Abstract(resumo):

Objetivo. Avaliar o excesso de mortalidade geral e por causas específicas e a mortalidade prematura nos Povos Originários do México (POM) entre 2015-2022. Métodos. 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), mortalidade proporcional e taxas de mortalidade por causas específicas. Os anos de vida potencialmente perdidos foram calculados usando a expectativa de vida específica por idade. Resultados. A pandemia de COVID-19 reverteu o excesso de mortalidade observado entre as POM durante o período pré-pandêmico (RTM de 1,1 [IC 95%: 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 e doença hepática alcoólica, 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. Conclusões. 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.

Keywords(palavra-chave):

mortalidade, populações nativas, disparidades de saúde, México

Content(conteúdo):

Most Mexicans are of mixed ancestry (1), as corroborated by studies indicating that Native, European and African ancestry are found in around 50%, 46% and 4% of Mexicans, respectively (2). 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 metropolis (3).
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
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 society (3).
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 Peoples (6).
Ethnic and racial health disparities highlight the need to provide health services that could contribute to the mitigation of such inequalities (7). 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 decedent (8), 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 surveillance (11). Such records are largely incomplete in rural Mexico, particularly among infants, and pregnant women of the MFN (12-15), and for neonatal tetanus (16). 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 (Cfr. eTable 1, for literature search strategy and results).
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 death (17). 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 found (12).
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 website (18), to mid-year population projections of the National Population Council (19). The age distribution of the index and comparator populations differ substantially (eFigure 1). 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.
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 (eTable 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 proportions (20). 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 3rd 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 2015 (21). 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 estimator (22).
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 2).
Figure 2
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 (eFigure 2).
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 (eTable 3).
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 ( , where e denotes exposure), was 12.9% ( , 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 3).
Figure 3
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 1, 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 the 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.
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 2, 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% CI: 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.
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).
Table 1
Table 2
The attributable number of deaths due to structural racism against MFN persons were 1,287 (i.e., ; 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 outside (23). When the vaccine was available by early 2021, MFN populations received a high priority (24). 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 avoidable (25). 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 US (26) and elsewhere in the Continent (27).
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 ALD (28), 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 ALD (29). It is widely documented that alcohol kills more Native Americans than any other group in the USA (30). Increased mortality from decompensated liver cirrhosis was associated with Native American ancestry, and admission to public hospitals in a multicentric study (31). Alcohol drinking in Mexico increased under the Spanish rule, and reached levels never seen before (32). 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 basis (33). 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 status (34).
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 health (35).
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 peoples (36).
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 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.
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