (41.1)	2,336,488	< 0.0001
No	110,802	2,882,523	2,993,325
Total	434,120	4,895,693	5,329,813*
Died at home				< 0.0001
Yes	315,023 (74.4)	2,357,241 (51.2)	2,672,264
No	108,617	2,248,639	2,357,256
Total	423,640	4,605,880	5,029,520*
Did not receive medical care before dying				< 0.0001
Yes	105,020 (24.6)	631,824 (13.0)	736,844
No	322,668	4,231,094	4,553,762
Total	427,688	4,862,918	5,290,606*
No health insurance plan				< 0.0001
Yes	158,040 (40.6)	1,208,984 (26.6)	1,367,024
No	231,152	3,334,544	3,565,696
Total	389,192	4,543,528	4,932,720*

• * Records with missing data not included
• Source: Research files from raw data obtained from INEGI.

The pre-pandemic “normalcy”

Given the significant impact of the COVID-19 pandemic on what one can consider usual under non-pandemic conditions, with multiple questions raised by this significance of the switchover, as discussed later, the rest of the results were limited to the pre-pandemic period (n = 2,915,459 death records of decedent 3+ years, 263,821 of them of persons who spoke MFN languages).

In 2015-2019, the age-adjusted all-cause mortality rate for 3+ year-olds who reportedly spoke native languages was 6.1 deaths per 1,000 compared to 5.4 deaths per 1,000 for their counterparts of the rest of the nation, for an age-adjusted MRR=1.1 (95%CI: 1.1, 1.1).

The attributable risk of death due to belonging to the first nations (AR = MR_e - MR_e /MR_e ), where e denotes exposure), was 12.9% (6.1 - 5.4/5.4), which translates into 34,033 excess deaths among MFN persons ages 3+ during the five-year period examined. The age-specific MRR showed also heterogeneity, with larger differences among the young (Figure 5).

Figure 5
Age-specific mortality rate ratios - Mexico’s first nations populations age 3+ years to the rest of the country - with log-normal confidence limits, Mexico 2015-2019.

The screening of the entire WHO’s List 1 to find out if there were specific causes of death that differed significantly for MFN populations and the population of the rest of the country, as indicated by the PMR followed. A PMR above 1, would tell an excess occurred. As shown in Table 4, we found excess mortality not for all infectious disease, but for some of them, including diarrheal diseases, respiratory tuberculosis and Chagas’ disease. We found excess mortality for certain cancers, including those originating in the esophagus, stomach, and liver. In addition, there was a larger proportion of deaths among MFN due to anemia, substance abuse, liver disease, malnutrition, hypertension, cerebrovascular diseases and atherosclerosis, other lower respiratory infections, chronic lower respiratory disease, from complications of pregnancy, labor and puerperium, as well as from falls and accidental poisoning by and exposure to noxious substances. The death records of MFN were five times as likely to have a poorly identified cause of death as the rest of the country.

Table 4
Percent distribution of underlying causes of deaths according to WHO's list of the ICD-10 among Mexico' first nations decedents 3+ year-olds and their counterparts of the rest of Mexico, 2015-2019.

List Num­ber	ICD Codes	Cause	First nations deaths	Per­cent	Rest of Mexico's deaths	Per­cent	PMR	95%CI
1000		All causes	263,821	100.0	2,651,638	100.0
1001	A00-B99	Certain infectious and parasitic diseases	6,312	2.4	62,537	2.4	1.0	1.0	1.0
1002	A00	Cholera	0	0.0			-
1003	A09	Diarrhea and gastroenteritis of presumed infectious origin	2,059	0.8	9,742	0.4	2.1	2.0	2.2
1004	A01-A08	Other intestinal infectious diseases	218	0.1	1,857	0.1	1.0	1.0	1.4
1005	A15-A16	Respiratory tuberculosis	958	0.4	6,131	0.2	1.6	1.5	1.7
1006	A17-A19	Other tuberculosis	135	0.1	1,230	0.0	1.1	0.9	1.3
1007	A20	Plague	0	0.0	0	0.0	-
1008	A33-A35	Tetanus	7	0.0	36	0.0	-
1009	A36	Diphtheria	0	0.0	0	0.0	-
1010	A37	Whooping cough	2	0.0	0	0.0	-
1011	A39	Meningococcal infection	1	0.0	17	0.0	-
1012	A40-A41	Septicemia	1,036	0.4	13,438	0.5	0.8	0.8	0.9
1013	A50-A64	Infections with a predominantly sexual mode of transmission	2	0.0	21	0.0	-
1014	A80	Acute poliomyelitis	0	0.0	0	0.0	-
1015	A82	Rabies	1	0.0	2	0.0	-
1016	A95	Yellow fever	0	0.0	0	0.0	-
1017	A90-A94, A96-A99	Other arthropod-borne viral fevers and viral haemorrhagic fevers	61	0.0	572	0.0	1.1	0.8	1.4
1018	B05	Measles	0	0.0	0	0.0	-
1019	B15-B19	Viral hepatitis	178	0.1	4,267	0.2	0.4	0.4	0.5
1020	B20-B24	Human immunodeficiency virus [HIV] disease	998	0.4	20,077	0.8	0.5	0.5	0.5
1021	B50-B54	Malaria	1	0.0	3	-	-
1022	B55	Leishmaniasis	0	0.0	5	-	-
1023	B56-B57	Trypanosomiasis	67	0.0	65	0.0	10.2	7.3	14.3
1024	B65	Schistosomiasis	0	0.0	0	0.0	-
1025	A21-A32, A38, A42-A49, A65-A79, A81, A83-A89, B00-B04, B06-B09, B25-B49, B58-B64, B66-B94, B99	Remainder of certain infectious and parasitic diseases	521	0.2	5,073	0.2	1.0	0.9	1.1
1026	C00-D48	Neoplasms	26,575	10.1	375,473	14.2	0.7	0.7	0.7
1027	C00-C14	Malignant neoplasm of lip, oral cavity and pharynx	417	0.2	5,158	0.2	0.8	0.7	0.9
1028	C15	Malignant neoplasm of oesophagus	558	0.2	4,365	0.2	1.3	1.2	1.4
1029	C16	Malignant neoplasm of stomach	2,988	1.1	25,139	0.9	1.2	1.2	1.2
1030	C18-C21	Malignant neoplasm of colon, rectum and anus	1,209	0.5	27,340	1.0	0.4	0.4	0.5
1031	C22	Malignant neoplasm of liver and intrahepatic bile ducts	3,037	1.2	26,229	1.0	1.2	1.1	1.2
1032	C25	Malignant neoplasm of pancreas	1,011	0.4	18,778	0.7	0.5	0.5	0.6
1033	C32	Malignant neoplasm of larynx	223	0.1	3,152	0.1	0.7	0.6	0.8
1034	C33-C34	Malignant neoplasm of trachea, bronchus and lung	1,239	0.5	29,230	1.1	0.4	0.4	0.5
1035	C43	Malignant melanoma of skin	210	0.1	3,026	0.1	0.7	0.6	0.8
1036	C50	Malignant neoplasm of breast	897	0.3	30,148	1.1	0.3	0.3	0.3
1037	C53	Malignant neoplasm of cervix uteri	1,575	0.6	16,396	0.6	1.0	0.9	1.0
1038	C54-C55	Malignant neoplasm of other and unspecified parts of uterus	254	0.1	4,987	0.2	0.5	0.5	0.6
1039	C56	Malignant neoplasm of ovary	648	0.2	11,140	0.4	0.6	0.5	0.6
1040	C61	Malignant neoplasm of prostate	1,874	0.7	27,934	1.1	0.7	0.6	0.7
1041	C67	Malignant neoplasm of bladder	195	0.1	4,949	0.2	0.4	0.3	0.5
1042	C70-C72	Malignant neoplasm of meninges, brain and other parts of central nervous system	532	0.2	10,015	0.4	0.5	0.5	0.6
1043	C82-C85	Non-Hodgkin’s lymphoma	780	0.3	11,311	0.4	0.77	0.7	0.7
1044	C90	Multiple myeloma and malignant plasma cell neoplasms	242	0.1	5,474	0.2	0.4	0.4	0.5
1045	C91-C95	Leukaemia	1,385	0.5	18,785	0.7	0.7	0.7	0.8
1046	C17, C23-C24, C26-C31, C37-C41, C44-C49, C51-C52, C57-C60, C62-C66, C68-C69, C73-C81, C88, C96-C97	Remainder of malignant neoplasms	5,057	1.9	66,021	2.5	0.8	0.7	0.8
1047	D00-D48	Remainder of neoplasms	2,244	0.9	25,896	1.0	0.9	0.8	0.9
1048	D50-D89	Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism	3,112	1.2	16,826	0.6	1.9	1.8	1.9
1049	D50-D64	Anemias	2,818	1.1	12,329	0.5	2.3	2.2	2.4
1050	D65-D89	Remainder of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism	294	0.1	4,497	0.2	0.7	0.6	0.7
1051	E00-E88	Endocrine, nutritional and metabolic diseases	47,738	18.1	481,807	18.2	1.0	1.0	1.0
1052	E10-E14	Diabetes mellitus	38,880	14.7	421,147	15.9	0.9	0.9	0.9
1053	E40-E46	Malnutrition	5,926	2.2	23,421	0.9	2.5	2.5	2.6
1054	E00-E07, E15-E34, E50-E88	Remainder of endocrine nutritional and metabolic diseases	2,932	1.1	37,239	1.4	0.8	0.8	0.8
1055	F01-F99	Mental and behavioral disorders	2,397	0.9	18,036	0.7	1.3	1.4	1.4
1056	F10-F19	Mental and behavioral disorders due to psychoactive substance use	1,786	0.7	10,410	0.4	1.7	1.6	1.8
1057	F20-F99	Remainder of mental and behavioural disorders	611	0.2	7,626	0.3	0.8	0.7	0.9
1058	G00-G98	Diseases of the nervous system	3,320	1.3	48,060	1.8	0.7	0.7	0.7
1059	G00, G03	Meningitis	106	0.0	1,473	0.1	0.7	0.6	0.9
1060	G30	Alzheimer’s disease	373	0.1	7,694	0.3	0.5	0.4	0.5
1061	G04-G25, G31-G98	Remainder of diseases of the nervous system	2,841	1.1	38,893	1.5	0.7	0.7	0.8
1062	H00-H57	Diseases of the eye and adnexa	11	0.0	62	0.0	-	-	-
1063	H60-H93	Diseases of the ear and mastoid process	18	0.0	164	0.0	-	-	-
1064	I00-I99	Diseases of the circulatory system	75,740	28.7	719,119	27.1	1.1	1.1	1.1
1065	I00-I09	Acute rheumatic fever and chronic rheumatic heart diseases	192	0.1	3,348	0.1	0.6	0.5	0.5
1066	I10-I13	Hypertensive diseases	10,242	3.9	94,517	3.6	1.1	1.1	1.1
1067	I20-I25	Ischemic heart diseases	41,688	15.8	405,010	15.3	1.0	1.0	1.0
1068	I26-I51	Other heart diseases	6,091	2.3	61,635	2.3	1.0	1.0	1.0
1069	I60-I69	Cerebrovascular diseases	16,354	6.2	138,569	5.2	1.2	1.2	1.2
1070	I70	Atherosclerosis	129	0.0	756	0.0	1.7	1.4	2.1
1071	I71-I99	Remainder of diseases of the circulatory system	1,044	0.4	15,284	0.6	0.7	0.6	0.7
1072	J00-J98	Diseases of the respiratory system	24,513	9.3	240,574	9.1	1.0	1.0	1.0
1073	J10-J11	Influenza	103	0.0	1,769	0.1	0.6	0.5	0.7
1074	J12-J18	Pneumonia	7,824	3.0	91,847	3.5	0.9	0.8	0.9
1075	J20-J22	Other acute lower respiratory infections	442	0.2	4,043	0.2	1.1	1.0	1.2
1076	J40-J47	Chronic lower respiratory diseases	13,003	5.0	109,840	4.2	1.2	1.2	1.2
1077	J00-J06, J30-J39, J60-J98	Remainder of diseases of the respiratory system	3,079	1.2	32,490	1.2	1.0	0.9	1.0
1078	K00-K92	Diseases of the digestive system	30,531	11.6	266,809	10.1	1.2	1.1	1.2
1079	K25-K27	Gastric and duodenal ulcer	957	0.4	10,727	0.4	0.8	1.0	1.0
1080	K70-K76	Diseases of the liver	21,147	8.0	148,768	5.6	1.4	1.4	1.4
1081	K00-K22, K28-K66, K80-K92	Remainder of diseases of the digestive system	8,423	3.2	107,253	4.0	0.8	0.8	0.8
1082	L00-L98	Diseases of the skin and subcutaneous tissue	811	0.3	14,029	0.5	0.6	0.5	0.6
1083	M00-M99	Diseases of the musculoskeletal system and connective tissue	1,775	0.7	20,124	0.8	0.9	0.8	0.8
1084	N00-N98	Diseases of the genitourinary system	9,318	3.5	98,573	3.7	1.0	0.9	1.0
1085	N00-N15	Glomerular and renal tubulo-interstitial diseases	973	0.4	10,829	0.4	0.9	0.8	1.0
1086	N17-N98	Remainder of diseases of the genitourinary system	8,345	3.2	87,744	3.3	1.0	0.9	1.0
1087	O00-O99	Pregnancy childbirth and the puerperium	489	0.2	3,384	0.1	1.5	1.3	1.6
1088	O00-O07	Pregnancy with abortive outcome	29	0.0	285	0.0	0.7	1.5	1.4
1089	O10-O92	Other direct obstetric deaths	319	0.1	1,686	0.1	1.9	1.7	2.1
1090	O98-O99	Indirect obstetric deaths	90	0.0	830	0.9	1.4	0.9	1.3
1091	O95-O97	Remainder of pregnancy childbirth and the puerperium	51	0.0	583	0.0	0.9	0.7	0.7
1092	P00-P96	Certain conditions originating in the perinatal period	0	0.0	0	0.0	-
1093	Q00-Q99	Congenital malformations deformations and chromosomal abnormalities	592	0.2	9,926	0.4	0.6	0.6	0.7
1094	R00-R99	Symptoms signs and abnormal clinical and laboratory findings not elsewhere classified	12,892	4.9	24,527	0.9	5.3	5.2	5.4
1095	V01-Y89	External causes of morbidity and mortality	17,677	6.7	251,607	9.5	0.7	0.7	0.7
1096	V01-V99	Transport accidents	3,774	1.4	55,496	2.1	0.7	0.7	0.7
1097	W00-W19	Falls	1,044	0.4	8,892	0.3	1.2	1.1	1.3
1098	W65-W74	Accidental drowning and submersion	544	0.2	5,189	0.2	1.1	1.0	1.1
1099	X00-X09	Exposure to smoke fire and flames	149	0.1	1,897	0.1	0.8	0.7	0.9
1100	X40-X49	Accidental poisoning by and exposure to noxious substances	484	0.2	3,226	0.1	1.5	1.4	1.7
1101	X60-X84	Intentional self-harm	1,732	0.7	23,788	0.9	0.7	0.7	0.8
1102	X85-Y09	Assault	4,930	1.9	96,174	3.6	0.5	0.5	0.5
1103	W20-W64, W75-W99, X10-X39, X50-X59, Y10-Y89	All other external causes	5,009	1.9	56,892	2.1	0.9	0.9	0.9
1902	U069	Zika virus disease NOS	0	0.0	1	0.0	-	-	-

• Source: INEGI’s mortality records of deaths occurring in 2015-2019.

Regarding the examination of highly preventable selected a priori, first, there were no or few recorded deaths from vaccine-preventable diseases. Moreover, the exclusion of children under 3 prevented the assessment of the occurrence of most of them, since they occur early in life such as the case of neonatal tetanus. There were no deaths from cholera or malaria either. However, as shown in Table 5, elevated age-adjusted mortality rate ratios were observed indicating disparities among MFN populations for diarrheal diseases (MRR = 2.3; 95%CI: 2.2, 2.4); tuberculosis (MRR = 1.9; 95%CI: 1.8, 2.1); malnutrition (MRR = 2.5; 95%CI: 2.4, 2.6); anemia (MRR = 2.4; 95%CI: 2.3, 2.6); other respiratory infections such as bronchiolitis and acute bronchitis (MRR = 1.2; 95%CI: 1.1, 1.3); alcohol abuse (MRR = 2.4; 95%CI: 2.2, 2.5); alcohol liver disease (MRR = 2.2; 95%CI: 2.1, 2.2); cervical cancer (MRR = 1.1; 95%CI: 1.1, 1.2); and complications of pregnancy, labor and puerperium (MRR = 2.3; 95% I: 2.1, 2.5). We noticed that malnutrition and anemia were reported across all ages, not only in young children or women of reproductive age.

Table 5
Age-adjusted mortality rates and mortality rate ratios among 3+ year-olds for highly avoidable mortality causes of death among Mexican first nations compared to the rest of Mexico, 2015-2019.

Cause (ICD codes)	First nations’ population		Rest of the country		Age-adjusted mortality rate ratio (95%CI)
	Deaths	Age-adjusted mortality 10-5	Deaths	Age-adjusted mortality 10-5
Diarrheal Diseases (A0)	2,277	5.4	11,599	2.4	2.3 (2.2, 2.4)
Tuberculosis (A15-19)	1,093	2.8	7,361	1.4	1.9 (1.8, 2.1)
Malnutrition (E40-46)	6,044	12.4	23,421	4.9	2.5 (2.4, 2.6)
Anemias (D50-D60)	2,818	6.2	12,329	2.5	2.4 (2.3 2.6)
Pneumonia (J15-J19)	7,824	17.7	91,847	19.1	0.9 (0.9, 0.9)
Other respiratory infections (J20-J22; J40)	554	1.2	4,719	1.0	1.2 (1.1, 1.3)
Alcohol abuse (F10)	1,764	4.6	9,733	1.9	2.4 (2.2, 2.5)
Alcohol liver disease (K70)	8,785	22.7	52,915	10.5	2.2 (2.1, 2.2)
Cervix uteri cancer (C53)*	1,575	9.1	16,396	7.9	1.1 (1.1, 1.2)
Complications of pregnancy, labor and puerperium (O00-99)**	482	4.4	3,348	2.1	2.1 (1.9, 2.3)

• * Only women 15+ years of age; ** only women 15-49 years of age.
• Source: INEGI’s mortality records 2015-2019.

Among MFN populations, there were 5,664,995 YPLL in 2015-2019, for an age-adjusted rate of YPLL of 169.6 per 1,000 person-years, and in the rest of the population of Mexico there were 64,124,535 YPLL for an age adjusted-rate of YPLL of 147.0 per 1,000 person-years, for a rate ratio of 1.2 (95%CI = 1.2, 1.2).

The attributable number of deaths due to structural racism against MFN persons were 1,287 (i.e., 2.3 - 1/2.3 x 2,277); 518; 3,626; 1,644; 92; 1,029; 4,792; 143 and 252, for diarrheal diseases, tuberculosis, malnutrition and its sequelae, iron-deficiency anemia, bronchiolitis and acute bronchitis, alcohol abuse, alcohol liver disease, cervical cancer and complications of pregnancy, labor and puerperium, respectively. In total there were 13,383, which are 40.0% of all excess deaths among people 3+ year-olds of MFN in 2015-2019.

Discussion

This report is the first to document mortality disparities among MFN populations. The reported 10% excess mortality among MFN populations is probably an under-estimate due to cultural preferences and the lack of access to healthcare services among the poorest Mexicans who are disproportionately members of MFN. We also found a 20% increase in the rate of YPLLs among MFN (YPLL RR = 1.2 [95%CI=1.2, 1.2]). These results highlight an excess of premature death among MFN, even though the largest burden of premature death occurs among those under five years of age, mostly ignored for MFN by the current deaths registration system. Had the information on language spoken by their parents of deceased children under 3 years of age been included in death certificates, the disparity would have been greater. Poor quality of the selection and recording of the underlying cause of death were more likely among decedents of MFN.

We found that during the pandemic (2020-2022), there was a reversal of the mortality disparities among MFN populations. During the pandemic, particularly in 2020, MFN communities were tightly closed to people from outside²³. When the vaccine was available by early 2021, MFN populations received a high priority²⁴. The lack of access to health services, which is more prevalent among MFN populations, could have resulted in fewer deaths being recorded. The mechanism by which this could have occurred is that MFNs persons who were ill and were not seen in health facilities circumvented the registration, because they died at home. Also, many health facilities were shut down for long periods during the first 2-3 years of the COVID-19 pandemic. Fear and misinformation and limited resources also could have contributed to a larger impact on the figures of deaths recorded among MFNs during the COVID-19 pandemic. To assess a potential gap in the mortality rates of MFN populations and the rest of the population, the pre-pandemic years for which data was available was a better choice.

We found that during 2015-2019, highly preventable causes of death claimed the lives of MFN populations, representing 40% of the excess mortality in the same period. Preventable or avoidable causes of death is a concept that assumes what would have happened had the population had access to modern health services. Access to these services is lacking in settings such as those where segregated MFN populations live. That has not happened by chance but because of a systematic underfunding of the governments dating back to colonial times. Aiming to highlight conditions that are highly preventable, does not disregard the claim of some health services researchers who consider that at least a large percentage of conditions such as heart disease, and diabetes mellitus are avoidable²⁵. On the other hand, the conditions we report in excess are considered preventable through public health interventions and selective primary health care such as food supplementation, oral rehydration, clean water supply, basic sanitation and hand sanitation, adequate prenatal care, traditional birth attendants training and support, referral of high-risk pregnancies, screening and referral for treatment of cervical cancer, alcohol drinking prevention and alcohol abuse counseling and rehabilitation, and health education, which should be a higher priority than sophisticated medical care.

Heart disease and stroke also occurred in excess among MFN populations. Stroke is known to be related to hypertension, but their diagnosis requires access to healthcare. Tobacco-related mortality is also highly preventable, and further research on this topic seems warranted. Same wise, diabetes mellitus requires lab testing, which may not be accessible to MFN populations. Diabetes mellitus is known to cause heart disease and affect disproportionately native populations in the US²⁶ and elsewhere in the Continent²⁷.

We found that both alcohol-associated liver disease (ALD) and alcohol abuse contributed to the largest number of deaths in MFN populations, among the causes considered as highly preventable. Alcohol use disorder is a term that describes the neurobiology of alcohol dependence resulting in compulsive alcohol drinking, and often ends in ALD²⁸, which occurs even at young ages, as found in the death certificates data of the rest of the Mexican population and in excess in MFN population. Native Americans have a larger of PNPLA3 G/G polymorphism, a known risk factor for the development of advanced ALD²⁹. It is widely documented that alcohol kills more Native Americans than any other group in the USA³⁰. Increased mortality from decompensated liver cirrhosis was associated with Native American ancestry, and admission to public hospitals in a multicentric study³¹. Alcohol drinking in Mexico increased under the Spanish rule, and reached levels never seen before³². There is a need for culturally tailored programs to prevent the use of alcohol, screening for alcohol abuse and alcohol-abuse rehabilitation services.

This report underscores some highly preventable diseases and conditions that still occur in excess in this vulnerable population and suggests monitoring the progress in closing the gaps on an ongoing basis³³. One unmistakably avoidable condition found as cause of the disparities was protein-caloric malnutrition, a condition well studied in Mexican children since the 1930s by Dr. Federico Gómez who proposed the famous weight-for-age classification of nutritional status³⁴.

There are several public health actions that are called for to bridge these gaps, including the provision of targeted interventions in geographic underserved areas, including food supplementation, health education, integrated management of common disease of childhood, prenatal care, revamping the training and support of traditional birth attendants, and the promotion of breastfeeding in targeted geographic areas with a strong component of community mobilization and outreach that is tailored to the culture and preferences, as well as the language spoken in the targeted areas.

There are no culturally competent health services available to Mexico First Nations populations, and there is an unmet need of health and public health professionals who speak native languages in Mexico. On September 30, 2024, after the submission of this report, the Mexican Congress approved an amendment to the Constitution providing rights to the MFNs and Mexicans of African descent including the appropriation of budget to local MFNs recognized peoples and towns, which should allow them to invest in development projects and health³⁵.

Adding the collection of the language spoken by the parents of decedents less than 3 years of age at time of death it is an easy to accommodate remedy to the death and census information system in Mexico. The notion that the child language cannot be established for the Census or Vital Statistics before he/she reaches 3 years of age denies the ethnic identity of the parents and does not serve the purpose of the item in any of the data collection forms. The Census is an instrument for budget allocation according to Mexican law, and the death certificate raison d’être is public health surveillance. Agencies serving MFN, and the communities themselves need to discuss and agree on the goals and how to monitor the progress, as call for by a global alliance of researchers working towards the control of non-communicable diseases with indigenous peoples³⁶.

It has been found that in such small rural areas there is not qualified personnel to fill out the death certificate. However, the certificate does not need to be filled out by a medical doctor. The forms need to be available, though and the local officials and community health workers need training in filling out the certificate. To complement the systems, door-to-door sampling surveys using verbal autopsies can be of great value.

Limitations

Incomplete recording of deaths, particularly among infants and young children, which occur more often among MFN populations than the rest of the country is the main limitation of the data. The likely direction of this bias is towards the null (i.e., MRR = 1), that is a conservative bias, as the disparities are likely greater than those depicted in this report. Second, we excluded records with missing data, perhaps reflecting the complexity of the self-report since most Mexicans who speak other languages than Spanish, also speak Spanish, the perceived status of inferiority or subordination of those speaking a native tongue. Also. it is unknown to what extent the question or item in the Census and death certificate correctly classifies the ethnicity of the respondents and decedents, respectively. The lack of access to modern healthcare likely results in missing death recording, and inaccurate cause of death recording, therefore explaining the excess deaths with underlying cause of death in the “Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified” category. We noticed the occurrence of deaths from malnutrition and anemias in older adults, which may suggest that weight loss or pallor, even low hemoglobin levels, if present may just indicate the occurrence of a chronic disease pathology such as neoplasms, which, in low-resource settings, may go undiagnosed.

Conclusion

Despite the well-documented under-recording of deaths among MFN population, and the lack of data for children under 3, we found a significant gap between the mortality of this group and the rest of Mexico population, a large proportion due to avoidable causes of death. Recognizing and monitoring these gaps will only enhance the ability of Mexico’s public health agencies to better serve the public.

Acknowledgments

The author would like to thank ECOSUR and SECIHTI for the salary support for the development of the project. Also, I would like to acknowledge the work of Yotzin Viacobo, leader of the team at the laboratory of MFN languages and technology at the Center for Digital Culture of the Ministry of Culture, who developed the map of Indigenous Languages of Mexico. Finally, would like to thank Dr. Fernanda Bruzadelli for the translation of this text to Portuguese.

References

• ¹ Salazar-Flores J, Dondiego-Aldape R, Rubi-Castellanos R, et al. Population structure and paternal admixture landscape on present-day Mexican-Mestizos revealed by Y-STR haplotypes. Am J Hum Biol 2010; 22(3):401-409.
• ² Moreno-Estrada A, Gignoux CR, Fernández-López JC, et al. Human genetics. The genetics of Mexico recapitulates Native American substructure and affects biomedical traits. Science 2014; 344(6189):1280-1285.
• ³ Bonfil Batalla G. México profundo: una civilización negada. México. México: Fondo de Cultura Económica; 2019.
• ⁴ Ortiz Hernández L, Ayala Guzmán CI, Pérez-Salgado D. Posición socioeconómica, discriminación y color de piel en México. Perfiles Latinoamericanos 2018; 26(51):215-239.
• ⁵ Martínez-Ramírez J, Puts D, Nieto J, G-Santoyo I. Effects of facial skin pigmentation on social judgments in a Mexican population. PLoS One, 2023; 18(11):e0279858.
• ⁶ Mexican Congress. Law of the National Institute of Indigenous Peoples [Internet]. [cited 2024 may 23]. Available from: https://www.diputados.gob.mx/LeyesBiblio/ref/linpi.htm
  » https://www.diputados.gob.mx/LeyesBiblio/ref/linpi.htm
• ⁷ Nolte E, McKee M. Does health care save lives? Avoidable mortality revisited. London: Nuffield Trust; 2004.
• ⁸ Federal Daily Record: Mexican Official Standard (nom-035-ssa3-2012), for health information [Internet]. [cited 2024 jun 11]. Available from:
• ⁹ https://dof.gob.mx/nota_detalle.php?codigo=5280848&fecha=30/11/2012#gsc.tab=0
  » https://dof.gob.mx/nota_detalle.php?codigo=5280848&fecha=30/11/2012#gsc.tab=0
• ¹⁰ Novak B, Hernández Flores JA. A year and a half into the pandemic in Mexico: evidence of differences in COVID-19 mortality between Indigenous and non-Indigenous populations continues to accumulate. AlterNative 2022; 18(4):613-624.
• ¹¹ Salas-Ortiz A. Socioeconomic Inequalities and Ethnic Discrimination in COVID-19 Outcomes: the Case of Mexico. J Racial Ethn Health Disparities 2024; 11(2):900-912.
• ¹² Thacker SB. Historical Development. In: Lee LM, Teutsch SM, Thacker SB, St. Louis ME, editors. Principles and Practice of Public Health Surveillance. New York: OUP. 2010.
• ¹³ Hernández B, Ramírez-Villalobos D, Duarte MB, Corcho A, Villarreal G, Jiménez A, Torres LM. Subregistro de defunciones de menores y certificación de nacimiento en una muestra representativa de los 101 municipios con más bajo índice de desarrollo humano en México. Salud Publica Mex 2012; 54(4):393-400.
• ¹⁴ Canales JL, López P, Narro J, Almada I. El subregistro de la natalidad y la mortalidad en una comunidad rural en México Salud Publica Mex 1980; 22(2):123-134.
• ¹⁵ Tomé P, Reyes H, Piña C, Rodríguez L, Gutiérrez G. Características asociadas al subregistro de muerte en niños del estado de Guerrero, México Salud Publica Mex 1997; 39(6):523-529.
• ¹⁶ Bautista-Jimenez ER, Lopez-Arellano O. Muerte materna en mujeres indígenas de México y racismo de Estado. Dispositivos biopolíticos en salud. Salud Problema 2017; 11(21):28-53.
• ¹⁷ Cárdenas Ayala VM, Núñez Urquiza RM, Brogan DR, et al. Neonatal tetanus mortality in Veracruz, Mexico, 1989. Bull Pan Am Health Organ 1995; 29(2):116-128.
• ¹⁸ Instituto Nacional de Estadística, Geografía e Informática (INEGI). Estadísticas de Defunciones Registradas [Internet]. [cited 2024 mar 16]. Available from https://www.inegi.org.mx/programas/mortalidad/#microdatos
  » https://www.inegi.org.mx/programas/mortalidad/#microdatos
• ¹⁹ Mexico's National Institute of Statistics, Geography and Informatics (Instituto Nacional de Estadística, Geografía e Informática (INEGI). Censo de Población y Vivienda 2020. Tabulados interactivos. Población mayor de 3 años. Por etnicidad, sexo y edad [Internet]. [cited 2024 mar 16]. Available from: https://www.inegi.org.mx/programas/ccpv/2020/#tabulados
  » https://www.inegi.org.mx/programas/ccpv/2020/#tabulados
• ²⁰ Mexico's National Population Council (CONAPO). Bases de datos de la Conciliación Demográfica 1950 a 2019 y Proyecciones de la población de México 2020 a 2070 [Internet]. [cited 2024 mar 16]. Available from: https://www.gob.mx/conapo/documentos/bases-de-datos-de-la-conciliacion-demografica-1950-a-2019-y-proyecciones-de-la-poblacion-de-mexico-2020-a-2070
  » https://www.gob.mx/conapo/documentos/bases-de-datos-de-la-conciliacion-demografica-1950-a-2019-y-proyecciones-de-la-poblacion-de-mexico-2020-a-2070
• ²¹ Rothman KJ, Lash TL. Precision and Study Size. Ch 15. In: Lash T, Van der Weele TJ, Haneuse S, Rothman KJ, editors. Modern Epidemiology. Philadelphia: Wolters Kluwer; 2021. p. 358.
• ²² Global Burden of Disease Study 2015. Global Burden of Disease Study 2015 (GBD 2015) Reference Life Table. Seattle: IHME; 2016.
• ²³ Haneuse S. Introduction to Categorical Statistics. In: Lash T, Van der Weele TJ, Haneuse S, Rothman KJ. Modern Epidemiology. Philadelphia: Wolters Kluwer; 2021. p. 404.
• ²⁴ García J. Los indígenas de México se cierran para frenar al coronavirus [Internet]. 2020 [cited 2024 mar 16]. Available from: https://elpais.com/sociedad/2020-04-21/los-indigenas-de-mexico-se-cierran-para-frenar-al-coronavirus.html#?prm=copy_link
  » https://elpais.com/sociedad/2020-04-21/los-indigenas-de-mexico-se-cierran-para-frenar-al-coronavirus.html#?prm=copy_link
• ²⁵ Cruz A. Inmunizar a indígenas y reos debe ser prioridad, pide Salud [Internet]. 2021. [cited 2024 mar 16]. Available from:
• ²⁶ https://www.jornada.com.mx/2021/01/05/politica/005n3pol
  » https://www.jornada.com.mx/2021/01/05/politica/005n3pol
• ²⁷ Eurostat/European Commission/OECD. Avoidable mortality: OECD/Eurostat lists of preventable and treatable causes of death. Directorate F: Social statistics. (January 2022 version) [Internet]. 2022. [cited 2024 mar 16]. Available from: https://www.oecd.org/health/health-systems/Avoidable-mortality-2019-Joint-OECD-Eurostat-List-preventable-treatable-causes-of-death.pdf
  » https://www.oecd.org/health/health-systems/Avoidable-mortality-2019-Joint-OECD-Eurostat-List-preventable-treatable-causes-of-death.pdf
• ²⁸ Howard BV, Lee ET, Fabsitz RR, et al. Diabetes and coronary heart disease in American Indians: The Strong Heart Study. Diabetes 1996; 45(Suppl. 3):S6-S13.
• ²⁹ Palatnik M, Silva Júnior WA, Estalote AC, Oliveira JE, Milech A, Zago MA. Ethnicity and type 2 diabetes in Rio de Janeiro, Brazil, with a review of the prevalence of the disease in Amerindians. Hum Biol 2002; 74(4):533-544.
• ³⁰ Arab JP, Dunn W, Im G, Singal AK. Changing landscape of alcohol-associated liver disease in younger individuals, women, and ethnic minorities. Liver Int 2024; 44(7):1537-1547.
• ³¹ Oliveira CPMS, Cotrim HP, Arrese M. Nonalcoholic fatty liver disease risk factors in Latin American populations: current scenario and perspectives. Clin Liver Dis 2019; 13(2):39-42.
• ³² Spillane S, Shiels MS, Best AF, Haozous EA, Withrow DR, Chen Y, Berrington de González A, Freedman ND. Trends in alcohol-induced deaths in the United States, 2000-2016. JAMA Netw Open 2020; 3(2):e1921451.
• ³³ Farias AQ, Curto Vilalta A, Momoyo Zitelli P, Pereira G, Goncalves LL, Torre A, Diaz JM, Gadano AC, Mattos AZ, Mendes LSC, Alvares-da-Silva MR, Bittencourt PL, Benitez C, Couto CA, Mendizabal M, Toledo CL, Mazo DFC, Castillo Barradas M, Uson Raposo EM, Padilla-Machaca PM, Zarela Lozano Miranda A, Malé-Velázquez R, Castro Lyra A, Dávalos-Moscol MB, Pérez Hernández JL, Ximenes RO, Faria Silva G, Beltrán-Galvis OA, González Huezo MS, Bessone F, Rocha TDS, Fassio E, Terra C, Marín JI, Sierra Casas P, de la Peña-Ramirez C, Aguilar Parera F, Fernandes F, da Penha Zago-Gomes M, Méndez-Guerrero O, Marciano S, Mattos AA, Oliveira JC, Guerreiro GTS, Codes L, Arrese M, Nardelli MJ, Silva MO, Palma-Fernandez R, Alcantara C, Sánchez Garrido C, Trebicka J, Gustot T, Fernández J, Clària J, Jalan R, Angeli P, Arroyo V, Moreau R, Carrilho FJ; ACLARA Study Collaborators. Genetic Ancestry, Race, and Severity of Acutely Decompensated Cirrhosis in Latin America. Gastroenterology 2023; 165(3):696-716.
• ³⁴ Gibson C. The Aztecs Under Spanish Rule: A History of the Indians of the Valley of Mexico, 1519-1810. Stanford: Stanford U Press; 1964.
• ³⁵ Braveman P, Tarimo E. Social inequalities in health within countries: not only an issue for affluent nations. Soc Sci Med 2002; 54(11):1621-1635.
• ³⁶ Gómez F. Desnutrición. Bol Med Hosp Infant Mex 1946; 3(4):543-551.
• ³⁷ Diario Oficial de la Federación. Federal Daily Record: Decree amending, adding and repealing various provisions of Article 2 of the Political Constitution of the United Mexican States, regarding Indigenous and Afro-Mexican Peoples and Communities [Internet]. 2024 [cited 2024 mar 16]. Available at: https://www.gob.mx/inpi/documentos/decreto-dof-30-09-2024-reforma-al-articulo-2o-de-la-constitucion-en-materia-de-pueblos-y-comunidades-indigenas-y-afromexicanos
  » https://www.gob.mx/inpi/documentos/decreto-dof-30-09-2024-reforma-al-articulo-2o-de-la-constitucion-en-materia-de-pueblos-y-comunidades-indigenas-y-afromexicanos
• ³⁸ Meharg DP, Naanyu V, Rambaldini B, Clarke MJ, Lacey C, Jebasingh F, Lopez-Jaramillo P, Gould GS, Aceves B, Alison JA, Chaiton M, Chen J, Gonzalez-Salazar F, Goodyear-Smith F, Gwynne KG, Lee KS, MacKay D, Maple-Brown L, Mishara BL, Nigenda G, Ramani-Chander A, Sherwood SG, Thomas N, Thrift AG, Anderson M. The Global Alliance for Chronic Diseases researchers' statement on non-communicable disease research with Indigenous peoples. Lancet Glob Health 2023; 11(3):e324-e326.

• Data availability statement
  The data sources adopted in the research are indicated in the article’s body.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva, Vania de Matos Fonseca

Data availability

The data sources adopted in the research are indicated in the article’s body.

Publication Dates

• Publication in this collection
  03 Aug 2026
• Date of issue
  July 2026

History

• Received
  11 Sept 2024
• Accepted
  28 Feb 2025
• Published
  02 Mar 2025