# Establishing a Tribal Environmental Health Collaborative in San Diego County

# 2007 - 2008

# 

# Environmental Public Health Leadership Institute Fellow:

# Paula Stigler, MSPH

*Environment Program Manager and Tribal Liaison*

The San Diego Foundation /Pala Band of Mission Indians

*2508 Historic Decatur Road Suite 200*

*San Diego, CA 92106*

*(619) 814-1366 paula@sdfoundation.org*

# Mentor:

# **Charles D. Treser, MPH**

*Senior Lecturer;* Department of Environmental and Occupational Health
Sciences

University of Washington

# (Acknowledgements):

### **Emily Young, PhD**

*Environment Program Director;* The San Diego Foundation

### **Lenore Volturno, BS**

*Tribal Environmental Program Director;* Pala Band of Mission Indians

### **Keith Pezzoli, PhD**

*Professor of Urban Planning;* University of California San Diego

### **David Pellow, PhD**

*Professor Ethnic Studies;* University of California San Diego

**Hiram Sarabia, MS**

*Research Associate SBRP;* University of California San Diego

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

Tribal communities in San Diego are mostly dependent on federal Indian
Health Services for all their public health and environmental health
needs. There are more than eighteen tribes and only one federal
environmental health officer with limited jurisdiction on tribal lands.
San Diego County and other local or state agencies also do not work
within tribal jurisdictions; consequently it is the growing
responsibility of tribal governments to increase their capacity to work
within their own communities to address interrelated health and
environmental concerns.

A tribal environmental health collaborative was assembled to address the
assessment of key priority areas and interventions of the identified
priorities. Partnerships were formed between multiple tribal
environmental departments, tribal non-profit organizations, universities
and federal agencies to accomplish the goals. The collaborative meets
every month and follows an established action plan. Through
collaboration building with Tribal EPA's and other environmental health
programs, a better understanding of what the most serious environmental
health problems within these communities, may be ascertained in order to
directly address these issues via tribal resources.

If this newly developed Tribal Environmental Health Collaborative is
successful, it will serve as a model group working towards the following
goals: completion of a comprehensive analysis of local tribal statistics
and human/environmental health concerns; strengthening and expansion of
a network of organizations working with tribal populations to more
effectively monitor and abate environmental hazards to human health, as
well as advocating for public policy that ensures clean environments and
healthy communities; increased knowledge and capacity among tribal
communities and tribal environmental programs to address critical
environmental health risks and concerns; and building of a strong
coalition of organizations working to advance solutions to interrelated
health and environmental concerns on tribal lands.

# INTRODUCTION/BACKGROUND:

San Diego County is home to the highest number of Native American
reservations per county in the nation, with 18 federally recognized
reservations and an estimated population of about 6,800 total living on
tribal reservation land. Tribal communities have historically been
marginalized, with forced relocation from their native lands and
diminished or limited access to natural resources upon which they depend
on for their livelihood. The majority of San Diego county tribes are
non-gaming, with residents that live far below poverty level. Tribal
reservations are completely responsible for their own infrastructure and
community needs.

Many reservations are completely lacking or have insufficient access to
basic services such as clean water, proper solid waste removal and
adequate sewage treatment. This lack of services has created
environmental health issues and concerns within these already at risk
communities. Many tribal communities are also disproportionately
impacted by health problems such as asthma, digestive and circulatory
problems and metabolic disorders that could be directly related to
exposure to environmental pollutants. Moreover, more toxic waste and
dump sites are located on or near tribal reservations than any other
community in the county, with several more being proposed for the near
future. Most reservations rely upon groundwater as their main source of
drinking water and are not connected to the regions plumbing system. It
is critical that there are proper monitoring systems in place within
these communities which assist in tracking and abatement of the primary
sources of pollution that pose the greatest public health risks.

####### ***Problem Statement:***

####### Tribal environmental departments (EPA's) are charged with educating community members as well as developing policies and regulations for the tribal government in regards to protection of the environment. However, tribal EPA's are not receiving adequate information and resources to address environmental health problems within their communities. Indian Health Services (IHS) does not have sufficient resources or capacity to deal with all of the risks of so many constituents while there is also an apparent gap in communication and trust between many tribal programs and IHS. 

***Key Variables Graph:***

It is expected that as tribal EPA's become more aware of potential and
real environmental health issues facing their communities that more
resources will become available to decrease those risks posed to public
health. Resources may come from new found sources dealing with
environmental health (e.g. tribal funds, community foundations, federal
sources not normally utilized by tribal communities) or pressure from
tribes to advocate for more funds from federal sources to address the
issues.

####### 

####### ***Causal Loop Diagrams and applicable archetypes:***

####### 

> **SHIFTING THE BURDEN**

####### 

####### 

####### 

####### 

####### 

####### 

####### ***10 Essential Environmental Health Services:***

####### ![](media/image2.png){width="3.75in" height="3.8125in"}

**Figure 1: 10 Essential Environmental Health Services**^1^

####### This project addresses the following components of the 10 Essential Services of Environmental Health:

-   **Assessment**

    -   Monitor health by analyzing data provided by IHS and local
        health clinics; surveying community members through tribal
        EPA's.

    -   Diagnose and Investigate environmental health problems and
        health hazards in the community by providing tribal EPA
        directors with an opportunity to discuss and learn about local
        environmental health issues in their communities.

-   **Policy Development**

    -   Inform, Educate, Empower tribal governments and EPA's by
        providing them with facilitated meetings to educate them on
        environmental health issues through utilization of PACE EH,
        supporting materials, guest lecturers, and other resources.

    -   Mobilize Community Partnerships to identify and solve
        environmental health problems. The program coordinator has
        developed a collaborative forum to bring issues to the table and
        potential partners to help addressed the identified needs.

    -   Develop Policies to provide additional resources for tribal
        EPA's to be able to investigate environmental health concerns in
        order to best ensure adequate tribal policies to protect public
        health.

-   **Assurance**

    -   Enforce Laws through tribal ordinances developed around
        environmental health protections.

    -   Link to/Provide Care for community members through IHS,
        universities, non-profits or other entities that are culturally
        competent.

    -   Assure Competent Workforce within the tribal EPA's and
        organizations working with the tribal communities.

    -   Evaluate the success of the program by implementing surveys
        regularly within communities.

####### ***National Goals Supported*** 

[CDC Health Protection Goals^2^]{.underline}

-   #44: Promote homes that are healthy, safe, and accessible.

> By enhancing communication between tribal EPA's and community members
> a system can be developed where homes are surveyed by trained
> individuals who can identify environmental health risks.

-   #45: Promote adoption of behaviors that keep people healthy and safe
    in their homes.

> Through outreach and education about the dangers of environmental
> health contaminants (e.g. cigarette smoking, wood burning stoves,
> pesticide use, etc.) tribal EPA's can assist community members in
> improving the health of their home.

[National Strategy to Revitalize Environmental Public Health
Services^3^]{.underline}

-   Activity VI-AI-1: *"Identify stakeholders who influence all
    components of the environment (built and natural) that have an
    impact on environmental public health services."* This activity is
    being met by providing information to tribal EPA's and other
    collaborators.

-   Activity VI-AI-2: *"Support activities (e.g., conferences, meetings,
    seminars, etc.) that influence stakeholders to work together to
    improve environmental public health."* This activity is being met by
    the Tribal Environmental Health Collaborative convening's that bring
    tribal EPA directors together to discuss environmental health and
    identify critical needs and intervention activities.

-   Activity VI-AI-3: *"Develop mechanisms for regular communication and
    coordination among stakeholders"* This activity is being met by
    directing the healthcare providers at the community health clinic
    and the IHS health clinic to communicate with tribal EPA's when
    confronted with an illness of environmental etiology.

Project Logic Model:

+------------+--------------+--------------+-------------+------------+
| **Resource | ##           | ### Outputs  | **Short &   | *          |
| s/Inputs** | # Activities |              | Long Term   | *Impacts** |
|            |              |              | Outcomes**  |            |
+------------+--------------+--------------+-------------+------------+
| **         | -   Form     | -   \#       | ###         | **         |
| Partners** |     c        |     partners | Short Term: | Behavior** |
|            | ollaborative |              |             |            |
| -   Tribal |              |    committed | -           | -          |
|     Env    | -   Educate  |     to       |   Increased |  Community |
| ironmental |              |     c        |     co      |            |
|     D      | participants | ollaborative | llaboration |    members |
| epartments |     on       |              |     between |            |
|            |     e        | ```{=html}   |     tribes  |   identify |
| -   EPA    | nvironmental | <!-- -->     |     and     |     and    |
|     tribal |     health   | ```          |             |     avoid  |
|            |              | -   \#       |    partners |     env    |
|    program | -   Develop  |              |             | ironmental |
|     co     |     surveys  |    community | -           |            |
| ordinators |              |     surveys  |   Increased |  stressors |
|            |    utilizing |              |             |     at     |
| -          |     PACE EH  |  implemented | partnership |     home   |
|    Medical |     as a     |     and      |     op      |     and in |
|            |     template |     received | portunities |     their  |
|   Partners |              |              |     and     |            |
|            | -   Identify | -   #e       |             |  community |
| -   IHS    |     who will | nvironmental |    dialogue |            |
|            |              |     health   |     with    | -          |
|    officer |  participate |     projects |     IHS and |  Increased |
|            |     in       |              |     tribal  |            |
| -   Native |     survey   |    conducted |     EPA'    |  knowledge |
|            |     im       |              |             |     of     |
|   American | plementation | -   \#       | -           |     env    |
|     Env    |              |     partners |   Increased | ironmental |
| ironmental | ```{=html}   |              |             |     health |
|            | <!-- -->     |    requested |   resources |     issues |
| Protection | ```          |     as guest |     for     |     among  |
|            | -            |     speakers |     en      |     tribal |
|  Coalition |    Establish |     and      | vironmental |     EPA's, |
|            |     c        |     c        |     health  |     g      |
| -   Rural  | ommunication | ollaborators |             | overnments |
|            |     link     |              |    programs |     and    |
|  Community |     between  | -   \#       |             |            |
|            |     tribal   |     tribal   |             |  community |
| Assistance |     EPA's,   |              |             |            |
|     C      |     IHS and  |  governments |             |    members |
| orporation |              |     who      |             |            |
|            | ```{=html}   |     commit   |             |            |
| ```{=html} | <!-- -->     |              |             |            |
| <!-- -->   | ```          |    resources |             |            |
| ```        | -            |     to       |             |            |
| -          |    Implement |     e        |             |            |
| University |     surveys  | nvironmental |             |            |
|            |     in the   |     health   |             |            |
| scientists |              |     programs |             |            |
|     and    |  communities |              |             |            |
|     r      |              |              |             |            |
| esearchers | -   Analyze  |              |             |            |
|            |     surveys  |              |             |            |
|            |     and      |              |             |            |
|            |     develop  |              |             |            |
|            |              |              |             |            |
|            |   priorities |              |             |            |
|            |     list of  |              |             |            |
|            |     e        |              |             |            |
|            | nvironmental |              |             |            |
|            |     health   |              |             |            |
|            |     problems |              |             |            |
|            |              |              |             |            |
|            | -   Develop  |              |             |            |
|            |     policies |              |             |            |
|            |     and      |              |             |            |
|            |     allocate |              |             |            |
|            |              |              |             |            |
|            |    resources |              |             |            |
|            |     to       |              |             |            |
|            |     address  |              |             |            |
|            |              |              |             |            |
|            |   priorities |              |             |            |
+------------+--------------+--------------+-------------+------------+
| **R        |              |              |             |            |
| esources** |              |              |             |            |
|            |              |              |             |            |
| -   Staff  |              |              |             |            |
|            |              |              |             |            |
| -   Env    |              |              |             |            |
| ironmental |              |              |             |            |
|            |              |              |             |            |
| Protection |              |              |             |            |
|     Agency |              |              |             |            |
|     (EPA)  |              |              |             |            |
|            |              |              |             |            |
| -          |              |              |             |            |
|    Centers |              |              |             |            |
|     for    |              |              |             |            |
|            |              |              |             |            |
|    Disease |              |              |             |            |
|            |              |              |             |            |
|    Control |              |              |             |            |
|     and    |              |              |             |            |
|            |              |              |             |            |
| Prevention |              |              |             |            |
|     (CDC)  |              |              |             |            |
|            |              |              |             |            |
| -   The    |              |              |             |            |
|     San    |              |              |             |            |
|     Diego  |              |              |             |            |
|            |              |              |             |            |
| Foundation |              |              |             |            |
|            |              |              |             |            |
| -   Tribal |              |              |             |            |
|     g      |              |              |             |            |
| overnments |              |              |             |            |
+------------+--------------+--------------+-------------+------------+
|            |              |              |             | *          |
|            |              |              |             | *Results** |
|            |              |              |             |            |
|            |              |              |             | -   More   |
|            |              |              |             |            |
|            |              |              |             |  efficient |
|            |              |              |             |     and    |
|            |              |              |             |            |
|            |              |              |             |  effective |
|            |              |              |             |     public |
|            |              |              |             |     health |
|            |              |              |             |     system |
|            |              |              |             |            |
|            |              |              |             | -   Fewer  |
|            |              |              |             |     visits |
|            |              |              |             |     to     |
|            |              |              |             |            |
|            |              |              |             |    clinics |
|            |              |              |             |     due to |
|            |              |              |             |     e      |
|            |              |              |             | nvironment |
|            |              |              |             | al-related |
|            |              |              |             |            |
|            |              |              |             |  illnesses |
|            |              |              |             |            |
|            |              |              |             | -          |
|            |              |              |             |   Improved |
|            |              |              |             |     health |
|            |              |              |             |     of     |
|            |              |              |             |     p      |
|            |              |              |             | opulations |
+------------+--------------+--------------+-------------+------------+
|            |              |              | **Long      |            |
|            |              |              | Term:**     |            |
|            |              |              |             |            |
|            |              |              | -           |            |
|            |              |              |   Increased |            |
|            |              |              |     number  |            |
|            |              |              |     of      |            |
|            |              |              |     tribes  |            |
|            |              |              |     i       |            |
|            |              |              | mplementing |            |
|            |              |              |     en      |            |
|            |              |              | vironmental |            |
|            |              |              |     health  |            |
|            |              |              |             |            |
|            |              |              |    policies |            |
|            |              |              |     and     |            |
|            |              |              |             |            |
|            |              |              | regulations |            |
|            |              |              |     on      |            |
|            |              |              |     tribal  |            |
|            |              |              |     r       |            |
|            |              |              | eservations |            |
|            |              |              |             |            |
|            |              |              | -           |            |
|            |              |              |   Increased |            |
|            |              |              |     number  |            |
|            |              |              |     of      |            |
|            |              |              |     tribal  |            |
|            |              |              |             |            |
|            |              |              | governments |            |
|            |              |              |             |            |
|            |              |              |  supporting |            |
|            |              |              |     en      |            |
|            |              |              | vironmental |            |
|            |              |              |     health  |            |
|            |              |              |             |            |
|            |              |              |    programs |            |
|            |              |              |     for     |            |
|            |              |              |     their   |            |
|            |              |              |             |            |
|            |              |              | communities |            |
|            |              |              |             |            |
|            |              |              | -   Federal |            |
|            |              |              |     EPA     |            |
|            |              |              |             |            |
|            |              |              |   providing |            |
|            |              |              |     en      |            |
|            |              |              | vironmental |            |
|            |              |              |     health  |            |
|            |              |              |             |            |
|            |              |              |    specific |            |
|            |              |              |     funding |            |
|            |              |              |     and     |            |
|            |              |              |             |            |
|            |              |              | educational |            |
|            |              |              |     op      |            |
|            |              |              | portunities |            |
|            |              |              |     for     |            |
|            |              |              |     tribes  |            |
+------------+--------------+--------------+-------------+------------+

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal:*** To increase the capacity of tribal EPA's to address environmental health problems within their communities.

***Health Problem:*** Lack of awareness and resources to address
environmental health issues among tribal communities.

####### ***Outcome Objective:*** By January 2009 environmental health priorities will be identified in at least 8 tribal communities in the San Diego region and environmental health projects will be implemented. 

####### ***Determinant:*** Gap in resources and information regarding environmental health has caused tribal EPA's to not focus on environmental health priorities within their communities.

***Impact Objective:*** By 2009 have applied for funding through federal
CARE program for project implementation as well as leverage funding from
tribal governments and other sources.

####### ***Contributing Factors:***

1.  Lack of personnel and funding resources as Indian Health Service is
    significantly under funded, and tribes are not getting all of the
    services and the medical care that they need; tribal EPA's do not
    have the capacity and/or resources to implement environmental health
    programs.

2.  Learning curve for tribal governments and EPA's on topics related to
    environmental health.

3.  Little to no communication between tribal governments, environmental
    offices, Indian Health clinics and IHS environmental health officers
    due to strained relationships and/or lack of time and resources.

4.  Overburdened staff has not allowed for formal follow-up policies or
    investigations to be developed and implemented concerning
    environmental health problems.

####### ***Process Objectives***

1.  By July 2008, complete community environmental health surveys in the
    participating communities

2.  By December 2008, evaluate and prioritize top environmental health
    issues in the San Diego regions tribal communities.

3.  By January 2009, develop a strategic action plan to address
    priorities.

4.  By 2010, receive support for project implementation.

5.  By 2011, re-evaluation of communities through surveys.

# 

# METHODOLOGY:

*Event and Activities*

**Event:** Develop a Tribal Environmental Health Collaborative with at
least 6-10 tribal representatives and outside partners of their choice.

**Activities:**

-   Tribes were contacted and invited to join the Tribal Environmental
    Health Collaborative.

-   Chuck Tresor gave a presentation on the basics of environmental
    health and the collaborative agreed to meet regularly and to discuss
    partnerships.

**Event:** Develop an action plan

**Activities:**

-   Meetings were held with potential partners to find out what services
    could be provided to them through partnering.

-   PACE EH was discussed and models were used to develop implementation
    tool

-   Prepare surveys for dissemination in the communities

-   

-   The age-adjusted prevalence was calculated and charts were developed
    using Microsoft Excel software

**Event:** Development of resources for project implementation

**Activities:**

-   Analyze survey results and prioritize environmental health concerns

-   Present findings to tribal forums and governments, federal
    government, IHS and other partners

-   Locate sufficient funds to address problems and implement projects

# NEXT STEPS:

The next steps for the successful implementation of this project are as
follows:

1.  Ensure the tribal environmental health collaborative is sustainable
    and has sufficient funding to continue.

2.  Continue building the collaborative by conducting regularly
    scheduled monthly meetings and continuing to invite key players to
    participate.

3.  Develop a tribal PACE EH tool that is easy for tribal EPA's to
    implement as needed.

4.  Finally, a re-evaluation of environmental health knowledge among
    tribal community members and tribal EPA's.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Paula Stigler***

This experience with the Environmental Public Health Leadership
Institute (EPHLI) has provided me with skills and knowledge that will be
invaluable to me in implementing environmental health programs with
tribes and other communities now and in the future. Being overwhelmed
with an environmental health disaster in the middle of my fellowship
proved to be very challenging, yet I had already been provided through
EPHLI with the skills necessary to properly address the emergency. I was
able to utilize materials, other fellows and my mentor during the
disaster and found that EPHLI was not just a program but a true network
of environmental health experts. This program helped me to understand
what type of leader I truly am and how best to improve on my weaknesses
and enhance my strengths. It has been an honor to participate in such a
prestigious program with such a wonderful group of people.

# 

# ABOUT THE EPHLI FELLOW(S)

**Paula Stigler, MSPH**

Paula Stigler has been working with the tribal communities of Southern
California and Baja California for over 6 years. She is implementing a
tribal environmental health collaborative with The San Diego Foundation
as well as serves as a liaison for a water infrastructure project in
Baja California indigenous communities which is being sponsored by the
Pala Band of Mission Indians. Paula also serves as the tribal co-chair
for the San Diego/Tijuana Air Quality Taskforce and has recently
finished her master's degree in environmental health sciences at San
Diego State University with a special focus on environmental issues and
indigenous cultures.

# REFERENCES

1.  Osaki, C., eds.. *10 Essential Services of Environmental Health.*
    Northwest Center for Public Health Practice, Universtiy of
    Washington School of Public Health and Community Medicine, Seattle;
    2004.

2.  Centers for Disease Control and Prevention. *Health Protection
    Goals*. Atlanta, GA: Department of Health and Human Services. Oct
    2005.

3.  Centers for Disease Control and Prevention. *A National Strategy to
    Revitalize Environmental Public Health Services*. Atlanta, GA:
    Department of Health and Human Services. Oct 2003.