Ethics in public health research: changing patterns of mortality among American Indians.

Mortality rates for American Indians (including Alaska Natives) declined for much of the 20th century, but data published by the Indian Health Service indicate that since the mid-1980s, age-adjusted deaths for this population have increased both in absolute terms and compared with rates for the White American population. This increase appears to be primarily because of the direct and indirect effects of type 2 diabetes. Despite increasing appropriations for the Special Diabetes Program for Indians, per capita expenditures for Indian health, including third-party reimbursements, remain substantially lower than those for other Americans and, when adjusted for inflation, have been essentially unchanged since the early 1990s. I argue that inadequate funding for health services has contributed significantly to the increased death rate.