Physical Health Conditions of the Amish and Intervening Social Mechanisms: An Exhaustive Narrative Review

1. BMI, Physical Activity, and Body Image

One’s weight and physical activity are indicators of overall health. Do Amish score better on these indicators? Results tend toward a “yes” but are not conclusive. In Aylmer, ON, Amish adults had but a 4% obesity rate and the children’s rate was even lower (Bassett 2008; Bassett, Schneider and Huntington 2004). In Lancaster County, PA, Body Mass Indexes (BMIs) for Amish women and children were lower than nearby non-Amish in two studies (Hairston et al. 2013; Miller et al. 2007) and lower for adult men and women compared to a European American sample for a sleep study (Zhang et al. 2019). However, age-graded studies have revealed variations. In Lancaster, BMIs were higher for 45–60 year old men and women (Snitker and Shuldiner 2004). In Holmes County, OH, male and female Amish respondents aged 18–24 had lower self-reported obesity rates than non-Amish respondents; however, obesity rates were similar between Amish and non-Amish adult men and higher for adult Amish females (Fuchs et al. 1990).

Lifestyle patterns and cultural values likely explain Amish body weight differences. Physical work is an Amish value. In several studies, Amish individuals’ daily physical activity contributed to lower BMIs (Armer and Radina 2006; Bassett 2008; Esliger et al. 2010; Gillum et al. 2011) and Amish individuals were likely to associate physical activity with good health (Farrar, Kulig and Sullivan-Wilson 2018a; Garrett-Wright, Main and Jones 2016; Gesink et al. 2017). Physical activities may include household and farm chores, greater use of non-motorized transportation such as walking or wheeling, active play, and occupations demanding manual labor (Bassett et al. 2007; Esliger et al. 2010), although physical activity varies depending on settlement (Snitker and Shuldiner 2004). In Aylmer, Amish males and females had, respectively, 10 & 3.4 hours a week of vigorous activity, 42.8 & 39.2 hours of moderate activity a week, and 18,425 & 14,196 steps a day, with no age-related decrease in this activity between 6 and 60 (Bassett 2008; Bassett, Schneider and Huntington 2004). Lancaster Amish children, compared to non-Amish children, spent 34 more minutes a day in light activity and 53 more minutes in moderate to vigorous activity (Hairston et al. 2013). Given this physical activity, Amish are significantly less likely to exercise or diet to reduce weight (Armer and Radina 2006; Fuchs et al. 1990; Gillum et al. 2011; Levinson et al. 1989; Miller et al. 2007; Trier 1991). The higher rate of physical activity may be one reason Amish people live longer than the non-Amish despite lower hospital use rates (Mitchell et al. 2012)

Regarding body image, Amish women and men in two Lancaster studies frequently self-appraised their BMI as slightly under to slightly overweight (Miller et al. 2007; Platte, Zelten and Stunkard 2000). Body dissatisfaction among Amish women has been positively correlated with BMI (Davidson et al. 2018) and age (Platte, Zelten and Stunkard 2000); possibly, older women’s weight may result from high birth rates (Fuchs et al. 1990). Despite some evidence for negative body image, Amish women, compared to a Catholic and non-religious sample, were less likely to report that body image impacts personal emotions and more likely to use religious coping strategies to deal with a negative personal body image. Indeed, the ideal body image for a female Amish sample was more realistic (heavier shaped) than a Catholic sample, although similar to a non-religious sample (Davidson et al. 2018).

2. Diet and Supplements

Distinct from American diets, Amish diets are sometimes considered “healthier” but not always. On the one hand, compared to common American diets, the Amish diet includes more home grown fruits and vegetables (Gillum et al. 2011), raw milk, meat slaughtered and smoked at home, fruits and vegetables stored over the winter, foods picked and canned at home, whole grains, pickled foods, and desserts, and fewer refined grains, some vegetables, and sodas (Cuyún Carter et al. 2011; Miller et al. 2017), a spread amazingly consistent with a 1950s Kalona, IA, Amish settlement report (Von Heeringen and McCorkle 1958).

On the other hand, Amish diets have greater consumption of lard, butter (Gillum et al. 2011; Von Heeringen and McCorkle 1958), beef, pork, and salt (Trier 1991), although another study found lower rates of Amish adding salt “most of the time” (Levinson et al. 1989). Additionally, 1% of Amish respondents reported rarely or never buying butter or cheese from a grocery store compared to 6% of all respondents (Cuyún Carter et al. 2011), suggesting a stronger dependence on store-bought butter. Furthermore, neither common American diets nor Amish diets met cancer risk reduction standards (Cuyún Carter et al. 2011).

Amish respondents rank nutrition as the highest health promotion and maintenance behavior (Armer and Radina 2006; Gesink et al. 2017) and some families actively promote good nutrition as a preventive health measure (Farrar, Kulig and Sullivan-Wilson 2018a; Garrett-Wright, Main and Jones 2016; Palmer 1992). Further research should explore this apparent discrepancy between dietary practice and emphasis on nutrition.

Amish have a significantly higher rate of daily supplement use than the general U.S. population: 71% in Milverton, ON¹ (Gesink et al. 2017); 77% in Lancaster County (Reed et al. 2015); and 82% and 90% for males and females, respectively, in Holmes County (Cuyún Carter et al. 2012), which is up from a prior study’s rates of 62.6% and 73%, respectively (Levinson et al. 1989). Specifically, Amish are significantly more likely to use herbal supplements, (notably Echinacea and garlic), enzymes (for women), vitamins, and minerals; they are less likely to use aspirin regularly (Cuyún Carter et al. 2012). Nutritional and herbal supplements are among the most common forms of complementary and alternative medicines among Amish (Reiter et al. 2009) and are negatively correlated with use of conventional medicine (Reed et al. 2015). Some variation follows gender, age, and marriage. Amish women use dietary supplements significantly more than men, rates between husband and wife are positively correlated, and use with age is consistent for women but varied for men (Cuyún Carter et al. 2012; Reed et al. 2015; Reiter et al. 2009). In a study focusing on the mineral selenium, Amish consumed more self-harvested food in an area with low selenium content in the soil than urban populations, but both consumed similar amounts of selenium. This was due in part to both populations accessing store-bought flour. However, Amish subjects still had lower rates of selenium in the blood (London et al. 1981; Snook et al. 1983).

The typical Amish diet is well-documented but the health outcomes remain relatively unexplored. Recent changes in some Amish diets from increased store purchases and fewer home-produced products provide an opportunity to compare health outcomes. Additionally, we know little about what religious-cultural patterns support Amish diet and supplement use patterns. Increases in non-agricultural occupations and deliberate exercise signal that physical activity and diet may be changing. Further, while supplement types and use frequency have been studied, little is known about knowledge and attitudes that make supplement use so common.

3. Cancer

Amish cancer rates are generally lower than non-Amish rates (Thomas et al. 2002; Troyer 1988; Troyer 1994; Westman, Ferketich and Kauffman 2010). Of all deaths in a western New York settlement, cancer was the cause in only 20% of cases (Hewner 1997). Cervical cancer rates are lower for Amish women compared to non-Amish women (Cross, Kennel and Lilienfeld 1968; Troyer 1988; Troyer 1994). Amish lung cancer rates are also lower, even when compared to non-smokers among the non-Amish (Miller 1983; Troyer 1988; Troyer 1994), as are cancer rates for the colon/rectum, prostate, and ovaries. No significant differences exist for cancer rates of the bladder (Troyer 1988; Troyer 1994). That said, Gesink, et al. (2017) question whether overall cancer rates are as low as studies have argued, as under-screening may contribute to underreporting.

Despite this positive cancer profile, some notable exceptions exist. Amish youth experience higher rates of leukemia while Amish women not only have significantly higher rates of breast cancer compared to non-Amish but also have one of the highest rates in the world. Amish women have a greater risk of fatality with stomach cancer compared to Amish men and non-Amish (Troyer 1988; Troyer 1994). One general practitioner among the Amish felt cancer of the bowel may be higher (Lehman 1994).

Lifestyle factors may explain some differences in rates (Gesink et al. 2017; Hamman, Brancik and Lilienfeld 1981; Troyer 1988; Westman, Ferketich and Kauffman 2010). For example, Amish tobacco use is comparatively low, explaining in part the lower rates of lung and other tobacco-related cancers (Miller 1983; Troyer 1988; Troyer 1994; Westman, Ferketich and Kauffman 2010). Another study ruled out Amish-specific diets, food storage practices, and food preparation protocols as contributing to lower general cancer rates (Cuyún Carter et al. 2011). Why, though, do Amish women seem to have higher rates of breast cancer? They are less likely to obtain breast cancer screenings due to a lack of accurate information, transportation, means to pay for the service, sense of personal risk, shyness, and/or encouragement from physicians (Documét et al. 2008; Gesink et al. 2017; Katz et al. 2011). However, an absence of screenings does not cause breast cancer; several potential risk factors for breast cancer—early first pregnancy, breastfeeding, fat consumption, and obesity—have been ruled out (Troyer 1988), so the question of causes remains.

Due to certain built-in lifestyle and genetic controls, the Amish are a useful population for cancer research. Research on cancer among the Amish has revealed some interesting trends, although to what extent are Amish/non-Amish variations due to varying levels of screening? A possible solution is to analyze cause of death in state records and identify probably Amish adherents. We feel the Amish are an underutilized population for studying the lifestyle, environmental, technological, dietary, and genetic causes of cancer. Furthermore, most Amish cancer research is dated, so renewed study is justified and old findings should be revisited.

4. Cardiovascular

Comparative research about cardiovascular complications has yielded inconsistent results. A 1970s project spanning the Northern Indiana, Holmes County, and Lancaster County Amish settlements found that, while the leading causes of death among Amish and neighboring non-Amish were related to cardiovascular complications, Amish males aged 49–69 had a significantly lower risk and Amish females 70+ had a significantly higher risk than non-Amish people (Hamman, Brancik and Lilienfeld 1981); such rates may be even lower were Amish people to have the same telecommunication and transportation advantages as non-Amish people when medical assistance is needed (Troyer 1994). Consistent with these findings, a Holmes County study found that Amish were significantly less likely to report high blood pressure, although these self-reported data may be skewed if Amish awareness of high blood pressure is lower due to infrequent screenings and checkups (Fuchs et al. 1990).

Yet, in Northern Indiana, rates of cardiovascular disease were higher among the Amish than the national average (Gillum et al. 2010). In Holmes County, Amish women reported higher stress compared to non-Amish respondents (Fuchs et al. 1990) and Amish females 70+ had a significantly higher risk of cardiovascular-related deaths than non-Amish (Hamman, Brancik and Lilienfeld 1981). In Milverton, ON, 45% of Amish respondents, especially women, named circulatory system conditions as an individual health problem (Gesink et al. 2017). And in a Western New York settlement, cardiovascular causes accounted for 54% of all deaths (Hewner 1997). Such contradictions in research findings could indicate over- or under-reporting due to differences in checkups and diagnostic testing, changing health trends within the Amish, comparisons of unlike measures, or differences within specific Amish populations. For example, one study found that, the stricter the particular Mennonite/Amish denomination, the slower blood pressure increased as one aged (Jorgenson et al. 1972). Future research should clarify these mixed results.

Most remaining cardiovascular research—as summarized by Gillum and Staffileno (2011)—focuses on determining the genetic basis of cardiovascular conditions, is within the Lancaster County Amish settlement, and does not necessarily make recommendations based on findings (Sorkin et al. 2005). Genetic causes may explain some cardiovascular conditions, though not to the exclusion of some cultural and environmental causes (Jorgenson et al. 1972). One general practitioner feels that blood matching is occasionally problematic since Amish may have rare blood types (Lehman 1994).

Type II diabetes mellitus among Lancaster Amish is 50% lower than non-Amish (Hsueh et al. 2000)—one more recent non-comparative study found that 4% of Amish self-reported diabetes (Reed et al. 2015)—yet, the impaired glucose intolerance (IGT) rate was higher (Hsueh et al. 2000). Possibly, Lancaster Amish may not be protected against glucose intolerance but fewer individuals with IGT then develop diabetes. Potential explanations for these patterns include (1) a particularly active lifestyle in early life (Hairston et al. 2013), and (2) genetic resilience to IGT progressing into diabetes, as IGT does not aggregate in families but diabetes does (Hsueh et al. 2000). In another area, Northern Indiana, 29.5% of 200 Amish patients had a family history of type II diabetes mellitus (Gillum et al. 2010), though no comparison statistics to non-Amish were provided.

Despite their low observance of explicit preventative measures, many Amish do have naturally active lifestyles, diets high in fruits and vegetables (though high in fats as well), comparatively low tobacco use especially among women (Fuchs et al. 1990; Gillum and Staffileno 2011; Gillum et al. 2010; Gillum et al. 2011; Reed et al. 2017), and, possibly, some genetic resilience to cardiovascular diseases (Sorkin et al. 2005). Those directly affected by cardiovascular complications are the main ones seeking preventative information, though evidence suggests their lifestyle practices do not change in response (Gillum et al. 2011). More research is needed to better understand the link between ethnic lifestyles, genetics, and cardiovascular conditions, and to develop programs that decrease the Amish risk for cardiovascular disease and heart attacks.

5. Communicable Diseases and Immunizations

Most Amish individuals neither fully accept nor reject immunizations for their children, but attitudes vary by settlement and affiliation. The percent of Amish households with partially vaccinated children (i.e. every child had received at least one vaccination) were 84% for Arthur, IL, and 68% for Holmes County, while the percentage of totally unvaccinated households were, respectively, 4% (Yoder and Dworkin 2006) and 14% (Wenger et al. 2011). In addition to differences between settlements, affiliations show different vaccination rates; in Holmes County, all New Order Amish households but only 84% of Old Order households had at least some children immunized.²

These findings raise questions about why many parents decline common immunizations for their children. The most important factor was not religious beliefs or barriers to access but fear of side effects. In Holmes County, 47% of respondents stated they knew somebody who has suffered side effects from vaccines (Wenger et al. 2011), and, of respondents with unvaccinated children, 44% reported safety concerns as the primary reason they chose not to vaccinate (Kettunen, Nemecek and Wenger 2017). Friends and family were the main information sources about vaccines, and their advice disproportionately affected younger parents. Of the parents who did not completely vaccinate their children, 86% reported they would be more likely to consider immunizing if they knew it was safe (Wenger et al. 2011).

Case studies detail several epidemics of rubella, pertussis, measles, and other communicable diseases among the Amish population. These studies focus on a disease’s spread and containment as well as outcomes for the Amish population. Rubella outbreaks occurred in Ethridge, TN, and Holmes County, in the early 1990s. Infection was almost entirely confined to Amish patients, the bulk being younger (Briss et al. 1992; Jackson et al. 1993). In the winter of 2009–10, a pertussis outbreak occurred in Arthur, IL. The overall rate of unvaccinated patients was 79%. Most patients were under 18, of which 74% had not been vaccinated; none of the adult patients had been vaccinated. Although symptoms did not differ significantly between the vaccinated and unvaccinated, the latter had longer lasting coughs and significantly more secondary household transmissions. An immunization campaign was launched in response, leading to the administration of 254 vaccines (Medina-Marino et al. 2013). In 2014, a measles epidemic struck Holmes County and smaller settlements in neighboring Knox and Ashland Counties; 89% of patients were unvaccinated and transmission primarily occurred within households. An estimated 14% of Amish individuals within affected households had received the MMR vaccination prior, a low rate compared to the 88% rate for non-Amish people. Containment efforts included isolation of affected individuals, quarantine of susceptible people, and administration of the MMR vaccine to 10,000+ individuals. The outbreak affected the Amish almost exclusively. Due to the successful containment efforts, only 1% of area Amish residents were affected, with an attack rate of 12 per 1,000 individuals (Gastañaduy et al. 2016).

While many Amish settlements cannot be characterized as highly unvaccinated, immunization rates likely still fall below non-Amish neighbors. Amish people’s attitudes toward immunizations tend to be selective and critical. When a communicable disease reaches Amish people, intense socializing, such as at bi-weekly church services and within large families, diffuses the disease. In cases above, the disproportionate amount of infected young suggests an “island epidemiology” scenario, where disease contraction is cohort-specific due to periods between outbreaks that make younger populations that have not been exposed before particularly susceptible (Briss et al. 1992). A simulation of two measles epidemics, including the 2014 outbreak, emphasizes the importance of a fast, strategic immunization response, lest the virus spread and settle in for a year or more (Thompson and Kisjes 2016). These findings suggest that we need more knowledge about the thick cultural underpinnings of Amish reservations toward vaccinations and conditions under which acceptance and rejection occur.

6. Environment-Induced Immunity

The Amish may have a bolstered immune system due to their exposure to farm animals. A comparison of fecal samples from Amish infants and nearby non-rural infants revealed that Amish infants had a wider range of microbes and more beneficial bacteria. Injecting these samples into newborn pigs confirmed that the Amish sample aids in the immune system’s development (Dhakal et al. 2019).

To investigate differences in resilience to asthma, researchers compared northern Indiana Amish children—who are exposed to dust from farms with animals such as horses—to, in one study, Swiss farming children and non-farming children, and, in another study, Hutterite children—who have many similar social and religious attributes as the Amish people but have less interaction with livestock on their highly mechanized farms. In the Swiss comparisons, Amish and Swiss farming children, who are both exposed to barns and consume raw milk, have lower frequencies of asthma than non-farming Swiss children (Holbreich et al. 2012). In the Hutterite comparison, Amish children had lower asthma rates even though their homes had higher levels of common allergens and higher endotoxin levels. Amish appear to have an innate immunity to asthma due to their farm environment (Hrusch et al. 2019; Stein et al. 2016). Amish individuals who live on farms and interact with livestock may also have stronger immune systems.

7. Sleep

Two extensive studies of Lancaster Amish people analyzed sleeping patterns. In the first (n=723), participants wore a waist-based accelerometer and, in some cases, kept a sleeping diary (Evans et al. 2011). In the second (n=3,418), participants self-reported nighttime sleep schedules (Zhang et al. 2019).

Results suggest a morning preference (mean wake/sleep times being 5:06am/10:00pm); for men, an earlier wake time, shorter sleep duration (18.6 minutes less), and greater daytime sleepiness compared to women; in summer compared to winter, a later bedtime and shorter sleep duration; among adults aged 18–29 and 70+, a longer sleep duration compared to middle-aged adults; with increasing age, an earlier wake time; a positive correlation between daytime physical activity and earlier wake time (but not bedtime); longer sleep duration for those working in sales and marketing versus farming and contracting; a correlation for sleep durations among household members, with the strongest relationship between spouses and second strongest between same-sex siblings; and a heritable effect for sleep duration (minor effect), a morning/evening-orientation scale, a sleepiness scale, and wake time but not for bedtime or sleep duration (Evans et al. 2011; Zhang et al. 2019).

Zhang, et al. (2019) hypothesized that Amish sleep duration may be longer than non-Amish European Americans, as Americans’ sleep duration has declined in recent years, possibly due to extended work hours, artificial light exposure, and stress. Compared to a non-Amish European American sample from another study, mean sleep duration for Amish participants was 7.8 minutes shorter; Amish bedtime and wake-time were earlier by 80.4 minutes and 87.6 minutes, respectively; and the incidence of Amish who were short or long sleepers was lower. These findings did not support the hypothesis, which opens possibilities for other hypotheses focused on the culture, work demands, and natural light exposure.

8. Genetic Disorders

Due to strict endogamy and a negligible number of recent converts to the Amish church, Amish marriages on average have a high rate of consanguinity, which increases the risk of certain heritable diseases (Hammond and Jackson 1958; McKusick 1973; McKusick 1978). Diseases tend to be place-specific, as Amish tend to marry within their area or, if outside the area, into historically related churches. Around 25% of the variability associated with age of death is attributed to genetic factors (Mitchell et al. 2001). Indeed, in Lancaster County, rates of infant birth defects for Amish are higher than non-Amish (Miller et al. 2007). High consanguinity can also work to the advantage of Amish health, as certain genes can provide protection from, for example, certain cancers (Westman, Ferketich and Kauffman 2010). Amish generally understand that certain disorders are inherited, even if they are relatively unfamiliar with the field of genetics (Brensinger and Laxova 1995).

From a voluminous, technical literature, researchers have identified over 250 Amish- and Mennonite-specific genetic disorders, which have been compiled into searchable databases, such as the Amish, Mennonite, and Hutterite Genetic Disorder Database (www.biochemgenetics.ca/plainpeople) (Payne et al. 2011) and the Windows of Hope Project (wohproject.com). Detailed summaries of the genetics literature are available elsewhere (Cross and Crosby 2008; Hou et al. 2013; Patton 2005; Strauss and Puffenberger 2009; Troyer 1994).

9. Tobacco and Alcohol Use

While Amish tobacco use is relatively low, some use exists in certain affiliations and settlements. Tobacco use is a moral issue that has long divided Amish affiliations. Some forms of tobacco are accepted by Swartzentruber churches and some Andy Weaver and Old Order churches, notably Lancaster Old Order churches. Tobacco is rejected among New Order, New Order Christian Fellowship, and Kenton Amish (Petrovich 2017).

Three Lancaster-based studies found comparable rates of current Amish tobacco use. In the first, 17.6% of men were current tobacco users and 43% reported having ever used tobacco—57% had only smoked cigars; 27%, cigarettes; 6%, pipes; and 9%, more than one. The median age of first use was 16, with a range of 6 to 53 (Nugent et al. 2014). The second focused just on smoking; 15.6% of men were currently smoking and 34% had ever smoked—64% had smoked cigars; 46%, cigarettes; and 21%, pipes. Less than 1% of Lancaster Amish women reported having ever smoked (Reed et al. 2017). The third found that 18.3% of men and 0.05% of women self-reported as current smokers (Zhang et al. 2019). The percentage of Amish men who smoke in Lancaster is thus comparable to the 15.5% of all adult Americans who smoke,³ although Amish women’s rate is substantially lower. The Northern Indiana Old Orders have a lower rate for males, at 9.5%, but slightly higher for women, at 2.1% (Gillum et al. 2010). In an older study, the Holmes County Amish have an 11.1% rate for men and nearly 0% for women (Levinson et al. 1989). In Lancaster, tobacco use tends to follow family lines, with heritability accounting for 66% of variance in smoking (Nugent et al. 2014).

Among Amish men, smoking is associated with higher BMI, older age (Nugent et al. 2014; Reed et al. 2017), lower high-density lipoprotein cholesterol, higher triglyceride levels, higher resting heart rate, and greater aortic size (Reed et al. 2017). The overall Amish rate of tobacco-related lung cancer is lower in part because tobacco use is lower (Miller 1983; Westman, Ferketich and Kauffman 2010). In Lancaster, while 12 cases of cancer were expected among the Amish, only one was reported, which was of a smoker. Such a low rate is probably due to low second-hand smoke exposure (Miller 1983). The low rate of tobacco use may be one reason Amish people live longer on average than non-Amish people despite lower hospital use rates (Mitchell et al. 2012).

As with tobacco, Amish alcohol use is low. In a Holmes County study, 6.4% of men and 1.7% of women consumed some quantity of alcohol, which was likely concentrated among adolescents (Levinson et al. 1989).

Amish adolescents are an at-risk population for tobacco and alcohol use and abuse. Compared to non-Amish peers, Amish public school students in northern Indiana were more critical of drug abuse and perceived drug abuse as higher among their non-Amish peers. Yet, Amish students felt more susceptible to peer pressure and they more positively evaluated alcohol and tobacco compared to other substances, making their drug use particularly “Amish” (Cates and Weber 2012). Indeed, among some Amish groups, including the Old Orders of northern Indiana, on one’s 16^th birthday (or thereabouts), norms are inverted as adolescents begin a period of “prescribed deviance.” During this stage, many engage in peer pressure-driven substance abuse that leads to mental stress and guilt due in part to fear of dying during their period of rebellion (Reiling 2002).

10. Periodontal Conditions

A cluster sample of 121 subjects from 21 Amish families in southwestern Michigan had better periodontal health—i.e., rates of gum- and tooth-related disease and tooth retention—than Midwestern averages despite lower rates of brushing and visiting the dentist. These findings were unexpected, as insufficient knowledge about proper oral hygiene practices is associated with a lack of oral care, which in turn is associated with periodontal disease (gingivitis, plaque, and calculus) and missing teeth. The authors hypothesized that, possibly, Amish dietary practices provided some protection, as Amish tend to eat three big meals a day with little snacking (Bagramian, Narendran and Khavari 1988).

An expanded study of Amish (n=282) in the same settlement again revealed an unexpectedly low rate of periodontal disease given their formal education levels and poorer dental habits (Bagramian et al. 1993). The third and final study compared Amish (n=330) and non-Amish (n=215) subjects in the same settlement. The Amish had slightly higher rates of periodontal disease. Even if statistically significant, the differences were clinically small, which was surprising, given that Amish care practices were much poorer (Bagramian et al. 1994). No other oral hygiene and periodontal research has been performed in other Amish communities or since these studies from 1988–93.

11. Traumatic Injuries and Safety

The profile of Amish injury types reflects their lifestyle: agrarian, labor-intensive, and technologically selective. Contexts of particular risk include exposure to large animals, early working age, transportation by buggy, the farming/outdoor season (spring to fall), operation of heavy or dangerous machinery, and rural recreation (Beaudreault, Jepsen and Dellinger 2009; Burgus and Rademaker 2007; Gilliam et al. 2007; Hamman, Brancik and Lilienfeld 1981; Jones 1990; Jones and Field 2002; Jones et al. 2013; Rhodes and Hupcey 2000; Vitale et al. 2006). Common proximate causes of injury include falls, farm equipment impact and run-overs, animal contact, and horse and buggy crashes with automobiles, and then, to a lesser degree, slips, saw cuts, drowning, chemicals, and suicide (Fisher, Hupcey and Rhodes 2001; Forward et al. 2010; Hubler and Hupcey 2002; Jepsen et al. 2012; Jones 1990; Jones and Field 2002; Jones et al. 2013; Rhodes and Hupcey 2000; Rhodes and Hupcey 2002; Vitale et al. 2006). Compared to area non-Amish in Southwestern Ontario, Amish had fewer injuries from motor vehicle and ATV (All-Terrain Vehicle) crashes but more injuries from falls, animals, and buggy-motor vehicle crashes (Forward et al. 2010). Amish are more likely to treat minor injuries at home using complementary and alternative methods, such as aloe vera, Union Salve, Watkins Salve, or Kerosene (Gerdner, Tripp-Reimer and Sorofman 2002).

Injuries vary by age and gender. Men are injured more frequently than women (Gilliam et al. 2007; Hamman, Brancik and Lilienfeld 1981; Vitale et al. 2006) by a rate of around 3 to 1 (Hubler and Hupcey 2002; Jones 1990). Compared to adults, children have a high number of injuries, e.g., a majority of farm fatalities involved children under 16 (Jones and Field 2002; Jones et al. 2013), a lower median age of injury compared to local non-Amish minors in southwestern Ontario (Forward et al. 2010), an average age of 19.8 for admissions at one hospital (Jones 1990), and reports from 70% of 47 Central Pennsylvanian Amish teachers that they or a child in the family had sustained a farm-related injury (Fisher, Hupcey and Rhodes 2001). In a western New York settlement, injuries from accidents were found to account for 15% of fatalities, the third highest cause after cardiovascular and cancerous fatalities (Hewner 1997).

Horse and buggy crashes have received sustained interest, perhaps due to the novelty of Amish transportation methods. Motorist speed is a frequent factor in crashes and the most common collision scenario is the motorist rear-ending the buggy (Aaland and Hlaing 2004; Anderson 2014a; Ives and Brotman 1990), suggesting that the speed difference between a buggy and automobile is a chief challenge. While scholars have responded by focusing on buggy conspicuity through attention to rear markings, e.g. reflective tape and the slow-moving vehicle emblem (Eicher, Bean and Buccalo 1997; James 2001), recent studies question the extent to which rear-end crashes are due to “not seeing the buggy”—i.e. the buggy was not conspicuous—versus other factors not related to conspicuity, such as the sun’s glare, careless attempts at passing, and motorist impairment and distraction (Anderson 2014a; Anderson 2014b; Anderson 2014c; Garvey 2003; Gorucu, Murphy and Kassab 2016). Buggy-motor vehicle crashes often result in minor or severe—but less often mid-range—injuries for the buggy occupants (Vitale et al. 2006), who have a rate of injury three times that of motor vehicle occupants (Gorucu, Murphy and Kassab 2016).

Existing studies demonstrate a high frequency of childhood injuries and fatalities, but we do not know if Amish injury/fatality rates are higher than non-Amish rates, as injury research offers no standardized comparisons. Further, little is known about the extent to which injuries lead to fatalities. Regarding road safety, as the Amish population continues to grow, crashes between motor vehicles and buggies are expected to increase. While several common crash scenarios are now well documented, research has not adequately investigated the impact of recommended safety measures, especially buggy markings and lighting. If anything, the efficacy of buggy markings is now challenged. As marking recommendations may become law and trigger legal conflicts, more research is needed about marking effectiveness.

12. Burns and the B&W-Burdock Leaf Therapy

Research about Amish burn injuries highlights the risks and outcomes of child burn patients and the medical efficacy of the burns and wounds ointment (B&W) and burdock leaf therapy.

Compared to non-Amish children, causes of Amish child burn injuries are narrower and usually involve household tasks. Serious burns are uncommon but, when they occur, are often more extensive and require longer hospitalization. Amish girls are at a greater risk of serious injury despite little difference in burn cause between genders (Rieman et al. 2008), possibly due to working more closely with heat sources in the home such as stoves, hot liquids, and gas-powered lighting. Researchers have responded with burn prevention educational materials for the Amish (Rieman and Kagan 2012).

In recent years, many Amish have adopted the B&W and burdock leaf therapy as an alternative to burns and injuries necessitating skin grafting. Outcome data provide mixed results. On the one hand, it is not a sterile practice (Amish Burn Study Group et al. 2014), and, in one case, the treatment failed to heal a young Amish man with third-degree burns covering 75% of his body (Kahn, Demme and Lentz 2013). Furthermore, replacing or using this treatment in conjunction with conventional medical practices, such as skin grafting, remains controversial (Hess 2018; Kahn, Demme and Lentz 2013; Lee and Ruth-Sahd 2011).

Other studies support the practice as valid, though call for more research. Specific ingredients may be effective even if the clinical efficacy of the overall treatment remains unknown (Amish Burn Study Group et al. 2014; Kahn, Demme and Lentz 2013; Lee and Ruth-Sahd 2011; Main, Williams and Jones 2012; Rieman et al. 2014; Trinkle 2016). Nevertheless, that overall treatment, when well monitored and conducted by trained nurses and Amish burn dressers, shows some effectiveness in managing pain, bringing about faster healing, and preventing infection for first- and second-degree burns (Amish Burn Study Group et al. 2014). In general, Amish participants advocate the treatment, self-reporting quicker and less painful healing than medical burn dressings (Hess 2018; Main, Williams and Jones 2012). In a retrospective analysis, one institution followed up with five patients that opted for home salve/leaf treatment when doctors had recommended skin grafting; all patients had healed in a reasonable time without further complications (Flurry et al. 2017).

13. Fertility and Birthing

All Amish couples, with the exception of a consistently infertile 3% (Acheson 1994; Greksa 2002; Smith 1960; Wood et al. 1994), have children. Completed family live births vary by settlement and cohort but are all high, from 4.x (Colyer et al. 2017) to 7.8 (Acheson 1994; Dorsten 1994; Greksa 2002). Through the first half of the 20^th century, the Amish had children younger, older, and more frequently than national averages (Smith 1960); fertility has remained steady (Cross and McKusick 1970; Ericksen et al. 1979; Markle and Pasco 1977), with only modest place- and time-specific increases (Bailey and Collins 2011) or decreases (Colyer et al. 2017; Dorsten 1999; Greksa 2002). Consequently, age distribution skews heavily toward the young; in one settlement, the elderly consisted of 2–3% of the population, compared to 18% among area non-Amish (Hewner 1997).

Compared to non-Amish, Amish women may have lower rates of cesareans and higher rates of vaginal births after cesarean than the national average (Deline et al. 2012; Jolly 2014). Compared to local non-Amish, Amish labor lengths are either comparable (Lucas et al. 1991) or shorter (Jolly 2017), and infant birth rates are either fairly similar [western New York] (Lucas et al. 1991), or else rates of low infant birth weights and pre-term births are lower [Lancaster County, PA] (Miller et al. 2007). A Midwestern study (Resseguie 1974) found that Amish women in their 30s and 40s show lower rates of stillbirths; a higher ratio of subfecund non-Amish women yet trying to have successful pregnancies in their 30s and 40s may explain the difference. For a detailed review of the Amish fertility literature, see Colyer et al. (2017).

14. Sexually Transmitted Diseases (STDs)

The Amish emphasis on endogamy and their stigmatization of copulation outside of a lifelong, heterosexual marriage limit the prevalence of illness correlated with multiple sexual partners such as cervical cancer and sexually transmitted diseases (Acheson 1994; Cross, Kennel and Lilienfeld 1968; Westman, Ferketich and Kauffman 2010). Most Amish adults are church members and married, and the church negatively sanctions all forms of extra-marital copulation for members. A prevalent assumption is that some young adults—those who are flouting the Amish church’s institutionalized values and are, typically, unbaptized, and therefore not formally subject to the church’s sanctions—are sexually active but prefer other Amish partners and generally follow shotgun wedding practices, limiting the risk of STDs spreading even among those with multiple partners.

Tangled, Reductionist Mechanisms: What Exactly about Amishness Matters?

While studies have quantified the dependent variable (health) with diligence, the population-specific intervening mechanisms producing these outcomes are not well understood. In seeking an explanation, researchers typically address ethnic properties of Amishness, including structural, cultural, and biological/genetic aspects (Floersch, Longhofer and Latta 1997), relying on two reasonable findings about Amish ethnicity, respectively, (1) that the population is clearly delineated vis-à-vis social membership, and this status predisposes individuals toward interactions that reproduce cultural patterns (Enninger and Wandt 1979; Hurd 1985; Škender 2020; Stein et al. 2020); and (2) genetically, Amish ancestry is traceable to a handful of early Swiss-German migrants (Cross and Crosby 2008). Consequently, because Amishness is apparently self-evident as an ethnic group, research frequently explains outcomes by identifying those conspicuous lifestyle patterns characteristic of the ethnic group—e.g., obesity is lower since Amish walk more—with only a few studies identifying novel, well-grounded mechanisms—e.g. exposure to farm animals bolsters immunity. So, broadly speaking, research often explains health differences as a product of overarching Amish difference.

While the Amish population is identifiable and socially salient to both members and non-members, treating Amishness itself as a self-contained, a priori mechanism explaining all population health statuses is reductionist, oversimplifying causality. Even though Amishness is often treated as a cohesive, typological contrast to “modern” society, Amish ethnicity overlaps with and is nested within other social identities and institutions (Anderson et al. 2019; following Wimmer 2013) and represents multiple uniquely Western developments, including their New World migrant-based ethnicity, religiosity rooted in the Protestant Reformation, and the market-oriented family farm economic system (Lutz 2017). Further, Amishness as an identity is neither the only nor always the most important association individuals carry. Individuals manage multiple, nested identities which may be within or transcend the Amish identity: family, kin, church, affiliation, plain Anabaptist, neighborhood, business employee/er, and American, among others (Wimmer 2013). Many other nameless but relevant identities are shaped by various mix-and-match attitudes toward alternative health practices, tobacco use, youth deviance, evangelical religious thinking, transportation modes, occupations, modern birth control, fashion, and household appliances and food preparation equipment, among other salient identifiers.

In sum, the Amish are not a monolithic society, nor is “Amish” a total identity-institution governing all behavior, nor do the Amish represent a holistically coherent, functional ethnic system; they operate by an organizing interactional logic as much as by tensions, discrepancies, and contradictions (Billig and Zook 2017; Sewell 1999; Swidler 2001). Consequently, the way Amishness impacts population health must be better qualified. While this multidimensional conception of Amishness makes it more difficult—but not impossible (Wimmer 2013)—to typify, it better accounts for reality’s complexity and opens the way for research to better nuance how, when, and why Amishness impacts health outcomes. Three changes are suggested.

First, researchers should pay closer attention to deep cultural systems (Jolly 2017; Patterson 2014), suggesting that medical and social researchers should collaborate in both identifying Amish/non-Amish differences and accounting for inconspicuous cultural mechanisms. Researchers should move beyond speculative discussion sections and integrate cultural investigations into quantitative research. Second, research must include more cross-settlement (Jepsen et al. 2012), cross-affiliation (Holbreich et al. 2012), and cross-population (Bagramian et al. 1994; Katz et al. 2011) designs. Without comparisons, we risk identifying spurious relationships between Amishness and health. While multi-site research may be cost and time prohibitive for local institutions, researchers can replicate studies conducted elsewhere to generate comparisons. Researchers geographically constrained can validate extra-local research by the advances comparative studies bring to local understandings. Third, researchers should justify why they are studying the “Amish” as a population and who this includes. Conservative/plain Anabaptist groups, including various Amish, Mennonite, and other affiliations, intersect in multidimensional ways, as do ex-adherents and ethnically/religiously related populations. Researchers should explicitly bound and sensibly define the population according to research objectives. Researchers should also consider analyses where the population focus is fluid and flexible, based on an intensity or severity of affiliation (Wimmer 2013) rather than superficial in-/out-group delineations. In sum, thick, comparative, and population-justified analyses of Amishness (and plain Anabaptism) will help us better specify causal pathways from social variable to health outcome and disentangle mechanism effects (Goldman 2001).

Missing Variables

Amish health research provides minimal analysis of standard social mechanisms impacting population health, including economic status, educational attainment, healthcare access, and inter-group prejudice. Such mechanisms are frequently analyzed for ethnic groups but not for the Amish. We will emphasize four.

Education is arguably the most important predictor of health outcomes among Western populations (Mechanic 2007). Nearly all Amish cap formal education at 8^th grade, yet health is surprisingly good. Rather than discarding education from analysis, researchers should select another proxy for education beyond institutional attainment level. Amish individuals certainly have uneven opportunities for acquiring knowledge—both the “declarative” (i.e. facts and events, commonly associated with formal education) and the “procedural” (i.e. experience-based know-how, represented by access to apprenticeships, commercial-industrial institutions, the right reading material, and vertical social ties) (Patterson 2014). Such measures, if operationalized, can replace the proxy of formal educational attainment and permit analysis of this apparent Amish educational enigma.

Class differences exist among Amish despite their apparent inconspicuity (Moledina et al. 2014). Socio-economic status can affect health through exposure to occupational/environmental hazards, decreased access to support, and increased stress and risk-taking behaviors, with poor health and low socioeconomic status mutually reinforcing across generations (Haas 2006). Socioeconomic status merits deeper consideration in future Amish health research.

Healthcare access pertains most immediately to healthcare facilities, a notable challenge for rural areas. Yet, research on Amish health conditions rarely measures how barriers to healthcare impacts health. Such studies are needed.

Discrimination affects health outcomes, as has been well-documented for African Americans and other ethnic minorities (Gee and Ford 2011; Williams, Neighbors and Jackson 2003). Evidence exists that some prejudicial attitudes toward the Amish exist, yet we know neither about the extent nor the way it affects population health (Anderson and Decker 2020; Byers and Crider 2002; Park 2018).

Methodological Considerations

Amish health research incorporates designs using self-report data and clinical evaluation but has not addressed methodological reliability despite documented irregularities in Amish health literacy, health system usage, and expression of symptoms. In particular, self-report data may introduce diagnosis bias (i.e., discovering conditions comes from using diagnostics) and variation from structural-cultural contexts (Burgard and Chen 2014). Consequently, self-reports may complicate cross-population and Amish-internal comparisons.

Further, while many Amish health studies document health and well-being contrasts for specific topics, we have no summary measures—a single figure representing a population’s relative mortality and morbidity. Summary measures would permit meaningful comparisons of life quality between Amish and other populations, monitor health changes, and catalog health inequalities within (Murray, Salomon and Mathers 2000).

Finally, Amish health conditions will change over time. However, nearly all studies provide cross-sectional data at one point; few studies are longitudinal or offer a time series of cross-sectional data. One place to begin is with program evaluations; while some needs assessments and program descriptions exist, very few programs have published evaluations (Miller-Fellows et al. (2018) is a noteworthy exception). Have interventions changed rates of a given health condition? A second strategy for obtaining cross-sectional data over time is replicating older studies. Finally, longitudinal studies can provide valuable information for how Amish individuals experience health events across the life course, especially the way early life events influence quality of life and subsequent health events.

Policy Considerations

This review suggests several policy considerations. Population-specific health interventions are tasked with more than changing health outcomes for individuals but, at a larger scale, shifting the whole normal distribution of disease by addressing population-wide mechanisms (Rose 2001) including ethnic and environmental contexts. This review identifies gaps in our understanding of mechanisms. As Amish people are often hesitant to trust external direct interventions beyond their control (Sauder 2020), agents implementing interventions must be cautious about direct interventions until research has better isolated mechanisms.

Even without identifying the mechanisms, the Amish health profile has specific contours that shape services. Agencies should plan to adjust services accordingly. For example, health services must be prepared to address rare genetic disorders, impacts of alternative medicine, farm injuries, breast cancer, and immunization-preventable diseases. In particular, many advances in genetics research—and now burn treatment therapy—come from Amish-based studies, so working effectively with this population is important for health knowledge.

Finally, because the Amish are growing, any unresolved Amish-specific public health concerns will only increase. For example, as Amish internally diversify in their positions on information and communications technologies, health disparities may increase as services move to digitized platforms (Timmermans and Kaufman 2020). As another example, the Amish have a disproportionate share of individuals who reject many or all vaccinations. The possibility for whooping cough, measles, rubella, pertussis and other vaccine-specific outbreaks will only grow. More recently, many Amish have demonstrated both reluctance and resistance toward simple preventative measures for coronavirus, including masking, social distancing, and postponing large events (Duran et al. 2020). While effects may be limited were the society sesf-contained, some Amish travel extensively, and Amish in settlements once closed to tourism and commercialization are opening to casual non-Amish customers. Consequently, the Amish response to contagious diseases is bound to be a reoccurring public health concern.