CDC/ATSDR Tribal Advisory Committee Meeting

2/18/14

Atlanta, Georgia

1 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
Councilman Chester Antone: Good morning. Can I have all the TAC members up at the 

table? We’re going to go ahead and start. We’re running just a little bit late. I’m going to go 

ahead and go with our agenda. Your binder should have the agenda for Tuesday and we have 

the opening blessing and I’ll go ahead and provide that for us this morning. We can all stand 

and do prayer. We do that in Indian country all the time, every time we meet.

Opening Blessing

Councilman Chester Antone: Right now I’m going to go ahead and go around the table for 

introductions. I’ll start from over here to the right and we’ll come this way to introduce yourself 

before we get to Dr. Monroe and CAPT Wilkins.

Tim Gilbert: Good morning everybody. My name is Tim Gilbert. I’m from the Portland area. I 

work for the Confederated Tribes of the Umatilla Indian Reservation. Glad to be here.

Cathy Abramson: Good morning. Cathy Abramson. I am a Council Member from the Sault 

Ste. Marie Tribe of Chippewa Indians. I’m also the chair of the National Indian Health Board 

and I am representing the Bemidji area for this committee.

Council Member Leslie Sampson, Sr.: Good morning. I’m Council Member Leslie Sampson. 

I’m representing the Noorvik Native Community. I’m from the northwest part of Alaska. This is 

my first TAC meeting and first time in Atlanta. 

Vice President Rex Lee Jim: Good morning. I’m Rex Lee Jim, Vice President of Navajo 

Nation.

(Inaudible speaker)

Chairman Steve Cadue: Steve Cadue, Chairman of Kickapoo Nation.

CDR Bobby Rasulnia: Good morning. Bobby Rasulnia, Acting Deputy Director for the Tribal 

Support Unit.

CAPT Craig Wilkins: Good morning, Craig Wilkins, Acting Director for the Tribal Support Unit.

Councilman Chester Antone: I’m Chester Antone, currently serving as the chair and I’m from 

the Tucson area.

Dr. Judith Monroe: Judy Monroe, Centers for Disease Control and Prevention, Office for State, 

Tribal, Local and Territorial Support.

2 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
Chairman Herman Honanie: Good morning everybody. I’m Herman Honanie, Chairman of 

Hopi Tribe, northeastern Arizona.

Chairman Robert Flying Hawk: Good morning. My name is Robert Flying Hawk, I’m the 

Chairman of the Yankton Tribe.

Dr. Jay Butler: Good morning. My name is Jay Butler from Anchorage, Alaska. I’m with the 

Alaskan Native Tribal Health Consortium and I’m the Alaska area authorized representative.

Lisa Pivec: Good morning. My name is Lisa Pivec and I am the authorized representative for 

the Oklahoma area, Citizen of the Cherokee Nation.

Council Member Patricia “Patty” Quisno: Good morning. I am Patty or Patricia Quisno from 

the Fort Belknap Indian Community. I’m a council member there and Billings area delegate.

Councilman Chester Antone: Thank you. I’m going to go ahead and turn it over to Judith 

Monroe.

Dr. Judith Monroe: Thank you, Chairman Antone. First of all, I just want to give a very warm 

welcome to all of you attending our TAC and our Tribal Consultation. It’s exciting for us here at 

CDC to have you here. I want to especially welcome our eight new TAC members. I know we 

just did introductions but I want to call out our eight new members. That’s Principal Chief 

Michell Hicks with the Eastern Band of Cherokee Indians, Chairman Robert Flying Hawk with 

the Yankton Sioux Tribe, Chairman Herman Honanie from the Hopi Tribe, Chairman Steve 

Cadue with the Kickapoo Tribe in Kansas, Secretary Shawna Gavin with Confederated Tribes 

of the Umatilla Indian Reservation represented by Mr. Tim Gilbert today. I want to also 

welcome Council Member Patricia Quisno for the Belknap Indian Community and Council 

Member Leslie Sampson with the Noorvik Native Community and Council Member Andy 

Joseph, Confederated Tribes of the Colville Reservation who should be calling into the 

meeting. Do we know, was he able to call in? He was gonna listen in, is that correct? He 

wasn’t able to join us in person. I do want to give a great thank you to Councilman Chester 

Antone Tohono O’odham Nation for his leadership on the TAC. Again, we look forward to this 

particular TAC meeting and look forward to working with you. I also would like to thank the 

TAC members who are continuing their service with us, President Alicia Reft from the Native 

Village of Karluk and represented by Dr. Jay Butler today, Lt. Governor Jefferson Keel of the 

Chickasaw Nation and represented today by Lisa Pivec and Vice President Rex Lee Jim, 

Navajo Nation. Also with him today is the authorized representative, Ms. Ramona AntoneNez. Director Cathy Abramson from the Sault Ste. Marie Tribe of the Chippewa Indians, and 

Councilman Chester Antone with the Tohono O’odham Nation. I would like to thank everyone 

for continued service, and for those of you that are new with us, thank you for your public 

service and all that you do for the American Indian/Alaska Native communities. We are very 

excited to have 13 members on the TAC now and this promises to provide us very valuable 

insight here at CDC and guidance for our programs and you’ll be hearing over the next couple 

3 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
of days from many of the leaders here at CDC and you will have a chance to work with them. 

We look forward to some meaningful discussion and consultation. CDC respects the tribal 

sovereignty and self determination for tribal governments and we would like to strengthen our 

relationship and partnership with the tribes. Before I turn it over to Captain Craig Wilkins, 

Captain Wilkins asked if I might tell a quick story about my own background. So I am a family 

physician by training and had planned to practice medicine throughout my career. I had a 

colleague that I worked with in a laboratory that left the laboratory and went to New Mexico to 

work with one of the tribes in New Mexico. I developed a great interest and hoped to actually 

practice medicine when I went to medical school with the Indian Health Service. So that was 

my plan, then I got married during medical school and my husband’s plans changed my plans. 

But I did have a National Health Service Corp commitment which took me to rural Appalachia 

and what I learned when I went to this community; the people living in the mountains had a 

very different culture. I had to learn their values for me to be effective in really treating them, I 

needed to understand what was important to them, what their fears were, and their great 

values. So there was one particular individual, his name was Tiny. Now, he was the tallest 

person in the county but Tiny had never been across the county line. One day he came to see 

me while very ill and it turned out that he had endocarditis. He had a very severe heart 

infection and it meant that he had to go two counties over to the large hospital to be able to be 

cared for. And he didn’t want to go. He was fearful. He’d never left the county line. He feared 

that if he left the county he would die because people went to the hospital to die. That was his 

belief. So it took us three days with all the family and all the community to convince him that 

he should in fact get the care that he needed. He did finally go. He had a very successful 

surgery and very successful treatment. Returned to the county, of course, telling all of his 

friends that the hospital wasn’t so bad and that they could cure folks. But I think the most 

important thing with Tiny is when he returned, he’d always had the best garden in the county 

and that next summer he was back again providing the best fruits and vegetables that were 

available in the county and went on to live many years after that. So what I learned in the rural 

community was the importance of understanding one another, working together, understanding 

cultural differences and, again, the fears of individuals and their strengths. So I hope with our 

TAC today that over the next couple of days we enrich one another with understanding culture 

and for you all to have an understanding of what CDC has to offer and how we might partner 

together in the most effective way for the best health outcomes. So I’ll turn to Craig Wilkins, 

Captain Wilkins.

CAPT Craig Wilkins: Good morning, and welcome again. On behalf of Dr. Tom Frieden, our 

CDC Director, Dr. Judy Monroe, our OSTLTS Director, and on behalf of our Tribal Support Unit 

within OSTLTS I would like to welcome you here to our annual TAC meeting and our 10th

Biannual Tribal Consultation Session. It’s an honor to come before you today and especially 

welcome our current and new TAC members and to the tribal leaders and tribal elders. I would 

also like to welcome our Federal Tribal and CDC partners who are in attendance. Also to our 

CDC /ATSDR leadership, and to our CDC ATSDR staff and colleagues who are here 

representing your respective programs. The planning of this meeting has occurred over 

several months and has been planned by you, the Tribal Advisory Committee. And on behalf 

4 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
of the Tribal Support Unit I would to thank you for your leadership and guidance and efforts to 

bringing this meeting into fruition. This is your meeting and we thank you for your efforts. I 

would also like to thank Chairman Antone for his leadership and guidance. I would also like to 

thank the office of the director, their staff, our OSTLTS staff and other CDC /ATSDR staff for 

your collective efforts in the planning of this meeting. In particularly our volunteers, our note 

takers, our tribal escorts and those that are outside doing the registration. But there are three 

people in this room—actually, I think there’s two right now, on behalf of CDRCDR Rasulnia 

and myself that I especially would like to recognize at this time who, without their efforts, hard 

work and dedication, we would not be here this morning: So I would like Molly Sauer, April 

Taylor, and Miatta Dennis to please stand to be recognized. 

(Applause)

CAPT Craig Wilkins cont’d: As most of you know, we are currently in the midst of our 2014 

winter Olympics in Sochi and in the spirit of these games I’d like to share a story with you. 

When I was growing up, some of my favorite sports heroes were Olympic athletes and Olympic 

champions; in particular, the games of the summer Olympics. These next couple of slides that 

I’m going to show you are not meant to be exclusive but I wanted to show you a couple of my 

favorite past Olympic champions that some of you may recognize. This first individual I think 

most of you know is Jim Thorpe. Jim Thorpe was a member of the second Fox Tribe from 

Oklahoma who, in the 1912 summer Olympics in Stockholm, Sweden won the biathlon and the 

decathlon. One of the major things about Jim was the first time he ever entered the decathlon 

event was at the Olympics in 1912. Second, is Jesse Owens. Jesse Owens, an African 

American runner who participated in the 1936 Berlin Olympics. He was the first runner and 

first Olympic athlete to win four gold medals in an Olympic event. Bob Mathias who at the age 

of 17 had just graduated high school and won the decathlon in the 1948 Olympics held in 

London, England. Wilma Rudolph who in 1960 participated in the Rome Olympics and won 

three gold medals. Wilma overcame, as a young child, polio and scarlet fever to become one 

of the greatest runners ever in the history of the Olympics. I think some of you know this 

gentleman. One of my heroes, Billy Mills. Billy Mills wasthe second Native American to win a 

gold medal. Here he is in the 1964 Olympics in Tokyo, Japan where he won the 10,000 

meters. There has been no other American before 1964 or since 1964 that has ever won the 

10,000 meters. Shun Fujimoto participated in the 1976 Montreal Olympics and one of the 

things that impressed me the most about him, he helped Japan win the team gold in the 

gymnastics on a broke knee. How he could stand during poll vaulting and on a pommel horse 

and the rings, doctors there could not understand. And finally, Nadia Comaneci. Nadia won 

the gold medal in the 1976 Olympics also held in Montreal. She was the first gymnast ever to 

score a perfect ten in gymnastics competition. But probably my favorite Olympic athlete who 

wasn’t even a champion and actually finished last in his event was John Stephen Akhwari who 

was a young African runner who participated in 1968 Olympic games in Mexico City in a 

marathon. Early in the race he was pushed down and fell hard, severely injuring his knee and 

leg. But he continued to try to run even after his coach told him to stop running, and other 

competitors told him to stop running. But he continued on. 

5 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
(Video)

CAPT Craig Wilkins cont’d: Like John, I think each of us at some point, whether in our 

personal or professional lives, have fallen but we’ve gotten back up. Some are battered, some 

are bloody and perhaps with pain hobbling our ever step we have endured with courage in the 

heart to continue in the race our creator has placed us in. I hope these next two days will allow 

us to continue to strengthen and to start new meaningful dialog and consultation with you, the 

Tribal Advisory Committee, and to answer the question John did. We are here not only to start 

the race but to continue and complete the race in improving Native public health in our 

American Indian and Alaska Native communities. I would like to close by quoting my favorite 

Olympic saying out of respect for each of you. Ask not alone for victory but ask for courage, 

for if you can endure, you not only bring honor to yourself, you bring honor to us all. Thank 

you.

Councilman Chester Antone: Thank you, Craig. I would like to ask CDR Rasulnia to the 

microphone and we’re now into our Tribal Advisory Committee business. So if Bobby could go 

ahead and—or actually I have Bobby Rasulnia and April R. Taylor, but I did ask April if she had 

gotten everybody at the table as far as roll call is concerned. Have you gotten everybody, 

April?

April R. Taylor: Councilman Antone, we have everyone except for Principal Chief Hicks. He is 

on the way. And Council Member Andy Joseph, if you are on the phone, if you would please 

send us an email and let us know your confirmation. Everyone else is at the table.

Councilman Chester Antone: That’s Andy Joseph and Mr. Hicks?

April R. Taylor: Yes.

Councilman Chester Antone: Okay, thank you. Now I’ll turn it over to CDR. Rasulnia.

CDR Bobby Rasulnia: Good morning everybody. Thank you for being here. We’re looking

forward to the next couple of days. What we wanted to begin with is TAC business with 

Chairman Antone and then discuss the proposed TAC engagement framework. Chairman?

Councilman Chester Antone: I want to begin our discussion today by going over our roles and 

responsibilities here as members of the TAC. We’re asked that we all make a good faith effort 

to attend all the meetings. If you can, be sure to send your authorized representative. Also 

the area reports that the Tribal Support Unit send out, it has been changed from the previous 

one that was quite a long form. But the objective of those area reports is to give CDC some 

idea of what’s going on within the tribal nations and they also use that for planning purposes to 

be able to address policy issues that they may see throughout the Indian country. And thirdly, 

our dissemination of information to local area tribes and we need to make sure that we give the 

6 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
area tribes the information we receive from CDC or anything else they need to know. I know a 

lot of areas have health boards and I think that would be a good place to do it, so everybody 

has information. Also we need to be aware of our area health needs as far as public health 

needs. Anything that has to do with CDC we need to make that known either through our area 

reports or here at our meeting so we can try to address that somehow. I wanted to say that 

much to all of us. I think we’ve all been here in these positions long enough to know what we 

really need to do in order to provide that voice for the tribal nations and being able to consult 

with the federal government, as governments ourselves also and I think that is the most 

important thing we need to exercise,so that is our role and responsibility. So from here on, I 

will give a brief update on our recent Secretary’s Tribal Advisory Committee meeting which 

occurred last week in Washington, D.C. I’m only going to go over the remarks that were made 

to the Secretary of Health and Human Services, Kathleen Sebelius. The first priority that we 

went over with Secretary Sebelius was the consultation item that needs to be upheld to the 

highest level and that’s what we’re doing here tomorrow, consulting with the CDC and that 

comes from a long history of the United States recognizing Indian tribes when they first arrived. 

Even before it was called the United States they realized they had to deal with the populations 

that were here already and that began the consultation process way back then and it is 

addressed in the Constitution of the United States. So that becomes really important when 

raised to the level that we understand, that we are at that level to converse with the federal 

government on an equal basis, and that’s one of the things that we hold dear but we also—Mr. 

Bryan Gladys. President had relayed that to the Secretary. The next major issue that we 

entertained was the contract support cause and I think you all pretty much know how important 

this is for tribes to be able to get their contract support dollars and we recognize that we should 

be on the same standing as I’ve heard mention. Some of the defense contractors will get all of 

their contract support but why aren’t we getting that, and over a period of years it has grown to 

such an amount that now we’re forced to kind of have to take some out of IHS, you know, Dr. 

Roubideaux has said that we got an increase—Indian Health Service got an increase. That 

may be so but it’s actually a ten million decrease because when you pay out contract support 

cost, you’re tapping into your allocation for direct services. But I think that will work out as we 

go forward and that’s why we work with the Indian Health Service and figure out ways to 

minimize impact to the tribes because contract support costs are important. When you look at 

years from now, 20 or 30 years from now, tribes maybe able to leave IHS with their trust 

responsibilities and have everything at the tribal level being managed by the tribe, that may be 

the goal but in the meantime we need to go through the pains of doing that. Also to the 

discussion we had with exempting IHS from the cost and reduction on the long haul, some 

tribes had navigator issues. One of the issues is the tribal ID’s and the lack of knowledge 

about the Indian Health Service from the calling centers. We have limited understanding of the 

Indian Health Service and language aspect of the navigator centers. The other items that we 

brought up were the 477 programs that tribes have. Some have it with the states. In fact, in 

our situation our tribe flows through the state, we don’t have the 477 as on our own. The 

Indian Health Act, we also have as a priority from last year. The Secretary sent a letter to the 

governor or the Director of the Child Health.

7 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
Vice President Rex Lee Jim: Thank you Mr. Chair, members of the committee. I would 

recommend that we act on this later on during the day because we haven’t had the chance to 

read it or consult with those who are representing us. Maybe that’s one of the reasons why 

nobody is seconding it because it’s the first time we’ve seen it. It’s several pages and.... 

Councilman Chester Antone: If that’s okay with Ms. Abramson who made the motion, we’ll go 

ahead and do that and address it at a later time, this afternoon maybe. Is that okay with 

everyone? Okay, we’ll go ahead and do that and address it at a later time. So at this time, I’m 

going to continue with two other items we have for our TAC business. Our summer Tribal 

Advisory Committee meeting which is usually held in Indian country we’re going to need at 

least maybe three locations. If anybody wants to submit to host, please let the advisory 

committee know. We do have some issues on that. We need to maybe find out if we’re under 

the federal government office building still or can we waiver that. Does anybody know? Do 

you know, Judith? I believe we can ask for a waiver from the Secretary if we wanted to hold 

our meeting outside of a federal building in Indian country because that was one of the 

mandates they made, so I think we can go through Stacey Ecoffey at IEA and have her ask to 

waive that so we can have it in a tribal site. So we just need to clarify that and hopefully we’ll 

be able to do that. I know we had entertained—once before but it wasn’t working out because 

of the short notice, I guess. So we welcome any suggestions. Three would be good so we 

could see which location, what the variables are.

Cathy Abramson: I just recommend when it’s not in the winter. I recommend our place but not 

in the winter.

Councilman Chester Antone: Okay. Vice President Jim?

Vice President Rex Lee Jim: I think the other restriction with it, I’m not sure whether they left it 

there, is not to have it at a casino and resort, but if it’s owned by Native, is it allowed?

Councilman Chester Antone: Yeah, I think what restrictions they made at that time was that it 

had to be a federal building, and I think that we could ask for a tribal site outside of a federal 

building, then I think that would open up the casino thing because as you recall the 

transportation services administration did a lot of partying so that’s why they put a restriction 

on us but, you know, if you agree, we can go ahead and try to ask if any area submits to host 

and they want to hold it in their casino, we can include that, ask and see if we can get that. 

Broken Arrow is a good place I think. Never been there, but... Better quit while I’m ahead. 

Okay, the other—and please just let us know, let myself or April or Craig know if you’re 

suggesting to host. I’m now going to go into the Tribal Advisory Committee engagement plan 

and I want to thank Ramona Antone-Nez. She is, I believe, the only one that submitted 

comments to that and we appreciate that very much. And I just wanted to let you know, 

especially now with the federal budget as it is, I think it’s going to require us more and more to 

engage with CDC as well as other agencies that some of us sit on those Tribal Advisory 

Committees to find out other ways of doing things because an example is I’ll be submitting 

8 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
testimony and I’ll be talking to what we call the Rocky Mountain Spotted Fever issue in 

Arizona. One of the things that was suggested early on was if we could engage the military 

industrial complex as far as kennels are concerned because they can make preparation for 

housing inmates pretty quickly. So if they can do that, why can’t we try to get them to try to 

come on to tribal nations to build things of that nature or even to provide services. In Arizona I 

think we’re toying with that idea. In fact, I think they’re kind of looking at having the Army spay 

and neuter. So those kind of elaborations is what we really need to look at and this 

engagement plan becomes very important because then the TAC is engaged in that. It is 

important, too, because in years past, at least in 2007 when I was first appointed to this 

committee by the Tohono O’odham Nation, we always had this issue with CDC and probably 

other federal agencies but from my experience here we’ve always had this issue where we 

provide testimony. We provide the needs at consultations that the tribes provide information 

and testimony but we never get a response. It falls into a vacuum of sorts and so that has 

been one of the main issues we’ve had as the TAC needs to know where our testimony goes. 

Is it just an exercise that we do? And is that all there is? We do need to get that response 

from CDC, so that’s where this Tribal Advisory Committee engagement plan comes to the floor 

because we are here and we need to recognize that we deal with the CDC on a governmentto-government level and therefore we need to get in there and work with CDC and see what 

good we can do. That has been one of the main issues and we do have this engagement 

plan. Of course, there’s going to be questions coming up. Some of you may have concerns 

as far as the engagement plan is concerned. It’s a living document and we can play with it, but 

the important thing to remember is we need to continue that role and our roles as elected 

officials to be able to do that with CDC, and CDC on their side also needs to recognize this 

government-to-government relationship and take it seriously because only if both of us tribes 

and government take it seriously then we can move ahead. Mr. Gilbert?

Tim Gilbert: Thank you Mr. Chair. I’m glad you shared that. I guess I had a question about 

the process of information you just shared with regards to minutes and testimony, etc. and this 

is a formal consultation so my question kind of is a little bit about these past minutes but 

maybe more about how this meeting is being captured both minutes and testimony, I guess. I 

have a question about the very topic you just spoke to. This appears to be the conversation 

that the representatives had at that February meeting. I don’t see any motions in here but was 

there a tribal testimony that accompanied or supplemented the minutes, and maybe more for 

my own benefit how this meeting is documented, somebody’s probably capturing our dialog 

here via similar minutes, but are motions not a part of the formal process for the TAC? In other 

words, when you hand this over to CDC and this is what the tribes want to share, is it the 

minutes that you’re turning to in terms of guidance or is it the testimony or both, I guess. 

Thanks.

Councilman Chester Antone: I think both because I know there’s issues that come up in the 

TAC meeting that are important and have something to do with the tribes and what their issues 

are but more importantly in consultation where we’re actually submitting testimony and I think 

that a lot of the issues that when CDC goes back into the minutes and the recordings, then 

9 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
they’re able to glean what those issues are. So I think it comes from a combination but more 

so in the consultation arena where they’re right there. CAPT Wilkins?

CAPT Craig Wilkins: Yes, in a few minutes when CDRCDR Rasulniagives his update on the 

TAC Engagement Framework, that was one of the things that we noted that CDC as an 

agency had to have more consistent feedback not only from our minutes but the 

recommendations that were coming out not only from the senior leadership roundtable 

discussion but also during formal tribal testimony. So we felt that CDC as an agency needed 

to have more consistent effective communication that went back out to the Tribal Advisory 

Committee meetings and capturing all the dialogue that occurred during the consultation.

Councilman Chester Antone: With that, I’m going to turn it over to CDR. Rasulnia on the 

engagement plan.

CDR Bobby Rasulnia: Thank you Chairman. As Chairman Antone has mentioned, this has 

been a dialogue in the last seven months about how to formalize the process of capturing the 

requests coming from the TAC and how CDC can be able to address those in a systematic 

and timely fashion. So what we’re going to present today is a draft version of a framework we 

have put together with the 2013 TAC members, and I know those of you that are new haven’t 

had a chance to really look at this, and we’ll talk about next steps and how you can contribute

to the design and framework itself. As Chairman Antone has mentioned, really this came out 

of the fact of how are we going to implement the CDC ATSDR TAC policy and what are some 

of the activities that we can begin working on throughout the year and enable some consistent 

and regular communication with the TAC and CIO offices so we become, at the tribal support 

unit, a facilitator in addressing some of the issues TAC will bring up during these biannual 

meetings. The Chairman also mentioned early on in our seven months that we really need to 

go beyond the two meetings and communicate with the TAC on various issues throughout the 

year. So I’ll be providing some examples of what the plan looks like. This is, again, in draft 

format and we welcome all of your input as we move forward in the next month or so. It is a 

living document which means it does change from time to time depending on the needs that 

need to be addressed for the TAC members. Some repeat as what Councilman Antone said. 

And again, really it’s to recognize that this is a government-to-government relationship, 

implement the TAC and respond to it as requests come forward and the questions come 

through CDC itself. So the framework as we discussed with the TAC really falls under three 

large categories. One is the actual policy and consultation, the program support, which we’ll 

give you some examples, and partnerships which is both internal and external partnerships 

with our own centers and institutes and offices as well as external partners with national 

organizations and I will specifically talk to some of the work that we are beginning to do with 

NIHB tribal public health workgroup which is meeting this Friday at the Emory conference 

center I believe. And we’ve taken some snippets of activities and objectives out of it. You will 

find in tab 10 the draft TAC engagement framework and plan, so please refer to that. We will 

be asking for your comments in the next month or so. Again, when it comes to the policy itself 

this is designed to implement it through the TAC. Any questions that come through any 

10 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
presentations that have been requested by the TAC or whether it is through tribal testimonies 

we do have today five note takers on top of the recording that is being done for the 

transcription of the notes that are capturing the issues that come up, and today you’ll have two 

opportunities to hear back what those issues are so we can all be on the same page as to how 

CDC is going to respond to those within a given timeframe. So one will be at 11:30 where our 

note takers will be summarizing and giving back those issues that the TAC wants to hear and 

one will be at 5:00 o’clock again so we are all on the same page. And this implementation of 

any issues that come up through the meetings or consultations or testimonies, as you can see, 

has a timeframe on it as to where CDC has to respond back. Now, it may not be directly 

through the tribal support unit because a lot of these are program-specific questions. Again, 

we are going to be facilitators of gathering that information asking the CIO’s to respond to it 

and filter it back to the TAC itself. Some highlights of some of the program support. Again, 

what we are going to be doing is we need to have a stronger relationship between the TAC 

and CIO’s. We do know that some of the centers, institutes and offices within CDC already 

directly work with tribes and national partners, but to have some more coordinated and 

consolidated way of capturing some of that information through our facilitation back to the TAC 

so you do know what is happening across CDC at any given point in time. This also will 

include a quarterly—on top of the minimum monthly calls with the TAC—a quarterly call on any 

specific issues or new information that CDC is working on with tribes that we’ll be coordinating 

through the TAC as well. So it’s going to be a full engagement throughout the year beyond the 

two meetings that we do have. And one of the specific activities here is to take the 

recommendations, comments and tribal testimonies and either respond to them or begin 

working with our CIO’s to develop resources for dissemination which I believe is another new 

concept, and Chairman Antone was very adamant about being able to take that information 

and making it into a service whether it’s technical assistance, resource delivery, so we are 

going to be working on operationalizing each of those requests that come through tribal 

testimony or those requests. The other one as I mentioned earlier, is to really begin 

strengthening our relationships internally and externally to have some visibility for the TAC 

within our centers, institutes and offices, and be able to have that dialog outside of this formal 

meeting structure that we do have. So we’ve already made some rounds with our CIO 

leadership to begin thinking about how can we engage them in working with specific needs of 

the TAC. The other one is, again, reaching out to our external partners and the National Indian 

Health boards has been a great conduit for us. We have a new cooperative agreement with 

them that is developing a tribal public health workgroup to address some of the Indian Health 

board issues, and they have just provided us a list of their new membership that is also going 

to be providing a lot of the technical advice to our members as well as any questions arise. So 

it’s going to be a great partnership. We are also looking for them as a conduit for resource 

gathering and dissemination in and out of CDC so we’re really looking forward to the new 

cooperative agreement and the relationship that we have within NIHB and we are looking to 

strengthen some of the other relationships but that’s a work in progress at this point. The next 

steps for this, since there are eight new members is to be able to gather your comments and 

reviews within a month of our next call, so I’m hoping our next call is going to be in two weeks. 

I think that’s one of the things the Chairman will be discussing later on. From there, gather 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
your comments and then take it to our CIO’s because we know that they are going to be—half 

of the equation here, they are the subject matter experts, they are the programs, and see how 

we can bridge that gap between the TAC members and our CIO’s especially, and the same 

thing really goes for working with our partners. So this information is also going to be shared 

with our partners outside of CDC and see how we can, as a trio, work together to address 

some of the TAC concerns. We have already started implementation of the 2014 draft 

engagement plan. The other activity that the TAC has requested in the past is looking at 

strengthening our relationship and activities with the Indian Health Service. Captain Craig 

Wilkins and I were in D.C. two weeks ago meeting with the Indian Health Service on what are 

some of the work that we could do either through the Tribal Epi Centers or through the policy 

office on examining what are the current activities or MOU’s that we do have with IHS 

consolidating those and sharing that information with one another, and from there begin 

developing a game plan on how to bridge clinical services that they provide to the population 

health based services that CDC provides. So we are already beginning to implement some of 

the concepts that the TAC has provided in the plan itself. We hope to get a lot of comments 

from you on the plan and hopefully formalize it within a month after our next meeting. Thank 

you.

Councilman Chester Antone: Thank you, Bobby. We’re kind of far ahead on the agenda so 

we’re gonna go on a break in a little bit but I just want to make one final point, that the Tribal 

Advisory Committee, by its very name, advises CDC on things they may have questions on so 

I think it is incumbent upon the CDC to ask the Tribal Advisory Committee about any issues 

they may be seeking advice on from Indian community because if you notice the format, we’re 

kind of the same way. The TAC meetings from before we have presentations, we have a little 

business, then we have presentations after. But this go around the Tribal Support Unit did ask 

what exactly we wanted from these presentations and developed a format to how the 

presenters are going to make their presentations to us and trying to answer some of the 

questions in the format that we wanted them to do it in. I think as we move forward, one of the 

items we may want to address is maybe we might want to have a discussion ask for a 

particular presentation if we have issues with it and then during that presentation or after we 

could have a discussion on what we recommend to the CDC. That’s just a thought but we do 

need to have CDC ask for any issues they may be struggling with as far as the tribal nations 

are concerned to ask specifically for our input. So with that, I’m going to call for a 15-minute 

break. It’s 9:45 now so we’ll come back at 10:00. 

CAPT Craig Wilkins: Just a reminder for the TAC members, if you want to fill out your lunch 

order and give that to Miatta Dennis.....(Break)

Councilman Chester Antone: I would also like to mention that we have Jefferson Keel here 

who just came in, took his seat for Oklahoma area, and Craig Wilkins has an announcement to 

make and then after that I will turn it over to Bobby who will have some additional comments 

on the engagement plan, and then from there they will go into their tribal support unit update. 

So with that I’ll turn it over to Craig.

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forward”.
CAPT Craig Wilkins: Thank you Chairman Antone. Just one final roll call. If you didn’t get a 

chance to fill out your lunch order.....

Okay, just some clarifications and details on the actual engagement plan. In section ten where 

you see the draft, the policy and consultation section also discusses renewing the timeline and 

activities for renewing the actual Tribal Consultation every five years. That includes also the 

discussions on the charter renewal as well as the issues resolution which is, I believe, some of 

the concerns that have come up on the TAC before and how to respond to it. So please look 

at that section carefully when you are reviewing it to make sure that we are addressing your 

needs as we move along. The section that also is needing some more detail through more 

discussions with the TAC as well as the CIO’s is the partnerships section which is the very last 

section of the plan itself. We’re more than happy to put more detail in it. These are just broad 

strokes. We can divide those out depending on what the TAC feels is necessary, so when you 

are reviewing this document, please focus on those two areas especially. I’m more than happy 

to address any questions that you may have. 

Councilman Chester Antone: Okay, we’ll go ahead into the Tribal Support Unit update. 

CAPT Craig Wilkins: Thank you, Chairman. CDR Rasulnia and I would like to provide a quick 

update on our Tribal Support unit. We have a small team within the office but a hardworking 

team that CDR Rasulniaand I have had the pleasure of working with these last 6-7 months that 

we’ve been on as Acting Directing and Acting Deputy Director details, so it’s been a pleasure 

to work with them. As Dr. Monroe stated earlier in her opening remarks, CDC/ATSDR has a 

commitment to our Indian tribes through our special commitment and unique relationship with 

our tribes and are committed to fulfilling a critical role in promoting the health and safety of our 

Indian tribes. Before any actions are taken that would significantly affect our Indian tribes, 

government-to-government consultationis critical to be conducted with our elected Indian tribal 

leaders or their designated representatives to the extent practical and permitted by law. As

CDR Bobby Rasulnia just mentioned about our tribal consultation policy, and Dr. Monroe 

mentioned that as well, our first tribal consultation policy was signed off in 2005. I had the 

opportunity to be a part of a workgroup that put the first tribal consultation policy together. As 

you noted, it was updated last November and signed off and approved by the Tribal Advisory 

Committee. Basically, the update was—the main revision to ensure compliance with federal 

law and the current HHS tribal consultation policy. As Chairman Antone mentioned earlier, our 

TAC charter was also updated basically to ensure the alignment was with our revised policy 

and then to incorporate some of the TAC member comments that came in that CDC 

responded to. The charter policy basically again reaffirmed through CDC and ATSDR that we 

will try to honor the sovereignty of our Indian tribal governments, respect the inherent rights of 

our Indian tribal self governance, and then continue to work and collaborate on a governmentto-government basis. Tribal Advisory Committee, as Chairman Antone mentioned, you as a 

TAC advise us, the CDC and ATSDR on policy issues and broad strategies that affect native 

tribes and people. The full core of TAC members is 16 and as Chairman Antone and Dr. 

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forward”.
Monroe stated earlier, we just completed our recruitment process where we have now 13 new 

TAC members. The 16 members are made up of representatives, one delegate and one 

authorized representative from a federally recognized tribe in each of our 12 IHS areas, and 

then from our federally recognized tribes at large we have one delegate and one authorized 

representative from each of the four federally recognized tribes. We have several things within 

our role within the Tribal Support Unit within OSTLTS. One is we try to serve as a conduit 

between Indian country and CDC, and one of the things as CDR Bobby Rasulnia stated in his 

earlier remarks about the engagement plan, how important and critical that is that we serve as 

kind of what we call that go-between CDC and Indian country. We uphold the tribal 

consultation policy that was just revised and voted on last November. Our role was to help 

facilitate and be a part of the Tribal Advisory Committee for our two biannual meetings and our 

work throughout the year on issues that the Tribal Advisory Committee, you as its body, 

presents to us. Then our office, we try to provide subject matter expert, technical assistance 

and policy guidance not only through our office but also through CDC leadership and those 

CDC/ATSDR staff that are involved in working out in Indian country on public health issues. 

And then one critical piece of this is our work in trying to liaison more with the department and 

some of our federal partners which is key. One of the things that CDR Rasulnia and I, when 

we came on board in this detail role, we were asked to look at our Tribal Support Unit 

structure. So in meeting with staff and meeting with OSTLTS we kind of came up with four, 

what we call buckets of operations that we felt would carry us forward in working out in Indian 

country being a small Tribal Support Unit. First of all, communication. I cannot stress how 

important communication is, not only internal to CDC staff and CDC leadership that we work 

with, but of course external. Communication around policy and communication around 

reporting. Our technical assistance and partnership support, and our extramural funding. Dr. 

Frieden will be giving his CDC Directors’ update tomorrow and talk a little bit about funding and 

budget and then we have our very critical important presentation tomorrow about budget and 

funding that’s going out to Indian country. Our CIO engagement. That’s one of the things that 

CDR Rasulnia and I have been involved in, knowing that it was critical that we work with our 

CIO’s here at the agency on tribal issues. And of course, our partners and stakeholders that 

we collaborate with and network. And then, of course, our Tribal Advisory Committee 

recruitment. We just completed I guess I would say our first wave of recruitment. We still have 

three seats remaining as Chairman Antone mentioned. That process of recruiting for those 

final three seats will occur after this meeting is over. We have two biannual meetings; our 

fall/winter meeting, we are here today, and then our summer meeting as Chairman Antone 

mentioned that we would like for you as a Tribal Advisory Committee to start thinking about so 

we can start making preparations for hosting the meeting somewhere out in Indian country. I 

mentioned our charter. Our charter is being revised to align to our revised policy and as 

Chairman Antone mentioned, looking at it once we fill our remaining three seats on any issues 

or questions that come up about the charter that we could address those at that time. And 

then part of this continuing engagement that CDR Rasulnia mentioned that we feel as CDC 

and we feel as a Tribal Support Unit, needs to have more of it continuous engagement with 

each of you as well as our Tribal Advisory Committee. And then any management and 

logistics. Our staff back here, April in particular, is your go-to person with some of these 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
management and logistics issues. And then management operations. As I mentioned, we’re a 

small staff. There’s just a few of us. We do not really have a budget per se. Our budget 

comes under the budget ofour overall OSTLTS budget. And one of the things that CDR 

Rasulnia is going to focus on in his remarks is to talk about data management and how 

important that is. And then our internal infrastructure. As I mentioned earlier, we revised the 

CDC tribal consultation policy that was signed off and voted from the TAC last November. We 

updated our TAC charter. We initiated recruitment for our 11 open TAC seats, and as I 

mentioned we have three yet remaining that we need to fill. Then we begin work with six 

awardees under the tribal public health capacity building and quality improvement cooperative 

agreement which was a new FOA. 

CDR Bobby Rasulnia: Great. Out of this slide I want to concentrate on bullet three as well as 

four and five. One of the things that we notice is a gleaming gap in our work with tribal nations 

is again partnerships, and our first cooperative agreement that we really have with our partner, 

with National Indian Health boards, has turned out to be a real complement to some of the 

activities that TAC has been doing and I believe will be in concert with what they will be asking 

for from CDC. Caroline, I don’t want to steal your thunder but I’m gonna kind of talk about a 

little bit of the activities here. I know you were talking with them as well on Thursday. But what 

we have done is the tribal public health workgroup is going to really be looking at some of the 

funding issues that CDC has identified for either direct or indirect funding to tribal nations. It is 

also going to focus on some of the data and surveillance gaps within Indian country whether it 

is looking at heart disease and stroke, for example, and how to collect data, or YRBSS and 

BRFSS standardization and the ability to incorporate that within the CDC BRFSS and YRBSS 

frameworks. They will be doing a presentation for the TAC on Thursday as an example of 

some of the activities as well as for the workgroup. And the other gleaming gap that we do 

have here at CDC is at our emergency operation center. There really is very little awareness 

of where to go access travel information and be able to get a situational awareness on tribes 

during emergencies. And one of the things that through the cooperative agreement that we 

are doing through the vulnerable populations desk at the EOC is to put NIHB who really does 

have the pulse of a lot of the activities around the country with them to be able to identify how 

to begin devising a plan approach and resources provided to CDC in order to be able to 

access tribal data and tribal information as events happen. There is an activity through the 

cooperative agreement that we’re also working on which is the Anthrax Dark Site. So when an 

anthrax event happens, this site will pop up and what we’re doing through the NIHB 

cooperative agreement is providing those resources for outreach to be able to both notify as 

well as gather intelligence within communities about an event such as Anthrax. Now, I’m sure 

this is the beginning of many types of activities like this for emergency preparedness and 

response, so these are just several glimpses of work we are beginning to do through out 

partnerships. There are many more activities such as the public health stories from the field 

that OSTLTS manages. NIHB will also be coordinating, gathering some of those stories to be 

published and disseminated through all of the state,local,tribal,territorial health departments as 

well as through avenues of NIHB to show successes of public health interventions and 

programs across the nation. And that’s one thing that we really have lacked here at CDC is to 

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highlight those successes and this will be one avenue out of many such as the “Did You Know” 

product that OSLTLS puts out, the “Have You Heard”, which I believe Dr. Monroe will be 

talking about tomorrow. So part of it is to get information out, part of it is to provide CDC with 

the information that it lacks, and really understanding where tribes are when it comes to issues 

such as emergency preparedness. So it’s going to be a great partnership, I really do believe, 

and this is a five-year cooperative agreement which more work through that is going to be 

coming along. Of course, TAC will be not only notified but asked to provide input on some of 

this work that is happening as part of our contiguous engagement through the engagement 

framework that we discussed earlier. So we are working to implement that as fast as possible. 

The other thing is the consolidation of our data management system. We get a lot of requests 

from both HHS as well as other entities including within CDC that want to know an X issue 

about tribes, or it’s a consolidation of funding that is happening through CDC which you will be 

hearing about tomorrow afternoon through the CDC budget discussion. This data 

management system is being looked at; it’s a SharePoint system that’s going to be developed. 

We’re consolidating the number of requests and the timing of the requests so we don’t go out 

to our CIO’s and ask too many times on what data we need that we need to report either up 

the chain or within the CIO’s. So right now we’re under the requirements gathering phase of 

the project identifying variables and timelines and the types of reports that we want to come 

out of this, either ad hoc reports or standard reports. Within the next two months we will be 

coming to the TAC to look at the framework itself on the data management plan and see if 

there’s any gleaming issues we’re missing that could provide input for either any types of 

reports that are required by you, by HHS and federal opdivs and even within our CIO’s. We 

will be going to our CIO’s as well to not only test the system but also come up with a protocol 

of timeline of how we can collect a lot of this information. Most of the time when we send this 

information out, it’s always an emergency, it’s always due in two weeks’. We’re trying to 

change that both internally and externally. So it’s a huge project and I hope that we’re able to 

show this to you in the next two weeks or so. This data management tool is also part of the 

issues resolution that we discussed earlier so anything that comes out of the tribal testimonies, 

any technical assistance that is requested either from individual tribes or the TAC or our 

partners or even within CDC, this will help document and begin looking at patterns of 

information that are requested from us and be able to predict some of the things where we can 

be proactive and respond to them. So it’s a huge project but definitely worth it and needed. 

The other thing that we are also going to be working through the TAC as well as the NIHB 

workgroup is going to be the redesign of our Tribal Support Unit website within OSTLTS. It 

took a lot to put the current website together and now we’re taking the next steps of 

customizing it to both tribes as well as the TAC, to our external partners and then to the CIO’s 

here within CDC. So we’re in the initial phases of looking at what the structure of this is going 

to look like and how we’re going to be that conduit, that facilitator of information in and out of 

CDC. We get requests right now from a tribe or a TAC member that wants information out of 

some section of CDC, and right now we have to really work, in not so much of an efficient way, 

of getting that information from the CIO back out to the TAC. So what we want to do is try and 

provide as much information that is a priority to the TAC as well as to our partners and tribes 

on this website. Again, this is a pretty big task but we are going to be coming to you for both 

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forward”.
the design of it, the beta testing of it and looking for the type of information that you would like 

to see on this website as well as the usability testing that our communications office will be 

doing on this website. Big task. May take a few months. Please be patient with us. The 

design phase is the most important. If we can get the design right this time, what we can do is 

just built upon it from thereon. Any questions? Thanks.

Councilman Antone: That is our update from the Tribal Support Unit. If there’s any specific 

questions that you don’t want to ask at this setting, you can always approach Craig and Bobby 

and ask them what you need to know from them, so feel free to do that. At this time I’m going 

to move over to the National Center for Environmental Health. Cathy?

Cathy Abramson: I don’t have any questions, just a comment. I just really am excited about 

how well this is set up and I think it’s going to be really nice and informative. So I look forward 

to seeing how this all works out. Looks great.

Councilman Antone: Thank you, Cathy and I might add that it was NIHB who requested that 

there be an office set up for tribal affairs. This is it. Okay, I’m going to turn it over to Annabelle 

M. Allison, National Center for Environmental Health, Agency for Toxic Substances and 

Disease Registry, Office of Tribal Affairs update.

Annabelle Allison: Thank you, Chairman. Good morning everyone. My name is Annabelle 

Allison. I’m a member of the Navajo Nation originally from New Mexico. I’ve been with CDC / 

ATSDR now for just under six years. It’s gonna be six full years in April of this year. I work for 

another tribal office here at CDC/ ATSDR and it is for the National Center for Environmental 

Health and the Agency for Toxic Substances and Disease Registry, or ATSDR for short. 

ATSDR is involved in hazardous waste issues and helps to prevent or mitigate the harmful 

effects of exposure to hazardous substances on human health. And so a lot of our focus at 

NCEH and ATSDR is around environmental health topics and toxic and chemical exposures. 

Although it is a separate office from OSTLTS we do collaborate very closely with each other. 

We stay in contact and, again, want to thank you for inviting me to come and speak today. I’m 

going to talk a little bit about some activities that my office has been engaged in over the past 

six years and more heavily what’s been happening in the last couple of years. So I’ll talk a 

little bit about the executive, our mandate and our efforts to really work towards policy 

implementation of tribal consultation and coordination, and then I’m going to talk a little about 

an initiative that I began in 2011 called the National Tribal Environmental Health think tank, 

and of course my office has been facilitating the Working Effectively with Tribal Governments 

course, and then lastly I’ll follow up with some updates on our epidemiological study known as 

the Navajo Birth Cohort Study. So as OSTLTS, as the folks here from the Tribal Support Unit 

have reiterated a lot this morning, we really are trying to ensure that the mandate of 

consultation coordination with tribal governments is increasing. One of the things that I’ve 

been doing with my center is to engage with the various divisions and really discuss ways we 

can encourage coordination and consultation with tribes on concerns they may have regarding 

hazardous waste sites or public health concerns from chemical or toxic exposures. We also 

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have been identifying mechanisms where we can invite tribal representatives from across the 

country to participate in some of our national partnerships and committee that we have going 

on at the national level as well. We really try as much as possible to utilize the tribal 

consultation policy as well. In the past I think a lot of discussions had occurred primarily 

through state and federal government discussions, we are really trying to push more to ensure 

tribes are at the table for some of those discussions that impact them. And, of course, we also 

have the HHS tribal consultation policy and annual reporting that we engage in as well. So the 

National Tribal Think Tank, Environmental Health Think Tank began in 2011 and really the 

goal with this was for me to develop a strategic plan for my office. At the time I was there, I 

was three years into the job and one of the things I really noticed was we really needed to build 

a foundation and to build sustainability, and I needed some input in what the direction of the 

office we wanted to take. And I felt like if I could do this, I could kind of gage it by talking to my 

colleagues out there but I wanted to ensure that the input was coming from them and it was a 

really keen difference because I went in with a certain idea of what I thought the priorities 

would be and actually came out with entirely different priorities. So this really was a very 

advantageous effort. So the thing I also wanted to ensure was that we were making the most 

effective use of my office’s resources by establishing and focusing on key priorities. In the first 

year with this think tank what I did was recruit 12 tribal professionals from across the country 

who were either first in public health or environmental issues, or who were new coming into the 

field. It was a very diverse pool. We had experiences versus new incoming young 

professionals but we also had very different regions that were represented throughout the 

United States, and we also had the public health professionals and those who were engaged 

in the Environmental Protection Agency side that came together. It actually was a very 

successful engagement. One of the first things that we worked on was to develop a vision and 

mission for my office. In the mission, the portion, we really discussed to a great deal what we 

wanted our pillars to be, what we wanted the foundation of the office to be, and policy 

implementation, communications and outreach, equitable distribution of resources, training, 

education and workforce development, collaboration and partnership and technical assistance 

became those pillars. And with policy implementation, of course, the first thing they said they 

wanted to be clear was to ensure that we coordinate and consult with tribes on issues that 

affected their lands, their jurisdictions, their people. The second thing that we wanted to do 

was more communication and outreach. We really wanted to talk and give visibility to some of 

the issues that tribes were facing. In terms of equitable distribution of resources, one of the 

things with CDC that many tribal professionals have conveyed is that a lot of the funding, 

though it is congressionally mandated funding, tends to go to states and local entities and they 

want to discuss mechanisms for how we could either make it—create a path for direct 

appropriations or at least engage more closely with the states on some of the priorities that 

have been established that involved tribes. Training, education and workforce development, 

this one was really key because there is this emphasis now on really wanting to increase the 

number of American Indian Alaska Native professionals in public health careers so we’re trying 

to look at mechanisms that we can engage in order to accomplish this here at CDC. And then 

collaboration partnerships, reaching out to others whether it be tribal serving organizations, 

other tribes or other state and local national organizations to really get the word out and to see 

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forward”.
if there’s avenues for partnerships. And of course, technical assistance. As I mentioned, 

ATSDR, a lot of our work is engaging on issues around hazardous substances or chemical and 

toxic exposures and so we want to ensure that the appropriate technical assistance is there as 

well. The ground work for the Office of the Tribal Affairs was also established with the first 

year of the think tank. They said to the Office of Tribal Affairs, as you do this work, remember 

these key things: respect the sovereignty and self governance of tribes; acknowledge trust 

responsibility; recognize the spiritual and cultural uniqueness of tribes; apply the seven 

generation teachings; honor the use of traditional knowledge and recognize the relationship 

between culture and environment and encourage transparency teamwork and collaboration. 

It’s really been helpful to have these as my guiding principles as I do the work and as I engage 

with my colleagues internally, and as we work with other national organizations out there. It’s 

amazing how much education and communications is required to really have an understanding 

of the importance of why tribes need to be at the table for many discussions. These are just 

some pictures of our think tank members in action. So we finished year one and the goal, 

again, for year one was really for my office to establish a strategic plan and at the end of the 

first year’s efforts, the think tank members really felt like they were getting a lot out of the 

collaboration we had created, and so they asked us to continue the think tank into year two. 

So last year one thing we did was increased the membership to 14 members and then we 

focused on establishing five top priorities that we would then take forward to really focus on in 

the future. And the things that came out included food safety, resource extraction, 

infrastructure and system development, climate and health, and clean air. One of my tasks out 

of year two is really to begin working with the NCEH/ATSDR divisions to address the different 

priorities that are listed. Yes, sir?

Vice President Jim: I’m just curious as to why water is not up there because in Navajo you 

have that uranium contamination to water and everything.

Annabelle Allison: That’s a great question. Water was definitely up there. It was probably the 

6th one in terms of priorities but when we came together in year two, we did an exercise where 

we asked the tribal professionals to go out and talk to their colleagues and find out what they 

would consider some of the top priorities as they did their work. So they brought back these 

priorities and we probably had at least 25 or 50 different topics, and we had to get that down to 

the top five and we discuss the different items and had different individuals break out into 

groups and have discussions, these top five came out. And that’s not to say that we still won’t 

discuss the other priorities, it’s just these top five are what we’re going to work on over the next 

immediate year. But water was definitely a close six. Yes, sir?

Vice President Jim: On your category of climate and health, would that include things like 

droughts?

Anabelle Allison: Yes.

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Vice President Jim: Okay, because in Arizona at least we’re being impacted by this long 

number of years of drought and getting a little concerned with the lack of moisture, and I guess 

I’m beginning to really believe in this warming of the climate myself. So that’s really 

concerning because our cultural practices depends largely still on our ability to do dry farming 

but without the winter and even summer precipitation it’s just getting dryer and dryer so we’re 

really concerned about that area as well.

Anabelle Allison: Thank you. Yes, climate and health is definitely inclusive of drought and 

public health so we’re looking at it from the public health perspective definitely. In fact, in 2012 

we did host a series of four webinars talking about climate and public health and one of those 

webinars was specifically geared to American Indian and Alaska Native populations. And for 

that particular webinar we did have a large turnout. I believe we had something like 180 

participants in that and we had several speakers from various tribes and tribal serving 

organizations who gave the presentations and it was really eye opening in terms of the interest 

that there were out there but it was also really helpful in terms of the potential for networking 

that we can do because the participants not only included tribes and tribal serving 

organizations, it also included federal agencies, academia, national partners, and I think that 

was a really good opportunity to gain visibility. So other products we hope to get from year 

two, again, are to consolidate the different five priorities and summarize and develop a plan for 

how we want to address them. So in year three—we are going to do another year of the think 

tank—in year three what we’re gonna do is take those five priorities and really get out into the 

field and start working with different partners and different entities to see if there are ways we 

can collaborate and see if we can increase the ways that tribes are participating in some of 

these discussions. Another thing that came out of the think tank is that we were able to get a 

panel session at the American Public Health Association conference that was held in Boston, 

Massachusetts in 2013. We had three members of the think tank participate in that panel 

discussion and we also developed a video to talk about some of the issues tribes were facing 

and it was a very successful event. We got really good feedback from the participants. The 

video was really well received. And in terms of getting—again, another example of how we are 

trying to get more tribes to the table is we do now have two members who serve on a National 

Tribal Environmental Health partnership council which is hosted by my center. Yes?

Chairman Steve Cadue: This is Steve Cadue, Tribal Chairman of Kickapoo Nation. I’m an AtLarge delegate. Had several issues, questions, items. How does your office—I’ll list these 

things and maybe you can try to answer them if you note them. Climate change, of course, 

water, drought, the floods, water quality, radon gas, and the issue of fracking that’s a big 

controversy in drilling into the ground. Can you tell me how your office is dealing with those 

issues?

Annabelle Allison: We have been working on the various issues on a case-by-case basis. We 

are definitely getting more interest and inquiries to our agency about fracking, for example. 

The numbers have increased, and we kind of look at it on a case-by-case basis depending on 

what they’re asking for and really how it applies to public health and what potential exposures 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
there might be. I know the Environmental Protection Agency also is really closely engaged in 

this andwe try to collaborate with them as much as possible. If you do have any questions or if 

you are concerned and would like to inquire more about fracking, we can definitely work with 

you to try to respond to your concerns.

On the issue of water, that’s a treaty issue.

As a treaty issue, yes.

Water rights is treaty supported. Do you support or work with the Indian Affairs about water 

rights?

Annabelle Allison: We have not engaged with them, that I’m aware of, on anything in that 

realm in terms of water rights. We really just look at it from the public health perspective in 

terms if the water is safe to drink, is the water safe to use? That’s really what we focus on. 

We don’t get into the legal aspects of it.

Chairman Steve Cadue: Well, you may have heard of the Winner’s Doctrine which I think is a 

U.S. Supreme Court decision in 1908. It’s a great decision for Indian tribes —and we’re 

heavily involved in that issue, as many other tribes. But an issue that was not talked about a 

whole lot nearly a century ago was water quality. Now, of course, it’s paramount. That’s why I 

think CDC and Indian Health Service should be very supportive and provide assistance, I think, 

to the mission of water rights in the BIA. That’s more of a comment than a question to you but 

I hope that you take that under advisement.

Annabelle Allison: Thank you. So as I mentioned in the webinar series that when we did the 

one specifically for American Indian and Alaska Native populations, unresolved water rights 

definitely came up as a topic. The other thing that came up was appropriate funding to be able 

to address concerns from drought. And then I think a third one was access to resources and 

existing tools that might help tribes to address droughts. So those were some of the things 

that did come out of this discussion.

Councilman Chester Antone: One of the items back to the issue of radon gas where we’re 

detecting this emission is with Indian HUD housing and that’s another area of collaboration that 

I think we need to have you involved with. But I think that’s the charge of this committee and 

the committee has, since its inception, talked about collaboration between all of the federal 

agencies having a trust responsibility as you know very well. But the radon gas issue, we fear 

that when we get into some real intense testing in the next 30 days or so, we may have some 

real problems. We may have to go back to Indian HUD for assistance on that but, again, I 

think we’d like to call upon you for support. That’s all I have.

Okay, thank you. 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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Lt. Governor Jefferson Keel: I have a couple of questions. My name is Jefferson Keel. I’m 

Lieutenant Governor of the Chickasaw Nation. I represent the Oklahoma City area. I want to 

just focus on the think tank just a minute. We talk about developing policy and making 

recommendations on policy. How were those members selected to participate in the think 

tank? That’s number one. And recognizing it’s a small group, if it’s national in scope then are 

all areas represented? And then we talk about consultation. Is it consultation—the product 

then becomes whether or not it’s considered consultation. If not, how does it differ from tribal 

consultation because we’re talking about developing national policy and it occurs to me and I 

was just prompted to remind that when we develop policy, everyone should be involved in the 

process.

Annabelle Allison: Yes. So in terms of the membership, the one thing that we wanted to do 

was try to make it as diverse as possible. We wanted to get the regions represented as much 

as possible. We had an existing national initiative known as the National Conversation. In that 

conversation we had six workgroups and there was a tribal representative on each of those 

workgroups and we used that as the basis for developing the think tank because we knew that 

a lot of the topics that were going to come out of the National Conversation were going to fit 

pretty well with the scope that we were envisioning for the think tank as well. We knew the 

discussions around environmental health and ways that we could be more effective was really 

going to help us to move forward. So we used those six think tank members and then we 

recruited others based on region and based on experience. The other thing that I really 

wanted to do was get individuals who were funded by Environmental Protection Agency dollars 

involved as well because we wanted to make that connection between the environment 

discussion and the public health discussion. So we tried to do that as much as possible, too. 

And then the other thing that we really wanted to do was include those who were versed, who 

were experienced, had been in the field for many years and mix that with the individuals who 

were just coming into the field as well. So really tried to take different things into consideration 

with the membership. The second thing is—actually I think it was the third thing but the 

consultation question. Is it consultation? A lot of the tribal think tank members feel that it was 

consultation, and we really did try to format the meeting so that we were getting as much 

feedback as we could. We understood that we could not get everybody at the table but we 

tried to be inclusive—as much as possible we asked the think tank members to reach out to 

their constituents to gain feedback. They had what we called homework assignments where 

they had to go out and get feedback and they brought that back as well. I think I might have 

missed the question.

Lt. Governor Jefferson Keel: Well, my concern is that when you’re talking about being 

inclusive, there may be areas that have specific focus or priorities that they would want to 

focus on. Chairman Cadue talked about fracking but there are other regions in the country 

when you talk about water quality and other things that may be different, for instance, in the 

northwest when they’re talking about fish resorts and the southwest where there’s very little 

water where they have real problems with water, not to mention the quality. So I just want to 

make sure that I understand the purpose of the think tank as well as what the product is going 

22 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
to be once you finish, and then want to make sure that all areas are represented accordingly. I 

guess it comes back to my question about consultation. Consultation would then occur if it’s 

national in scope, then it should be all areas need to be included in that and all tribal leaders 

need to have the opportunity to consult prior to any decisions being made on expenditure of 

funds or how we’re going to proceed in the future.

Annabelle Allison: Thank you. Here’s another picture of the think tank members. As I 

mentioned, what we’re going to do for year three is really try to focus on engaging with external 

partners and organizations, and I guess the purpose really is—as I mentioned initially, the 

purpose was to develop a strategic plan for the office and it really is kind of a direction or a 

scope for my office to focus on because the thing that I realize after being here for several 

years is that as a one-person office you have to really focus in on certain activities and not run 

in several different directions because you really can’t, and water quality, fracking, we’ve got a 

birth cohort study that is happening that brings up the issues of uranium mining and oil and gas 

extraction. There are various things that come up and the key is really to try to address what 

you can in a focused way and that’s really what I was attempting to do with the think tank is to 

hone in on the things that we could do and do effectively. And part of that is recognizing that 

we need partners, we need to be able to collaborate with others in order to do it effectively and 

part of that is raising awareness and gaining visibility about some of the issues tribes are 

facing. So this is a mechanism to be able to do that so we really want to reach out to partners 

more not only tribal serving organizations but also other national organizations that may not 

have had tribal issues brought to the table before. So the thing that we’re going to attempt to 

do this year is really focus on external partners and organizations to continue talking about the 

different environmental health topics and the priorities and again, offer actionable 

recommendations that my office can continue to do in order to really bring forth the issues that 

the tribes are facing. So one of the things that came out of the strategic plan in this logic 

model representation, this visual representation. So what we’ve done so far is identified short 

term, intermediate, and long term outcomes and ultimately some of the things that we hope to 

accomplish as a result of some of the work that we do over the next couple of years. Again, 

one example of a short-term outcome is to increase knowledge of some of the issues that 

tribes are facing and getting out there with more agencies. And then some of the long-term 

work would be systemic change that occurs as a result of some of these discussions. And 

ultimately we do want sustainable and self-determining tribes and tribal communities. We want 

access to clean air, clean land, clean water and a holistic view of health and being able to live 

in healthy conditions. So some of these ideas we’ve put forth are ultimately for that long-term 

benefit. So switching gears now I also wanted to talk about a training course that my office 

has been engaged in for the last couple of years. It’s called Working Effectively With Tribal 

Governments. It’s a course that my office facilitates and offers to fellow CDC and ATSDR 

colleagues here. I invite two tribal professionals to serve as co-instructors and we go into a 

little bit of American Indian and Alaska Native history and then we talk about some of the 

current issues, the public health and environmental issues that tribes are facing today, and 

some of the unique cultural values that shape American Indian and Alaska Native views of 

health in the environment. It’s a really good course. It’s a two-day course. It used to be a 

23 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
one-day offering. It’s a very full course but we’ve gotten really positive feedback about the 

curriculum and our colleagues have really felt like they’ve gotten a lot out of this course. 

Chairman Steve Cadue: CAPT Wilkins, could you go back to that last slide? In the schematic 

up there it talks about supporting equitable economic development. This is Steve Cadue. 

Well, that’s a large area that we could spend a whole day on just itself, but Captain Wilkins, 

when we look at economic development not just here but in the tribal support unit and the 

mission, is there any one office that’s concerned about this issue of economic development in 

the—is there something focused about economic development?

CAPT Wilkins: Chairman, I’m not quite sure about economic development. Are you making 

reference to budget or funding type issues?

Chairman Steve Cadue: Well, we’re here to look for solutions and I think economic 

development assisting or supporting our health issues is a key, and I think we ought to try to 

put some more focus about economic development. That’s all I wanted to bring to your 

attention for now.

Cathy Abramson: Well, when I think of economic development, I think of our fishermen and 

the importance of keeping our waters healthy so our fish stay alive so that those guys are out 

there making a living with their fish, and then we have our wild rice, and if our waters aren’t 

healthy, our wild rice isn’t going to grow. You know, that’s economic development to me 

because a lot of people sell their rice and their fish. That’s economic development.

There’s three areas that I wanted to bring up. Listening to everybody reminds me of these 

areas and two are related and that is of dumpsites which have been created in the past by 

federal agencies which has now created a serious concern and its impact to underground 

water, drinking water, and local springs and so forth. The other is our one and only landfill on 

the reservation which was created some 20-30 years ago maybe and I’m not sure at that point 

what the regulations were, whether creating a landfill versus what the regulations are now and 

what we need to be able to be in compliance, is a big huge concern to many of us on the 

reservations of the tribal consult at this point. And then the third one is water, again, with us 

finding arsenic in our water for the last 15-20 years and it’s just been a really, really slow 

response by federal agencies and so now where we’re finally getting a little bit of movement in 

this area to have to work on plans to import water from within the reservation but it’s about a 

20-mile solution costing millions and millions of dollars to have to pipe it into 2-3 area myasis 

which is half of our reservation and nearly practically half of our population. And so with that 

kind of quality of water it’s very concerning to us and I’m not sure whether there are any other 

reservations with that kind of situation. So it’s kind of alarming and there’s a real huge dyer 

need for federal agencies to come in and help us out and look at the situation and see what 

can be done and hasten the response to correcting the situation. Thank you.

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
Annabelle Allison: Thank you. The landfill that you mention, is that the current one that is 

being assessed right now for uranium like previous contamination dumping? Okay. My 

understanding is that ongoing assessment is happening right now of the landfill and they’re 

trying to determine any levels of contamination that might be occurring. Thank you.

Cathy Abramson: Finally, on a previous slide you talked about several points and I’ve heard of 

the seven generations teaching and I’m not very familiar with it. You talk about having respect 

and knowledge as far as other tribes are concerned and their teaching and I’m kind of curious 

and maybe you and I can get together later on to get some more information on that. Thank 

you.

Annabelle Allison: Sure. Just real quick, the general idea behind the seven generation 

thinking was really like as you do your work, think about the impacts of future generations, you 

know, understand that our philosophy, the American Indian and Alaska Native philosophy is to 

look at future generations as we deal with the current issues today. That was really the 

philosophy from behind that, but we can definitely talk more. Okay, I think I’m running out of 

time. 

Councilman Antone: Thank you. I was curious about that seventh generation philosophy, too, 

so one time an elder informed me and said a lot of people misunderstood the seventh 

generation. What he said was, you think three generations back whatever you learned from it 

and then think three generations into the future, and based on all of that you apply it to this 

generation, this is the seventh generation, he said. So that’s how it’s—

Annabelle Allison: Yeah, that’s a great way to look at it.

Councilman Antone: Now, the other thing I’m interested in is the think tank we talked about 

earlier. I’m not sure whether we consider that consultation. I think that needs to be endorsed 

by tribal leadership to make this tribal consultation and then to send representatives there. 

The other is when we talk about food, one of your number one pillars under health, food it said. 

We’re interested also in traditional food and how to re-cultivate not only like corn and squash 

and those things that we do naturally but sometimes we need to replant traditional food, so I 

guess that’s out there in the wild because of overpopulation and overuse sometimes they 

disappear. So we need to find a way to re-cultivate in the natural environment as well and find 

ways to fund those kinds of activities because they not only function as food to nourish our 

bodies but also as medicine. They are also connected to our prayers and songs and dances 

and so it’s a holistic approach. So when we talk about food, we need to look at that as well 

and not just what we buy in stores or elsewhere. Thank you.

Annabelle Allison: Thank you. So I just wanted to quickly mention that in this fiscal year we 

are planning to offer two more Working Effectively With Tribal Government training courses; 

one in April and one in September. It is now offered through our CDC university learning 

portal. The last thing I wanted to mention is to give a quick update on this birth cohort study 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
that we are conducting on the Navajo Nation. Back in fiscal year 2010—actually 2010 through 

12 we did get a congressional mandate, a congressional appropriation to conduct an 

epidemiological study on the Navajo Nation for two million per year for the three-year period. 

And the study is going to follow a cohort of pregnant Navajo women and evaluate the potential 

associations between uranium exposure during pregnancy and the reproductive outcomes, 

and the development of the children is going to be followed during the first year of life. So we 

have just begun the recruitment process of the pregnant Navajo women and so far we’ve 

analyzed over 80 samples. It is a very comprehensive, very complex engagement process. 

We are working with several entities of the Navajo Nation. The University of Mexico was given 

the award through a cooperative agreement to design and carry out the study and we’ve also 

had to work very closely with the Navajo Area Indian Health Services to utilize their clinics and 

also for community outreach as well. We are planning to conduct a best practices training on 

laboratory sampling, I believe either in March or April of this year. We’ve also hired several—

with the monies that were appropriated—several health professionals have been hired to 

assist with in the field, on the ground activities. It’s been a very extensive collaboration with 

different entities. A lot of training had to be conducted, a lot of outreach that is still ongoing 

and numerous attempts to recruit. It’s been a really good process. We’ve learned a lot and 

we’ also really have tried to encourage the local entities to really take on a lot of the 

components of the study as well. That’s all I have in terms of updates.

Councilman Antone: Thank you, Annabelle. I have two, I have Mr. Jim and then Tim Gilbert 

and I’ll just let you know that we are approaching the lunch break in a couple of minutes.

Vice President Jim: Thank you. Two things. Those two courses you’re talking about, are 

members of TAC able to attend those or can you do a modified version for this leadership for 

one day because we also need to learn how to network and collaboration and so on. That’s 

one. The other is when we talk about best practices, I always say we need to add the word 

appropriate—best appropriate practices. Thank you.

Annabelle Allison: Absolutely and definitely taking into consideration some of the cultural 

aspects which have been very unique for the Navajo Nation. Thank you for that. In year three 

actually one thing I did not mention is we will be taking components of the curriculum for the 

Working Effectively with Tribal Government(.?. 133:38) course and offering it to national 

organizations. We’ve gotten several requests for that so we’re very happy to hear that and so 

we can definitely modify something if there’s interest in doing that. 

Mr. Tim Gilbert: Hi, Annabelle, thanks for the presentation. The chair is asking me to be quick 

so I’m going to talk fast. I had two really quick comments. One is related to the funding, the 

birth cohort study, how is that funded?

Annabelle Allison: That was a congressional appropriation that was given so from 2008 to 

2012 Congress had actually given monies to various agencies to conduct assessments and 

remediation activities of uranium.

26 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
Mr. Tim Gilbert: So via CDC?

Annabelle Allison: Yes. So the money came to us at ATSDR and we put it into a cooperative 

agreement and put it right back out.

Mr. Tim Gilbert: I appreciate that. One of the points I wanted to make was early on in one of 

your slides one of your pillars was increased resources or equitable distribution resources, and 

I guess the comment I wanted to make especially with our OSTLTS staff here is that from my 

perspective if we’re sitting here—I think one of the gentlemen made the comment that this is 

the 10th tribal consultation. I don’t think that means ten years, it means it’s the 10th, but when 

we’re sitting here for the 110th consultation, I would like to think that one of the main 

benchmarks that we took into account and show movement on is that there are more 

resources coming from the Centers for Disease Control to help tribes whether that’s through 

cooperative agreements or grants or maybe it’s people like you working with other HHS 

agencies like NIH to bring more resources to tribes. So I guess as OSTLTS kind of refines 

their plan, I think that’s in the top three anyway for me that I’d like to know that there are 

agencies like yourself or departments working with, collaborating with tribes to accomplish that, 

to get more resources and so I’d like to just throw it out there that it should be a benchmark 

that we should always be paying attention to. The second one is really quick. I would be 

remiss if I didn’t mention that the tribal leadership for where I work is also concerned about first 

foods. It kind of goes back to a comment Mr. Jim made about the importance of traditional 

foods. We have a real growing interest in first foods and health and finding that right balance. 

I don’t know how the Centers for Disease Control could help us think of ways to funds those 

types of efforts. I think there difficulty maybe craft into a usual type of funding agreement but I 

just wanted to put that out there from our region. So thanks again.

Annabelle Allison: Okay, thank you.

Councilman Chester Antone: Thank you, Annabelle, for your presentation. Right now we’re 

gonna have Molly give a brief summary of this morning’s session.

Molly Sauer: Okay, good morning. So just as we talked about at the beginning, we’re going to 

give a quick summary of the morning session right before lunch each day and then the 

afternoon session at the end of the day to kind of make sure we’ve captured the key points. 

So we have about five that we’ve grabbed as the top issues from this morning, and of course, 

there are more in the minutes. As you mentioned, we have five people taking notes right now 

and we also will have a transcript of the recording that’s being taken as well. So the first issue 

is on the draft engagement plan, and as a follow-up item just to reiterate, we will be sending 

out the draft plan to all of the TAC members to make sure we have input from the new 

members as well as those who’ve already provided input over the last couple of months. 

Regarding the three vacant seats that still exist on the TAC, we have California, Albuquerque 

and Phoenix currently open, and after this meeting we will do a second wave of recruitment to 

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make sure we can get all three of those seats filled. The next meeting of summer 2014 which 

we anticipate being out in Indian country per discussion. If you have suggestions for a location 

or dates or if you’re interested in hosting, please let us know. We are looking for three 

suggestions and we can kind of work out everybody’s schedules to see what works best. You 

can send those to April or if it’s easier, to tribalsupport@cdc.gov and we will gather them and 

reach back out to everybody. To reiterate, we touched base on the meeting minutes from the 

February 2013 meeting and that was just a TAC meeting, we did not have a consultation at 

that time. So those minutes are in your binders and if you have a chance to review them, we 

can revisit that later today for a vote. We had an initial motion but have tabled it until later this 

afternoon. And just to follow up from Annabelle’s presentation there were a couple of items 

raised about making sure that water, radon, droughts, and economic development are all 

included in the activities that the think tank is working on. And additionally the request to have 

a TAC-specific version of the Working Effectively With Tribal Governments training provided so 

that information is getting shared on both sides of the aisle. So are there any other key issues 

from anybody?

Director Cathy Abramson: Yep, somebody said fracking. I know in the Great Lakes that’s a 

big issue as well as there’s a pipeline that’s old and I can get more information on it but that’s a 

big issue right now.

Molly Sauer: Thank you.

Councilman Chester Antone: I just had one additional comment and that had to do with the 

think tank and the product not being considered consultation. When we talk about 

consultation, that means that tribal leadership needs to be involved in that and I didn’t see any 

tribal leaders in that think tank.

Molly Sauer: Thank you.

CDR Bobby Rasulnia: And, Molly, also the comment about budget and being able to see how 

we can work through more direct funding for tribes which will be addressed tomorrow 

afternoon with the CDC budget as well, so you can ask more questions at that point in time as 

well.

Chairman Herman Honanie: I’m just thinking as I’m listening to everybody and all the topics 

that are being mentioned and it just occurred to me with this think tank I think it’s a really 

important initiative and an important effort in talking about the issues that I think every tribe 

faces out there. And so if the think tank could take it upon itself and think about how it can 

work with—I know this is a huge task, but the universities throughout the states and wherever. 

And the reason why I say that simply is because I have a grandson who is just now entering 

the University and he’s going into public health, and as I was sitting here listening to her, I was 

just thinking and going through my mind it would be a really, great, great learning and 

curriculum to make it a part for Indian students that are interested in the area and to combine 

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forward”.
that with law and everything else that could really, really be an asset to our tribes respectively. 

So however that can be able to work I think would be great. I don’t know how you could be 

able to begin to do that, but just my own idea about things. Thank you.

Councilman Chester Antone: As mentioned by Jefferson Keel that we need to somehow 

formalize this think tank as part of a consultation because I think the work they do is so 

important.

Molly Sauer: Thank you.

Also the discussion on traditional foods..?.. follow up.

Councilman Antone: If there are no others, then we can go ahead and break for lunch and 

12:30 is the native specimen discussion. Very important, so if we can try to be on time to start 

that up. And just to offer a suggestion we can always put the product from Annabelle’s 

presentation as a consultation agenda item.

Councilman Antone:....and to Delight Satter and Doris Cook. I will turn it over to you.

Delight Satter: Thank you Councilman. My name is Delight Satter and we have a presentation 

for you today on a really important project. Can you hear me? We’re presenting on a project 

that is in the early phase. It’s the Native Specimen’s Management Policy for CDC and we are 

so excited to present to the Tribal Advisory Committee again today. To start off our 

presentation we thought, because we have so many newer members we should tell a little bit 

of the history and how we got here. So I’ll give a very brief overview and as anyone in this 

room who knows me knows I will be available after the meeting if anyone likes to talk story for 

quite some time. When I first started here a couple of years ago, two women came to me and 

one was nearing retirement. Judy Delany and her colleague, Carlin Collins, was looking to 

outreach to the Tribal Advisory Committee. Both of these women had long and stellar careers 

at CDC and they wanted to provide some technical assistance for Tribal Laboratories, whether 

that’s a small laboratory in a health clinic with one microscope, or help with how do you write a 

large contract for outsourcing your laboratory testing. So Carlin presented to the Tribal

Advisory Committee in 2012, and it was a great presentation. And then the Tribal Advisory 

Committee knew she had presented where she comes from and Shambavi will go through 

where she is now where Carlin was. And the TAC started to talk about native specimens 

because, of course, that’s an issue across the country and within HHS and other committees. 

So we began a discussion that, yes, CDC does have native specimens in its collections. And 

Carlin came back to CDC and reached back to OSTLTS to begin a discussion and a dialogue 

around the management of these specimens. So I thought I would give a little bit of 

background as to how come we’re here today. It was because a couple of CDC folks were 

interested in doing similar work around native communities and through discussion with the 

TAC, this is where we ended up. Of course, they did follow up on the offer for support for 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
technical assistance to tribal clinics as well. I just wanted to thank the STAC members who 

are here. They’ve heard me present briefly on this project before at the STAC and that’s a 

good connection that we have, and I was really pleased to see that the councilman, Herman 

Honanie, is here because when I was at the STAC over a year ago presenting, during lunch he 

said to me, thank you for working on that native specimens and if you ever need anything, just 

let me know. And that was really wonderful and very helpful to me. It kind of spurred me on 

and I reported back to the group, do you know that we have support from other members, too, 

and this is really important work that we’re engaging in. So it was really nice and I’m so glad to 

see that you’re on the TAC now. So now we’ll enter the formal presentation and I’d like to 

introduce Dr. Shambavi Subbarao who will correctly pronounce her name for you.

Dr. Shambavi Subbarao: Okay, thank you very much for that introduction. Good afternoon 

everyone. My name is Shambavi Subbarao and on behalf of the Division of Laboratory 

Programs Standards and Services I’m honored to be included in this Tribal Advisory 

Committee meeting this afternoon. The Division of Lab Programs Standards and Services is 

fully committed to working with the Office of State, Territorial Local and Tribal Support, 

OSTLTS, in developing a CDC policy for the management of biological specimens collected 

from Native Americans. I would like to acknowledge Dr. David Holmes who presented to this 

committee in February of last year. I’d also like to introduce two of my colleagues from my 

division who are here today and are sitting in the audience. They are going to play a key role 

in this policy development effort. Dr. Judith Giri who is an expert in specimen management 

and Stacy Howard who is the Associate Director for Policy in my division. So moving to the 

next slide, this is an organizational chart of the Office of Public Health Scientific Services 

(OPHSS). Dr. Chesley Richards is the Director for OPHSS so that’s the organization you see 

in the top blue box. The mission of OPHSS is to lead, promote and facilitate science 

standards and policies to reduce the burden of disease in the United States and globally. 

There are two centers in the office. On the left side you see the National Center for Health 

Statistics and on the right side the Center for Surveillance, Epidemiology and Lab Service, or 

CSELS. That’s the center in which my division is in. Dr. Michael Iademarco is the Director for 

CSELS. My division is the last blue box at the bottom on the right side. It is one of four 

divisions in CSELS and I’ll talk a little bit more about it in the next slide. The other three 

divisions are focused on epidemiology and analysis, informatics and workforce respectively. 

So the mission of the Lab Programs Standards and Services, this is the division, is to improve 

the quality of lab testing and related practices in the United States and globally and we’ve 

achieved this through the development and evaluation of innovative training for laboratories by 

developing technical standards, practice guidelines and reference materials. So a primary 

area of work that this division focuses on is to provide scientific and technical support to the 

Center for Medicare and Medicaid Services, CMS, for the clinical laboratory improvement 

amendments regulation of 1988, also known as CLIA 88. The CLIA 88 regulations include 

federal standards that are applicable to all U.S. facilities or sites that test human specimens for 

the diagnosis, prevention or treatment of disease or assessment of health. These sites include 

hospitals, reference labs, physicians offices, public health labs, a variety of other locations. 

Anywhere where human samples are handled they come under CLIA 88 federal regulations 

30 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
and we provide assistance to CMS on the scientific and technical aspects of implementing 

those regulations. So a second area of focus for my division is to provide specific cross cutting 

scientific support services to CDC. One of these is the CDC ATSDR Specimen Inventory and 

Repository or CASPIR for short. This bio repository is located on a CDC-owned campus 

northeast of the city, northeast of Atlanta and houses almost six million biological specimens 

that have been generated from numerous domestic and international studies that CDC has 

conducted or led. So moving to the next slide. The intent of this slide is just to give you an 

overview of topics that we will be addressing during this session. First, I will provide some 

background to put the need for a specific policy for the management of Native American 

specimens into context. Next, Delight Satter will discuss the proposed approach that we plan 

to take for developing a policy for Native American specimens. And finally, Dr. Doris Cook 

who is sitting on my right side will engage all of us in a discussion where we will seek your 

valuable input.

Chairman Steve Cadue: Steve Cadue of the Kickapoo Nation. I have a couple of questions. 

About once a month Tribal Government meets with the health clinic director and staff on issues 

and doing a survey. We don’t get very good cooperation from the State Division of Vital 

Statistics and we would like to get specific information from the U.S. Census Bureau. It might 

be a question I would ask Dr. Frieden, too, but do we have a right? What right do we have to 

Native American data from the Division of Biostatistics or the U.S. Census Bureau?

Shambavi Subbarao: I don’t think I would be able to address that question directly but I can 

certainly find out from Dr. Richards and see what response we can get or help we can provide 

from the National Center for Health Statistics which is our sister center. So maybe after the 

meeting if I can get the specifics of your question I can try to follow up in terms of getting an 

answer to you. 

Delight Satter: As well, the ladies are taking notes and so when a question comes up that

might not be directly for this panel, it will go into the system and it will be sorted. Bobby will 

ensure that it’s sorted to the right center, institute or office, and so we don’t have responsibility 

for the National Center for Health Statistics or the U.S. Census would be housed, but because 

you’re present here asking these questions, we can sort it to the right person who can help you 

with that. And then regarding the Division of Biostatistics and the cooperation, that would be 

the same group as well as perhaps OSTLTS because it has some partnerships with some of 

those leaders so perhaps Dr. Monroe would want to—you know, the role of state tribal 

partnerships and access to information and data that they would want from vital records. 

Shambavi Subbarao: Okay, should we continue? So a little bit by way of—

Councilman Chester Antone: Sorry, before you go on I think—Mr. Cadue—that as we speak 

and as the note takers are taking notes and the recording would take out your question from 

there and address it more fully. Although they’re saying they can’t address it at the moment, 

they would have to go back and get some more information, and I guess that’s part of the 

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forward”.
response that we want from CDC on those specific questions. So that’s what you’re saying, 

right? Are you okay with that Mr. Cadue? Are you done? 

Okay. Continue.

Shambavi Subbarao: Thank you. So we’re all reminded that the Havasupaicase against the 

Arizona Board of Regions that highlighted the shortcomings of the current legal and ethical 

framework governing the collection and management of biological materials for research. This 

also demonstrated the failure to account for assessments of risk and harm that are specific 

and unique to identifiable population groups and Native American Tribes. At CDC specimens 

are managed in compliance with specific HHS and CDC policies such as the HHS policy for 

human subjects research and the CDC specimen policy. However, these policies currently are 

not specific to Native American specimens. You’re also aware of the Federal Native American 

Graves Protection and Repatriation Act (NAGPRA) which concerns Native American remains 

but there is very little information regarding biological specimens. So the purpose of this slide 

is to put things in context and really highlight the need for us to develop a policy that addresses 

specifically Native American specimens. The next slide gives you a little more background on 

CASPIR. As I mentioned earlier, in our division we are responsible for the management of 

CDC’s biological repository, also known as CDC ATSDR Specimen Inventory Repository or 

CASPIR for short. Last December, CDC approved its first policy for prospectively managing 

specimens and sample management at CDC, and the policy does make reference to other 

applicable guidelines, policies and laws. CDC has specimen collections that were obtained in 

the course of CDC’s work, utilized to support CDC’s responsibility to protect the health of the 

public. For example, preserved specimens from CASPIR have been used to study the origins 

of Hantavirus, HIV AIDS, numerous other diseases as well as setting limits on the levels of led 

and gasoline and so on. So it’s impacted a number of different areas. It’s important to note 

that CDC obtains such specimens from outbreak investigations, routine surveillance that CDC 

is responsible for, and other public health investigations. The six million specimens in CASPIR 

are the total number of specimens preserved there, and these include some specifically 

obtained from Native American populations. The goal is to inventory and preserve the known 

Native American specimens. The recommended strategy is to focus on developing a policy 

first to address the governance of these specimens, and in the course of policy development 

we will address the existing specimens. There are currently only very few existing policies and 

guidelines that we can refer to in reference to developing a CDC policy for Native American 

sample management. The first is a tri-council policy statement. The ethical conduct for 

research involving humans, chapter 9, that is research involving the first nations in Impetus 

people of Canada. Dr. Doris Cook who is with us today is a world renowned expert in 

American Indian Alaska Native research ethics and policy, and played a role in developing this 

document. We’re honored to have Doris Cook here today as part of CDC’s project team 

providing advice and expert consultation on the development of a policy for Native American 

specimen and sample management. The second document that I have highlighted on this 

slide is the Indian Health Service draft guideline for implementing and complying with Indian 

Health Service policy on specimens. The work in this area by Drs. Bill Freeman, Phil Smith, 

32 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
and Alan Trachtenberg of the Indian Health Service will be very helpful to us and we look 

forward to opportunities in the future to engage with our sister agency on this effort. The third 

document referred to on this slide is the Alaska Area Specimen Bank Policies and Procedures

which was co-developed by the Alaska Area Native Health Service or AANHS, the Arctic 

Investigations Program Indian Health Service CDC. This document was approved by the 

Indian Health Service and the CDC IRB and the AANHS research and publications committee. 

So these are the few existing models that we have with us today that will help guide us. We’re 

also grateful to Dr. Jay Butler and other members of the Arctic Investigations Program CDC 

Alaska for sharing their experiences and look forward to having a representative from AIP in 

the workgroup that will develop the CDC policy. I would now like to invite Delight Satter to 

speak to the next slide which is the approach for policy development.

Delight Satter: Thank you Shambavi. As we have noted earlier, this is a joint effort between 

the CSELS and OSTLTS. So these are two units within CDC who have a special joint project 

to develop this policy, and our approach includes the identification and engagement of 

stakeholders for information gathering and sharing and we can think of a few audiences that 

we will—well, we already have begun and will continue to turn to for advice. First, of course, is 

the Tribal Advisory Committee, and we have met on it a few times and we have a great 

discussion planned for today. We will have an external expert panel and we actually have a 

cooperative agreement with the Association of American Indian Physicians, AAIP, and this is 

one of their projects that we partner with them on. They’ll help us with the development and 

coordination of that body. We also have a CDC internal multidisciplinary working group. This 

is the group who will actually take the information that we gain from you from the—I call it EEP, 

the external expert panel and consider those as they develop the policy. Our internal group 

will include policy experts, ethics experts, legal, scientific experts, those who use specimens 

and a wide range of stakeholders. It will also include the CDC’s institutional review board, our 

own IRB, and then we’ll have additional stakeholders. That is our basic plan and we’d like to 

turn it over to Dr. Cook who could give us some information about our upcoming listening 

session.

Chairman Steve Cadue: Does the CDC as a federal agency have the final ultimate approval in 

the United States about this issue of specimen research and collection, or is it a different 

federal agency?

Shambavi Subbarao: What we are thinking of doing and planning to do is to develop a policy 

that addresses specimens that CDC, Centers for Disease Control & Prevention, has collected 

or has in its possession right now from Native American populations. Other agencies might 

look to our policy when it’s developed as a guiding document but we don’t have jurisdiction 

over what other agencies might do. So this is for CDC.

Chairman Steve Cadue: When a Native American such as myself utilize Indian Public Health 

facilities, is that data available to researchers without my approval? Because I’m using a 

federal agency, have I given something away? My right, I mean my blood, my whole....—

33 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
Delight Satter: I did want to respond to the first thing. When you said does the CDC have the 

authority to develop policy for the nation, we wouldn’t. We have the capacity to develop a 

policy for CDC and so higher level policy would be developed in another place. So that could 

be something the STAC would want to raise as a concern to the secretary or even at a 

different level. This policy would be for our agency. That said, the National Institutes of Health 

have already expressed that they’re very interested in seeing how our policy formation is 

developed. Indian Health Service is supportive of us in going in this direction and they are 

very interested to see what the outcomes of the policy would be and how that could be helpful 

to other federal agencies. Regarding access to your blood sample or tissue that was taken 

from you during a medical event, those don’t necessarily show up in our repository at all. We 

receive things from say an outbreak, medical confirmation that an outbreak was taking place. 

Sometimes labs are sent to CDC to our laboratories to confirm what was the disease or what 

was the person exposed to, as well as other ways we receive collections, which Shambavi can 

describe better than I can.

Chairman Steve Cadue: That slide, CDC internal multidisciplinary working group, you’ve got 

several different professional people. You’ve got legal. What does that mean? What do the 

legal people do?

Delight Satter: Whenever we develop a federal policy or management policy inside a federal 

agency, we include the legal, the Office of General Council. They review the policy to make 

sure it is correct. As well, within OSTLTS we have a group called the Public Health Law 

Program. They are not there as legal advisors to the federal agency but they do provide 

technical assistance to this project and to many other activities. Requests can come in from 

the public to that group. We had a request from California tribes on what their rights were for 

hunting and fishing. In our case we asked them to do a review of the legal landscape to see if 

there were any laws that we didn’t know about that we would want to take into account as we 

develop an operations policy. So that’s why legal is there. They’re always included in this type 

of development.

Delight Satter: So could you describe our listening session at the NRN?

Doris Cook: Yes, thank you. (greeting in tribal language). Good afternoon. My name is Doris 

Cook and I’m very pleased to be here with you this afternoon. I want to speak briefly about the 

learning session that will be held at the Native Research Network annual health research 

conference. That’s going to be held this year from June 1 to 5 in Phoenix, Arizona, and this 

year’s theme is resilience and that opportunity to have a listening session really plays well into 

the planning for this particular project. One of the major research activities of the Native 

Research Network which is a proactive multidisciplinary network of indigenous people who 

promote research, integrity, respect, trust, ethics, cooperation and open communications in the 

research context. One of their major activities is coordinating the annual research conference. 

This presents a wonderful opportunity for us, for CDC to begin to engage the indigenous 

34 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
community and thought leaders from the native community in the policy development process. 

Now, Delight briefly outlined for us the project strategy which begins with engaging 

stakeholders, and in this case it is Native Americans, in policy development. Generally the 

public expects to be involved in the development of public policy. Public consultations serve 

as a mechanism of public accountability. In the field of environmental health there is a legal 

right and public expectation for participation in government decision making. Certainly in the 

context of Native Americans there was also an obligation for consultations and that is through 

the executive order 13175 that was referenced numerous occasions earlier in this meeting. It 

requires meaningful consultations and collaboration with tribal officials in the development of 

federal policies that have tribal implications, and in addition to complying with the federal public 

policy consultations serve to improve the efficiency of and the transparency of the policy 

development process. The NRN conference presents an opportunity for CDC to engage 

native people by first sharing information on the need for policy around the management of 

native specimens and to continue to gather essential information on traditional values, ethics, 

and principles that will ground the development of the policy. CDC wants to get it right and 

start off by listening to what’s important to native people is a first step. Consultations and 

vetting of the policy with all stakeholders at key points will ensure that the policy developed is 

useful, usable, and consistent with traditional values and ethics. 

Delight Satter: Thank you. Some of the areas that we’ve discussed as the Tribal Advisory 

Committee in the past include the informed consent process and adequate consent process 

which Chairman Cadue is basically talking about. When he’s in a medical exam, is he 

consenting to allow his tissue to be used for other studies. And also, of course, this work 

includes the identification of native specimens in CASPIR, in our collections, and that work has 

begun. Protecting privacy and confidentiality, we expect to learn a lot about the way native 

people view that in different tribal settings as well as concerns around research use or the 

restricted use or is there broad use of specimens and what would tribal communities around 

research use. The conversations that we’ll have with community really allow us this 

opportunity, unique opportunity, to talk about the legal and social implications. These are the 

social and cultural implications, the traditional values and the concerns that only tribal 

communities can share with us so that we can make the best possible policy for the institution 

and the management of the specimens. And then finally would be the respectful disposition of 

the specimens when they’re no longer needed here. The studies may be over. You know, 

CDC has been here a long time. Some of the collections are from the 40’s and so the ultimate 

goal when there could be no more need for them here for public health purposes would be to 

identify the tribal community and return those specimens to the tribal community for 

appropriate ceremonies or whatever that community would choose to do. And that, of course, 

we would be asking the TAC to help us with the appropriate protocol and traditional protocol 

for that to happen as well. And with that, that’s the end of our official formal presentation. 

What we’d like to do now is we’re going to turn it over to Dr. Cook to help us with the 

discussion with you all and we’ll be listening and very excited to hear the comments and 

concerns and ideas that you have to share with us. Thank you.

35 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

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forward”.
Doris Cook: We have two bullet points that are on the slide and before launching into that 

discussion I thought it might be useful to speak briefly on the policy development process. If 

you do an online search on policy development, you can be just overwhelmed with some of the 

models and diagrammatic depictions of the policy cycle, policy models, and policy stages. 

What they all have in common are four basic elements. The first is identifying the problem. 

The second is formulating a policy to resolve the problem. The third is implementing that 

policy or policy change. And the fourth is evaluating the effect of the policy. The first step in 

identifying the problem is to define exactly what the problem is. You outline it. It involves not 

only recognizing that an issue exists but studying the problem and its causes in detail. This 

stage determines how aware the public is on the issue, decide who will participate in fixing it, 

and considers what means are available to develop a solution. The answers often help gage 

which changes are needed to address the problem and the policy agenda, which problems will 

be addressed. Now, identifying the problem can come from government, from special interest 

groups, from citizens, etc. The second stage is formulating a policy to resolve the problem. 

After it’s been identified and studied a new policy needs to be formulated or developed. And 

this stage typically involves discussions and debates between government officials, interest 

groups, individual citizens to identify some of the obstacles for policy development to suggest 

some alternative solutions and to set clear goals and list the steps that will be needed to 

achieve them. It also involves an information gathering stage, collecting expertise, reviewing 

existing policies, existing guidelines, programs and research. Once the policy is developed, it 

then needs to be adopted and that is the implementation stage. It’s that third step in the public 

policy process and one that can be difficult if those that are in charge of the policy aren’t fully 

committed. At this stage we want some fairly intensive discussion and debate amongst those 

establishing the policy to ensure that there is a full understanding of what the issues are and 

that we eventually get to a yes in the process. Clear communications and coordination are 

really essential as a dialogue with the public, and those that will be affected by the policy. The 

final stage is evaluating the effect of the policy change. This step usually involves studying 

how effective the new policy has been in addressing the original problem and also making 

some adjustments to the policy, some tweaks here and there and ensuring that those are 

implemented. Now, through these stages consultation is really quite important; consultation 

with the public, consultation with government officials; with all the stakeholders, and there are 

risks associated with not getting consultations right. Those risks of either limited consultations, 

not undertaking consultations or a poor consultation process are a limited understanding of the 

problem. For example, CDC goes forward with a policy that does not involve a consultation 

discussion with indigenous people, with native people, then we’re not convinced that the 

problem is really being addressed, that the underlying issues have not been addressed. This 

could lead to poor policy solutions. We could have negative feedback from clients or 

stakeholders in reaction to the policy, lack of policy coordination, so one area has one policy 

and perhaps another area has another conflicting policy, and part of that addresses what 

Delight spoke to earlier about the need for legal opinion, legal review to ensure that there’s 

consistency in policies that are developed that they are legitimate, and they pass the legal 

test. Certainly, a potential misdirection of funds. The first bullet speaks to the expectations 

from Native American communities but before we launch into that discussion I thought it would 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
be quite beneficial if we discussed what the core values are of the TAC. What core values 

should guide the development of policy. A value is a guideline or action and core values 

specify behavior that’s required to successfully accomplish its mission, and these values 

cannot be compromised. So I’d like to open up the floor to some discussion on the core values 

of what the TAC has and then we can relate that to community expectations. Just as an 

example, an example of a core value might be respectful engagement. Does TAC feel that 

respectful engagement is important, is it a core value of this group? And that would mean 

respecting each person’s unique attributes, focusing on strengths. Do we value diversity of 

skills, experiences and perspectives, do we look to the best in every situation.

Councilman Chester Antone: What I would want to know right now is what we’re talking 

about—the way I understand the conversation as it began is we have specimens here at CDC 

and so one of our suggestions in a previous meeting was we need to know the tribes that are 

affected by those specimens because we need to hear from them how they would want to 

engage with CDC on a return of those specimens to them, and at that time Tohono O'odham 

Nation has suggested that in conversing with our cultural preservation committee they asked 

us to look to Native American Graves Protection and Repatriation Act (NAGPRA)but under

NAGPRA we would have to find out whether those people that—if our tribal members had any 

specimens there, we would have to determine whether they are still alive or not. So when 

we’re talking about these native specimens, my understanding was that we were going to talk 

about the return of those and the identification of those specimens or the return of those 

specimens initially. Right now it seems that we’re talking about a return of specimens 

ultimately, but we’re talking about informed consent which means to me that we are going to 

do research and what do we need from the tribes in order to do that and that everything else is 

in between like the core values of how to do that. So now it comes full circle around the return 

of the original specimens that CDC has to research. I just wanted to lay that groundwork 

because as I understand it that’s how it began and then how we shifted from the return of 

specimens to the gathering of specimens.

Doris Cook: Yes, Chairman Antone, I recognize that was the initial concern of the TAC. 

However, this project is taking a project strategy that includes that but not as the first step. In 

order to understand respectful treatment of those samples, the ultimate disposition of those 

samples, we first have to understand what is it that the tribes value. Each tribe, as you know, 

has different culture, different traditions, somewhat different priority in the set of values. But 

each one is unique and before we launch on to developing a policy that would cover all of 

them, we need to understand more about what it is, how we would respectfully treat and 

therefore manage those samples. As a part of the development of the policy and gathering 

information toward the management of those samples we will be addressing the issue of 

disposition because disposition is the end stage, it’s how we manage the samples and how 

they’re ultimately respectfully treated at the end of it. But the disposition doesn’t come first. 

It’s getting a better understanding of what it is that tribes value so that we can develop policy 

that’s consistent with those traditional values and ethics.

37 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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Councilman Chester Antone: So presently we don’t have a policy as I understand it since we’re 

going back into what legal foundations there are or legal decisions that help formulate the 

CDC’s gathering of data whether it be blood, tissue or blood samples or human tissue.

Dr. Doris Cook: The policy that is currently in place is the health and human services policy 

that guides the management of all the samples. Now, I believe Dr. Shambavi has indicated 

that there is an effort to quarantine, to segregate those samples that they know are Native 

American samples to quarantine them until the policy is developed. Then they will be 

managed appropriately. But nothing is going on with them now until the policy is developed 

and implemented.

Councilman Chester Antone: So currently we just have some specimens that we’re discussing 

right now that are at the north of Atlanta, and so we’re talking about segregating that portion of

the specimens and leave them there until we develop a policy not of return of the specimens 

but of the overall gathering of specimens.

Dr. Doris Cook: Return is a part of the policy.

Councilman Chester Antone: That’s what I’m saying, we’re not talking about returning the 

specimens until we develop a policy that runs the gamut of the beginning to the end, right?

Dr. Doris Cook: Yes. But nothing will be done with them in the interim until we better 

understand what a respectful treatment of those samples constitutes.

Delight Satter: Yes, and we had talked over time about identifying the—going through the 

collections and identifying any that we could, keeping in mind decades ago race and ethnicity 

might not have been collected, not even gender or some of the things that we do have now. 

So we do have a very small number of specimens in the collections that we did find that were 

native. Some are still active and so they are still here because they’re a part of ongoing 

studies. But this policy would address new collections, newly identified efforts, as well as how 

do we treat the specimens when they’re here. It could go to Mr. Cadue’s question of who is 

allowed to use those specimens for other needs or for other research. And then finally, when 

the samples or the specimens are no longer needed, then what is our policy for their final 

disposition, the language that’s used in laboratories, or what we’d like to call respectful 

disposition as Indian Health Service calls it. And as we continue our discussion, we wanted to 

remind folks that some of our collections aren’t a part of research so there isn’t a consenting 

process. Not all specimens come from research studies. So we’ll have to have discussions 

about the values on that. Also, some of the specimens within CASPIR are infectious so it 

wouldn’t be safe to return some specimens that CDC is protecting the public from and that’s 

how they ended up here in the first place, but we still want to talk to communities about what 

their values are and how we can create the best policy that will address all of those concerns. 

And some of the tribes we don’t know. We know that they were native but we don’t know 

which tribe.

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Councilman Chester Antone: I want to recognize Rex and then Jay and then you....They had 

their hands up so we’ll go in that order. We’ll have Rex and then Jay Butler and then you. Go 

ahead Rex.

Vice President Rex Lee Jim: There is a health system on Navajo that has nothing to do with 

CDC, it has nothing to do with the U.S. policies. It’s in place, it’s workable and it’s effective. 

And it’s a traditional system, probably one of the few systems left where some Navajo’s don’t 

even go to hospitals or clinics or take pills but they go to the system and some of them live to 

more than a hundred years old just simply using that system. There are professionals from 

that area that I think you need to consult and work with. They knew we’re going through that 

external but they weren’t up there. We do have traditional laws, fundamental laws that 

preexisted Europeans coming over that guide how you get rid of certain remains. That system, 

I think needs to be addressed. When we talk about meaningful consultation and we talk about 

tribal sovereignty, we’re talking about sovereign practices that existed before all of this existed, 

and we need to acknowledge that and acknowledge it as a valid health system, it works and 

that the practitioners are just as professional as anyone with a Ph.D. or medical degree and we 

need to engage them at that level and respect them at that level. So culture, to validate us, is 

to simply acknowledge that system exists and there are professionals who exist and need to 

engage them at the same level as we do with researchers, people with Ph.D.’s and people with 

medical degrees because their training is just as extensive. So that’s one. When we talk 

about tribal sovereignty, we need to look into that. The other is we talk about tribal sovereignty 

in terms of government to government. We also have current systems in place, for example, 

the Navajo Nation has its own IRB. And some of those policies need to be looked at. Some of 

the Navajo Nation laws and codes and certain other tribal nations have similar policies and 

laws in places. We need to also take a look at all of that and see how they interface with what 

we are attempting to do here. That's important. And then we also have what's called the 

Medicine Man's Association on Navajo. These are medicine people from different, how do I 

say, different schools of medicine. We have ceremonies that specifically address mental 

health, ceremonies that specifically address illnesses that deal with cancers and different stuff 

like that, internal stuff, just like it's out here. We have systems like that in place. And so these 

are medicine people who practice this, they come together in association and discuss some of 

these issues. And the Navajo Nation constantly turns to them, as to how we address these 

specifics. So those are the types of groups that we need to think about. We have to look at the 

intellectual property rights, the laws and policies that are in place with indigenous nations as 

well. A lot of the time it has to deal with collective rights rather than individuals. So collective 

rights mean sometimes clan rights, extended family rights and then collectively as a whole 

nation. I think we need to look at that and see where we're at with that. So these are some of 

the values that you're asking us to look at. The other is in a holistic, comprehensive approach 

to health, we look at all aspects including the spiritual aspect. And in the specimens that 

remain that we will still have some tribal nations and some clans within the Navajo Nation 

believe that some of those are still alive and need to be respected as such. And in some 

cases, it may require if you're going to return them, certain ceremonies, songs and prayers 

39 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
associated with that. Those are the kinds of things that need to be looked at, the whole 

spiritual aspect. I know in Western medicine, you don’t worry about spirituality; it's just a 

specimen that you collected. But the health of the nation, the health of the community is 

dependent on how that's taken care of as well, because it’s the collective part of the whole 

process. So I'm just throwing out some ideas out there for now. Thank you.

Councilman Chester Antone: Jay?

Dr. Jay Butler: Thank you, Mr. Chairman. I simply was wishing to respond to Dr. Cook’s 

question and emphasize the value of tribal sovereignty and tribal self determination. That point 

has been made by Vice President Jim and much more eloquently than I ever could have put it. 

Thank you. 

Councilman Chester Antone: Mr. Cadue, then after that Cathy, you had your hand up. 

Chairman Steve Cadue: Mr. Antone, this issue and discussion, I would like for the TAC 

committee to explore and in my position, I indeed would like to see Indian medicine men 

culture people involved in this particular program. I want that entered into the record. Thank 

you. 

Councilman Chester Antone: Cathy?

Director Cathy Abramson: I agree with you. That came across my mind right away when we 

first started talking about this, Chairman Cadue. But yeah, another thing that expectations in 

communities I guess would be a definition of specimen would be nice because I think people 

need to know that. So we need to know what we're talking about. That could range from a 

number of things, correct? 

Shambavi Subbarao: That is correct. For our CDC policy on specimens, we have defined it. I 

didn't bring it with me. But it includes a variety of biologic samples that I've collected from 

individuals: blood, plasma, serum, tissue samples. So you're right, we do need to start off with 

what we have as the definition. I wish I had brought that with me. I don't have it right now. But 

that's also open for discussion, based upon what we learn. I think we're at the learning stage. 

We're just trying to gather information and feedback from everyone how best to move forward, 

but that's a good point. 

Director Cathy Abramson: Okay. Thank you. 

Councilman Chester Antone: Mr. Gilbert?

Tim Gilbert: Thank you Mr. Chair. I guess I think I understand what you're looking for, what 

you're trying to accomplish here. I had to review your slide again to make sure I—and I guess I 

40 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
have to say I think you're on the right track, I think you're trying to do the right thing, have a 

policy that accounts for American Indian and Alaska Native value systems and how you deal 

with these specimens. That said, I think you caught us at a disadvantage because there's 

probably a few of us that understand how exactly any one of those six million specimens you 

have in your bank ended up there. If I understand it right, so for example, tell me if I'm wrong. If 

we had an outbreak in Umatilla County, Oregon, for example, something, disease X, and it 

required some kind of outbreak investigation and CDC was involved, and specimens were 

collected as part of that outbreak investigation, they might end up in this bank as an example. 

One example of how they might end up there. 

Doris Cook: Yes. That is one example. Not all outbreaks necessarily end up in our bank, but 

we do have some collections as the result of outbreaks. 

Tim Gilbert: So, that's not research really. It’s outbreak investigation monitoring. I guess what 

I'm trying to point out is that understanding how those specimens end up there and how maybe 

those things that are in your freezers might actually be from American Indian or Alaska Native 

people would help this group discuss how they ought to be treated. So maybe a little bit more 

information about the bank would have been useful at some point. But I also, and maybe 

you've done that at different meetings and I missed it but it seems to me that there's maybe 

some confusion about this, does this involve Indian Health Service, our tribal sovereignty, etc. 

Maybe a little clarity about the bank would help. But I also read in here where you may not 

have to reinvent the wheel here. I know you've listed some Canadian resources as well as the 

CDC lab up in Anchorage. Or if we have Dr. Hennessy and Dr. Butler here that are more than 

familiar with the specimen bank up there and I'm sure that there are lessons learned from that 

journey. But anyway, I just wanted to say that a little more clarity on the bank would have been 

useful for this discussion. But I actually think you're on the right track. You're trying to honor 

tribes’ values systems in the specimens you might have in your repository and I think that's the 

right thing to do.

Shambavi Subbarao: If I could respond to that. Yeah, I think that's absolutely right. I think we 

need to look at what we have. I know that Dr. Giri who is sitting behind us, she started on that. 

We do know what specimens we have in CASPIR, and so there's some demographic 

information. I wish that we could have discussed it at this meeting. Perhaps the next time. I 

don't think this is maybe the second time that this issue has come up at TAC isn't it? It's not 

that --

Delight Satter: It's pretty fresh. 

Fairly recent. And we didn't have all the details at the last one that we have now. And we did 

our first phase of the legal review. So we gained some new information. So we're at the 

beginning. Yeah. And it's very helpful to hear how people think the presentation went. You 

know, like what's missing, because we're in it and so it's helpful to hear we need some 

41 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
definitions. Clearly, we're using words in different ways and so if we make sure everybody's 

talking turkey, that'll help. 

Councilman Chester Antone: Mr. Honanie, before I recognize you, I have some questions from 

Councilman Andy Joseph, who is on the line. So I would like to ask those, and then we'll get to 

Herman and then we'll get back to Mr. Jim. Andy Joseph asks, number one, were the people 

of sound mind when the specimens were taken? And then second, he asks did the tribal 

patients speak English.

Shambavi Subbarao: I don't think I could answer that right now. I don't have the data in front of 

me. But any time, if it's outside of an outbreak or routine surveillance, if it's for a research

project, there are very strict guidelines that we have to follow where an informed consent 

process is adhered to. And whoever is in charge of that, it has to go through CDC's IRB. So I'm 

quite certain that those issues would have been addressed, but I don't have an exact answer 

to give you on that specific question. 

Delight Satter: What we can do though, Councilman Joseph, is as we get to that place, you 

know provide that information, and those questions go specifically to a person's right. There 

are human rights to be included in research, and do they have the capacity to consent to 

participate in research, and was the researcher following class standards or was the linguistic, 

first language, was the consenting process done in the language that's understandable to the 

participant. These are requirements. But I do recall some of the projects that Judith was able to 

find some of the collections. Some of them are from the 1940s and one is more recent but 

that's an active project. A more recent one would have followed consenting guidelines. The 

ones that were from a long time ago, they were studying virus, like in Louisiana I believe, 

particular viruses. They're just looking for exposure to certain virus and immunological 

concerns. So it was a long time ago. That kind of information might not have been gathered. 

It's not sitting with the specimen. Brief note, studies in those days, the record keeping was 

different. So we wouldn't know the answers to those questions. 

Shambavi Subbarao: And for a lot of these answers we would have to go back to the specific 

programs that conducted these studies. What we do is we provide the repository space if you 

will, and manage the temperatures and the freezers and so on. But when we start talking about 

individual collections and projects, we have to go back to the Project Investigator. So that 

takes a bit of research and investigation to do. I would not have that information right now. 

Delight Satter: But it's very important for us to just even hear the questions help us prepare for, 

it goes to the values. Do people have, are they of sound mind and able to participate in 

research, if it is a research project. That certainly leads us to thinking about the core values, 

which of course align with the rules and regulations of research as well. 

Councilman Chester Antone: Mr. Honanie, and then Mr. Jim?

42 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
Chairman Herman Honanie: My comments are merely that when talking about research and 

taking specimens, my people have always been very concerned with it. And of course, in the 

early days because of the lack of knowledge they were pretty receptive to those kind of things 

until later on. And when you put up in your first slides, to have a supine matter, my immediate 

concern or question was that court ruling curbed activities with regard to gathering specimens 

among Indian tribes today? I'm just asking. And then how it impacted actual research in Indian 

country for that matter. The other thing that Mr. Antone talked about, mentioned the return of 

these specimens, and I'm only speaking for myself, but I think it was that point, it's one of the 

things we don't really think about. We may engage and we may accept or approve of 

specimens or research to be taken and especially in a case of specimens taken, you know, we 

just kind of take it for granted that the specimens are going to be in good care and everything 

else. But then, what if there along comes a question and say we want those returned? But the 

question we don't ask ourselves is how do we handle that return, how do we safely keep them 

and is it something that we really should, or is it something from our hearts, it's just not within 

and it goes against our grain of culture and everything else and we should just let it die or 

whatever. I'm not sure. That's kind of an interesting question that I have to wrestle with and 

how we would be able to answer that at our local level because I just don't feel and think that 

we have any of the technical or other kind of means to be able to preserve any kind of return of 

specimens. That also brings up the point that when you mentioned the NAGPRA Act and the 

return of artifacts, and what's being done to preserve them and then when they’re returned, we 

have to wrestle with that. We have to hire consultants to assess them, examine them to see 

what they've been preserved with and if they're usable or not. Then we have to make decisions 

upon that, from that point on. And so how we keep them at that point is just a matter of utilizing 

the recommendations of these consultants in terms of how they advise us. So those are really 

kind of complex issues we have to deal with when it comes to that. But as far as specimens 

are concerned, that would really be a challenge for me to deal with. And finally, with regard to 

tribal IRB’s, I don't know how many years it's been since HOPI has tried to develop an IRB and 

it's a very complex task, it's a very complex matter. And so I guess when you're talking about 

this kind of effort, I'm just wondering if there's any TA or assistance for respective tribes to get 

assistance in being able to do that. I know I've seen and I haven't read every page of the 

Navajo IRB because it's about that thick, but it's a very, very complex matter and complicated 

matter to deal with and I know that a lot of tribes just don't have the wherewithal to be able to 

develop something like this instantly. But I think it is important. I just advocate research today 

from the perspective that if it's going to help our people and so forth, and it really doesn't have 

to involve specimens, I think for the most part, we can be able to support that. But I think we 

still need policies and regulations in house to be able to do that and I guess in this case, work 

with CDC or any other federal agents that's going to conduct these research. So all the way 

around, we really have to cover ourselves and not just from the point of sovereignty, but in 

house be able to establish applicable policies and so forth. So I myself, it's going to take a lot 

of effort and a lot of homework to get to the point where we can safely say we're ready and 

we'll take on research and we'll be able to call the shots from our perspective. Thank you. 

43 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
Councilman Chester Antone: I’m going to recognize Mr. Rex Lee Jim, and then after him will 

be Tim Gilbert.

Vice President Rex Lee Jim: Thank you again, Mr. Chair. In Navajo, they always say [Tribal 

language]. It means Navajo’s are saying, we're being over studied. You never tell us what they 

do with the outcome. So one of the expectations I think is feedback. What do you do with the 

research, the outcome, how does that inform policies, here, nationally, and how does that help 

the people from which you have collected data. Is there more money appropriated to prevent 

more diseases. Were there policies made to make access to health care a lot easier and 

quicker and more efficiently, effectively and how – what they really want to know is if you take 

something, how will I benefit from it, how will my community benefit from it? So that kind of 

feedback is important. Rather than just general national Native American, well this is what's 

going on, but back to the communities themselves. So that's an outcome that we, that's an 

expectation we'd like to have. Now, the other is when it comes to the specimens, the return 

and disposition, maybe we need to have a policy for the old stuff and then another one for the 

current one to move forward. Thank you.

Councilman Chester Antone: Mr. Gilbert?

Tim Gilbert: Thank you Mr. Chair. I realize I'm using up all my feedback chips here, so I'm 

going to try to be brief here. I just wanted to reiterate what I said the first go around, which is 

as part of an advisory role, I really think that your group should sit down with the artic 

investigations program in Anchorage and review their protocols for specimens, etc. But I guess 

the longer I sit here, the longer, the more questions I got, but I was curious, we're talking about 

a policy to deal with the existing specimens, rather than a policy that would deal with incoming 

new specimens is my first question. 

It’s both. 

All right. I had a third point. Maybe I got hung up on the second point. I might have to come 

back Mr. Chair. 

Councilman Chester Antone: At this point, I need to recognize that Shawna Gavin from the 

Portland area, general counsel secretary is also on the line. I just needed to let you know that. 

And she sent along some comments. She says, I agree it's very important to define specimen 

and the policy that we're working on is that we must address both the informed consent and as 

Joseph mentioned, ensuring the language barrier issue is properly addressed. Those are two 

comments from Secretary Gavin. Tim?

Tim Gilbert: Sorry. I just remembered my third point. It's in regard to access to the specimens 

in the repository. Can you speak maybe briefly about the policy for how those are accessed or 

not, once they're in the specimen bank?

44 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
Shambavi Subbarao: So right now they're accessed mainly by—the big collections are 

accessed by researchers, the PIs that want to send it to their collaborators for the studies. So 

it's more of an internal access process. There is a new mandate from HHS to make all 

federally owned collections and policies more publicly available or at least for information sake. 

So we're working towards that, but right now the access is more internal for CDC scientists. 

And one thing Delight wanted me to sort of emphasis or explain a little better, is that a lot of the 

collections that we hold are not from research projects. These are more from surveillance 

efforts that CDC conducts for a variety of diseases. Or they are from outbreaks. So I was just 

looking at the list of specimens collected in the early 1960s, that I think these are linked to 

Native American samples. For example, incidences of community onset pneumonia. There's 

HIV infected men in which the subjects were from Denver, Colorado. Investigation of an 

outbreak of hepatitis A and B in a community on the border of Utah and Arizona. So these are 

specimens that I guess came to the knowledge of EIS or epidemiologists at CDC who set up 

investigations and collect samples and was sent to CDC for confirmation. That's what these 

are. So a lot of these, again, I have to emphasize that when we start getting into the discussion 

through our internal work group, we will need to draw in the people that are PIs, that are 

project investigators for these studies and really understand what these studies were about, 

how these were collected. For lack of a better way to say it, we're sort of managing the 

repository right now and trying to do due diligence in making sure we have a policy in place 

that really respects these specimens, taking into account everything that we hear from this 

group and going forward. So there's more players than what you see here to help us guide the 

process. 

Tim Gilbert: Mr. Chair, I guess I would just say that, thinking out loud, but I don't recall details 

of the Havasupaicase, but it seemed like it was an access problem. In other words, there may 

have been specimens collected for one reason, but accessed for a whole different reason by a 

different PI to answer a different question. And then there wasn't the ability to manage that in 

terms of reporting on that, and how the findings of that secondary analysis was portrayed in 

the literature. And that's an area of concern that I would put out there. I don't know if this group 

has a fix but if there's a way that we could understand who is accessing data or specimens that 

might be from American Indian Alaska Native subjects, however old or however dated those 

specimens are, and either the research question is, or something to give us a clue about that 

secondary analysis and so you don't have a repeat of the Havasupai The last thing you want 

is that kind of access and that kind of PR problem of maybe a well intended PI wanting to do 

some research in his or her area and then misstating things about whatever, in the literature or 

whatever. I'm just thinking out loud in terms of, is there a gatekeeper. I'm not even sure what 

to call it, function, that we could at least understand who is trying to access specimens that 

might be from American Indian and Alaska Native specimens.

Shambavi Subbarao: Well, if it's an IRB approved protocol, the IRB does not have an annual 

but periodic reviews of the study. They do look at all of that. The informed consent should be 

water tight. The Havasupai case was clearly a breach of informed consent. The samples were 

45 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
given for I think a diabetes study and they were used for other purposes that was never agreed 

upon. CDC has a human subject protections’ office, they have an IRB, two or three IRBs, I'm 

not quite sure. But all of this is reviewed and looked at. So again, the internal work group that 

we're going to have will involve one or more people from the IRB office to specifically inform us 

and guide us on the process. 

Councilman Chester Antone: Okay, go ahead, Delight and I have a few questions before we 

go to your next question, Doris. 

Delight Satter: And what you're describing, what everyone is describing, is exactly what we're 

going to explore on site. Coordinating that information and the internal multidisciplinary 

workgroup helped us learn more about how do you use it, what do you do, what do you know 

people used to do, and how we are going to get that information together so that all of those 

positions know their needs. These are actual researchers who are working on public health 

issues. They need access to the specimens to do some of the studies. How do they need it, 

how should our policy protect native values and native concerns and still be able to complete 

the research as well. Then I know, Tim said we should work with AAIP a couple of times, and I 

forgot to say we already are. So Judith Giri has already spoken with Dr. Hennessy and we are 

actually meeting tomorrow to further our communications. Thank you. 

Councilman Chester Antone: Okay, before we go into the next question, real quickly, the return 

of specimens and/or human remains is both a celebration and also it has certain things 

attached to that which falls in the realm of our medicine men. And it is not necessarily bad, but 

occasionally there are things that need to be fixed up. I want to put that to you because our 

tribes specifically have these, that's why we claim human remains that are in the southern 

Arizona museum and then when we take them, we lay them properly, rebury them properly 

and that comes with a ceremony, which is usually tended to by our medicine people. And I 

wanted to relay that to you because all tribes are different, as you well know. The other thing I 

wanted to let you know in terms of the development of your policy or the policy, or I should say 

our policy, is that we need to have a trust, particularly the use of others, using for other 

purposes, that we should be informed of that. I think it's as simple as that, because when we're 

not, then it raises to a different level. Then we have problems. But if we're aware that these 

things are going on, then I think we're okay with it, at least some of us. But some of us really 

need to be informed and I think that informing tribesof your protection that we're holding that 

trust. I just wanted to leave you with that and then I'm going to turn it over to you, Doris, for the

next question that you want feedback on.

Dr. Doris Cook: Yes. Thank you very much. This has been very informative and when we 

receive the notes, it will be quite useful to get to the next stage. It's been very helpful to hear 

the listing of those core values that this group has, like respect for tribal sovereignty, trust, 

information sharing, partnerships, etc. As a next step, I'm wondering how we can best address 

the expectations for that with the help of the Tribal Advisory Committee. 

46 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
Councilman Chester Antone: I’ll leave it open now for anyone, the membership. Well, I'll take 

a stab at it. To address the expectations from the tribal communities which are already laid out 

in some of the responses from the membership, the example I used inform us of how these 

specimens are going – if there's a change in direction in other words from the collection of 

specimens from its original purpose, then one of the ways to address our values or the values 

from the native communities is just to be informed. And that's why I say that for myself, it's 

really simple to just tell someone hey, this is what we're planning to do. Even though it's not 

what we originally or we’ve already finished our original mission but we would like to go into 

this. And provide the reasons why. The use of these specimens aside from its original 

purpose, it's going to be used to address this particular onset of this disease which isn't here 

yet, but we want to know how to deal with it before it gets here. For instance the bird flu. So 

those questions, I think it's mainly just trust and honesty. And if you incorporate those with the 

values in this policy, then I think we're on our way. You know, I sit on the health research 

advisory council for the Department of Health and Human Services. I've always said that it's 

good that we are the tribe that finally did an IRB for our research code. We haven’t formulated 

the IRB yet but we realize the potential, the benefit of doing research. We look at Alaska's 

setup over there where they have specimens on hand and if anything breaks out, they're able 

to use that to determine certain things occurring from there. So that in itself it is something I 

look forward to. There are certain research activities that I'm interested in but they don't involve 

blood samples or human specimens, at least not initially. But to test the outcome let's say of 

traditional foods, if you did research on foods from the desert and you picked what do you call 

that group? If you pick a group that ate nothing but traditional foods aside from another, the 

usual group, then you might require blood samples or human tissue in order to analyze how 

effective that was. You know what I'm saying? So initially it doesn't involve blood or human 

tissue but somewhere down the road it may, in order to realize what the benefit or the outcome 

is, whether it benefits us. So I think maybe just putting the honesty part of it, the trust part of it, 

just informing tribes of what we are doing and what we intend to do aside from the original 

purpose. I think that goes a long way into carrying those values that you asked about earlier 

and people here provided you with those values so we just formulate a policy that's based 

around it. That's what I would lend to this discussion at this time.

Chairman Robert Flying Hawk: Thank you, Mr. Chairman. I haven't said anything up to this 

point and I think I might have to say something here. But am very thankful for the opportunity 

to be here and to hear the discussion. And I was just thinking about the words that I've been 

hearing and respectful and humanity, and thinking about a story I had heard growing up about 

this place, this land. And then somebody came over, said I'm cold and I'm hungry. So there 

was a hand that reached out and said here is something to eat and get warm. I see that as 

humanity in that respect and then the humanity of it all. I believe the community is that unseen 

and unasked virtue that's there when things like these are done with policy. And for this 

committee to give an answer, it's nation to nation, I believe, in our Great Plains area. The 

chairman, the presidents, the leaders of those bands, those tribes are moving towards that and 

I think across Indian country today and the movement is that as we ask each other, we all are 

47 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
a nation, we all have our ways of life. But they are basic. And so I have made myself clear as 

mud I think. But thank you. I just wanted to share those thoughts that I've been having.

Councilman Chester Antone: Mr. Jim?

President Rex Lee Jim: Thank you. We would like to address the second question, the Navajo 

Nation and then I will allow Ms. Antone-Nez to address that. Thank you. 

Ramona Antone-Nez: Good afternoon. There are six points that we would like to share. One is 

to continue discussion through regular reports back to the TAC. Two is to develop a timeline to 

meet specific activities. Three is to engage a focus group with traditional medicine people. 

Four, provide existing policies to the TAC for better understanding of how specimens are now 

collected and stored. Five, develop a flow chart of feeders into the bank. How are the 

specimens collected, how are they stored. And I think that would help with knowing what your 

current policies are now. Number six is to develop a subcommittee or workgroup to help in 

designing how the policy framework could become. And that would also feed into number one 

in terms of regular report backs to the TAC. Those are recommendations from Navajo area. 

Thank you. 

President Rex Lee Jim: And just to add one more to that. That is to do a survey of current and 

existing policies and so on in Indian Country, the nations and what their policies are, their IRBs 

and use that as a guide. 

Councilman Chester Antone: Cathy?

Cathy Abramson: Well, mine was just going to be a quick answer as I'm thinking about how I'm 

just going to go back home and if somebody would give me a summary of the specimens and 

just a short summary of what they are, and I want to go give tobacco, not to smoke, to our 

healers so they can give me advice on what to do. And I will bring it back. 

Councilman Chester Antone: Well, if there’s no one else, I would just like to ask to conclude 

your presentation. And if you gotten what you wanted.

Delight Satter: Indeed, I have. Thank you very much. It's been very useful. I'm very pleased 

with the discussion. I think there was so much information I got on the values and certainly its 

relationship, the core values relationship to community expectations. I think that you will 

certainly be very pleased to know that many of these points of recommendation that you have 

will be included in the work plan as a natural part of policy development. That information 

gathering of all of the guidelines that are available, what's going on in Indian Country. Also 

internationally. I mean there have been many developments in countries that have indigenous 

populations. And we look to them for guidance as well. Many, certainly the items that were 

raised I think are very easily accommodated and fit in with the overall project strategy which 

starts off with a sort of a bottom up process, starting with dialogues and discussions with 

48 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
indigenous communities, with communities, elders, with groups like TAC. One of the things 

that I'm certainly committed to over the next couple of weeks is to develop a protocol for 

communications and that would be communications between the internal expert group, the 

internal working group, the TAC and the body that is yet to be formulated, the expert panel. 

The regularity of communications, the requirement for reporting, at what point is there a 

delivery of updates and other reports, and certainly another item that is going to be part of the 

strategy is also the analysis of particular issues that are special to Indian Country and those 

that really do need an in-depth analysis. So those are part of the overall strategy as well as the 

formal consultations and the vetting of the policy that will be developed. We certainly want to 

insure that CDC gets it right. And that means going back to, back to the well, back to the first 

folks that we talked to about values and ethics to see if what we heard is indeed what they 

said. So that would be confirming that those values, which will ground the development of 

policy, have been appropriately captured. And vetting with other parties. There are other 

groups that will be affected by the policy and we want to ensure that it's going to be acceptable 

and workable to them as well. And of course that ultimately means it would stand a much 

greater degree of acceptance in Indian Country as well as with CDC and those folks who will 

be implementing that policy. Thank you very much for sharing. I really do feel that I've gotten a 

lot out of the discussion and look forward to continuing to dialogue with all of the groups and 

certainly have taken notes about the references to other individuals and other policies in 

existence. So thank you. 

Councilman Chester Antone: Okay. Any additional comments, we are ready to move on.

Delight Satter: Thank you. And we really want to acknowledge, we are very fortunate to have 

Dr. Cook working with us on this project. And we want to acknowledge Dr. Monroe for 

providing the resources to allow us to do that, so thank you. 

Delight Satter: I also forgot to say something. This happens to me all the time. Mr. Chairman 

Honanie, two resources for developing IRB exists currently, not that we couldn't talk about 

others. But Allen Trachtenberg at Indian Health Service has the responsibility for helping tribes 

develop their own IRB systems. But then also, the Office for the Protection of Research 

Subjects within OMB at the super level and HHS also has a whole system to help with the 

development of IRB. And you might not know this, but Bobby actually in his former life, used to 

work with those folks. And I have too far ago, I can't remember who they are but we can get 

you connected with that other resource in addition to Indian Health Service. I hate to have 

those things to come up like that, but that's the way my brain works. 

Chairman Steve Cadue: Chairman Antone 

This is Steve Cadue, Kickapoo Nation. It's been my good fortune to have practiced tribal 

sovereign governments for nearly 40 years and I appreciate the sensitivity of this particular 

discussion. It's probably one the most things that makes us unique in the relationship with the 

United States of America and what we come here for, consultation with CDC. There is a 

49 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
uniqueness about Native American people. And we're unique within ourselves also. You don't 

see one Indian, you see them all. We have a uniqueness and we're very proud of that. And it 

was recognized by the United States of America at the very beginning of this country. I really 

hope, Mr. Antone, that this particular discussion gets the proper people that I, and others, have 

mentioned involved with this committee and this discussion and this program. [Thank you. 

Councilman Chester Antone: Thank you for your presentation and the discussion. And we will 

just go ahead and go on with our agenda. Presently, we'll be entertaining these strengthening 

tribal public health through accreditation and performance improvement, have that discussion 

and we'll go turn it over to Liza Corso and Harold Pietz.

Liza Corso: Good afternoon. Thank you for the opportunity to be talking with you today about 

accreditation. My name is Liza Corso. I'm with OSTLTS with the division of public health 

performance improvement. Harald Pietz is joining me also with the same division within 

OSTLTS. We're going to be talking about accreditation today. What I thought would be helpful 

is if we spend some time quickly reviewing some of the key points about the national 

accreditation work. I know some of you are somewhat familiar with this and have been 

engaged in different ways. Others may not know much about the national accreditation 

program. So we thought it would be very helpful to talk a little bit about the national efforts and 

what this national voluntary accreditation program looks like. We can also then discuss a little 

bit about some of the efforts to advance tribal accreditation. And finally, we have some 

questions to prompt some discussion and we're hoping for some dialogue and questions and 

answers that both Harold and I can engage with you about. So first of all, the national voluntary 

accreditation program for public health departments. It's actually ran by a 501(c)3 organization 

named the Public Health Accreditation Board. PHAB is the acronym that's used. Since the very 

inception of this effort, the work has been co-funded by CDC and the Robert Wood Johnson 

Foundation which has been a really nice partnership. It's been a nice match between a federal 

organization and a philanthropic organization co-supporting this effort. But this has very much 

been an effort driven by the field through practitioner input, through committees, through 

testing and now overseen by a board of directors that also is very representative of the field. 

After several years of development and testing, the program formally launched in September 

2011 and the website that you see up on the slide here, www.phaboard.org is where you can 

find all the key information about accreditation. The standards and measures that represent 

the meat of any accreditation program. Information about the accreditation process and names 

of the boards of directors and other committee members. Just everything that relates to the 

accreditation program. At this point, there are quite a few health departments that have applied 

to accreditation. At the time we actually finalized the presentation, which was in mid-January, 

the need to put this into clearance, there were 260 health departments in ePHAB. That 

includes two tribal health departments, 24 states, and the remainder are different local health 

departments that have applied through different ways, both locally as well as centralized states 

or multi-jurisdictional applications. At this point right now, 269 health departments in the 

system. I will say this also includes those that are accredited. So we now have 21 health 

departments that are accredited, two states and the remainder are locals. The whole purpose 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
of the national accreditation effort is not for the sake of a compliance program or accreditation 

for accreditation's sake. But the real interest in it is to advance the quality and performance of 

public health departments. And when we say public health departments, this has been a 

program that has been developed with the eligibility language for state, tribal, local and 

territorial health departments. And I'm going to talk a little bit about the efforts and engagement 

of tribal perspectives in this process and how that has led to that piece of that program. As I 

said, it's really all about advancing the quality and performance of health departments. With 

that said, as with any other accreditation program that we've seen, hospitals, day care centers, 

schools, the public really expects accreditation. Many of your organizations may be involved in 

health care oriented accreditation through AAAHC or CHAP. These are programs that are well 

recognized in terms of giving a level of accountability or credibility or recognition. That is 

something that we hope as PHAB becomes more well institutionalized in public health, is 

something that is really seen as a strong benefit. Obviously, the opportunity to improve the 

whole public health department and the infrastructure. Thinking of health departments as 

programs that have different bricks, this is something that really represents the mortar in 

between those bricks. Something that pulls the health department together. And then all the 

different services that a health department delivers, seeing that strengthen regardless of the 

different programs and across all programs. Let me briefly tell you about the different elements 

of the PHAB accreditation program. As I noted before, all accreditation programs, and many of 

you may be well aware of this, of course, are based on the existence of standards. What 

health departments or what any organization being accredited needs to meet to achieve 

accreditation. And the PHAB accreditation process, those standards and measures exist 

across a framework of 12 domains. Those domains are based on the 10 essential public health 

services. Two additional domains have been added to address administrative capacity and 

management, as well as engagement with the governing entity. And by choosing and by the 

work groups, again comprised of practitioners from the field, choosing to use the essential 

services framework as the framework for those domains, they really looked at this as intending 

to provide a strong foundation for all public health programs. There are three prerequisites that 

need to be in place before even applying to accreditation. These are actually found within the 

different standards and measures. But PHAB thought this was a good litmus test to make sure 

that no one was applying prematurely, because these are fairly hefty documents and do take a 

real commitment and time. First of all, having a community or state or tribal public health or 

community health assessment. Obviously, that makes sense because any health department 

should be working with their community partners to really understand what the prevailing 

health status of the population is, what the key issues are, and working with their partners to 

address those issues. And that of course, also where the community health improvement plan 

comes into place. Using the results of the health assessment, both data and community 

perceptions to identify priorities and address those and use resources wisely to address the 

priorities of the community. And finally, of course, a health department strategic plan is the 

third prerequisite. The PHAB accreditation process is very much like other accreditation 

processes in that it uses an external validation process, site visitors that are comprised of peer 

reviewers, state, local, tribal, leader, public health leadership attend the site visit and develop 

the report. In fact, PHAB is always looking for more site visitors. So if that's something that any 

51 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
of you are interested in, I know some of you might be doing this already. That is something that 

it's of keen interest not just to ensure for example there are tribal representatives or tribal site 

visitors to go visit tribal organizations, but also to visit state health departments and local 

health departments, because the engagement with tribal populations and with tribal, whether 

they're in the jurisdiction or adjacent to the jurisdiction and there's collaborative issues that 

need to be addressed, that brings new perspectives that can be very important to the process. 

Once accredited, health departments then must be reporting for five years throughout this five 

year accreditation status. And then that accreditation is good for five years. These are the 12 

domains that I just referenced. Again, in accordance with the 10 essential services which have 

been reworded to better fit what a health department or an organization should be doing. And 

then those new 11th and 12th domain addressing administrative and management capacity 

and the engagement with the governing entity. I wanted to very quickly show you a sample 

standard since I know some of you might be very well familiar with this and others are not. This 

is what it looks like if you were to take a look at the version 1.0 of the PHAB standards. They 

also just released version 1.5 which I'll talk about in a moment. But this of course is one that 

comes from domain two, investigate health problems and environmental public health hazards 

to protect the community. Within each domain, there are several standards. And then which 

under each standard, there are measures and required documentation. I want to point out that 

you see in this one, standard 2.1A. “A” means this is a standard that is relevant for all kinds of 

applicants, state, tribal, local, and territorial. There are some standards that have a “T” after it. 

That means that those are ones that are very specific to the tribal organization, or tribal health 

department that would be applying. That doesn't mean that the domains and standards look 

extremely different than the state versus tribal organizations, but it does mean that the 

language and the examples of documentation have been addressed and adapted to better fit 

the tribal setting, for example, or to best represent what state health departments could be 

submitting if it's an S, or local if it's an L. So in that sense, PHAB has tried to work with its work 

groups to develop standards and measures that are both consistent yet flexible to address the 

different types of applicants. I just mentioned that the one example that you just saw came 

from version 1.0, which was the first version that has been released to the field. Just a couple 

of weeks ago, PHAB released its version 1.5. It essentially looks the same. The standards and 

the domains very much remain the same. However, there are some new areas for emphasis. 

Health equity, which is something that I know input from tribal organizations was definitely 

included there as well as in fact all the accreditation improvement processes for development 

of 1.5. Public health ethics, public health communications, science so a little bit more in 

regards to communications and updating some of the processes and types of documentation. 

So for example, if a health department is using social media, the opportunity to prompt for that, 

it doesn't necessarily require that represent—of course acknowledging that some health 

departments are not able to do that, or are not seeing that as a good opportunity quite yet. 

Public health work force and of course public health informatics, a fast moving area that there's 

a lot of opportunity to see what the trajectory should be from 1.0 to 1.5 and then beyond. So 

that the standards can represent something that actually continues to push practice forward, 

but also stays relevant as the practice evolves and updates over time. The majority of the 

changes from 1.0 to 1.5 however, I don't think were content oriented and I don't think PHAB 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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would say that either. They really represented editorial changes for clarity and requests from 

the field for doing this. In fact, PHAB leadership is the first to say that they came out with this 

new version much earlier than they had anticipated coming out with updated version. So the 

editorial changes represent wording language changes that are better understood and respond 

to some of the questions that they've heard from applicants or those looking at this, as well as 

some additional specificity on time frame. So being very clear. This document needs to be 

something dated within the last three years. Or this document needs to be something that 

shows a date within the last five years. That does change from measure to measure. PHAB is 

planning and this is actually part of their CDC work plan with us, to hold a webinar for tribes. 

And I think they're actually planning this in partnership with the National Indian Health Board to 

highlight these changes. And so that will help to raise awareness and answer questions and 

advance dialogue among tribal organizations, looking at the accreditation program, preparing 

for accreditation and making sure folks are aware of 1.0 and 1.5 as well as where the future 

might bring. Now let me talk a little bit about CDC's role in accreditation support. As I've 

mentioned, we have been since the inception of this work, been co-funding the Public Health 

Accreditation Board. We continue to provide some funding for PHAB. And that goes for some 

of the operations but also the continuous improvement and evaluation work. Those of you who 

are familiar with the accreditation program know that applicant fees are required once you

apply to accreditation. That actually covers the site visit, the site visitor, travel, the process of 

monitoring and working with you for five years. So PHAB has done a very nice job of being 

very specific of what kind of funding goes to what kind of activities. We also support some 

different national partner organizations and work to develop national resources for technical 

assistance and training. And I'm going to highlight some of the resources that are available for 

tribal organizations when we get to some of the latter slides of this presentation. Because we 

see that technical assistance and training, educational resources, those types of things that 

reach populations in aggregate are a real opportunity. The National Public Health Improvement 

Initiative and the Performance Improvement Managers Network, were going to talk about that 

in a moment, as well as some of the incentives that we're trying to put into place. So NPHII, we 

have to make an acronym out of everything, don't we. This is the National Public Health 

Improvement Initiative. And this has been a cooperative agreement that has come out of 

OSTLTS, the key areas of emphasis for the NPHII cooperative agreement has been to 

accelerate public health accreditation readiness. It doesn't require accreditation or an 

application to PHAB but it accelerates the meeting of the standards and looking at those 

standards as something that represents what strong public health infrastructure could look like 

and should look like. And it also supports performance management and quality improvement 

practices. Through this, we've also established a national network of performance 

improvement managers. One of the elements of NPHII, of the NPHII cooperative agreement 

was that each grantee should hire or designate a performance improvement manager. And 

through that, each of those grantees, those PIMs have new connections through what we refer 

to as the PIM Network. So through a listserv, through monthly seminars, there's been I think a 

lot of nice peer learning that has occurred. And that includes between all grantees because 

we've really seen and learned and observed that every type of grantee can learn from every 

other. This has been supported through the Affordable Care Act, prevention and public health 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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and more information can be found on this website. There's a quick map of the NPHII 

awardees, but I'm going to skip right to this one, which specifies the NPHII tribal grantees. And 

with that, I want to pause here to see if Harald wants to add a little bit more in about any of 

these slides on NPHII. He's actually the branch chief that oversees where the NPHII program 

operations rests.

Harald Pietz: Thank you, Liza. Good afternoon. I think you're covering it very well on the 

points that we're trying to make. We've looked at it in the four years that we've been putting 

this together, great outreach to the tribes, to the territories, states and many of the locals. I 

can't stress enough the good work that's been going on, especially in Alaska, between the 

state of Alaska and ANTHC to really come together. It really embodies a lot of the work that 

we're trying to do within NPHII. Cherokee Nations certainly a solid grantee, always there, 

always helping out, always advancing the cause of tribe within NPHII and the proponents that

we're trying to make. Not to mitigate any of the other tribes and their activities, but since we 

have representatives here today, we'll call them out. And certainly Anita at Navajo Nation, 

many of the work that's going on is really good. We understand that every one of our states, 

every one of our locals, every one of our grantees is coming from a different point within 

accreditation and within performance improvements. So our objective is to advance people 

from where they are. We want to advance them to a state to which they can be a more 

efficient, more accountable, more effective health department, being able to use their funds as 

wisely as they can. As Liza pointed out, NPHII was a non-categorical grant or cooperative 

agreement that was put out and is used for the health department to be able to address those 

issues that they've found most pressing within their health department to advance that 

efficiency and that effectiveness concerning a target categorical programs, but also business, 

administrative issues. And we've seen large headway and great advances across all of the 

grantees. We look forward to continuing that and we'll be having a lot more discussion at the 

grantee meeting coming up in April of this year here in Atlanta. And we won't reserve any

further time since we're so pressed for questions at the end. 

Liza Corso: Thank you, Harald. One of the other ways that CDC has also been supporting and 

trying to advance accreditation is by making strategic and programmatic connections. Clearly, 

CDC does a lot to advance program categorical areas across CDC and out in the field. So one 

of the keen area of interests has been how do all of those programs and services that we're 

trying to support, how are they reflected in the PHAB standards and vice versa. How can those 

PHAB standards help to really advance and provide the right foundation for all the 

programmatic areas that our health departments are undertaking. So that has been a real area 

of interest. And we've been doing work across CDC, outreach and engagement to really make 

sure that there's awareness, that project officers that oversee categorical areas are aware of 

what PHAB accreditation is, so that when their grantee talks about that, that's something that's 

recognized and valued. But this is something that PHAB has been interested in too. In fact, we 

have been holding, and by we, I mean the global we. So PHAB in general has often been the 

one to convene these think tanks or often expert panels to really look at and explore topics that 

need a little bit more diving into. I mentioned earlier that informatics was an area that was 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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advanced and updated in the version 1.5. PHAB actually convened a couple of think tanks 

around public health informatics. Because the question was we really need people from the 

field and people who are expert, subject matter experts in this area to identify what are the key 

expectations of public health departments, where's the field going and what might that mean 

for the PHAB standards. So we're looking at this with lots of different topic areas. We've also 

looked at this in regards to expectations in regard to different programmatic areas. This is 

probably not even an exhaustive list. So I did take the liberty of including examples of, because 

I was sure I've actually forgot some. So this is examples of programmatic areas where we've 

been making these kinds of connections. Preparedness. There have been think tanks around 

public health preparedness that PHAB has convened. We've also done significant work with 

our office of public health preparedness and response to look at how accreditation crosswalks 

with the PHEP, public health emergency preparedness capabilities. So those expectations of 

preparedness grantees, how does that crosswalk and mesh with the expectations of health

departments as defined by PHAB. One of the things that we've talked about is what we want to 

look for, we refer to this as the twofers. Where can you be doing things that will meet multiple 

are of need, because that's, in a time like this when every organization is resource strapped 

those kinds of questions are really important. Chronic, maternal and child health. The list goes 

on and on. I've put some asterisks, you can see next to certain bullets up there, preparedness, 

immunizations, health care associated infections, the guide to community preventative 

services, a few others. That's where we have actually been working on tangible, concrete 

crosswalks. To highlight where there are key connections or you could look at PHAB standards 

in accordance or in relation to these topic areas or recommendations or other specific 

standards that come out in other areas. The one that came out, we actually just released a 

couple of months ago, in the fall, late fall. The guide to community preventive services, a 

crosswalk with the PHAB standards and guide recommendations. So if you're familiar with the 

guide, you know these are evidence based recommendations. And so this doesn't necessarily 

mean this is what you should do to meet a standard. But if you need to be doing work in an 

area to meet a PHAB standard, that crosswalk could help to point you in a direction of some 

evidence based recommendation and some interventions that come from the guide and vise 

versa. If you're doing work in certain topic areas in the guide, you can see where that might fit 

the work that you need to do to identify documentation for your PHAB accreditation activities. 

So let's move into talking a little bit about what work has occurred in collaboration with tribes, 

both in the past and in the present. First of all, I want to acknowledge that some of this work 

has been CDC supported, but also there's some work I'm going to be talking about that has 

been RWJ supported, the Robert Wood Johnson Foundation. We work very much in 

partnership with them on the accreditation activities and we often try to ensure that we are 

complementing and synergizing our investments. We obviously do not want redundancies, so 

in some places they've been able to support certain ideas. In other places, we've been able to 

advance certain efforts. Going back many years before even accreditation was launched and 

as it was still in development, the Robert Wood Johnson Foundation did do some work to 

support a very specific process with the National Indian Health Board around exploring tribal 

public health accreditation. I mentioned that, even though that was quite a few years ago, 

because I think that still represents the blueprint and the foundation for so much of what has 

55 “This document represents meeting minutes of the CDC/ATSDR Tribal Advisory Committee Meeting 

and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

Control and Prevention views or policy. This document is intended for your use only, please do not 

forward”.
continued to occur in regards to the collaboration and the input and how tribal accreditation 

works, how PHAB approaches this. Using that work, they convened, PHAB did convene a 

tribal think tank, where they spent some focus time looking at very PHAB specific questions 

that were related to the development of the PHAB accreditation program. And also, they had a 

PHAB tribal standards work group. So, a work group very much focused on developing the 

standards that would either say yes, we think the state or local standards are good for tribes, 

or we want something a little adjusted here. And here's why and here's the language that 

reflects, or the examples that reflect the documentation that might come from a tribal 

organization. The tribal think tank and the tribal standards work group actually represent good 

examples of where CDC funding has been able to support some of that effort in this area. 

There, of course, was a beta test process in 2010. Navajo, Cherokee and Keweenaw Bay 

were three tribal beta test sites. We just talked about NPHII and the performance improvement 

manager network. One initiative I did not mention quite yet is that through NACCHO, in the 

past, the National Association of County and City Health Officials, we have been able to get 

them to use their accreditation support initiative to also support tribal work. And that includes 

organizations like the Yellow Hawk Tribal Health Center and others that have – the purpose of 

that is a very small amount of funding has gone to all sites, the number of sites that have been 

funded local or tribal. But with a small amount of funding in a short period of time, often that 

can make a nice difference and serve as a good catalyst for accelerating work. There's always 

an ongoing opportunity for tribal participation in PHAB work groups, committees and think 

tanks. That's actually one of the points for dialogue I want to bring up. How to best make sure 

these opportunities are realized and how to make sure PHAB gets names of folks they should 

be inviting, and that tribal participants or tribal representatives are well aware of these 

opportunities. The work to advance accreditation is not just limited to accreditation. Both CDC 

and the Robert Wood Johnson Foundation are doing work that extends into the broader 

performance improvement and quality improvement arena. And so ensuring that there's tribal 

participation in these broader initiatives is also important. I know that National Indian Health 

Board is doing tribal public health accreditation advisory board and has convened that. So I 

wanted to acknowledge that. And of course, there are a variety of resources to support tribal 

accreditation readiness that have been developed through the years. I especially commend 

NIHB and also Red Star Innovation because I think their websites, and I have this on the next 

slide, they really do a nice job of calling out some of the very specific tribal webinars, as well as 

the guidebook and roadmap and other documents, tribal community health assessment guide 

for example, that really helped to provide the resources that organizations need to meet 

accreditation standards, and to undertake these activities, but also doing it in a way that 

addresses the approach that a tribal health department may want to take and the culture. The 

cultural issues that were working with. So the slide that you see up now has a variety of other 

websites in addition to NIHB and Red Star that I mentioned. Our own CDC accreditation 

website page and of course the PHAB page. The last link that I have up here, I just wanted to 

also mention the Journal of Public Health Management and Practice. The January/February 

2014 issue is a special issue on accreditation, it focuses entirely on accreditation. We use 

some CDC resources to ensure that it was available open access. So anyone can click on this 

link and see all of the manuscripts within there. It does include a commentary by Joe 

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Finkbonner and Aleena Hernandez about advancing accreditation among tribal organizations 

and there are other commentaries and peer reviewed manuscripts that may be of interest as 

well. So that concludes the more formal part of the presentation. I wanted to finish by sharing a 

few questions and opportunities that I thought could spark some of the dialog that we could 

spend the remainder of our time on. And let me just quickly share this and then we can jump in 

wherever you may have questions or thoughts. How can we advance awareness and interest 

in PHAB accreditation among tribal health departments? We know that the motivation or the 

incentives or even awareness for accreditation among tribal organizations may look different 

than it does among state and local health departments. And so we would love to hear from you 

what might be the best opportunities to advance awareness and interest. Are there venues or 

methods that we can better take advantage of, and by doing that, I'm thinking not just the tribal 

specific settings, like of course there's meetings such as this, there's conference, tribal 

conferences, such as the NIHB conference. But then, also how do we ensure that there's a 

strong tribal presence at, and tribal voice and representation among speakers in even more 

general settings. Settings that include all types of health departments. Harold mentioned 

earlier in April, we have our public health improvement training and our NPHII grantee 

meeting, making sure that discussion and dialogue are aware, and the inclusion of tribes is a 

very important part of that agenda, not just among the participants but having that be 

something that is very visible to all. And then the last part I wanted to talk about were some of 

the opportunities and challenges. I mentioned earlier tribal participation in accreditation 

opportunities. PHAB is always having a need for representation from all kinds of 

representatives. But this certainly includes the need for tribal representatives in their think 

tanks. This year, they are planning for a think tank on preparedness, one on health care and 

public health integration. And one on accreditation and quality improvement. There are others 

that will be occurring. Another on chronic disease. So how do we make sure that there are 

some good tribal representation there. We would love to be able to see if the TAC, the Tribal 

Advisory Committee, could be used to surface ideas, or we could even just let you know when 

these opportunities are and you can share ideas directly with that if you would prefer to take 

CDC out of that process. Site visit, as I mentioned there's a perpetual need for a site visitors 

and especially tribal site visitors. PHAB has a call for site visitors up on their website, so this is 

a plea to look at that if this interests you, or if you know if this interests any of your staff. We 

know that support for accreditation is important. We know that financial support is important. 

We are the first to be interested in more financial support for accreditation. So I am aware that 

that's probably an idea that you're thinking of and interested in, so we are always looking for 

those opportunities. But in the meantime, we also want the best ideas so that they're in our 

back pocket. So if funding becomes, if and when, I'm going to say when, funding becomes 

available, in the hopes that there is a when, funding becomes available, we have some very 

viable ideas that will really help to advance tribal accreditation. And then of course, there's an 

opportunity for continuous improvement and development of all those different kinds of 

resources and technical assistance and all the different – advancing these concepts among 

tribal organizations. So with that, I'm going to stop here and see if there are any questions or if 

this sparks any comments or thoughts that any of you would like to share. Thank you. 

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Councilman Chester Antone: Jay Butler?

Dr. Jay Butler: Thank you, Mr. Chairman. I wanted to follow up on your comments about the 

NPHII program. That's really been a marvelous opportunity for at least four of the organizations 

represented around the table. I can say for us in Alaska, it provided the opportunity to do the 

community health assessment and what was really unique was the partnership with the state 

of Alaska, dovetailing with some earlier activities they had which had absolutely zero tribal 

input to actually be able to come together as equal partners in that process. Unfortunately, 

we've also received the letter, as did everybody here that support is ending. So we've done the 

initial assessment and we're in the process of moving towards implementation but it looks like 

at least support from CDC is no longer present. I'm sure you've given this some thought. I'm 

wondering if you can give us any insight into where we should go at this point; should we be 

encouraging people to find other jobs. Thank you.

Harald Pietz: That's a very good question, Dr. Butler. Dr. Monroe and I were just talking about 

it before this session and were having conversations with Liza, Dr. Thomas and others. We are 

seriously looking at how to do this. We're refocusing the grantee meeting to really discuss 

closeout and the opportunities. We envision the opportunity for a no cost extension to be able 

to take any unspent funds and roll them forward for perhaps another 12 months for that 

extension to close out the activities. Given the uncertainty of any funding, I don't see any 

funding coming in FY'14, that is going to support NPHII or an accreditation like an opportunity. 

It's a very real question and I think every PIM, every PI, everybody that's funded or supported 

through the NPHII grant has to look at their own individual situation and see what's there, see if 

there are other opportunities. For those that receive other federal grants from CDC, there is an 

allowable use of some of that funding if it is one of the new FOAs that's been released in the 

last year or two, to use some of that money towards accreditation. And certainly those would 

support that kind of performance improvement aligned with NPHII. We are, everyday, looking 

at opportunities to see how we can find additional funding and where we can partner with 

potential funders to be able to support that. It’s unfortunate that we're right here in year four 

making huge strides, everybody is picking up and going out and didn't really see this one 

coming. Really hoping to get through year five and go out with a big bang. We currently have 

proposals being drafted for FY'16 and FY'15 to put into the budget to continue these things, 

but they're uncertain until the budget is actually signed. 

Liza Corso: Can I just pick up, explain what, because I realize I did not mention the FOA piece 

that Harald just alluded to. Since October of 2012, CDC has started using a standardized FOA 

template and guidance, so that any new FOA, funding opportunity announcement, I'm sorry, 

funding opportunity announcement that comes out from CDC, which once looked very different 

from program to program, now has a far more standard look and set of expectations, look and 

feel to it. Within that standardized template, and within that standardized guidance, there is 

now language that is since 2012, language that allows in the budget narrative section, 

language that allows for inclusion of budget items that advance work towards accreditation 

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and 10th Biannual Tribal Consultation Session and does not necessarily represent Centers for Disease 

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forward”.
standards and it specifically cites PHAB, the Public Health Accreditation Board accreditation 

standards, as long as it's in the spirit and the intent of the FOA. And so this isn't trying to take 

money away from categorical programs. This is recognizing that so much of what accreditation 

is about is in alignment and very synergistic with the expectations and the needs of all of the 

categorical programs. So those new FOAs that you may have been seeing since that time 

should have that language. What we can do after this point is provide an example of that so 

that that can go out in a note so you could see an example FOA and see what that looks like, if 

that's of interest to this group. 

Dr. Harald Pietz: If I may, so one of the things we'll be coming back to all the grantees and 

explicitly reaching out to the tribes, are we are gathering every success story we can get and 

we are trying very hard to pull all the NPHII successes together so that we don't lose – we 

mitigate the loss of momentum, that we're going to get with an early kind of shutdown. But we 

want to make sure that the literature is there, so that when we get another swing at this, we 

can hit it and we can start, much farther field and I think we've got a good base and we want to 

get into multiple bases in the next go round. So please, work with your staff back there when 

we reach out to them and start asking for additional stories, we're just looking for really meaty, 

I mean Dr. Butler, you get it, right? So what we're trying to get out of this, those are the things 

we're going to be collecting, putting out and disseminating in every venue that we can, and we 

encourage to take your own stories and put them out for the population and the whole nation to 

be able to read those and see the successes from every perspective. 

Lisa Pivec: Thank you, Chairman Antone. Lisa Pivec, authorized representative from 

Oklahoma. I don't have a question, more just comments. I know that the news came as very 

unpleasant news to all 73, I believe, grantees. But I think that it's important to recognize that 

tribal grantees are very unique in this sense. While most start and local health departments 

were using this for quality improvement or solely accreditation we were using it to build 

infrastructure that does not exist. And CDC of all agencies, should understand that the 

development of those domains enhances every single program and every bit of funding that 

CDC puts into Indian Country. Our programs are more effective when we have that 

infrastructure in place. And I've been the PI for numerous cooperative agreements over the 

years, and as this came into play, I clearly see how we could have multiplied the successes 

from past funding opportunities had we had this infrastructure in place. So I'm hoping that this 

infrastructure continues to be developed and that CDC will pass on the unique message from 

tribes in how they differ with this funding from local and state health departments. And building 

this infrastructure, whether we do it internally or we satisfy it through partnerships, it's 

extremely important for us and for the CDC so that your investments are done in a way that 

are going to impact Indian people and the people of the communities. Thank you. 

Councilman Chester Antone: Mr. Rex Lee Jim.

Vice President Rex Lee Jim: Thank you. Two issues. One is what you're doing in terms of 

capacity building for long term sustainability of these departments of public health. Two is what 

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are you doing in terms of allowing travel participation in state accreditation processes under 

STAC with this tribal state relationships. We’re interested in improving relationship so if some 

tribes do not have the capacity or desire to have their own public health institutions, how are 

you helping them with states? In Navajo, we are pursuing our own accreditation, but at the 

same time, we still would like to have a say in how Arizona, New Mexico and Utah develop 

theirs. 

Liza Corso: Absolutely. Thank you. Those are two very good questions. My understanding of 

your first question was what are you doing to build the long term sustainability of—I think in 

essence, the whole concept behind accreditation is that it is something that is intended to build 

long term sustainability of public health departments in a way not tied to a specific funding 

program or a cooperative agreement, but by achievement of accreditation and by standards 

that then their policy makers, elected officials or leaders will expect, brings a level of stability 

and sustainability even in tough times. We have heard from state and local health officials that 

during past years when budgets were extremely tight, that they were seeing other fellow 

leaders for other agencies in the state or local system be exempted from a new round of 

budget cuts because it would then impact their accreditation status; so the standards that they 

need to meet. Public health hasn't had that opportunity up until now. And so PHAB 

accreditation may actually bring a level of protection and stability to what can be expected of 

state, tribal, local, territorial health departments in a new way. With that said, there's no one 

place that we're looking for the long term sustainability in regards to building it. It has come 

from NPHII. We are also looking for it from investments from different categorical areas in 

regards to this new allowance with our funding opportunity. Many local health departments and 

state health departments have been doing this work without really acknowledging exactly what 

kind of cooperative agreement or funding it comes from. So I think it's something that isn't 

necessarily seen as tied to a specific funding area. For that reason, the incentives that come 

from CDC, both for preparing for accreditation as well as longer, down the road, once you have 

accreditation, what does accreditation mean, is it expected? Those are very important. So 

we've also been looking at incentives. It would be wonderful to hear from you, maybe not now, 

or in a future meeting, the kinds of incentives that you think would be especially compelling for 

tribal organizations. 

Vice President Rex Lee Jim: I was thinking in terms of the human resource development. 

Liza Corso: Yes, workforce. 

Vice President Rex lee Jim: So that when the funding runs out, then the people will be there to 

continue to run...Mm-hmm.

Dr. Harald Pietz: So just to add on to that, there are a couple of things. So certainly NPHII was 

not the beginning of performance improvement within public health. It's certainly built on the 

shoulders and giants that were running before us. But we do however, within my branch, 

provide technical assistance to health departments that are seeking information or technical 

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assistance around accreditation or any of the prerequisites for community health assessments, 

health improvement plans and strategic planning. We also work with our partners, and those 

resources are certainly available and adaptable to particular situations irrespective of the 

jurisdiction or the locality the individual is coming from. In no small part, with the four years 

that we have been able to advance NPHII through many of the partners, we hope for those 

that were directly funded, have learned, have benefited from the TA to understand quality 

improvement and performance management and may be able to sustain some of that work to 

offset some of the grants that they may no longer be getting. So we've seen efficiencies and 

effectiveness in processes that have done a return on investment in different areas and we 

hope that this ground work that has been laid can be continued and that eventually, NPHII was 

a five year initiative, we certainly hope for an addition to that and we're still working on those 

angles but there's hopefully enough penetration that occurred in those four years that people 

will be able to sustain the workforce improvement and the training around quality improvement 

that went in. It certainly does not replace the amount of funding that was going out. We had 

about $10 million go out over four years to the tribes. We'd like to continue that obviously or 

even expand upon that but we have to plan and all grantees need to be able to plan for 

sustaining it within their infrastructure because it is unfortunately very surprising but it is one of 

the few times I've ever seen where it actually said subject to the funding availability, and I’ve 

never run into that issue in running a grant program, we actually didn't have that funding that 

year. So it certainly disappointed all of us. But I looked from the committee here and from all 

the members outside , whether they're grantees or not, to be able to, what can we do to help 

you. Our resources are there to be consumed by anybody. They are publicly available. 

Liza Corso: I want to go back to your second question, Vice President Jim about the state and 

tribal interaction and the role that tribal organizations, or tribal representatives can play in state 

health departments that might be looking at accreditation and vice versa. In quite a few areas 

throughout the PHAB standards, there's a lot of attention to collaboration and interaction 

between, with partners, between other organizations that might be representing populations 

that are part of that area or adjacent to. And it's, highly expected in regards to thinking about 

the documentation that a health department might be looking at and submitting to the public 

health accreditation board, that they would be looking at the organizations that they're 

collaborating with. And you just mentioned the Navajo, New Mexico and Arizona. I mean 

ideally a strong application from New Mexico and Arizona would include some examples of the 

collaboration with the Navajo Nation. That would certainly be something that they would have 

to describe as part of describing their state population. The other organizations that provide 

public health within that organization. PHAB is the accrediting body, so I don't want to get into 

too much of what they would be looking for as the accrediting body. That's a very different role 

that we play from CDC. But I think what's in the standards is prompting in the right direction. 

But this is also why we're really interested in making sure there are very good and diverse 

perspectives as site visitors. And representation on think tanks and committees is the way to 

really make sure that the program exists and continues to be improved in the way that best 

supports and advances the field in the right way. 

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Councilman Chester Antone: Tim?

Tim Gilbert: Thank you, Mr. Chair. I wanted to throw our vote into the notion of finding that 

continued funding for the NPHII funding. Obviously, we're in the Portland area, the 

Yellowhawk Tribal Health Center has been pursuing accreditation for the last couple of years 

and—it's ironic, last week we presented our community health improvement plan and our 

strategic plan that was based on our community assessment to our governing board. And I 

mean it took months. And we wouldn't have been able to get as far as we did without some 

level of support from the Portland Health Board, which benefited from those resources. So if

you could find a way to continue that, we benefited a great deal from that. We'll keep forging 

on if it's there or not, but just wanted to advocate for that. I guess I also wanted to state that 

you had a question up there about how we can advance awareness. And I don't know if you've 

been out to our neck of the woods, or maybe to some of the other grantee sites but what I've 

experienced when we start to talk about public health accreditation in a community meaning or 

with our governing board, which is a lay board of members of our community, we're competing 

with the notion that we're trying to recruit a dentist and we're trying to provide primary care and 

we're down to two providers and we have such significant disparities in behavioral health and 

alcohol and drug that you literally are competing with at least half a dozen other things for their 

attention about why this is important. So I don't know, I don't have an answer for that, but it's 

been my experience maybe we need to train the people on the ground and on the front line 

about how to advocate for the benefits of accreditation. But that always seems to be a barrier. 

How do we get people excited when we have five other things that they think are more 

important ahead of it in line. The last thing I'd say, for the folks who make decisions about 

whether something is funded or not, it's also been my experience that it can be eye opening to 

come out and make a site visit and see what kind of capacity there is. I mean physical capacity 

and human resource capacity, look at the community, just to get a feel for what the difference 

is between maybe tribal public health accreditation and what might be state department of 

public health. I don't want to be a crybaby here, but if the state department of public health

accreditation starting point is here, ours is probably somewhere back here, just for where we 

are and what we do and the whole breadth of services we have to provide. Okay, I'm being a 

crybaby. But we're just at a different starting point and we had to catch up but we really 

appreciated the resources that came through that funding. And one last plug. When we also 

started, we received funds from NACCHO, I want to call it. 

Liza Corso: Yes. That's the accreditation support initiative that I mentioned.

Tim Gilbert: Right. And we had to pick some things to work on and one of the things that we 

chose was our understanding between tribal code and state and federal public health law; a 

really fascinating area, and just a plug for the CDC, we had folks from CDC, attorneys that 

really enlightened us on that topic, which can really be complicated. But we've been 

appreciative of the support all along. So thanks. 

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forward”.
Liza Corso: Those are excellent points. Thank you for sharing those comments. Certainly 

don’t think we could say and echo any more than you’ve said already the support for NPHII 

and how important that’s been, and I think your comment in fact reinforces the fact that 

especially with tribal organizations that NPHII support has been felt beyond the direct grantees 

so much more in the tribal community than for any other grantee, any other type of grantee 

when you think about the many different Alaska Native Tribal Health Consortium, for example, 

how many different tribes you’re reaching in Northwest Portland 40-something—

Tim Gilbert: Forty-three.

Liza Corso: Forty-three that are in that area. I do want to mention to you, it’s not CDC but it’s 

the public health accreditation board, it does speak to ensuring that the organizations you’re 

working with are well aware of the unique nature and the challenges faced by tribal 

organizations. PHAB or at Joe Finkbonner is one step ahead of you in that there’s going to be 

a public health accreditation board of directors meeting this summer in Portland and Joe is 

already planing to see how he can make use of that so that the board can get some interaction 

and awareness in regards to that area. So you may hear more about that directly from him. 

And then you also mentioned the fact that we all need to be—everyone in the field, at CDC, we 

all need to do a good job about describing the needs for accreditation in a compelling way, and 

in a way that competes effectively with things that are often seen as much more concrete and 

tangible. I think that’s a challenge that we face on a daily basis and we will continue to be 

working on that especially with our communications staff. Thank you.

Councilman Chester Antone: We have two presenters here and we’re kind of running over time 

so I’ll go ahead and entertain you and then we’ll take a very short break and then we’ll 

continue.

Lisa Pivec: Mine will be quick, I promise. Just a practical suggestion. I realize that you are not 

the public health accreditation board but in consulting and providing feedback to them one of 

the things that I think would help tribes nationally is that if health disparities were better well 

addressed in the PHAB standards or more articulated as to how you were addressing those as 

a state or local health department and proving how that you were addressing populations such 

as American Indian communities. Thanks.

Liza Corso: And I do wonder if the improvements that have been made in version 1.5 

addressing health equity really got at some of those health disparities issues. I think they also 

recognize they didn’t go as far as they could have, there’s a bit of a trajectory there, that’s 

something that’s going to continue to be pushed and changed over time, and I think the tribal 

voice in those discussions and those continual updates will be very, very important.

Councilman Chester Antone: Thank you for your presentation and we’ll take a ten minute 

break and then go right into the other two presentations.

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Liza Corso: Thank you very much.

Councilman Chester Antone: David Espey, we’re ready to begin the presentation and I’d just 

like to say that we’re kind of behind schedule now so we do have our five o’clock time to wind 

down so I’m going to turn it over to Ursula.

Dr. Ursula Bauer: Hi. Good afternoon. Hopefully you can hear me. So my name is Ursula 

Bauer and I’m the Director at the National Center for Chronic Disease Prevention and Health 

Promotion here at CDC and I’m delighted to be with you. Thank you for inviting me to provide 

an update. Since we last spoke, we have had a similar conversation over a number of years. I 

know that the personnel around the table do change so I’m eager to be with you again today. I 

thought what might be most helpful for our conversation this afternoon is to talk about our fiscal 

year 14 budget and how that has changed, particularly with regard to what’s of interest in 

Indian country. We fared fairly well in fiscal year 14 but our budget was completely turned 

upside down so there are a lot of changes that we will be undertaking this year and that affects 

many of our grantees including those in Indian country. So just as a refresher, the chronic 

disease center includes the agency’s activities around the leading causes of death, heart 

disease and stroke, cancer, diabetes, the leading actual causes of death, the key risk factors, 

tobacco use, alcohol use, poor nutrition, physical inactivity, and then oral health, reproductive 

health. So we focus on those leading actual causes of death and risk factors and one of the 

approaches we’ve taken to improving health over the last 10 or 15 years has been a 

community health approach where we invest in cross sectoral programs that really can bring 

together resources and opportunities and leadership from health, from education, from 

transportation, the local hospital, the local school, a whole range of sectors within a community 

and bring resources to bear on a particular problem, and I think you’re most familiar with that 

approach from our funding through the community transformation grants. And unfortunately, 

the community transformation grants which was a $146 million program that started in fiscal 

year 11 is one of the big changes in our budget. That program has been zeroed out by 

congress so this is the third year of what should have been a five year funding opportunity and 

that program will end at the end of the current project year. So that’s bad news for a whole 

number of grantees including seven awardees in Indian country. While we lost those dollars 

for the community transformation grants, those dollars have reappeared in our budget in our 

lines for diabetes and our line for heart disease and stroke prevention with the instruction, with 

the guidance from congress that we deploy those dollars toward primary prevention of 

diabetes and heart disease and stroke, and that we do that primarily through our state health 

department grant programs. We have an existing grant program that addresses heart disease 

and diabetes with state health departments. However, we see those dollars as a real 

opportunity to really grow and strengthen a coordinated and multifaceted chronic disease 

prevention program in Indian country that could over time and with some strategic advocacy 

really blossom into a full fledged chronic disease prevention program. So we are in the initial 

stages of congealing our thinking about what that kind of grant program might look like and I 

am fortunate to have the opportunity to talk with you about it this afternoon as well as to have 

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forward”.
had the opportunity to meet with many of you informally or formally as well as in previous years 

here with the TAC to get your best thinking about what such a program might look like. I now 

see an opportunity to begin such a program in the current fiscal year. So that’s one area of 

discussion that I’d really like to have your input on while we have some time together this 

afternoon. In terms of the multiple changes to our budget we also will have some additional 

funding opportunities that you all will be interested in. One is a new community prevention 

program. You might ask the wisdom eliminating one community program and starting a new 

program. I can’t really help you with that but that’s the reality that we’re in so we did receive 

$80 million from congress to begin a new community program with instruction that we pay 

special attention to local community work and tribes in particular were mentioned as potential 

grantees so you should look for that funding opportunity announcement coming out later this 

spring. I want to save time for the discussion that I just teed up so I’ll just give you one last 

announcement before we move into that, and that is from our tobacco control work. I’m sure 

that you are very familiar with our Tips From Former Smokers campaign that launched in 2012 

and has been running in 13 and now has just launched again in 2014. This has been a very 

successful program that has helped hundreds of thousands of smoker quit smoking. I had the 

honor very recently to present the U.S. Surgeon General’s Medallion to Nathan Moose, Oglala 

Sioux who was a participant in that 2012 campaign. He shared his story with the nation and 

he passed from his secondhand smoke-related lung disease back in October. Nathan was not 

a smoker himself but he did work for many years in a smoke-filled casino and suffered lung 

damage and passed away at the age of 54 last October, and I was able to confer the Surgeon 

General’s Medallion to his wife, Jean Anne Nespers for his dedicated and exemplary 

contribution to public health. So with that memory of Nathan, I’d love to hear from you about 

opportunities and your needs with regard to effective approaches to invest in grant programs in 

Indian country particularly around primary prevention of diabetes and heart disease and stroke.

Councilman Chester Antone: Questions or comments? Mr. Gilbert?

Tim Gilbert: Thank you, Mr. Chair. Nice to see you Dr. Bauer, Dr. Espey. I wonder if you 

could, on that last point where you’re trying to get some dialogue, can you maybe—I have a 

vision in my head about what primary prevention means but is there a CDC definition we 

should be paying attention to?

Dr. Ursula Bauer: Sure. So in terms of heart disease and stroke and diabetes prevention, we 

think mainly about diet, physical activity and tobacco use prevention. As I’ve talked with many 

of you and visited a number of reservations and visited with tribes, I’ve been intrigued by how a 

number have really been able to organize your chronic disease portfolio around healthy 

communities and healthy foods. Our traditional foods program in particular I think has been a 

catalyst for a lot of thinking. How to limit access to unhealthy foods and beverages, create 

smoke-free environments. So I imagine, although we have discussion before we put pen to 

paper in terms of the congealing of our thinking we’re looking at how can we deploy across the 

nation some kind of model that has the opportunity to really grow and flourish. So these might 

be smaller grants, see grants initially where we could build some success and demonstrate 

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impact and build the program, receive additional dollars in the future. But we need to focus in 

on sort of the core behaviors in environments that are causing the diseases. So would like to 

hear how we could best support tribes in doing that.

Councilman Chester Antone: Cathy?

Director Cathy Abramson: I was going to give some input earlier anyway and you’ll hear me 

say this over and over again when it comes to diabetes, stroke, and heart disease. Back at 

home, and I know many different places at a national level and I talk to a lot of tribal leaders 

and they give the message to as many people as they can that we want to use our own ways 

of getting back to being healthy again and that would include going out and hunting, fishing, 

gathering and that’s growing our foods and like we would go fishing, we would be able to take 

your family out and that’s what we still do; families together with good clean water, and you get 

exercise by going outside and you’re picking the blueberries and strawberries that have all 

these whatever it is they have that’s good for you. I don’t know all the names of it but it’s—and 

then you’re out amongst the—it dawned on me when I went picking medicines for our healers, 

I went to go look for St. John’s Wart which is for depression and it’s all over the place and 

you’re looking for this cancer medicine and that’s all there, too. So you’re out in the woods 

where all of this medicine is and it has to be good for you, you must be getting it all in there 

and it’s keeping you healthy, you’re gathering your food, you’re getting your exercise and 

you’re breathing in the medicines that keep you happy and healthy, not depressed, the St. 

John’s Wart. So those are the types of things that we have to get back to. So those are the 

types of things that we’ve got to keep teaching our children and our grandchildren. So things 

like that. Thank you.I do have a question though. The community transformation grants, 

they’re being zeroed out. When are they going to be done? At the end of 2014?

Dr. Ursula Bauer: So the grants are in their third year. The third year of funding began at the 

end of September 2013. So there was a full year of funding so that will bring grantees through 

the end of September 2014.

Director Cathy Abramson: Okay. 

Dr. Ursula Bauer: I wonder if I could ask a couple of questions as we think about ways to 

disseminate awards to tribes. There are a lot of tribes, I’ve heard loudly and clearly, that 

disseminating dollars through state health departments is not a preferred mode of distribution. 

But we struggle with our ability to reach many tribes given the number and I’m wondering 

about different national or regional organizations that might be helpful for distributing awards 

such as the National Indian Health Board, the Regional Health boards, the Tribal Epi Centers, 

a number of national American Indian Alaska Native organizations. Are those vehicles that 

work well or is there a stronger preference for a direct tribal award or does it vary depending 

on the size and the capacity of the tribe?

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Chairman Herman Honanie: Well, I was just going to comment somewhat along the lines of 

what the young lady talked about, getting back to traditions. I can’t help but recall when I was 

a young lad maybe when I was 12 or 13 and we had a huge village meeting and there was just 

some various discussions and I remember my grandfather was there and he spoke quite a bit 

about the changes, about how life was beginning to change from what they lived, and they also 

had an idea on how life was going to be. And one of the things he remarked on was there’s 

going to be a time when we will not be able to control our kids. I had no idea what that meant. 

I had no idea what that meant until I became a grandfather. And now that vision, philosophy, 

prophecy is so really true and along the way we’ve endured so many experiences and when 

we talk about health that’s very key to what he said is that we cannot control ourselves, we 

have not been able to convince and persuade each other that eating the right foods is the best 

thing, clinging to traditional practices is what we ought to do and so on. So all the good things 

we just kind of put to the wayside. But we’d rather engage in a sedentary lifestyle, junk food 

and foods of that type, and now here we are, we’re kind of going full circle saying, hey, I guess 

our forefathers or grandfathers were right about what they had to say, we just didn’t listen. We 

missed the boat ourselves and so here we are struggling and scurrying and trying to do—what 

can we do to improve our health? Is it too late? What should we do and now what do we do, 

where are we at? It’s still a struggle, it’s still an uphill battle to try to convince and persuade 

our young children, our younger people that the traditional viewpoints, traditional practices is a 

key to good health. So I think that’s where we’re at. We just have to keep moving on, we just 

have to keep practicing and doing everything we can within the family, within the clan, within 

the community and across the villages and across the reservation. I think it’s beginning to 

happen and one of the best things I think that happened, which is I call it a plus out of so many 

negatives, is the Facebook, social media. I get on Facebook every morning—well, maybe not 

every morning...four mornings out of five, which is okay, you know, and I post when I’m gonna 

walk, when I’m gonna jog, and I usually do it at 4:30, 5:00 in the morning. The temperature is 

this, conditions were this. And I encourage people. I try to do that. I’m the chairman of the 

tribe and I have a lot of followers or readers and they say, wow, thank you for that. But I’m 

hoping if we can be able to get everybody out there on the Hopi Reservation, if anything, 

walking and taking a look at their health and controlling their health and everything else, 

maybe we’ll get on the road to being a little bit more healthier than we are today. But that has 

to start someplace and I just say to my people, do it. Then hopefully we’ll get something going. 

But that’s really what I feel and so I constantly harp on my tribal council leaders and say, go 

out to the gym or go out in the trails everyday or if not everyday, every other day. We have got 

to be the ones to set the example and we’ve got to go out to the centers like Head Start, the 

daycare centers, the elementary schools, and high schools. We’ve got to be the ones to talk 

to them about what we’ve learned as older adults, as older Hopies and we have a whole lot of 

knowledge, and that’s what we need to impart on our young people. I guess I was just 

fortunate enough to be able to realize that and understand that, so it really has a lot of 

meaning and I take that to heart. A couple of weeks ago my family, my wife, my daughter, my 

three sons, and my two grandsons, we all ran in the Phoenix Marathon and boom, hit the 

waves on Hopi Reservation and I got nothing but positive remarks. And I said, it can be done. 

We just have to put our time to it, we just have to put our learning to it, wehave to put our 

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knowledge to it and really give credit to our elders. We’re losing so many of them, we’re losing 

so much of that knowledge, we’re losing so much of the ability to do that and some of us are 

considered young, we have to step up to the plate and we have to be the one toguess maybe 

re-implement or continue or sustain that practice and knowledge we’ve been given. So that’s 

why I say it’s very, very important that we continue to educate our people. That’s just one part 

of it. There are programs right now being put on by the health programs and so forth and I try 

to support them as much as I can. I try to be out there as many times as I can, but people 

need to realize and embrace those things that it’s for the good because I look at diabetes for 

one. We missed the boat on diabetes. What happened? Why are we just so—why are so 

many people diabetic? Then we have heart disease, then we have stroke, and on and on and 

on. What has happened to the Indian people? I think we just have to fault ourselves for not 

being able to keep up with our traditions. I think we owe ourselves a great deal of 

responsibility to—we must become responsible, we have to assume responsibility and get to 

where our ancestors came from and what they taught us. We just need to wake up and get on 

that road. That’s all. Thank you.

Dr. Ursula Bauer: Thank you very much. I wonder if there’s a way that CDC, through our grant 

program, could help ignite that kind of activity or accelerate the uptake of those behaviors. Is 

there a role for CDC in providing resources that might accelerate that progress.

Councilman Chester Antone: Mr. Jim and then Cathy.

Vice President Rex Lee Jim: Thank you. The Navajo nation prefers, as much as possible, 

direct funding. And to us it’s more than funding. It’s a government-to-government relationship; 

this federal government to the tribes are based on treaties. And those treaties don’t say we’re 

going to subject you to states or non profit organizations. It’s a direct relationship. So when 

you give funding to the states and then bring it back, you’re subjecting us to another sovereign 

jurisdiction. That’s what we don’t appreciate. So it’s best to do direct funding as much as 

possible. That’s one. The other, and just in conversation, in Navajo they say when our kids 

become the enemy, and sometimes well educated Navajo homes mean good but they’re 

conditioned into the western thought that the western way is the only way and the best way. 

So our own kids are coming back telling us we have traditions and now this thing in the past 

doesn’t work anymore and we have to move on. And those who also talk about Navajo 

traditions, sit there and say, oh, that’s coming out of such-and-such anthropologist’s work so 

they’re leading their culture through anthropological work and then imposing that on 

themselves and on others. So work used to be done there in terms of—so it really comes back 

down to traditional people, the ways of life and how do we engage our own young people in 

those activities. 

Vice President Rex Lee Jim: I agree with him, Chairman Honanie. It’s a very simple thing. 

They are very simple things. I think sometimes we focus too much on money. We think that 

things happen, that there will be positive results only if we have money. Sometimes I ask 

myself what can I do that will not cost money? And one of the things that we’ve been doing is 

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using students. We have what’s called Food Literacy Program, using several Navajo schools, 

high school students that do research on food stories, family recipes and they analyze it 

whether it’s a good recipe or not for the nutritional values. And that whole thing mushroomed 

into the study of food policies on the international to the local level, food economy, food 

desserts and how it leads to diabetes and obesity and other chronic illnesses, and they write 

about these and then they present them at different conferences. The latest one they 

presented at the National Consult Teachers of English. So they end up with having all these 

professionals, administrators and teachers and then they use social media, talking about 

Facebook to inform others so that’s something that students, are already there, we don’t pay 

them to be students, they have English classes, they have access to computers and just need 

to put a program together. I think CDC could somehow invest at that level because our 

students are intelligent. If you use their academic skills and knowledge of content areas and 

focus that to problem solving, how do you address obesity, how do you educate the community 

about public health and about food and nutrition and exercise and so on, yearly check ups and 

all these things and use students and their influence on the families, we know a lot of these 

children are running the families in Indian country, so you might as well tap into them and use 

them and allow our students to introduce healthy food items to their family and keep journals 

on what it does. So those are the kinds of activities that we could be doing. The other thing I’d 

like to do is I would sit with the behavioral health traditional practitioners or spiritual 

practitioners, preachers, priests, medicine people, NSE people and sit down with them and say 

here’s the problems we are having, I need your help, you guys have congregations and 

ceremonial gatherings over weekends and evenings and that’s the best time for you to talk 

about food, about exercise, put them apart of your prayers. Those are things that don’t cost 

anything. They are already in existence and we could tap into them and the influence they 

have. So I’ve been doing a lot of thinking about what are some things that’s already there in 

existence that I don’t need extra money for, just to sit down and convince them and talk to 

them. Those are the things that we’ve been doing and we need to do more of that. So the 

other thing, I think there was a saying that says something like keys to success are very simple 

steps but we forget those simple steps because they are so simple. Just like walking and 

running in the morning. That’s what we need to do. So the other thing we’re doing on April 5th

is what’s called Talking Things Through. We’re going to have a summit on negotiation, difficult 

conversations, conflict resolutions and all of that kind of stuff, and one of the main reasons why 

we’re doing that is we want to re-teach people how to talk things through. When you talk about 

chronic disease, when your father is diagnosed with terminal cancer, how do you talk about 

that in the family so that the children do not get depressed and then turn to alcohol and drug 

abuse and domestic violence. So those are some of the issues we’re dealing with and I think 

that’s important. CDC would also fund some of those areas, it’s not directly—well, it is directly 

related but it’s not a disease thing but when you talk about it, you can solve a lot of other 

issues as well. So those are some of the activities that we’re doing and we’re working with the 

Harvard Negotiation Project to put some courses together for elementary, junior high, high 

school and college and then a modified version to be taught at senior citizen centers and non 

profit organizations, youth organizations and churches and different places so that we really hit 

every area. And when you talk about education and outreach, I think that would do a lot of 

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good, especially during those difficult conversations dealing with chronic diseases and how 

families can respond when it hits them. And I just wanted to share that with you when you talk 

about asking us where can CDC invest in. I think these are some areas that you can invest in 

especially with the younger generation because they can do so much. Thank you.

Director Cathy Abramson: Well, there are a number of things that CDC can do with drugs. I 

don’t believe that going through a state would be helpful. I know it would be, and every one of 

us in here know it wouldn’t be. We’ve been fighting against that for years and years. It hasn’t 

helped us any way we tried. So it hasn’t helped us for years so it’s not going to change. We’re 

here and we’re telling you ways that funding can help us. There is a group of us here that 

we’ve given you ideas—our traditional ways are out there where I believe helping us to record 

them , to tell our stories and tell our ancestors’ stories on how we do things or used to do 

things and I think that’s very valuable for our youth and those to come because I do believe 

there will come a time in their lives that they will come around and listen and it’s gonna be 

good for them to have. I know you guys are great runners but I challenge you all to to a 

snowshoe race any day, or maybe a canoe race in the summer time. But there’s many things 

that we could do with funding that would help our people to get healthier. So to bring that 

along. But going through the state, No-does not help at all. So thank you.

Councilman Chester Antone: Is there anyone else, Mr. Gilbert?

Tim Gilbert: From the Confederate Tribes of the Umatilla Indian Reservation, we are constantly 

trying to figure out how to integrate what they call fresh foods and what you’ve heard from 

other folks around here which are traditional foods into wellness activities. So to your question 

about what might be good use of these monies or good ideas for primary prevention, etc., we 

just have struggled with angles from a public health perspective. We think of it one way, the 

people who are trying to push us to do more foods activities. Our tribal leadership saw it a 

different way and we haven’t figured out where the two met yet, but we know it’s big and we 

know it needs more attention. So that’s one thought. The second one I was just going to 

mention quickly is I was intrigued by what you were sharing with us from Nathan Moose’s 

story. We last week presented our last year’s report to what’s equivalent of our tribal council 

and part of that was a report on chronic disease and what we’re doing with that, and for that 

group, if you would have been speaking to them two years ago. We brought up the idea of 

second hand smoke in the casino, Umatilla the gaming tribe, and do a little quiz here with you. 

When we brought it up two years ago and we suggested that it might be a good initiative to 

think about in the interest of tribal members’ health, anybody who walks into the casino, what 

would be your thought on why they would push back on that notion? 

Dr. Ursula Bauer: Well, the counter argument we always hear is that we’d lose revenue.

Tim Gilbert: That’s interesting. That was number two. The first response surprised me and 

that was the response we’re a sovereign nation and the state has come to us and said that we 

need to do this and we’re not doing it because if we do it, we’re gonna choose to do it. And 

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then this past week when we shared—we have a new board and you can see the kind of the 

shift in thinking about smoking as a risk factor and its contribution to health. They started to get 

into that discussion again and they inched more towards it being a viable idea. I guess I’m 

putting it out there. It really is our number one risk factor for our top two leading causes of 

death. So we have a smoking casino. We don’t have a smoking policy in our housing for tribal 

members, just to give you a flavor of what we’re up against. So that would be my second area 

if I was to choose where we would value some resources on how to move the dot on smoking 

whether it’s second hand or actual smoking. Thanks.

Dr. Ursula Bauer: Thank you. 

Councilman Chester Antone: If there’s no one else, I just want to make a few remarks. 

Tohono O’odham Nation and we have the Tohono O’odham Nation community action 

program. Currently, they have two farms where they raise traditional crops and serve it in the 

Desert Rain Café among other traditional foods. We also have gardening in schools. The 

project is starting now because we recognize that a lot of the traditional foods have an impact 

on diabetes. We have 19.9% prevalence rate on the Tohono O’odham Nation. That has not 

moved for the past two years so we must be doing something right but we don’t know what 

that is. I think it’s a combination of traditional foods and exercise because the HOP program 

which is the Health O’odham Program gets into the elder centers. We have a number of them 

on the reservation and they provide exercise instruction, chair volleyball, chair exercises, but 

they do it. We also have facilities in about six orseven communities and so that part of it, I 

think, contributes to that percentage where it’s staying there and we need to know. We’re very 

good about keeping track of our prevalence rate but we’re not very good at finding out why it 

stays there, and I think that’s one of the ways in which grants could work because I think if we 

can bring ours down, then certainly CDC is going to become aware of how it was done, then it 

transfers over to other tribes. We use the tribal grapevine and things are becoming known 

pretty quickly. They don’t come in big reports, it’s by word of mouth. So if one tribe succeeds 

at a certain thing, automatically that word goes out not to CDC but amongst tribes. So I would 

take a look at that. Unfortunately, or fortunately, I’m not too sure yet, if the IHS data shows 

24% now but it’s along with the Tohono O’odham Nation so we have to figure that out. So 

we’ve been successful I would say at keeping it at that level and we just need to know what 

combination of efforts contributed to that because then that can be used by other tribal nation’s 

best practices or appropriate practices as Mr. Jim says. And I just wanted to relay that. I also 

particularly like the Hopies approach because if you’re an elected official and people know you 

as such, what you do—if they might emulate that or want to do that, then that also impacts the 

disease. So I wanted to share that much. I believe that all the people I had were wanting to 

address this issue, but I also wanted to ask you, are we going into colorectal? Okay, that was 

part of it so I wanted to make sure when we can go into that.

Dr. Ursula Bauer: Thank you very much.

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Dr. David Espey: Thank you very much. My name is David Espey and I’m the Acting Director 

of the Cancer Division here at CDC and my previous position and my position after this acting 

position is in the field in Albuquerque working with a team focusing on cancer prevention and 

some other issues. I would like to make a couple of comments before I launch into my 

colorectal talk and one is that all of the risk factors that you just talked about in the context of 

diabetes and heart disease and stroke are the very same leading preventable risk factors for 

cancer. So by making some progress on those fronts, you would certainly make some 

important end roads for cancer. Another is to urge the committee to consider and give us 

feedback about your feelings about the funding mechanisms because that’s a real struggle for 

us to partner with tribes. How do we overcome some of the administrative hurdles for getting 

funding out into the field? And then a third, I just found out a very moving testimony about your 

marathon and your practices in your tribe, and I agree with you I think there’s some modeling 

there that could be very important and potentially tapped in the context of this discussion. I was 

very impressed with that. So with that said, I’m going to cover two groupings of activities. One 

is the Colorectal Cancer Control Program that is supported directly out of CDC here in Atlanta, 

and then there’s the team I mentioned in Albuquerque with CDC funding coordinates several 

other colorectal cancer programs in the Southwest, Alaska and Northern Plains so I’d like to 

break the talk down into those two groupings of activities. But before I do, I thought it would be 

useful to set the stage a little bit as to why it’s important. I know someone or the committee 

wanted to hear about this but I think it’s a very timely topic, and the next couple of slides kind 

of lay out the case why it’s an important issue and this is a graph that shows the incidence, 

which is a measure based on cases of cancer diagnosed in American Indians, Alaska Natives 

compared to non Hispanic whites in a group of counties called Chisda Counties which are 

counties where tribal NIH program provide contract health services and where we believe we 

get more accurate information. And if you go all the way to the right where it says U.S. under 

the bottom, those are all regions combined and you can see the blue bar which is the AIAN 

rate compared to the green bar which is the non Hispanic white, about 20% higher, and this is 

all regions combined. But the story is really in the bars to the left of that, particularly the far left 

where you can see the Alaska incidence rate over twice that of the non Hispanic white rate, 

and important differences also in the northern plains and the southern plains. So the big 

discrepancies, and then the lowest rates are in the Southwest. And these are a similar graph 

with the mortality rates which are measured based on deaths from colorectal cancer using the 

same time period, the same Chisda groupings of counties, and again if you go all the way to 

the right, you can see about a 25% greater mortality or death rate from colorectal cancer in 

AIAN compared to non Hispanic white with a similar distribution, Alaska way in the lead. 

Alaska natives have some of the highest rates of colorectal cancer in the world and similar 

patterns in the northern plains and southern plains. And then finally in terms of graphs these 

are two sets of bars that show you the percentage of AIAN and non Hispanic white, they are 

diagnosed at early stage and late stage. And you can see that early is green and late is 

orange or brown, and the lower the orange the better and the higher the green the better and 

you can see pretty clearly just by glancing at this graph that there’s a big difference in the 

percentage of AIAN that are diagnosed at early and late stages compared to non Hispanic 

white. So that sort of sets the stage as to why I think it’s an important topic for the committee 

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and it’s also an important topic for us as a priority for the AIAN community to be talking about 

and trying to increase our delivery of colorectal cancer screening services. So the first part I’ll 

talk and give you sort of an overview of the Colorectal Cancer Control Program and then focus 

in a little bit on the four funded tribal programs, and this is just a graph of the 25 funded states 

and their four tribal programs; three in Alaska and one in Washington State. And the program 

is designed to increase colorectal cancer screening in persons over 50 and use to the extent 

possible the infrastructure that already exits with CDC funded programs like breast and 

cervical that many of you may be familiar with. The Wise Woman grant that’s in place in many 

places, and to try to utilize the existing infrastructure to deliver these services more efficiently. 

So similar to the breast and cervical program, and for those of you who aren’t familiar with it, 

it’s a program that’s been around for well over 20 years now that was started to provide breast 

and cervical cancer screening to women who were uninsured or underinsured and low income. 

And in the early phases of that program AIAN women were a priority for the program. But the 

breast and cervical program was a model for Colorectal Cancer Control Program but there are 

some important differences. And the key difference is breast and cervical emphasized early 

on and has throughout its life directly provided funding services to women so that they get 

these screening services, with some other promotional components to it but the focus has 

really been on funding the services. Whereas the colorectal cancer program came about in the 

era when we were anticipating healthcare reform and anticipating much more robust coverage 

for preventive services for a much greater proportion of the population so the focus was much 

more on getting people to have better uptake of those services instead of trying to provide 

them directly. There is a component of direct services but the focus of the program really is on 

promoting colorectal cancer screening through policy changes and working with health 

systems, health providers and public education and partnerships are a key part of that. So 

that’s sort of an overview of the colorectal cancer program. Now let’s focus a little bit on the 

tribal programs. There are four. The three in Alaska are the Alaska Native Tribal Health 

Consortium or ANTHC, Artic Slope Native Association and South Central Foundation, and then 

in Washington it’s the South Puget Intertribal Planning Agency or SPIPA which is much easier 

to say. And these programs have really drawn on some of the programmatic experience with 

other CDC programs like, breast and cervical. And, again, there is a component of providing 

direct services and as you may be aware, there’s a number of services that are recommended, 

not only colonoscopy, colonoscopy is the most common one now but also testing stool for 

blood and flexible sigmoidoscopy are recommended services, and there’s a mix of the types of 

screening services provided for the direct screening component of all of these programs. 

ANTHC has always had a very strong colonoscopy program as does Artic Slope which is a 

much smaller program also provides colonoscopy and mostly by the itinerate endoscope 

model where persons who are providing the colonoscopy travel from Anchorage to the sites to 

provide that service, and SPIPA also provides some colonoscopy. Flexible sigmoidoscopy, 

which is not used nearly as much as the service that is focused on by the South Central 

Foundation and Alaska, the programs are an unique occurrence in that they both share and 

manage a colorectal cancer screening clinic jointly. I believe it’s the first time that has occurred 

in the two organizations with ANTHC focusing on colonoscopy and referral for colonoscopy 

and South Central of flexible sigmoidoscopy, but orchestrating this through this joint clinic. 

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And then the Fit test which is sort of a modern version of the stool blood test is being used by 

SPIPA and is being introduced in ANTHC. And in terms of promoting screening services the 

program aims to support services that have had an evidence based and that have been shared 

with the public health and clinical community through a project called the Guide to Community 

Preventive Services. So the evidence is vetted for the utility of these services and that 

includes culturally appropriate patient navigation and provider education, one-on-one 

education through navigation and other community health training, social media, small media 

such as brochures in clinical settings, client reminders and the Tobacco Cessation has been a 

part of the colorectal program from the outset, not just in the tribal programs but throughout the 

four tribal programs and the 25 state programs. A lot of challenges especially in the Alaska 

setting with provider shortage, staff turnover, geographic isolation and cost of travel, very 

expensive to move around those long distances, competing priorities and particularly as 

programs move and there’s more self governance in Indian country, programs are moving 

away from RPMS and the programs that are being purchased by different tribal programs are 

not necessarily talking to one another and creating some problems for referral and 

coordinating care between programs. A number of lessons have been learned around trying to 

adapt these interventions that are vetted not necessarily for the tribal or native setting and 

trying to shoehorn them into a much, much different context, developing and getting culturally 

appropriate materials out, and then impact is also difficult to measure especially when there’s a 

mix of screening services, which in the case of colorectal cancer is a minor part of it, and then 

the broader population-based interventions are difficult to measure impact especially over a 

short period of time and this project is in its fifth year. So those were the activities that are 

supported directly out of Atlanta with my colleagues in the division, and this next set of 

activities covers projects that are coordinated with CDC funding but through the office of 

Albuquerque. There are three assignees in Albuquerque and one in Phoenix who support 

colorectal cancer either directly or indirectly in a number of ways and I’ll cover projects that are 

going on in the Southwest, several in Alaska. We have a long history of collaborating with our 

Alaskan colleagues. And the northern plains has been a particularly difficult region to get into 

and it evolves around a lot of the staff turnover issues but also the funding issue that we talked 

about and Ursula alluded to early on. I organized them just a little bit—most of them are the 

same. So in the Albuquerque area we have been working for several years with the 

Albuquerque Area Indian Health Board and the tribal epi center to try to tap the resources and 

experiences. The connections of the community health representatives (CHR) and the team at 

the health board, we’ve worked very closely to build colorectal health capacity with CHR’s and 

a component of this have established a colorectal health taskforce in each of the tribes, 

implement local health awareness and patient navigation activities, and then share these 

success strategies with other tribal communities. It’s been a very successful program. The 

organizers or the CHR’s go through a whole training program to get them up to speed with 

colorectal cancer, it impacts the screening modalities and they’ve done this with a number of 

different training tools including videos, anatomic models, visiting a local endoscopic clinic to 

see what happens when somebody goes to get a colonoscopy or flexible sigmoidoscopy and 

what they can expect so they’ll know when they talk to the tribal members who are anticipating 

this, and they in turn will go out into the community and use a number of innovative and 

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engaging tools like Bingo and some of the same training tools that they learned on to engage 

the community members and they’ve found this to be a very successful model to raise 

awareness and buy in by community members. And I think importantly they have found this to 

be successful in the Southwest and have provided these trainings in a number of other settings 

and these are just some places and dates where they’ve gone and done one in two-day 

workshops with those communities to try to raise awareness of the possible role of community 

health representatives and colorectal cancer screening, and then they’ve also done this at the 

CHR national conferences a couple of times. They’re developing—the DVD may actually be 

out, there’s a lot of excitement about producing this DVD that’s going to also be a tool for 

amplifying the message that the CHR’s are able to do in their communities. In follow up of this 

CHR activity, in the Southwest one of the concrete ways we would like to see what the CHR’s 

role is, is a randomized control trial where we’ll actually go to usual care which is generally 

giving out the stool slides in the clinic and then compare that with mail-out of the collection kits 

and then mail-out with follow up from the CHR’s to see if the CHR’s can indeed increase 

uptake because we’re moving into an era where it’s not just having the test available or having 

coverage, it’s the uptake and the realization that the community member has an important role 

in getting screened, not just having the screening be available. We’ve supported a number of 

projects in Alaska along the same lines with the community health AIDS program and Melanie 

Guava has been a wonderful collaborator on this project, and some of you from Alaska may 

remember this movie that came out a couple of years ago with the story of a very reluctant 

tribal member who didn’t want to get screened and didn’t want to hear his family’s messages 

about getting screened but was finally convinced, and it was a success and I think they even 

had some events around the release of this piece, and this was also done with funding from 

the Colorectal Cancer Screening Program for Artic Slope. And then also in Alaska, 

traditionally the only screening modality that has been recommended or utilized for Alaska 

natives for years and years has been colonoscopy because of the—I won’t go into the reasons 

but it was felt, for valid reasons, that the stool test did not work and we were able to do a study 

in collaboration with a number of partners in Alaska to demonstrate that it actually does 

perform quite well in the Alaska native setting, but it’s not a test that the provider community or 

patient community for that matter is used to doing, so we’re working with ANTHC on a 

demonstration project to introduce it into one or two communities to increase the capacity for 

screening. And then in the northern plains we’re working with the American Indian Cancer 

Foundation called Improving Northern Plains American Colorectal Cancer Screening, and the 

goal here is in a nutshell to go in and do an assessment of what a facility is currently doing in 

terms of screening and look at their tracking system and reminder systems, measure what the 

providers feel, know about colorectal cancer screening and then also look at what the referral 

capacity is or internal capacity for doing colorectal cancer screening, and then the next step of 

this is to move this into a limited number of the facilities that were assessed and work with to 

try to improve the performance of those facilities to deliver colorectal cancer screening 

services. These are GPRA measures. GPRA is a performance measure that is used by some 

of the tribal programs and used very enthusiastically by the Indian Health Service comparing 

the three screening services, colorectal, breast and cervical, and you can see there’s been 

some important progress in colorectal cancer screening, so we are making progress but you’ll 

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see the top part of that is well under 50% so we’re on a favorable trajectory but there’s a lot of 

opportunity and need to build on that. With that, I will stop. I’d like to acknowledge Djenaba 

Joseph and Don Haverkamp who provided most of these slides and Melissa Jim who is with us 

here who did the analysis for the data slides. So I’ll entertain questions.

Councilman Chester Antone: Thank you. If there are no burning questions, we’ll go right to our 

next presentation. We’re about half an hour into the hour. So are there any questions? 

Cathy?

Director Cathy Abramson: Is there any way that the community transformation grants, is there 

any way that they can do something about those that they can—I mean they’ve done such a 

good job with those. Can they apply for any of those grants coming out?

Dr. Ursula Bauer: This really does represent a broken promise to all of the grantees in the 

community transformation grant program, and I can’t explain what happened or why it 

happened but the program is being shut down after the third year of an anticipated five years 

of funding. We have certainly looked at ways that we could try to continue the program, at 

least bring it to the end of the five years and we have not succeeded in finding a way, although 

it’s not any solace to those who will be losing funding after the third year. I did mention two 

grant opportunities that will be released this year and I’ll mention a third, which is a new, 

REACH, Racial & Ethnic Approaches to Community Health funding opportunity, and again in 

the congressional language there’s a call-out to tribes among the eligible grantees. So that 

doesn’t mean that existing community transformation grant grantees will automatically get one 

of those awards but given the work that you have done over the last two, and moving into three 

years, you should be very strongly positioned to be competitive for those grants. And I would 

certainly urge all of the tribal grantees as well as the entirety of the grantees to really focus on 

how we can tell the story of what that grant did accomplish in that short period of time and 

what it could have accomplished had it lived out its full promise.

Councilman Chester Antone: Thank you. And I’ll call on the injury prevention folks. Dr. Ann 

Dellinger.

Dr. Ann Dellinger: I brought Holly Billie here with me. I think she knows some of you. She 

runs our Tribal Motor Vehicle Injury Prevention program. So we need our slides. So my 

request today was to talk about unintentional injury but also to include suicide at least a little bit 

and so the talk here is focused on unintentional accidents but I also have a little bit of 

information on suicides and homicides in AIAN communities. So I’m going to show you the 

picture with data and then Holly is going to talk to you about our program. So all of the 

information that I’m giving you, you can find on our website. There’s a query system and you 

can request injury deaths among males in ages 1 to 44, and you can come up with that kind of 

information. Here I just pulled—actually Holly pulled, this was her slide, unintentional injuries 

are the leading cause of death among AIAN ages 1 to 44. So we’re making a little bit of a 

switch. What our young people are dying of in all races and ethnicities are injuries and they’re 

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preventable. Typically, motor vehicle crash injuries are the leading cause. In AIAN 

populations second is poisoning, third is drowning. So this is five years of data combined 

looking by race, unintentional injury deaths ages 1 to 44 males and females together. And 

you’ll see that the AIAN community has a higher death rate than others if you go all the way to 

the end, that’s all races combined. So this one is intentional injury deaths so that includes the 

homicide and the suicide, and this is the same thing but with intentional deaths. You can see 

that African American Black community has the highest death rates followed by AIAN, and all 

races combined are at the end at the 16.3. Certainly ask me questions while I’m doing this, 

send up a flare. So you can also plot the leading causes of death from our website and this is 

just breaking it down. So that was ages 1 to 44. This is breaking it down, so what’s the 

leading cause of death for 1 to 4 year olds? It’s unintentional injuries, and 5 to 9 years old and 

10 to 14 and 15 to 24. Actually, in that 15 to 24 years old for AIAN, the first three causes of 

death are injury, injury and injury; unintentional suicide and homicide. If we go to the next age 

group, unintentional injury, unintentional injury, and then it drops down to the third leading 

cause of death but then again, the 25 to 34 years old in that group, the three leading causes of 

death are all injury. Now, on our website any of these boxes that are colored you can click on 

it and it gives you this information. So I click on the unintentional injury box and it tells me 

what kind of unintentional injuries. So more than half are car crashes, second poisoning and 

then drowning. So if you click on a suicide box, then it gives you this kind of information, the 

method of suicide. So the suffocation is the hanging and strangulation. And if you click on a 

homicide box, this is what you get. So about half from firearm. So to give you a little bit of 

information about something that we call the National Violent Death Reporting System, it 

started with 16 states. I looked on our website today and there are 18 states that collect 

information on violent causes of death and these are the states that are giving information. 

Homicides, suicides, homicide and suicide clusters and this is what they show for violent 

deaths by race, so you can see that actually among the violent deaths AIAN have the highest 

death rates. So there’s another measure that people use instead of just the deaths or injuries 

and it’s years of potential life lost. I don’t know if you’ve heard that before. People say YPLL 

like everybody understands it and I’m not sure that we all understand it but it’s a way to look at 

premature death and since injury ends up taking young people, it’s a measure that shows that. 

So say it’s potential years of life loss before age 75, so if I die at 54 today, I have 21 years of 

potential life that we just lost, and we can add up all those deaths and find out basically what’s 

killing our young people. So this is just AIAN, both sexes, all deaths and 23% of the years of 

potential life lost are to unintentional injury. Just a different way to look at the issue. And this 

is by race, all races to the end and it shows the unintentional injury death rate is the biggest 

chunk of years of potential life lost. Okay, so here this is another thing we can do on our 

website and that’s plot death rates by state, and the dark blue have the highest death rates. 

This is just for AIAN population. The problem with this is that you know that death rates aren’t 

equal across the state, so different populations are going to look a little bit different. So Holly 

is collaborating on a project that’s using mapping GIS, mapping and tribal boundaries and 

using zip code to see if she can differentiate death rates among different tribal populations in a 

state.How long will that be going on?

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Holly Billie: That will be going on through next year, through 2015.

Dr. Ann Dellinger: Okay. I have one more slide before I turn it over to Holly. So I put this in 

your notebook. This is the ten leading causes of death by age group just so you would have it 

in a spot where you could read the print and it wasn’t so small. The last thing I’ll tell you is that 

this whole little program where we query deaths, injuries, it’s called WHISKERS, and Holly is 

just finishing a project that has a WHISKERS tutorial for AIAN injury queries which is part of a 

toolkit that’s almost finished, too. So it’s a motor vehicle injury prevention toolkit with materials 

that tribes can do. It has posters, brochures, fact sheets and the video. I think that’s it. Holly 

is going to talk about our program.

Holly Billie: Good afternoon, everyone. I know it’s tough to listen to more information at the 

end of the day but we appreciate your attention. I’m Holly Billie for those of you who I haven’t 

met. I am Dine’ from the southern Utah portion of the Navajo Nation, and I work here as an 

injury prevention specialist and tribal liaison between IHS and CDC, and I haven’t been here 

too long, it’s almost five years, but I work mostly with tribes and some of the projects we have 

going on are—the first project I’d like to talk about is the Tribal Motor Vehicle Injury Prevention 

program. This is a cooperative agreement that looks to reduce injuries and death due to car 

crashes. And we have asked the tribes to try to reduce alcohol impaired driving, increase child 

safety seat use and increase safety belt use. This was a cooperative agreement where we 

asked the tribes to at least pick two of those three strategies to implement in their communities 

and then to tailor them so that they were appropriate for their communities. You can see that 

the tribes funded from 2004 to 2009 were San Carlos Apache, Ho-Chunk Nation of Wisconsin, 

White Mountain Apache, and Tohono O’odham Nation. And we had some really good results 

from these programs, this initial program that was from 2004 to 2009 and we have a second 

round of tribes that are funded. We have eight tribes that are funded currently. We are in the 

last year of funding for this group and that includes Kato Nation, California Rural Indian Health 

Board, Colorado River Indian Tribes, Hopi Tribe, we have three tribes from South Dakota, 

Rosebud, Oglala Sioux and Sistema Toyota. We also have Southeast Alaska Regional Health 

Consortium, and they are in their last year of funding and we have gotten some pretty good 

results that I’d like to focus on. The things they worked on, the things they included in their 

communities was working with police departments to increase enforcement because that has 

been shown to really be effective, and also putting the message out there about buckling up 

and not drinking and driving. There were several tribes that were able to strengthen or pass 

new laws that have to do with traffic safety and then there was also child safety seat 

distribution. And quite a few of the tribes have had pretty good results and there’s some 

general results up on the screen but I wanted to read a couple of results from some of the 

tribes that we’ve been able to get most recently that we’re pretty excited about. Oglala Sioux 

tribe increased their seatbelt use by 25.7%, reduce crashes with either injuries or fatalities by 

42%, reduced alcohol impaired crashes by 43%. Hopi tribe increased their seatbelt use by 

32%. Colorado River Indian Tribes reduced their crashes with injuries or fatalities by 47%. 

And Yurok Tribe increased child safety seat use by 21%. So the tribes have worked really 

hard and they’ve gotten some really fantastic results. We’ve heard today, and we also know 

from experience, that sometimes it’s hard to measure impact in a community but we know that 

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if we’re getting folks to buckle up and not drink and drive, that’s going a long way in preventing 

injuries and fatalities. One of the things that we have planned is to put out for other tribes’ 

lessons learned and we are collaborating with Indian Health Service and also BIA because 

they have traffic safety programs. We’re interested in pooling our lessons learned together so 

that we can get the word out about what has worked with these tribes that were funded 

through these different federal programs. And we are hoping to put this best practice manual 

or lessons learned manual out when the TIMVIP is completed, and this should be out in 2015. 

So that’s what we’re shooting for. Now, the tribes will be sharing their experiences and also 

their successes in a CDC sponsored webinar and I’d like to announce ahead of time to mark 

your calendars for June 17th of this year, 2014. CDC will be sponsoring a webinar that starts at 

2:00 p.m. Eastern and each of these eight tribes that are being funded now will tell about their 

programs and about their results. So we hope that you mark your calendars and join us in 

June. And then in July the tribes will come here and give their presentations in person to CDC 

Injury Center. So those of you who are in the Atlanta area in July are invited to attend that 

presentation by these tribes. Another project that we have going on is the CDC and Federal 

Highway Administration partnership. Dr. Bauer mentioned earlier that they struggle with the 

ability to reach many tribes. I think that a lot of CIO’s do including the Injury Center, and 

funding the four tribes was great, funding the eight tribes is better, and in an effort to try and 

reach more tribes we’re collaborating with the Federal Highway Administration in their Tribal 

Technical Assistance Program, otherwise known as the TTAP. Some of you may be familiar 

with the Federal Highway’s TTAP program. They have seven across the country and they 

cover various regions and if you know anything about federal highways their focus mostly has 

been on roads and bridges and fixing the roads to make them safer. But they are trying to 

include the behavioral side of traffic safety which is what CDC focuses on, the seatbelts and 

DUI prevention and so forth. So we’re partnering with them to provide injury prevention 

technical assistance to the tribes served by three TTAP centers and you’ll see the three TTAP 

centers listed. There’s one in California, at the National Indian Justice Center, there’s also the 

southern TTAP center and there’s the UTTC, the United Tribes Technical College in Bismarck, 

North Dakota that we’ll also be partnering with. And the idea really is to share with all the

tribes in those particular regions what we have learned from the tribes that were funded 

through TIMVIP and also the tribes that were funded through Indian Health Service. One FTE 

position will be placed in three TTAP centers and this will be a pilot project for two years, and 

we’re hoping that this combines what we have learned here at CDC with their behavioral 

approaches with the Federal Highway experience and they really haven’t established network 

already in traffic safety. They have an established network much like IHS does. IHS has a lot 

of people on the ground and CDC doesn’t necessarily have that but we’re able to partner with 

Federal Highways who has that network that can reach tribes very easily. So these positions 

will be Modified Safety Circuit Rider and, again, they’ll provide technical assistance and they’ll 

provide services to tribes in those regions, and they will start out by working with the tribes that 

are funded by Federal Highways, BIA, CDC and IHS and hopefully expand beyond that. We’re 

in the process right now of getting an inter agency agreement put together and we’re hoping 

we can get this started in the spring of this year. So these are the two bigger projects that 

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we’re working on and I guess that concludes our update from the Injury Center and I guess we 

can take questions if there are any.

Councilman Chester Antone: Are there any questions for the presenters?

Can you please send us the link to the webinar so we can disseminate it to the TAC, send it to 

the Tribal Support Unit office at OSTLTS, please?

Sure, we can do that. We can send out an announcement.

I don’t have a question but I wanted to just ask Holly if you know what STOP is on the Tohono 

O’odham Nation.

Holly Billie: Yep, I’m familiar with that program from the first round of funding. Is that going 

strong still?

Councilman Chester Antone: I was going to ask you to tell me what that is.

Holly Billie: Oh....It’s a seatbelt program.

Councilman Chester Antone: And when we have major celebrations, we have Police 

Departments out there making sure people have their seatbelts on. If they don’t have it, they 

get a ticket. The Tribal Court has a way of trying to reinforce the injury prevention. I just 

thought I’d throw it out.

Holly Billie: That’s really great news because we always hope for some degree of 

sustainability. Sometimes it’s tough when funding goes away. You hope that some parts of a 

program can still move forward and that’s one example of one of the activities that was 

sustained by the tribe even though there wasn’t additional funding provided. So that’s really 

good to hear.

Councilman Chester Antone: They also are helping us provide baby seats. Herman?

Chairman Herman Honanie: Thank you. I just want to ask you if our Hopi worker is aware of 

the TO’s program out there. Would he be knowledgeable of that?

Holly Billie: Greg Sehongva over at Hopi, he would be knowledgeable of the program that 

occurred over in Tohono O’odham, and if he isn’t, there’s information on our website and 

certainly we can share that information with him.

Chairman Herman Honanie: Well, you were out there about a month ago on the reservation. 

We had a chance to talk and meet with Greg and I think it’s a really important program 

because to this day I will never forget or have not been able to forget an accident, a crash that 

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occurred in King’s Canyon that took the life of a four-year-old infant, all because the infant 

wasn’t buckled in a safety seat and the crash took her life, and totally unnecessary. And ever 

since then when this program came to Hopi, I’ve really tried to do all I could to support, and to 

this day I do and I did mention to you that I was going to try to see if we could be able to do a 

mandatory seatbelt law in Hopi. So we’re still working on it. Give us time. Thank you.

Councilman Chester Antone: Thank you very much for that report. At this time we’ll have Molly 

just give us an update on what we talked about today this afternoon.

Molly Sauer: Good afternoon. We had a lot of discussion in the afternoon so I have a few 

more items than this morning. We’ll start with native specimens. So there were a lot of issues 

that came up today as we were talking through the new process that’s going on to develop an 

agency-wide native specimens management policy. A few highlights from that, and again, 

there’s a lot more that will be captured in the minutes but just a couple of the key items here. 

Questions were raised about what rights do tribes have to native-specific data; is the CDC the 

final authority on specimens management across all of the agencies of the federal 

government; what kind of ownership exists for the specimens that have been collected and do 

exist within the specimen bank here; what is the role of the legal entities that have been cited 

in the process so far; clarification that the discussion now we’re in the preliminary stages, this 

has not gone out for full consultation yet, so just to clear that up. Wanting to know more details 

about the specific studies that were conducted to collect the specimens that are currently in the 

bank here at CDC, specifically regarding informed consent and making sure that the language 

barriers had been addressed and I think the term was of sound mind while specimens were 

collected. Another key item was to include traditional medicine practitioners in the discussion 

as we move forward, and a change that’s been going on of how we’re looking at this process 

taking it from just a retrospective look at the specimens that already exist in the bank, and 

moving more into a longer term policy for the agency, so not only what we have but as we 

move forward and more specimens are collected having this in place for that. So again, there 

was a lot more that came out but those are some of the highlights. For accreditation we talked 

about NPHII’s funding coming to an end and looking for a mechanism to continue to support 

those infrastructure building processes in the tribal awardees and others and specifically the 

uniqueness of tribal awardees starting to build infrastructure from the ground up rather than 

just advancing what already exists. We talked about questions about the role of tribes in the 

state programs that are working on accreditation and similar procedures, and the role of 

workforce development in that process, and we also discussed needing to incorporate health 

disparities and health equity into the accreditation standards. For chronic disease a couple of 

highlights. We discussed that CTG will be coming to an end at the end of this fiscal year and 

some opportunities for new engagement specifically around heart disease and stroke and 

diabetes prevention. And the main point that came out of that discussion was the emphasis on 

trying to get back to traditional foods and traditional activities as a way to address those, and 

then of course as we’ve been hearing so far through several presentations that funding 

through states to reach tribes is not the way to go. And again, as several people mentioned, 

we will be talking more about the budget tomorrow and some of the funding that does exist 

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direct to tribes and indirect. So hopefully that will help resolve any questions around that. If I 

missed anything, I know we’re tight on time so please catch me. I will be at the back table and 

I will type it right into our notes. Thank you.

Councilman Chester Antone: Thank you, Molly. And before we leave, I just want to make an 

announcement. The CDC ATSDR TAC meet and greet with senior leadership and invited 

guests, please join us at Bone Fish Grill shortly after our last session today for dinner. We will 

be walking over to Emory Point across the street. Dinner officially begins at 6:00 p.m. This is 

an opportunity for our TAC members to meet our CDC ATSDR senior leadership in an informal 

setting. Also be sure to bring your nametags tomorrow....That concludes our session, and 

then do a blessing prayer and then we’ll formally end this day’s session....

(Inaudible speaker)

Councilman Chester Antone: Director Cathy Abramson, did you make the motion? And Vice 

President Jim second it? All those in favor say I. Against? Okay, the minutes are approved. 

Thank you for reminding me, Vice President Rex Lee Jim. Now we’ll do our prayer.

(Prayer)

END.

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