Department of Health and Human Services

Centers for Disease Control and Prevention 

Agency for Toxic Substances and Disease Registry

Tribal Consultation Advisory Committee (TCAC) 

January 26-27, 2010

Minutes of the Meeting

Table of Contents Page

January 26, 2010

Acronyms 3

Opening Prayer / Welcome / Introductions 6

Administrative Matters: Roll Call, Approval of Agenda, Approval of August 2010 Minutes 6

TCAC Members Regional / National Updates 7

Arizona Tribal Public Health Preparedness Strategic Plan 20

National Center for Injury Prevention & Control (NCIPC) :

Suicide Prevention Initiative and Collaborations with IH S & SAMHSA, Unintentional Injuries, and Other Activities 29

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP):

Program Priorities and Strategies in Indian Country

43

CDC Budget and AI / AN Resource Allocations 74

Open Discussion / Recess 85
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

2

Table of Contents Page

January 27, 2010

Call to Order and Opening Prayer 85

National Center for Environment Health (NCEH) / 

Agency for Toxic Substances and Disease Registry (ATSDR)

Office of Tribal Affairs (OTA): Activities and Updates

85

Updates from CDC in Response to TCAC Recommendations and Discussion of

Amendments to TCP to Reflect CDC Recent Organizational Improvements 

92

Updates from OS / Intergovernmental Affairs 94

Transition of Tribal Affairs (Including Tribal Consultation Policy {TCP} and TCAC) from:

Office of Minority Health and Health Disparities (OMHD) to Office of State and Local Support (OSLS)

98

Wrap Up / Adjournment 101

Appendix A - CDC Tribal Consultation Advisory Committee (TCAC) Update on Recommendations / Response January 

2010

103

Attendant Roster 122
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Acronyms 

AAIHB Albuquerque Area Indian Health Board 

AATCHB Aberdeen Area Tribal Chairman‘s Health Board 

AAT-PHEPC Arizona Association of Tribal Public Health Emergency Preparedness Coordinator‘s 

ACS American Cancer Society 

AzCPHP Arizona Center for Public Health Preparedness 

ADHS Arizona Department of Health Services 

AFN Alaska Federation of Natives 

AI / AN American Indian / Alaskan Native

AI ATS American Indian Adult Tobacco Survey 

ALHOA Arizona Local Health Officer‘s Association 

ANMC Alaska Native Medical Center 

ANTHC Alaska Native Tribal Health Consortium 

ARRA American Recovery and Reinvestment Act 

ATSDR Agency for Toxic Substances and Disease Registry

BIA Bureau of Indian Affairs 

BRFSS Behavioral Risk Factor Surveillance System 

CAB Community Advisory Board 

CBOs Community-Based Organizations 

CBPR Community-Based Participatory Research 

CDC Centers for Disease Control and Prevention

CEEDs Centers of Excellence in the Elimination of Health Disparities 

CLC Central Leadership Council 

CPPW Communities Putting Prevention to Work 

CRCCP Colorectal Cancer Control Program 

CRIHB California Rural Indian Health Board 

CVD Cardiovascular Disease 

DACH Division of Adult and Community Health 

DASH Division of Adolescent and School Health 

DCPC Division of Cancer Prevention and Control 

DDT Division of Diabetes Translation 

DRH Division of Reproductive Health 

DHSP Division for Heart Disease and Stroke Prevention 

DIR Division of Injury Response 

DNPAO Division of Nutrition, Physical Activity, and Obesity 

DOJ Department of Justice 

DOR Division of Oral Health 

DSLR Division of State and Local Readiness 

DUI Driving While Intoxicated 

DUIP Division of Unintentional Injury Prevention 

DVP Division of Violence Prevention 

EBCI Eastern Band of Cherokee Indians 

ELB Executive Leadership Board 

EPA Environmental Protection Agency

FMO Financial Management Office
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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FOA Funding Opportunity Announcements 

GDL Graduated Drivers Licenses 

GTHAN Greater Tulsa Health Access Network 

HHS Health and Human Services 

HIE Health Information Exchange 

HITECH Health Information Technology for Economic and Clinical Health 

HRAC Health Research Advisory Council (HHS)

ICC Incident Command Center 

IHBN Indian Health Board of Nevada 

IHCIA Indian Health Care Improvement Act 

IH S Indian Health Services 

IOM Institute of Medicine

IPV Intimate Partner Violence 

IRB Institutional Review Board 

ITA Inter-Tribal Agreement 

ITCA Inter Tribal Council of Arizona 

MCH Maternal and Child Health 

NACCHO National Association of County and City Health Officials 

NARA Native American Rehabilitation Association 

NARCH Native American Research Centers for Health 

NATIVE Study Native American Time to Treatment Intervention Evaluation Study 

NBCCEDP National Breast and Cervical Cancer Early Detection Program 

NCAI National Congress of American Indians 

NCBDDD National Center for Birth Defects and Developmental Disabilities 

NCCDPHP National Center for Chronic Disease Prevention and Health Promotion 

NCEH National Center for Environmental Health 

NCIPC National Center for Injury Prevention and Control 

NDIC National Diabetes Indian Coalition 

NDI National Death Index NDI

NDW National Data Warehouse 

NEPA National Environmental Policy Act 

NFPA National Fire Protection Association 

NHTSA National Highway Traffic Safety Administration

NIHB National Indian Health Board

NIOSH National Institute of Occupational Safety and Health 

NIMS National Incident Management System 

NMDH New Mexico Department of Health 

NNCTAPN National Native Commercial Tobacco Abuse Prevention Network 

NOHSS National Oral Health Surveillance System 

NPAIHB Northwest Portland Area Indian Health Board 

NPCR National Program of Cancer Registries 

NRF National Response Framework 

NVDRS National Violent Death Reporting System 

OADP Office of the Associate Director for Programs 

OCPHP Office of the Chief of Public Health Practice 

OCIFS Oneida Community Integrated Food Systems 

OD Office of the Director

OMB Office of Management and Budget 

OMHD Office of Minority Health and Health Disparities 

OPHG Office of Public Health Genomics 

OSH Office on Smoking and Health 

OSI Office of Strategy and Innovation 

OSLS Office of State and Local Support 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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OTA Office of Tribal Affairs

PHAB Public Health Accreditation Board 

PHER Public Health Emergency Response 

PIMC Phoenix Indian Medical Center 

PPHR Project Public Health Ready 

PRAMS Pregnancy Risk Assessment and Monitoring System 

PRC Prevention Research Center

REACH Racial and Ethnic Approach to Community Health 

RPMS Resource and Patient Management System 

SAMHSA Substance Abuse Health and Services Administration 

SES Socioeconomic Status

SHSP State Homeland Security Program 

SIDS Sudden Infant Death Syndrome 

SDPI Special Diabetes Program for Indians 

SHP School Health Profiles 

SHPPS School Health Policies and Programs Study 

SME Subject Matter Experts 

STDs Sexually Transmitted Diseases

SWOT Strengths, Weaknesses, Opportunities, and Threats

TAS Treatment as a State 

TCAC Tribal Consultation Advisory Committee

TCCCP Tribal Comprehensive Cancer Control Programs 

THPS Tribal Health Program Support 

THRIVE Teen Health Resiliency Intervention for Violence Exposure 

TTAG Tribal Technical Advisory Group 

UNC University of North Carolina 

USET United South and Eastern Tribes, Inc. 

WFRS Water Fluoridation Reporting System 

WISQARSTM Web-Based Injury Statistics and Reporting System 

WRIR Wind River Indian Reservation 

YRBS Youth Risk Behavior Survey 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Centers for Disease Control and Prevention (CDC)

Agency for Toxic Substances and Disease Registry (ATSDR)

Tribal Consultation Advisory Committee (TCAC) Meeting

Minutes of the Meeting

January 28, 2010

January 26, 2010

Kathy Hughes, TCAC Co-Chair

Vice Chairwoman, Oneida Business Committee

Chester Antone, TCAC Co-Chair

Legislative Councilman, Tohono O’odham Nation

Chester Antone officially called the meeting to order, welcoming everyone and thanking them for 

their attendance. He then delivered the opening prayer. Kathy Hughes extended her welcome 

and gratitude as well, and subsequently led those present in a round of introductions. The 

participant roster may be found at the end of this document. 

CAPT Mike Snesrud, Senior Tribal Liaison for Policy Evaluation

Centers for Disease Control and Prevention (CDC) /

Agency for Toxic Substances and Disease Registry (ATSDR)

CAPT Snesrud conducted an official roll, establishing that there was a quorum of TCAC 

members present. She then called for approval of the agenda for the January 26-27, 2010 

TCAC meeting:

Motion: Approval of Agenda

Reno Franklin made a motion to approve the agenda for the January 26-27, 2010 TCAC 

meeting. Mr. Finkbonner seconded the motion. The motion carried unanimously. 

Opening Prayer / Welcome / Introductions

Administrative Matters: Roll Call, Approval of Agenda, Approval of August Minutes
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

7

CAPT Snesrud then requested approval of the August 11 and 13, 2010 TCAC meeting minutes:

Motion: Approval of August 11-13, 2010 TCAC Meeting Minutes

Chester Antone made a motion to approve the August 11 and 13, 2010 TCAC Minutes meeting 

minutes, with minor edits to be sent to CAPT Snesrud, Co-Chair Kathy Hughes, and / or ChChair Chester Antone. Mr. Trudell seconded the motion. The motion carried unanimously. 

Overview

During this session, TCAC members were invited to report highlights of new or critical public 

health issues occurring since the February 2009 meeting. The following members articulated 

that they would also be submitting reports in writing: Mr. Antone, Ms. Begay, Mr. Finkbonner, 

Mr. Franklin, Ms. Reft, Ms. Manuel Ms. Sebattus, Mr. Secataro, and Mr. Trudell. 

Updates

Derek C. Valdo

Pueblo of Acoma 

Southwest Area Regional Vice President

National Congress of American Indians (NCAI) 

Mr. Valdo pointed out that the National Congress of American Indians (NCAI) is involved in all 

issues in Indian Country, including health. Must of NCAI‘s recent work has focused on the issue 

of health care reform, with an effort to keep Indian provisions within the law, maintain the 

services provided by the Indian Health Service, and protect sovereignty within the bills that are 

being passed. NCAI can provide a legislative report to the TACA if so desired. Mr. Valdo 

reported that the current NCAI President, Jefferson Keel, was unable to attend this TCAC 

meeting as he was preparing for the State of Indian Nations Address in Washington, DC. 

Roger Trudell, Chairman

Santee Sioux Tribe of Nebraska

Aberdeen Area

Mr. Trudell reported that Hepatitis C was on the rise in his region. The treatment regimen for 

Hepatitis C is long and largely unsuccessful because persons do not fulfill the treatment module. 

Childhood suicide is rampant in this area as well, as is obesity. Childhood and adult obesity 

prevention is very limited in this area and in all of the national budgets. He would like to see 

prevention and intervention addressed through a more thoughtful process. Without prevention 

or intervention, the back side is very costly. There are not enough funds in contract health 

services, and there never will be, to treat the continuing chronic illnesses in Indian Country. 

TCAC Members Regional / National Updates
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Those who participated in the National Budget Formulation and Area Formulations understand 

this. The Aberdeen Area leads almost all other areas in most adverse statistics. Without 

prevention and a definite surge of funding for prevention and intervention, chronic illnesses in 

this area will continue to regress and IH S will not be able to meet the needs of all of the 

members of the direct service area tribes. Hopefully, TCAC and others can put forth an effort in 

prevention and intervention. The Aberdeen Area is finding that most Hepatitis C results from 

the sharing of needles, which means they are still not addressing the drug problems in the 

community. 

Joe Finkbonner, Executive Director

Northwest Portland Area Indian Health Board (NPAIHB)

Mr. Finkbonner reported that there continue to be health disparities in the Portland Area. They 

are fighting the fight as they typically have. However, since last the TCAC met, H1N1 has been 

the priority for the majority of their tribal efforts. There has been a wide range in how the tribes 

have been treated, including: 1) as true partners in health jurisdictions wherein vaccine was 

allocated directly to tribes from the state, 2) being invited to participate in general population 

vaccine clinics by the local health jurisdiction, or 3) as clinical providers rather than as sovereign 

tribal health jurisdictions, with an inability to make local priority decisions about who would be 

vaccinated. The final vaccine uptake results should reflect which system worked best. 

Anecdotally, Mr. Finkbonner anticipated that the tribe with the ability to engage in local decision 

making, which was treated as a true partner, would show a higher vaccine uptake than the other 

two models. Given that his uncle passed away the previous week, Mr. Finkbonner was unable 

to obtain the data regarding uptake as he was spending time with family, but he indicated that 

his staff was working to compile these data as quickly as possible. 

Dee Sabattus, Interim Director

Tribal Health Program Support (THPS) 

Nashville, United South and Eastern Tribes (USET)

With regard to the United South and Eastern Tribes (USET), Ms. Sabattus reported that she and 

Mr. Valdo had been working diligently on health care reform and the Indian Health Care 

Improvement Act (IHCIA). USET‘s main priority recently for the tribes has been the effort to get 

H1N1 vaccines to tribal members. USET is also leading the national effort for Indian Country in 

applying for a $30 million grant under the Health Information Technology for Economic and 

Clinical Health (HITECH) Act component of the American Recovery and Reinvestment Act 

(ARRA). This funding would be utilized to establish American Indian National Health 

Information Regional Extension Centers. Another critical service USET provides to tribes is Epi 

Reports. Some of this year‘s reports include: Diabetes Audit Report, Cost Analysis, 

Hypertension, and Community Health Profiles. These reports are provided to tribes at each 

board meeting. One of USET‘s current projects is the Infant and Adult Mortality Project. 

Originally USET was funded through the CDC Racial and Ethnic Approach to Community Health 

(REACH) program to establish this program. The emphasis is on infant mortality and creating 

birth and death registries. One of the challenges has been acquiring data sharing agreements 

through the states. When USET first began this program, they had to purchase all of the state 

data from states, which was rather costly. They have been successful in entering data sharing 

agreements with some states. USET‘s Maternal and Child Health (MCH) Project has grown in 

scope. Originally, the MCH Project focused on describing the MCH status within the Nashville 

area. However, USET has been working with the University of Arizona and the University of 

Kentucky to develop an education and training program for tribal health department staff to 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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certify them in MCH health activities, which would also give them credit toward a Masters 

Degree at either of those two universities. Ms. Sebattus indicated that USET provided 

information to NIHB to post on their website if anyone was interested in further information 

about this program. The Data Quality Assessment Project has been underway for a couple of 

years. Examples of reports that this project has established include: Disease-Specific Data 

Quality Assessment Projects that will compare Tribal Resource and Patient Management 

System (RPMS) data to the National Data Warehouse (NDW) data to determine how it differs in 

order to inform tribes about changes needed in entering data and where data are lost. 

J.T. Petherick, Health Legislative Officer

Cherokee Nation, Oklahoma City Area 

Mr. Petherick indicated that the Cherokee Nation / Oklahoma City area includes Oklahoma and 

Kansas Tribes, and one tribe in Texas. Many exciting efforts have been taking place in the 

Oklahoma City Area. One effort that the Cherokee Nation is proud of, and is committed to 

working on with the tribes in their area and nationally, is that they are one of the Public Health 

Accreditation Board (PHAB) beta test sites along with the Navajo Nation and the Keweenaw 

Bay Tribe in Upper Michigan. The kick off meeting was convened in November 2009 in 

Washington, DC so they are still learning about the process and all of the requirements. Mr. 

Petherick explained that the PHAB accreditation process, currently in its infancy, is essentially 

to ensure that various government agencies are carrying out the primary components of public 

health. City, county, and state agencies are participating in the PHAB process in addition to 

tribes. Understanding their differences and how they can all work together is highly important. 

While it will take a considerable amount of work to address the PHAB accreditation criteria, the 

process will highlight areas in which Indian Country is successful, where improvements are 

needed, and what partnerships should be developed with city, county, and state health 

departments. The Cherokee Nation / Oklahoma City Area has also been heavily involved in the 

H1N1 response. It has been their experience, as is the nature of the epidemic, particularly on 

the tribal side, that they had fight to be involved in the process and for resources at the 

beginning, but later were overwhelmed with vaccine and could not give it away. 

The Cherokee Nation is a fairly large health system compared to a lot of other tribes, yet they 

had to advocate and fight to be involved in the process at the state level. For the most part, the 

State of Oklahoma is fairly receptive to working with tribes when the Cherokee Nation initiates 

conversations. However, it is always a challenge. Tribes in Kansas typically have a much more 

difficult time work with the state, which seems to be a population issue. Tribes in Texas have a 

very difficult time working with the state. Oklahoma and to some extent Kansas, have been 

involved in developing the statewide Health Information Exchange (HIE) programs for their 

states through ARRA funds. This involves various health systems and jurisdictions, and all of 

the complications that arise with that. Getting states and non-governmental health providers to 

understand what it means to work with Indian Country is always a challenge. The Cherokee 

Nation has been fortunate to already have been involved in HIE in Northeastern Oklahoma. 

They initially applied together with ARC to develop and HIE, so they believe it is a model that 

can be shared with all of Indian County and the rest of the nation. Now they are beginning to 

work with Tulsa, which is a metropolitan area near their jurisdiction, as well as with the Creek 

Nation. This is called the Greater Tulsa Health Access Network (GTHAN), which is developing 

an HIE in Tulsa. A lot of the contract health dollars are allocated to Tulsa, so they are very 

excited to be a part of this effort and the statewide efforts as well.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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The Cherokee Nation is close to finalizing the announcement for a new Epidemiology Director of 

their Epidemiology Center. There have been challenges over the last few years getting 

someone in place and getting them to stay. They hope to have someone in place who will stay 

long-term to work on many of the issues the Epidemiology Center has been created to carry out, 

but simply has not had the staff in place to do so. One of those efforts is data sharing issues in 

the Oklahoma City Area that have been difficult to overcome. One issue that affects the 

Cherokee Nation, but does not directly impact them, is the funding crisis being experienced by 

states. States are facing major budget crunches, which are likely to impact public health and 

trickle down in terms of how states work with tribes. It is important to be aware of this issue and 

determine what to do about it. In closing, Mr. Petherick informed everyone about the Cherokee 

Nation Cancer Summit to be convened March 3-5, 2010 in Tulsa, which is open to anyone who 

chooses to attend. Unfortunately, this summit is at the same time as the HHS Budget and 

Policy Consultation Meeting in DC. 

Roselyn Begay, Navajo Nation 

Division of Health, Program Evaluation Manager

Ms. Begay reported on behalf of Ms. Ecoffey, who was attending the Navajo Nation Council in 

session this week. She also recognized their Epidemiologist, Dr. Deborah Klaus, who is the 

Navajo Epidemiology Center Director. The Navajo Nation Council considered very important 

legislation for a commercial-free tobacco act during the past fall, which unfortunately failed 

passage. The Navajo Nation worked with a number of organizations in the Navajo Nation and 

also from South Dakota to outlaw commercial tobacco on the Navajo Nation. Since that time, 

this was assigned to the Navajo Division of Health to work closely with a number of 

organizations to reintroduce that legislation to the Navajo Nation Council. Their Division 

Director for Health has urged staff to closely coordinate and work with the legislative body to 

reintroduce similar legislation for the 2010 summer session. Another public health law that was 

updated with the Assistant of the Epidemiology Center and the Navajo Health Education 

program is about a 10-year old or so policy that the Navajo Nation approved regarding HIV / 

AIDS. They are hopeful that this updated legislation will be submitted to the Navajo Nation 

Council in the spring of 2010. 

The Navajo Epidemiology Center has been involved in a number of efforts, including H1N1. 

Across Indian Country, all of the tribes have played an active role in the H1N1 effort. Ms. Begay 

acknowledged Dr. Klaus for her keen role in making sure that daily information was 

disseminated and coordinated throughout the Navajo Nation, including IH S and various tribal 

programs, on H1N1 activities. The Navajo Epidemiology Center also coordinated through the 

Incident Command Centers (ICC) with data and other information pertaining to the Navajo 

Nation. Dr. Klaus also served as a liaison with the State Department of Self Health and CDC. 

The Epidemiology Center also coordinated the Breast and Cervical Cancer Screening Program. 

Of the 360 breast screenings, 17 were detected to be abnormal. Of the 1,000 cervical 

screenings, 63 were detected to be abnormal. This is a very important program, and the Navajo 

Nation applauded CDC for funding this program and requested continuing support. In the 

Community Health Representative (CHR) program, 36 CHRs attended an Introduction to Public 

Health and Community Health Assessment Training at Diné College, a local tribal college

located in Tsaile, Arizona. This is a pre-requisite to a Public Health Certification Program. 

Another 9 CHRs earned Public Health Certification through the Diné College and the University 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

11

of Arizona College of Public Health. Essentially, this program evolved through a Native 

American Research Centers for Health (NARCH) program years ago. The Bioterroism Program 

works very closely with the Navajo Area IH S and other tribal programs. In October, they staged 

a one-day mass vaccination event during which over 18,000 individuals were vaccinated. The 

Bioterrorism program also worked very closely with the Head Start and Navajo Area IH S to 

vaccinate children against H1N1 influenza. This program has spent an extraordinary amount of 

time with the Public Health Awareness Program regarding H1N1 and seasonal influenza 

through a variety of media and venues.

As noted, the Navajo Nation is one of the tribal sites that was selected to participate as a beta 

test site for the PHAB accreditation process. They are also preparing rigorously to conduct a 

self-assessment, and have recruited and established an internal advisory team. However, with 

the recent snow and wet climate in their area, a majority of the Navajo Division of Health 

programs (e.g., CHR, Bioterrorism, Health Education, Aging, and others) are very much 

involved and serving at the frontlines to help Navajo people who live in remote areas to assure 

that they are okay, have accessible roads for emergency and public safety vehicles, et cetera. 

Therefore, the beta test site activities were placed on hold. 

Lester Secatero, Chairman

Albuquerque Area Indian Health Board (AAIHB)

Mr. Secatero reported that one of his communities recently experienced two suicides. He 

explained that New Mexico is currently a half a billion dollars in the red. The state legislature is 

seeking to take by some of the funds they allocated to tribes in an effort to balance the state 

budget. Although there is a very nice train running from Santa Fe to Albuquerque, it will cease 

running in approximately one month if they do not locate $700,000. The way the state plans to

determine who owes money is that the associations and counties will be releasing their capital 

outlay reports. Based upon those reports, some of the tribes will likely have to return funds. 

There are now 20 Pueblos in the Albuquerque Area, with Ysleta del Sur Pueblo joining from El 

Paso. The Pueblos provided a list of priorities for the Albuquerque Area to NIHB in CD and also 

to the Obama Transition Team. They are closely monitoring the Indian Health Care 

Improvement Act. AAIHB has finally hired and Executive Director after being without one for 

about six months. They have had a difficult time keeping Executive Directors, who tend to leave 

after short periods of times. One never bothered to show up in the first place. They are hopeful 

that the new Executive Director, Loren Sekayumptewa, used to be in Gallup where he ran an 

alcohol and substance abuse program. AAIHB is constantly seeking funding. They submitted a 

breast and cervical cancer request to the Health Promotion and Disease Prevention through the 

Alliance for Healthier Generations, but this was not funded. 

Recently, Congressman Harry Teague from the House of Representatives attended an AAIHB 

board meeting. AAIHB requested everything they could possibly think of from Congressman 

Teague while they had his attention. They informed Congressman Teague that instead of 

waiting for IH S to build them a clinic, they built their own clinic through grants and loans totaling 

$3.4 million within a couple of years. They explained to Congressman Teague that while they 

were able to accomplish this, they were unable to staff this high tech clinic. They requested 

another $700,000 to supplement the funding for the clinic and also have approximately 

$385,000 in funds just sitting. It is very difficult to acquire funds because it has to be funneled 

through the Navajo Tribes, so they have been waiting for a long time for medical equipment. 

According to a survey Mr. Secatero read, the cumulative cases for HIV for the state is 279 for 

American Indians and Alaska Natives. People are finding out about the new Canoncito Health 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Clinic, and every year hundreds of new charts are completed. Albuquerque is slowing down on 

their dental services, and the nearest hospital is ACL, which is also slowing down. Thus, 

Canoncito Health Clinic has an overflow. They informed Congressman Teague that the facility 

needs an additional full-time medical doctor, full-time registered nurse, full-time pharmacist, 

part-time dentist, part-time psychologist, part-time social worker, and part-time optometrist plus 

the additional funding of $700,000. Mr. Secataro could not get into the dentist because so many 

people are waiting, which he said was why he sat before the TCAC with a toothache. 

AAIHB is working closely with the New Mexico Department of Health (NMDH), with regularly 

scheduled meetings and trainings. They have H1N1 training and disability services for children. 

They discuss data sharing agreements. They have a liaison position between the NMDH, the 

Tribes, and IH S and she is doing a super job. The AAIHB has also been a contracting agent 

for the Veteran‘s get together every November, which has large turnouts of people who travel 

from as far as Oklahoma. They conduct health screenings during this time, and various 

agencies come together, with IH S and the VA Hospital taking the lead. The Albuquerque Area 

has also established an Institutional Review Board (IRB), which was approved October 1, 2009. 

On this IRB are two doctors, a scientist, and two community members. This IRB was formed 

because AAIHB had to submit everything through IH S Headquarters. For Navajo Chapters in 

the Albuquerque Area, they still have to go through the Navajo Nation IRB. It is said that the 

AAIHB has contact with over 100,000 American Indians from 27 Tribes. They have plans to 

expand, and are getting to know the Denver Urban Center fairly well, are working with Texas, 

and are really going to work on the Albuquerque Urban Center.

With respect to epidemiology, AAIHB has a couple of on-going projects. One of these is the 

2009 Southwest Tribal Youth Project Schools. Data collection is conducted at middle and high 

schools among American Indian Youth. This has been done with 22 schools total. Another 

project, which is funded by CDC, is the Southwest Tribal Behavioral Risk Factor Surveillance 

System (BRFSS). They conduct community assessments in person and by telephone. There 

must be tribal-approved training and data collection assessments to identify and prioritize health 

needs. Their NARCH-5 is good until 2013 and they should soon receive notification about their 

NARCH-6. 

Cynthia Manuel, Councilwoman

Tohono O’odham Nation

Indian Health Board Tucson

Ms. Manual indicated that she had been out for a while because she was hit by a truck, but 

made it through and was very happy to be back. She reported that NIHB, through a cooperative 

agreement with CDC, had been able to disseminate information through various mechanism 

such as the NIHB Washington Report bi-weekly newsletter that provides updates on current 

legislative issues, health care reform, the Indian Health Care Improvement Act; the NIHB Health 

Reporter that is published quarterly and includes updates and information on upcoming events 

throughout Indian Country; NIHB Health Alerts; Restoring the Balance tribal public health 

brochures, which are sent to tribes to help them understand the importance of public health; 

information on H1N1; NIHB listserv; a TCAC yearly calendar; the Tribal Public Health 

Accreditation beta testing; technical assistance to the Advisory Board; and the Save the Date for 

the Public Health Summit to be convened May 18-20, 2010 in Albuquerque. NIHB continues to 

make the H1N1 health issue a priority in Indian Country. For her tribe, this continues to be an 

issue because they live right on the border with Mexico. Many illegal immigrants cross the 75-

mile international boundary that runs through the reservation. The activities being planned are 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

13

the beta testing data collection and the summit as mentioned. The theme for the summit is ―A 

New Decade of Indigenous Public Health.‖ The summit will offer additional training 

opportunities for evaluation and grant writing. On September 30, 2009 was the close of the 

Healthy Indian Country Initiative and the resource guide will be published in February 2010. 

Dissemination of the Restoring the Balance of Tribal Public Health brochure began in late 2009 

and has disseminated over 5,000 copies of brochures to the Tribal Health Centers, Directors, 

Tribal Epidemiology Centers, and IH S facilities. A second dissemination is planned for the 

broader population. 

Reno Franklin, Chairman

California Rural Indian Health Board (CRIHB)

Mr. Franklin recognized staff members who traveled to Atlanta to assist him in answering any 

questions posed regarding California issues. He stressed that the CRIHB has great staff and 

quipped that he was fortunate to have stolen some staff from Mr. Finkbonner‘s area who clearly 

saw the light and beauty of the California weather. California has a number of issues, one of 

which is the weather, which does wreak havoc on them (e.g., El Nino every 10 years, a tornado, 

et cetera). It seems whenever there are state of emergency declarations in California, they are 

for everyone except the tribes. This is an issue when many people are dependent upon 

medications that CHRs drive out to their areas. People cannot receive medication refills when 

there are no roads. 

Regarding H1N1, California has 110 federally recognized tribes. CRIHB was asked to go to the 

state to request Public Health Emergency Response (PHER) funds. Mr. Franklin said he was 

not really sure how that worked because CRIHB submitted a great application for PHER 

funding. Written by Dr. Kim, the application was basically to track H1N1 (e.g., surveillance), 

mini-grants to tribal health programs that would offer after hour vaccine clinics, the creation of 

culturally competent materials to address social distancing, a culturally competent media 

campaign (e.g., brochures, PSAs, et cetera). The state still has not responded. Tribes are told 

that if they want PHER funds, they should work with their states and counties. However, 

California could care less. Although these funds were earmarked for tribes, the state keeps 

them. California is broke and does not want to give up any funds, yet tribes are being asked to 

go to them for what is rightfully theirs. Another issue is that California told the tribes to work with 

their counties, which have no concept of consultation or any desire to consult with tribes if it is 

not going to center around the county gaining something out of it. California has 52 counties, 

zero of which have engaged in consultations with tribes. Not a single county has consulted with 

tribes in its area. Not one of the counties has stepped up to offer assistance. Some areas in 

California cannot give away the H1N1 vaccine. His own county, Sonoma, is flooded with H1N1 

vaccine while the county right next to them, Mendocino, has people dying because they are not 

able to access vaccine. 

This issue is being created by whomever has control of vaccine supply and disbursement. 

Another problem in California is that their Epidemiology Center does not have any data sharing 

agreements. There is no standard protocol for Tribal Epidemiology Centers to access data. 

This is extremely problematic in California. If the Area Office would spend as much time 

worrying about how to get more funds for California as they do worrying about how they are not 

going to share data with the Tribal Epidemiology Center, they would be much better off. These 

agreements are desperately needed, and the tribes should probably form a support group in the 

form of a lawsuit. If they are denied access, particularly on foolish reasons, there should be

some intermediary to whom they can turn. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Chester Antone, TCAC Chair 

Councilman, Tohono O’odham Nation, Tucson

With regarding to disseminating information, Mr. Antone reported that the Tohono O‘odham 

Nation contacts tribes in the area, and relies mainly on the listserv that CDC, NIHB, and NCAI

send information out on. The Tohono O‘odham Nation now ranks number one in diabetes,

which they are not really proud of. They are trying to do all that they can to try to combat that. 

Their Wellness Center opened January 12, 2010, the purpose of which is to try to get people to 

be more active because they realize the importance of taking their medications, eating right, and 

exercising to reduce diabetes.

Unfortunately, five Tohono O‘odham Nation individuals took their own lives. Suicide is a major 

issue that they have, which goes against the tribal philosophy that the Creator gives life and 

should be the one to take it back. They are trying to deal with this situation, and are trying to 

use the State Regional Behavioral Health Authorities, because they are access eligible through 

Medicare / Medicaid to qualify for services for crisis intervention. They take people no matter 

what.

Mr. Antone indicated that the next Friday he was supposed to play in a basketball game. The

Tohono O‘odham Legislative Council challenged a game with the San Simon Health Center

staff. San Simon began operations a year ago. Building this facility was a joint venture 

between the tribe and IHS, and the facility has been staffed. This is an important collaboration 

between IH S and the tribe. The basketball game will occur for the grand open for Behavioral 

Health Services that relocated there. The nation overall is trying to decentralize services, so 

Behavioral Health Services now has a location within the IH S facility so that referrals can be 

made directly within the clinic. Also in this facility are Health Transportation and Adult Protective 

Services. They opened a shelter for adult citizens who may be in situation where they need 

protection, which has 12 beds (6 for women and 6 for men). The second one they are going to 

work on is in his district in the west. They plan to turn one of the rental homes there into a 

Senior Center Protective Center. Unfortunately, there is a lot of alcoholism, drug abuse, et 

cetera. The whole culture has turned around such that elders need protection, particularly 

around the 1st or the 3rd. It is unfortunate that they now have to provide this.

With respect to public health preparedness, they are working with Pima County and the Mexican 

Government on a tri-national plan to address emergencies. The Domestic Affairs Committee is 

addressing that. This also addresses the health component due to H1N1. A lot of the early 

incidents of H1N1 came from Mexico. With 75 miles of that border that is wide with no cities, 

this is important to be aware of. H1N1 education has been done pretty much throughout the 

nation ever since it began, and more importantly because of the recent letter sent by Dr. 

Sebelius regarding the Native American community being most hard hit. Overall, the mission 

has had a pretty good relationship with Pima County and the Arizona Department of Health 

Services. Early on, they conducted a lot of public relations through the radio. They have been 

doing this so much that the Health and Human Resource Development Committee, which Mr. 

Antone sits on, will occasionally visit the schools to meet with the administrators to learn how 

things are going. They went to the Santa Rosa Boarding and Day School, and he was surprised 

because when they walked in the halls they saw many posters regarding how to prevent H1N1, 

and children‘s posters. It made him feel good that the message was getting through. One issue 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

15

regarding public health information is that somehow, they completely missed out on the debate 

over mercury nasal sprays until much later. There was a concern regarding H1N1 vaccine, 

particularly for pregnant women. It was later disproven, but astoundingly they did not know.

They have a fair coming up soon, during which they conduct the Red Dress Fashion Show to 

inform about cancer and are going to include men this year. They also have a one half 

marathon.

In closing, Mr. Antone said that TCAC should be aware and at forefront of the organizational

changes occurring at CDC. TCAC should be aware of recommendations that were made 

previously and where they will be addressed within this reorganization, because they no longer 

have the Executive Leadership Board or the Central Leadership Council. He understood that 

this was where most of the TCAC‘s recommendations were previously forwarded to be worked 

on by Dr. Bailey who mentored them. TCAC really needs to know where those 

recommendations will go and by whom they will be addressed. He thought this was one of the 

most important things they needed to consider. A lot of the centers have their charge already, 

so TCAC must determine which ones they need to concentrate on. 

Alicia Reft

Alaska, Karluk Ira Tribal Council

Ms. Reft indicated that there was not a great deal to report since August. She expressed 

gratitude to those who made it to TCAC meeting convened in Alaska in August 2009. She 

noted that while she was with the Karluk Ira Tribal Council, her report was coming from the 

Alaska Native Tribal Health Consortium (ANTHC) in Anchorage. 

Regarding hepatitis and liver cancer, ANTHC has had a successful Hepatitis B Program over 

the last 25 years. One of their providers, Brian J. McMahon, MD, contributed to a recent 

Institute of Medicine (IOM) report titled, Hepatitis and Liver Cancer: A National Strategy for 

Prevention and Control of Hepatitis B and C. CDC has been supportive of the work related to 

Hepatitis care in Alaska. [Citation: IOM (Institute of Medicine). 2010. Hepatitis and Liver 

Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Washington, DC: 

The National Academies Press]. This report is also available on the IOM website.

With regard to sexually transmitted diseases (STDs), the rates of STDs, particularly Chlamydia, 

remain high in Alaska. This past winter, the website iknowmine.org was launched as an 

innovative way to reach teens and young adults with sexual health information. Some of the 

goals include encouraging testing for STDs, including rapid testing, partner notification, and 

increasing awareness and education via technology that teens can relate to. 

In terms of H1N1, it was anticipated that the annual meeting of the Alaska Federation of Natives 

(AFN) would be a place where H1N1 would be transmitted, given that thousands of Alaska 

Native people attend this meeting each fall. The ANTHC system offered innovative ways to 

educate about H1N1 prior to people leaving their villages or regions. These included use of 

social media tools and video / audio public service announcements. 

Pertaining to suicide prevention, northern regions in Alaska had some of the highest suicide 

rates in the nation. Recently, the Behavioral Health and Injury Prevention Programs worked 

together to convene the first Alaska Suicide Prevention Summit, which was well-attended by 

tribal leadership. ANTHC will continue to provide applied suicide intervention skills training.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Concerning the Alaska Native Epidemiology Center, cancer is a leading cause of death among 

Alaska Natives. Colorectal cancer is the most diagnoses cancer. The Epidemiology Center 

Director, Ellen Provost, has recently completed her last breast cancer chemotherapy treatment. 

She has been a model EpiCenter Director and model patient. During the AFN this year, they 

had a super colon, which people could walk through to make the point that this disease is 

preventable, treatable, and bearable. This is a wonderful program and people in her area are 

finally being treated for colorectal colon cancer. 

Kathy Hughes, TCAC Co-Chair

Vice Chairwoman, Oneida Business Committee

Ms. Hughes indicated that she represents the Bemidji Area, which includes Minnesota, 

Wisconsin, Michigan, and Iowa and encompasses 35 tribes. Unfortunately, it seems like their 

health priorities never seem to change. These continue to be diabetes, cardiovascular disease, 

cancer, and obesity. Some changes are occurring recently, however. They are observing a 

continuing increase in youth obesity. Some of the national studies are reflecting this as well. 

They began programs in the school in Oneida in K-12 and Head Start pertaining to nutritious 

foods and teaching youth about healthier snacks. They have their own Oneida Community 

Integrated Food Systems (OCIFS) and their own farm and herbal market. Through OCIFS they 

are trying to introduce healthy snacks and healthy meals to the school system. In the last two 

years, they have had Oneida Black Angus Beef that they can now serve in the school. In the 

Head Start program, they have changed Halloween to a healthy snack event. Instead of giving 

out candy, they now provide healthy snacks such as goldfish, graham crackers, et cetera. A 

three- or four-year old does not really notice. They are just excited about going around and 

getting something in their bag. With youth obesity is that now Type 2 Diabetes is being 

diagnosed at a younger and younger age. While there is an elder group in which they are 

maintaining and getting diabetes under control, now another generation is beginning to have 

diabetes, which did not occur before. They are controlling it at one end and losing it at the 

other. The focus is still prevention and maintenance, but is moving from the elder to the youth 

population. This is unfortunately, but hopefully they will get this under control much sooner with 

the younger group. It is also an indication that they need to make some changes to how they 

are approaching obesity and diabetes overall. They recently developed a calendar. Each page 

has information on nutrition and diabetes, and each month has a recipe. The Diabetic Team 

developed the calendar with funding from CDC. They also developed a medicine wheel, funded 

100% by Merck, which includes a carbohydrate counter and the number of calories various 

types of exercise burn. Ms. Hughes shared examples of each of these items with those 

present. She thought they could accomplish much more with additional partnerships.

H1N1 was, of course, a very hot topic for their area as well. Similar to what was heard from 

others around the table, they still have vaccine left. They have gone through all of the priorities 

and held their last open clinic the week before. It was not clear to Ms. Hughes why everyone 

was not acquiring the vaccine. Though initially there was a concern about it being a new 

product and whether it was safe, she did not believe this was the major concern. Instead she 

thought that it was because H1N1 was not personal—they have not had an occurrence in the 

community that made it personal and increased interest in being vaccinated. However, a tribal 

employee died from H1N1. She was 24 years old, so she was in the high risk category. She 

worked in the casino. Because it was a very public facility, they did the best they could to 

downplay what was occurring, which perhaps also contributed to the number of people being 

vaccinated. It was good for business, but may have been bad for increasing the incentive for 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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people to get vaccinated. There has been a high occurrence of H1N1 in Wisconsin, so it is 

believed that there will be a third wave.

Wisconsin recently passed a state law for a statewide smoking ban in all public facilities, which 

goes into effect in July 2010. This is a Catch-22 for the tribes, especially for Oneida, because 

tobacco sales is one of their higher revenue generation businesses. They are concerned about 

the health of their tribal members and employees, but they cannot afford to lose any revenue. 

The economy affects the tribes even more so because they are also short in the beginning, so 

having the economy in a slump makes it much more challenging. There is probably no state in 

the country that does not have a deficit budget. Some are much larger than others, but if 

something is not done, every tribe will be in the same situation. Tribes are trying to obtain 

funding from states that are already trying to figure out ways to not allocate more funds, 

especially to tribes. This will continue to be a problem. Oneida has not yet determined how 

they plan to deal with the smoking ban. They are working on a tribal law that will implement a 

smoking ban in part in some public facilities, but they are trying to protect the casinos to keep 

smoking available there.

In Wisconsin, data sharing is an ironic situation. In Wisconsin, there are 11 tribes. It is the 

State of Wisconsin who is trying to get the state to sign data sharing agreements. This differed 

somewhat from what she had heard others around the table say. Oneida has signed that data 

sharing agreement. She indicated that she would provide a copy of that agreement as a sample 

for everyone else. In a meeting Ms. Hughes attended the week before, the Wisconsin State 

Medicaid Director indicated that of the 11 Wisconsin tribes, 4 had signed the agreement to date. 

She told him she would assist in getting the other tribes to sign on as well.

They have excellent consultation programs in Wisconsin and Minnesota. Michigan is struggling 

somewhat, but is beginning to improve in some areas. Wisconsin meets twice a year with the 

Secretary of Health Services for the State of Wisconsin. If they have any issues any other time 

during the year, they have no problem getting a meeting with the Secretary. They are currently 

working to finalize a long-term care agreement. There was recently a meeting on Oneida, and 

there will be a couple more meetings, but Ms. Hughes said she hoped that the long-term care 

agreement could be finalized within the next couple of months. The long-term care agreement 

is important because it extends services for which they will be able to receive reimbursement 

from the state for in-home care primarily. They do have a nursing home and are trying to 

acquire reimbursement for some of those services as well.

Ms. Hughes said she thought the organizational structure occurring within CDC was an issue 

with which the TCAC should become very familiar. While they were receiving information as the 

discussions were taking place, she did not know whether the TCAC had sufficient input on the 

organizational change, and she was extremely surprised to find out the week before that it was 

published in the December 28, 2009 Federal Register, but was not published for comments. It 

was published as a done deal. In reviewing that organizational structure, she believed that the

TCAC had really lost ground and that the relationship they were trying to formulate with CDC 

was taking a step backwards under the new administration and new organizational structured. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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With that in mind, she expressed her hope that during their time in Atlanta, they would have 

more opportunity to discuss this, particularly in terms of speaking to Dr. Frieden directly about 

the organizational structure and the lack of consultation before putting the new structure into 

place. 

Regarding the Census, which would begin in April, Ms. Hughes stressed the importance of 

tribes getting their people counted. CDC is one of the places where this is most important 

because CDC funding is based on population numbers. Tribes are already short on funds. 

From an Oneida standpoint specifically, the 2000 Census has their numbers at a little over 700 

yet they have over 16,000 members. Tribes must take responsibility for helping to ensure that 

their numbers are counted accurately. 

Discussion Points

 Mr. Franklin agreed with the reorganization issue, and articulated how disappointed he 

would be if tribes were dropped into an Office of State and Local with no Tribal listed in the 

office name. This will be a slap in the face for all tribes. Therefore, he expressed his hope 

that they would hear that this was a foolish mistake that would be changed.

 Ms. Hughes said she did not know of any place where there was this type of relationship 

between tribes and counties. Their protocols simply do not take them to that level. 

 With regard to the organizational improvement process, Dr. Bryan responded that it had 

been interesting and it was just now occurring to him that the public input on this process did 

not take place the same way it did during the prior reorganization process several years 

ago. He pulled up the Federal Register announcement to review it again, and concurred 

that it was basically an acknowledgement that this was occurring, and it occurred on an 

internal basis fairly quickly. He said he thought those were reasonable questions to ask Dr. 

Frieden, although he did not believe the lack of public input was limited to tribal input. It 

seemed to be more broad, but the infrastructure was something that needed to change 

quickly, though he said he would leave that for Dr. Frieden to speak to. Dr. Bryan said he 

thought it was also important for the CDC leadership to hear the TCAC‘s concerns about the 

visibility of a Tribal office and where it sat within the organizational structure. On the other 

hand, he thought it was important for them to know what had been occurring behind the 

scenes in terms of what he and CAPT Snesrud observed as a new level of very visible 

support and interest in bringing together a tribal unit that extends beyond two tribal liaisons 

and that builds some staff and fiscal support to do the things that they have struggled to do 

from year to year with just two people. That support is tangible, real, and put him and CAPT 

Snesrud in a more optimistic frame of mind than they have been in many years about that. 

There are practical issue with regard to where a unit would sit organizational that has to do 

with the fact that the further a group is ―up the food chain‖ the less the opportunities for 

building structure with staff and a larger budget due to the constraints around how OD 

offices are funded and staffed. Dr. Bryan said he did think it was a good discussion to have, 

and that the juncture was immediate. He and CAPT Snesrud met the previous day with 

Karen White who is heading up the Office of State and Local Support (OSLS). State and 

Local means Tribal and Territorial. It is not in the name, but that is what it means. That was 

a clear message from Dr. Frieden as this new office was formed. They wanted to move the 

tribal activities within OD out of the minority health umbrella and more in the mainstream of 

government-to-government relationships. That was done by design because they really 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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wanted to put Tribes on the same level with State and Local, so Tribal is going to add its 

own box wherein it is institutionalized in the agency that whenever they were talking about 

State and Local, they were talking about Tribal governments as well. He thought that there 

was still time for input. On a very short timeframe between this meeting and may, he and 

CAPT Snesrud were charged to work with OSLS to think through what the strategies would 

be for this new unit and for Indian Country involvement across the agency. While there was 

a lot of momentum going on, that did not preclude the need to ask the hard questions. 

 Ms. Hughes said she knew that with CMS and the Tribal Technical Advisory Group (TTAG), 

it was never dreamed when that advisory group got together that they would be formalized 

statutorily. They are the only tribal advisory group that is statutorily created. Funding and 

getting any support were always an issue. They began with only one person, and they have 

staff who are able to assist with the work flow. She expressed her hope that with 

discussion. They could garner the proper support for the TCAC. They are responsible for 

Indian Country and for acquiring the funding needed for Indian Country from CDC. She 

personally believes that this relationship is still so new that there are areas of the CDC that 

they have not even tapped. She said that knowing that Oneida had actually received quite a 

bit of CDC funding, though other tribes could not seem to crack open that door. This is very 

difficult because everything is competitive with CDC, and many of the tribes do not have the 

administrative skills and support to be able to write the applications. Technical support is 

extremely difficult to come by, as are the data that are needed to be able to compete for 

these funds. Many challenges remain for the tribes in terms of working with CDC.

 Dr. Bryan thought that the session on Thursday would offer a great opportunity to address 

H1N1. He expressed his hope that during the H1N1 timeframe, they would hear the good, 

the bad, and the ugly. A number of lessons have been learned, some of which are very 

positive, and others of which have been more challenging and frustrating and have varied 

from region to region. H1N1 activities were winding down, and there was less concern with 

a third wave as all of the indications were that vaccine uptake / coverage across the country 

was approaching levels consistent with herd immunity in many places. However, there were 

still isolated pockets of activities, which could have more impact on more rural Indian 

communities in the future. This highlighted the need for continued emphasis on distributing 

vaccine and increasing coverage in areas where there may not be herd immunity. This 

should be treated as a preamble to what still could be a major pandemic, or avian influenza, 

or anything else that arises next. Because they had people‘s attention, it was the right time 

to talk about what lessons were learned and how things could be fixed for the future. The 

other recurring theme he heard pertained to data sharing. Dr. Bryan stressed that they 

wanted to be the tribes‘ advocates with their colleagues at the IH S, but was somewhat 

limited in what they could do in that capacity. Though he was not sure what the problems 

and fixes would be, but thought that they could do more on the CDC side if the issues were 

with the state where they might have more leverage in terms of negotiating and working on 

tribes‘ behalf in terms of data sharing. He stressed that the more specifics they had on this, 

the better on the federal or state side. 

 CAPT Snesrud added that her recollection was that when they were planning for the August 

2010 TCAC meeting, they identified the need to have a specific focus on data sharing during 

a TCAC meeting. Perhaps as they looked toward the next meeting, they could consider 

adding this to the agenda and bringing in key representatives to dialogue with the TCAC, 

including IHS representatives and state colleagues. If they were very intentional, they could 

have the kind of in-depth conversations they needed to. In addition, she reminded everyone 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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that their previous dialogue with Dr. Bailey regarded developing a site where they could host 

TCAC related materials. This has been set up, but with the reorganization changes at CDC 

and health care reform issues, they had not launched it yet. This is an FTP site to which the 

primary and alternate TCAC representatives will be given passwords. She is in the process 

of setting that up so that they will have fairly complete files for each meeting back to 2007. 

The representatives would also have an opportunity to post information from their Area 

Health Boards or Tribal Epidemiology Centers. The site will not have interactive capabilities, 

but there are mechanisms that they could use as they continued to improve their 

connectivity, such as a blog. They have relied heavily on NIHB and will continue to do so 

with their permission and assistance with circulation / dissemination of information. 

 Ms. Hughes added that there is also another source on the internet that can be used for 

sharing of data and communicating back and forth, which she indicated she would provide 

to CAPT Snesrud. 

Luke Johnson

Fort Mojave Indian Tribe

Public Health Emergency Preparedness Coordinator

Brenda Granillo, Director

Arizona Center for Public Health Preparedness 

Mr. Johnson indicated that he was from one of the 22 Arizona tribes, and that he and Ms. 

Granillo were there to present information to the TCAC on work that they are doing in Arizona. 

Arizona is a very progressive state tribally. With regard to the Environmental Protection Agency 

(EPA), Region 9 is always a trendsetter for all of America. The tribes in Arizona are also the 

trendsetters for Region 9. There were very interesting comments earlier in the day about the 

H1N1 vaccine problems occurring in California and other areas. This is different in Arizona. 

When Janet Napolitano was the Governor of Arizona, she stated that all Arizona Departments 

were to have a consultative agreement with tribes, and they did this. This included Arizona 

Department of Health Services (ADHS) that the PHEP Coordinators work with. They have an 

extraordinary relationship compared to what is occurring across American with Tribes. Based 

on that, Arizona Indian Tribes in the PHEP programs enjoy a very unique relationship with the 

State of Arizona in the H1N1 work. To improve upon and enhance that, the State of Arizona 

ADHS program appoints a tribal representative who is called the Tribal Preparedness 

Coordinator. They have contracted that with the Fort Mojave Indian Tribe, the tribe to which Mr. 

Johnson belongs. So his office enjoys the privilege of going to all of the reservations in Arizona 

to work with all of the PHEP Coordinators in the advancement of their PHEP H1N1 programs. 

A collaborative team effort that they have in place, that is comprised of a body of five tribes that 

represent all Arizona PHEP Coordinators, decided in May 2009 to develop a strategic plan for 

all of the Arizona PHEP Coordinators and their work that would be consultative to the ADHS. 

The following map reflects where some of the tribes are located: 

Arizona Tribal Public Health Preparedness Strategic Plan
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

21

Some of the tribes are quite large, with the Navajo Nations being the largest. Others are quite 

small. Tribes range from 60 to over 100,000 people, so they are quite diversified. Yet, all of 

these tribes in Arizona have come together as a PHEP program, and through a collaborative 

effort decided that they wanted this strategic plan. 

Of the state land mass, 23% are Indian Lands comprising 31,615 square miles or 20,233,600 

acres. Of the Arizona population, 9% are Native Americans. The ADHS PHEP program serves 

178,846 people. Based on the demographics of tribal presence, Arizona has mandated each 

state department to implement a government-to-government consultation process. The Arizona 

tribal profile is as follows:

Arizona Tribal Profile

Nations (4) Tribes (15) Communities (3)

Navajo Nation

Ft. McDowell-Yavapai Nation

Tohono O’odham Nation

Yavapai-Apache Nation

Cocopah Pascua Yaqui

CRIT Quechan

FMIT San Carlos Apache

Havasupai Tonto Apache Payson

Hopi White-Mountain Apache

Hualapai Yavapai-Prescott

Kaibab-Paiute Southern San Juan Paiute 

Pueblo of Zuni 

Ak-Chin

Gila River

SRPMC
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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With respect to the tribal healthcare structure, Arizona tribes are provided healthcare services 

through IHS and PL 93-638 programs. There are 9 hospitals that are Title III, Title V, or IHS 

facilities. There are 51 ambulatory clinics that provide services from Title III, Title V or IHS 

facilities or tribal developed facilities. Based on tribal presence and the need for quality 

healthcare programs, healthcare systems have also implemented a government-to-government 

consultation process including ADHS and CDC.

Regarding tribal PHEP programs, based on the consultation policy, the ADHS reaches out to 21 

tribes, with 15 signed onto the PHEP program and 3 in the introductory process. Arizona tribal 

PHEP funds are based on a distribution formula, with a $50,000 base amount and a populationbased calculation of tribal members residing on reservations based on the 2000 Census count. 

Tribes and counties have specific deliverables and IGA contracts. A Tribal Collaborative Team 

of 5 representatives was introduced in 2006, which serves as an Executive Body to address a 

unified approach to emergency events (e.g., Strategic Plan). ADHS provides a Tribal 

Preparedness Coordinator who assists tribes with daily PHEP operations issues and questions, 

visits tribal programs, and coordinates meetings. CDC provides PHEP cooperative agreement 

funding to 62 grantees, which include 50 states, 8 territories (Puerto Rico, the Virgin Islands, 

American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Republic of the 

Marshall Islands, Republic of Palau, and the Federated States of Micronesia), and 4

metropolitan areas (Washington, DC, Chicago, Los Angeles County and New York City). 

Ms. Granillo explained that the Arizona Tribal PHEP Collaborative Team has developed a 

Strategic Plan as a unified tribal PHEP plan to address tribal health issues by preparing for and 

responding to tribal people‘s needs to improve the health of tribal people on their lands with a 

mission and vision statement, identified core values and guiding principles and established 

focus areas. The basic aim of strategic planning is to actively determine the nature or character 

of the organization and to guide its direction. It identifies the mission and mandates of the 

organization and devises strategies for fulfilling its purposes:

In July 2009, The Arizona Center for Public Health Preparedness (AzCPHP) was asked to 

facilitate first session. They began with a basic SWOT Analysis (strengths, weaknesses, 

opportunities, and threats) to formulate the mission, vision and goals. The process was very 

rudimentary in the beginning, but became much more expansive as time passed. Tribes had a 

more vested interest of the benefits and value to having a strategic plan as new BP begins in 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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2010. They met monthly through December 2009, adding supporting evidence to support each 

goal and objectives pertaining to other programs in place that can work under this model. 

Though PHEP has been allocating funding since 2003, this is a strategy that had never been 

implemented. Though it seemed as though they were taking a lot of steps backwards, a new 

guidance will be issued in August 2010, so the timing was perfect to start with a strategic plan. 

The plan is for fiscal years 2010 through 2013. The strategic plan is a framework for decision 

making, it sets out a vision for how to move forward, and is a stimulus for change. In general, 

the Arizona tribes do have a good relationship with ADHS; however, there are still some 

challenges and there is still some resistance amongst the leadership within ADHS. On January 

15, 2010, the plan was presented to the ADHS Interim Director, Mr. Will Humble, who fully 

endorsed the plan. Garnering that support was key, so this was a major accomplishment. 

The strategic plan components include the following:

 Mission Statement

 Vision Statement

 Core Values and Guiding Principles

 Focus Areas

 Goals (6) and Strategies

 Objectives

 Key Performance Indicators

 Supporting Research and Evidence

 Appendices (Supporting Tribal Consultation Policy)

As noted, use of the new guidance will begin in August 2010. One of the key strategies in this 

plan was to be able to identify new initiatives to enhance existing tribal PHEP program. In the 

past, if funding was not spent it would be returned to the state health department where it was 

spent on other programs. The idea was to include a goal or strategy regarding how to 

reallocate those dollars for the tribal PHEP program. One of the first initiatives proposed was to 

developed a tribal needs assessment, which was scheduled to begin in February. Arizona 

participated as one of the state models for Project Public Health Ready (PPHR), which is funded 

through National Association of County and City Health Officials (NACCHO). However, 

because the tribes are not counties and do not fit within that model, they were not part of the 

assessment. However, Ms. Granillo‘s argument was that tribes should have been part of the 

assessment because it would have offered a better picture of the state of preparedness for that 

state. Of the 15 counties in the state, 14 participated in PPHR, but there was no tribal input at 

all. The tribal needs assessment will help to identify gaps in training, personnel, resources, and 

infrastructure and greatest threats to the tribes and will be competency and capability-based. 

The next step will be to establish a formal Arizona Association of Tribal Public Health 

Emergency Preparedness Coordinator‘s (AAT-PHEPC) and executive body, and to implement 

the plan.

Mr. Johnson then discussed the mission and vision statements and the goals and objectives of 

the strategic plan.

The mission statement is as follows: 

The Arizona Tribal Public Health Emergency Preparedness Programs, in coordination 

with the Centers for Disease Control and Prevention and the Arizona Department of 

Health Services, serves as the focus for tribal health issues by preparing for and 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

24

responding to our people‘s needs through tribal leadership and an integrated all-hazards 

approach to improve the health of tribal people on their lands. 

The vision statement is as follows: 

It is through listening and learning we can understand what to recommend what is best 

for the people. As a liaison body we will listen to the drum beat and heart beat of the 

people‘s needs, as well as the latest medical technology to learn what is best for our 

people. It is our vision to listen, to learn, to understand, to respect, to acknowledge, and 

only then can we act wisely to create an effective emergency preparedness program for 

the health of our ―People.‖

The strategic plan goals are presented and are to be understood as follows:

 Only Goal 1 is determined as a long-term goal, wherein as in other agency programs, tribes 

may attain the status of ―treatment as a state‖ and based on eligibility requirements, have 

direct funding from the CDC

 Goals 2 through 6 address the consultation process between the state and tribes under the 

cooperative agreement to improve in determining programs that have a direct impact to 

tribal healthcare needs.

Goal 1 & Strategy

 Goal 1: To foster government -to-government relationships to enhance tribal preparedness. 

 Strategy 1: To improve the relationship with the CDC to promote advocacy and support for 

tribal goals, objectives, and new initiatives.

Objective 1.1: To develop a process that facilitates inquiry for direct funding from the CDC.

Objective 1.2: To increase inter-tribal communications.

Objective 1.3: To increase the multi-jurisdictional coordination across and between 

neighboring agencies.

Objective 1.4: Recognition of some tribes‘ capacity to sustain PHEP activities for treatment as 

a county (TAC) and treatment as a state (TAS) 

Supporting Evidence

 EPA has ―treatment-as-state‖ TAS programs. Several Arizona tribes have met eligibility 

requirements and have a direct TAS relationship with EPA

 IHS has the ―self-governance‖ program through PL 93-6318 Title 3 and Title 5 programs 

where tribes meeting eligibility requirements manage their healthcare separate from IHS 

intervention

 State Homeland Security Program (SHSP) provides supplemental funding directly to eligible 

tribes to strengthen tribal governments to associated risks

Each of these support examples have common elements that were implemented in becoming 

direct government-to-government relationship programs. An agency consultation process 

brought about the government-to-government programs. Each program was enacted by a

Congressional act. Each program establishes eligibility requirements. Tribes have met 

requirements and enjoy a direct government-to-government relationship.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

25

Goal 2 & Strategy

 Goal 2: To create effective community awareness, preparedness, training and education 

programs for the health of native people.

 Strategy 2: To evaluate existing infrastructure to identify gaps to improve agency capacity 

to plan, detect, respond, recover, and mitigate public health emergencies. 

Objective 2.1: To align the tribal PHEP program to the 9 CDC Preparedness Goals.

Objective 2.2: To build community awareness through educational and outreach programs for 

native members.

Objective 2.3: To collaborate with respective agencies in community awareness programs for 

native members off-reservation.

Objective 2.4: To develop operational capabilities to respond to public health threats by 

developing tribal use of the Navajo and the Inter Tribal Council of Arizona (ITCA) Epi Center‘s, 

which must be supported by additional funding sources and inter-tribal agreements (ITA‘s).

Objective 2.5: To enhance the communities we serve through surveillance and mitigation 

activities.

Objective 2.6: To ensure resources are available and allocated for effective community 

response 

Objective 2.7: To increase trained emergency preparedness personnel in community outreach 

and awareness programs. 

Goal 3 & Strategy

 Goal 3: To establish a process to review and have input into the requirements of Public 

Health Emergency Preparedness Cooperative Agreement(s).

 Strategy 3: To meet with appropriate agency officials to discuss and review cooperative 

agreement requirements, limitations, expectations and explanation of the conditions of 

appropriations within a timeframe that allows for efficient planning.

Objective 3.1: To identify and establish a process that allows tribes an effective review of 

budgets, which includes active participation by the Tribal PHEP Collaborative team with

appropriate agency officials during the initial planning period of the Cooperative Agreement.

Objective 3.2: To actively participate and have tribal collaborative team representation in state 

grantee awardees meetings to facilitate transparent communications regarding the cooperative 

agreements.

Objective 3.3: To establish a process that identifies new tribal initiatives with unspent funds in 

alignment with cooperative agreements.

Objective 3.4: To establish a vetting process that aligns deliverables and budget with tribal 

priorities.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

26

Goal 4 & Strategy

 Goal 4: To enhance the integrated all-hazards approach to public health emergency 

preparedness.

 Strategy 4: To adopt the National Incident Management System (NIMS), the National 

Response Framework (NRF) and other standardized policies, procedures and training to 

enhance All-Hazards Public Health Preparedness and Response within Tribal Communities.

Objective 4.1: For Public Health Preparedness and Public Health Incident Command Tribal 

Staff to meet a minimum level of NIMS compliance consisting of ICS 100, 200, 300, 700, 800 & 

808

Objective 4.2: To incorporate National standardized guidance and compliance standards within 

Tribal Public Health Preparedness plans, policies, procedures and exercises. 

Objective 4.3: To develop All-Hazards Public Health Preparedness Plans for each Tribal 

Community.

Objective 4.4: To increase workforce development by attending trainings, conferences and 

workshops to build and foster tribal knowledge and experience in an all-hazard, integrated 

approach to Public Health Preparedness and Response.

Objective 4.5: Develop a coordination and integration strategy to work with other responder 

disciplines in an all-hazards emergency.

Objective 4.6: To participate in activities that support the framework of the NACCHO Project 

Public Health Ready Recognition Program (PPHR), this would need to be adapted to meet the 

needs of the tribes thus requiring funds (i.e. carry-over or set-aside funds). 

Goal 5 & Strategy

 Goal 5: To enhance the recognition of the Tribal Collaborative Team as the executive body 

for Arizona Tribal Public Health Emergency Preparedness Coordinator‘s.

 Strategy 5: Formalize the development of an Arizona Association of Tribal Public Health 

Emergency Preparedness Coordinator’s (AAT-PHEPC), which would facilitate the 

development of an executive committee that serves as the liaison to all PHEP coordinators.

Objective 5.1: To draft a set of By-Laws that provides a foundation for the establishment of 

AAT-PHERC.

Objective 5.2: To provide for a systematic review of the proposed By-Laws within six months 

of the initial draft.

Objective 5.3: The proposed By-Laws may include the provision of sub-committees to carry 

out the work and advocate on behalf of the Association.

Objective 5.4: The proposed By-Laws may also include the establishment of a Tribal 

Collaborative Team to represent the Association in meetings with the State of Arizona, County 

Associations, federal agencies and other entities as may be determined by the Association.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

27

Goal 6 & Strategy

 Goal 6: To identify alternative funding and contracting mechanisms for tribes to participate 

in Public Health Emergency Preparedness Activities to include ADHS PHEP contracting 

program.

 Strategy 6: To establish a process or system for identifying funding sources and 

opportunities.

Objective 6.1: Utilize the Inter Tribal Council of Arizona (ADHS contracts with ITCA) to identify 

alternative funding and contracting mechanisms, sources and procedural requirements for Tribal 

Public Health Emergency Preparedness.

The Arizona tribal populations range from 162 members to over 200,000 members. This goal 

addresses the needs of small tribes to join county partners as ―jurisdictional partners‖ taking the 

lead and the small tribe having quality Public Health Emergency Preparedness program filling 

the people‘s needs.

Ms. Granillo reported that there have been numerous benefits to the strategic planning process. 

Arizona governments, either the state or tribal governments, have exhibited strong leadership in 

the arena of the consultation process. GOAL 1 has the vision of one day for successful tribes in 

the PHEP program to have a ―treatment as a state‖ consultation status with the CDC and have 

direct funding as demonstrated in other agencies. This is the only long-term goal as noted. 

GOAL 3‘s intent is to insure that tribes have a voice at the ―consultation table‖ when the 

cooperative agreement is finalized at the state awardee-to-tribal government level when 

decisions are made. GOAL 5 establishes a tribal executive body that is representative to the 

state for all of the Tribal PHEP programs when the need arises. GOALS 2, 4, and 6 address 

improving the consultation process in the cooperative agreement scope of work.

The Arizona Association of Tribal Public Health Emergency Preparedness Coordinator‘s would 

be established as a formal association modeled after the Arizona Local Health Officer‘s 

Association (ALHOA), the Tribal Collaborative Team will serve as the executive body for the 

Tribal Public Health Emergency Coordinators. Through the Arizona Association of Tribal Public 

Health Emergency Preparedness Coordinator‘s Association there would be an executive body 

for advancing the government-to-government consolation process.

There were also challenges, such as 21 tribes coming together in a unified PHEP approach. 

There have been monthly meetings since July 2009 to finalize the plan. Receiving endorsement 

and support from the ADHS Interim Director was a challenge, but has been accomplished. With 

respect to implementation of the plan, the challenges include limited resources, limited 

personnel, maintaining continuous buy-in and support, et cetera. The Tribal Strategic Plan will 

prove to be a valuable consultation tool as we in Arizona tribally unified meet the challenges of 

the Public Health Preparedness Program initiatives.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

28

The next steps are to receive endorsement from the AHDS, which has been done; share the 

report with CDC TCAC, which has been done; receive support from CDC on initiatives and TAS 

for some tribes; receive input from other tribal PHEP programs across the country; implement 

the plan; and evaluate and monitor the plan (including maintaining and updating the plan). The 

Arizona Tribal Strategic plan is a ―living document‖ and will continually be updated to meet the 

challenges of bioterrorism or disease outbreak. 

Ms. Granillo concluded that one of the initiatives they would also like to move forward on 

pertains to how to use Tribal Epidemiology Centers more effectively. She also shared the 

website address for the strategic plan, and contact information for herself and Mr. Johnson.

The strategic plan website is as follows:

http://www.azdhs.gov/phs/tribal/TribalPreparedness.htm

Contact information is as follows:

Brenda Granillo, MS, Director

Arizona Center for Public Health Preparedness

bgranill@email.arizona.edu

(520) 626-0617

Luke Johnson

Tribal PHEP Coordinator

Ft. Mohave Indian Tribe

lukejonhson@fortmojave.com

(760) 326-9650

Discussion Points

 Mr. Johnson stressed the importance of reading every word of every cooperative agreement 

to clearly understand what is being agreed to.

 Ms. Hughes said that she personally was not aware of a strategic plan in the Bemidji Area, 

although she knew that in Wisconsin there were agreements. However, it was not clear to 

her whether all 11 Wisconsin tribes have the same relationship with the State of Wisconsin. 

They do have the collaborative letter from each of the tribes in Wisconsin. They also had 

the opportunity to test the plan with H1N1. In distributing the vaccines, they actually referred 

to the preparedness plan to establish clinics and working relationships with the tribes and 

counties. They also had a significant snow storm that affected several areas across the 

Midwest, particularly the smaller communities and the reservation, which presented another 

opportunity to test the plan. Though unfortunate, each event does offer the opportunity to 

test and improve the plan. She said she would inquire as to whether they had a formal 

strategic plan. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

29

Overview

Mick Ballesteros, PhD, Acting Associate Director for Science

National Center for Injury Prevention and Control (NCIPC)

Centers for Disease Control and Prevention (CDC)

Dr. Ballesteros indicated that NCIPC‘s mission is: ―To prevent injuries and violence and reduce 

their consequences so that people can live to their full potential.‖ CDC began studying home 

and recreational injuries in the early 1970s, violence prevention in 1980, and was established as 

a CDC Center in 1992. Within the large agency of CDC, organizationally NCIPC sits within the 

Deputy Director of Non-Communicable Diseases, Injury, and Environmental Health. The other 

national centers grouped with NCIPC include: National Center for Birth Defects and 

Developmental Disabilities (NCBDDD), Nation Center for Chronic Disease Prevention and 

Health Promotion (NCCDPHP), and National Center for Environmental Health (NCEH) / Agency 

for Toxic Substances and Disease Registry (ATSDR). CDC‘s new organizational structure and 

NCIPC‘s organization structure are as follows:

CDC New Organizational Structure 

DIRECTOR

Deputy Director

Associate Director for Program

Associate Director for Science

Associate Director for Communication

Chief Operating Officer

Chief of Staff

Associate Director for Policy

Office of Dispute Resolution and Equal Employment Opportunity

Office of Public Health Preparedness

and Response

Deputy Director for State and Local Support

National Institute for Occupational Safety

and Health

Deputy Director for Surveillance

and Epidemiology

Deputy Director for Non- Communicable Diseases, Injury

and Environmental Health

Deputy Director for Infectious Diseases Center for Global Health

National Center for Health Statistics

Offices of Surveillance, Epidemiology, Informatics, Laboratory Science, and Career Development

National Center on Birth Defects and Disabilities

National Center for Chronic Disease Prevention and Health Promotion

National Center for Environmental Health/Agency

for Toxic Disease Registry

National Center for Injury Prevention and Control

National Center for

Immunization & Respiratory Diseases

National Center for Zoonotic, Vector-Borne & Enteric Diseases

National Center for HIV/AIDS, Viral Hepatitis, STD & TB

Prevention

National Center for Preparedness, Detection &

Control of Infectious Diseases

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

 

Office of the Director

Acting Director

Robin Ikeda, MD MPH

Acting Deputy Director

Amy Harris, MPA 

Acting Associate Director for Science

Mick Ballesteros, PhD

Acting Associate Director for

Extramural Research

Adele Childress, PhD

Health Communication 

Science Office

Director Wendy Holmes, MA

Office of

Program Management

and Operations

Director

James Belloni, MA

Acting Office of Policy, 

Planning and Evaluation

Director

Sara Patterson, MA

Office of Statistics

and Programming

Director

J. Lee Annest, PhD

Division of

Injury Response

Director

Richard C. Hunt, MD, FACEP

Division of Unintentional 

Injury Prevention

Director

Grant Baldwin, PhD, MPH

Division of

Violence Prevention

Director W. Rodney Hammond, PhD

NCIPC Organization Chart

NCIPC is one of the smallest centers within CDC, encompassing only about 1.5% of CDC‘s total 

budget and having a staff of about 130 people. Dr. Robin Ideka is NCIPC‘s Acting Director. 

There are several key offices, including those focused on communications, policy, extramural 

research, and statistics and programming. The primary organizational units of the center, where 

the ―on-the-ground‖ work occurs are the three divisions: Division of Injury Response (DIR), 

Division of Unintentional Injury Prevention (DUIP), and Division of Violence Prevention (DVP).

NCIPC recognizes that injuries occur despite all of the efforts made in prevention, so DIR works 

to improve injury care and response practices. Their goal is primarily secondary and tertiary 

prevention (e.g., once an injury has occurred, minimizing injury severity and long-term 

consequences). These consequences can be extensive and wide-ranging. Injuries have 

physical, emotional, and financial consequences that can impact the lives of individuals, 

families, and society. Some injuries can result in temporary and long-term disabilities. DIR is 

divided into two teams: Research Team and Program Team. The priority topic areas include: 

Acute Injury Care, Alcohol Screening, Field Triage, Blast and Explosion Injuries, Mass 

Casualties, and Advanced Automatic Collision Notification. DIR also runs the Core State Injury 

National Center for Injury Prevention and Control (NCIPC) 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

30

Program, which is a 30-state grant program through which CDC provides state health 

departments the resources and training needed to build a solid infrastructure for injury 

prevention and control. This allows the state grantees to collect, analyze, and use injury data 

and to implement and evaluate interventions. Much of the programmatic work that NCIPC does 

as a center flows through the Core State Injury Programs. 

Unintentional injuries, homicide, and suicide, are the leading cause of death for people 1 to 44

years of age. DUIP is mainly concerned with primary prevention, and has to teams: Home and 

Recreation Team and Motor Vehicle Team. The Home and Recreation Team addresses issues 

concerning: Falls, Residential Fires, Drowning, Poisoning, and Sports. The Motor Vehicle 

Team addresses issue pertaining to: Drivers, Occupants, Motorcyclists, Pedestrians, Bicyclists, 

Teen Driving / Graduated Drivers Licenses (GDL), and Alcohol Impaired Driving. These injuries 

can occur in a variety of settings, including schools, homes, roads, playgrounds, recreational 

sites, public parks, and community. The setting affects the risks and prevention strategies. 

Work-related injuries are actually the purview of the National Institute of Occupational Safety 

and Health (NIOSH), which is another institute within CDC, so in general, NCIPC does not deal 

with work-related injuries. In general, death rates from unintentional injuries have been either 

stable or increasing. However, there are three areas with increasing rates of death, including 

falls among older adults, drug overdose and poisonings, and deaths among motorcyclists. 

Thus, DUIP is working diligently to better understanding why these increases are occurring and 

what can be done to address them.

Violence is also a serious public health problem in the US. From infants to the elderly, it affects 

people in all stages of life. In 2006, more than 18,000 people were victims of homicide and 

more than 33,000 took their own lives. The number of violent deaths tells only part of the story. 

Many more survive violence and are left with permanent physical and emotional scars. 

Violence also erodes communities by reducing productivity, decreasing property values, and 

disrupting social services. DVP is committed to stopping violence before it begins. This is the 

largest division within NCIPC. There are three branches: Etiology and Surveillance, Prevention 

Development and Evaluation, and Program Implementation and Dissemination. The priority 

areas for violence prevention include: Intimate Partner Violence, Sexual Violence, Child 

Maltreatment, Youth Violence, and Suicide. Emerging areas include: Global Violence 

Prevention and Elder Abuse.

All three of the divisions within NCIPC work across the public health model to conduct 

surveillance, conduct foundational intervention and dissemination research, and implement and 

evaluate programs. NCIPC has three priority areas of focus: Child Maltreatment Prevention, 

Older Adult Fall Prevention, and Motor Vehicle Injury Prevention. These are priorities because 

of their high costs, the availability of solutions to address the issues, and the severity of the 

related injuries and their consequences. In these areas, NCIPC is making an extra effort to 

show some national leadership in pushing research and dissemination of prevention strategies. 

Injury is a significant public health problem. In 2006 in the US, there were 179,000 injuryrelated deaths and more than 3 million individuals were treated for injuries in emergency 

departments. Injuries are not accidents, unpredictable, random, or uncontrollable acts of fate. 

The steps of the public health model can be used to understand the magnitude of the problem; 

identify risk and protective factors; and develop, test, evaluate, communicate, and implement 

prevention strategies and policies. Injuries are understandable, predictable, and preventable. 

NCIPC has worked with local public health agencies by providing technical assistance on data, 

study design, program development, et cetera. NCIPC has subject matter experts (SMEs) for 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

31

most areas of injury and violence. At the request of local communities, NCIPC can conduct 

EpiAid investigations on discrete public health issues. NCIPC also allocates funds through 

grants, cooperative agreements, and contracts on a competitive basis to address specific 

research questions or develop specific programs or products. In 2009, NCIPC released the 

second version of its injury research agenda. This document, titled CDC Injury Research 

Agenda, describes the scope of research needs and priorities in injury and violence for 2009 

through 2018. Revising the first version of the research agenda allowed NCIPC the opportunity 

to review research accomplishments and progress toward NCIPC‘s goals. The agenda is 

organized by topics that essentially track the divisions, and includes a section on research 

priorities for cross-cutting topic areas. The document can be viewed in its entirety at the 

following address: http://cdc.gov/injury/researchagenda

NCIPC also has an injury data query system called the Web-Based Injury Statistics and 

Reporting System (WISQARSTM). This is an interactive database system that provides 

customized reports on injury-related data. It is a very user-friendly site of which one can 

download US and leading causes of death and injury, and obtain the most recent statistics for 

fatal and non-fatal injuries. Additionally, data were recently added from the National Violent 

Death Reporting System (NVDRS). Depending upon which database is being used, queries 

can be run on injury intent, mechanism, year, race, and state. In 2010 and 2011, additional 

modules will be added to WISQARSTM, one of which is a mapping function that will allow for the 

creation of national, state, and county level maps for injury mortality rates; and the other is a 

cost module that will permit the estimation of direct medical costs for injury mechanisms for 

specific populations.

The following additional resources are also available from NCIPC:

 Injury Surveillance Training Manual

http://www.cdc.gov/ncipc/dvp/InjSurveillance/InjurySurveilance.htm

 This manual was developed to be used in international settings in low-income countries. It 

addresses the basic concepts of surveillance, data sources, coalitions, methodology, 

development of an analysis plan, and how to use injury surveillance data to inform 

prevention programs. This is a very good resource to assist in thinking about capabilities 

and needs in communities.

 The History of Violence as Public Health Issue

http://www.cdc.gov/violenceprevention/pub/history0fviolence.html

This document, published in 2009, describes when and how violence was recognized as a 

national and global issue. This is a very nice review of the timeline of the last 30 years, 

including seminal event and reports on violence as it became recognized as a public health 

issue.

 Protect the Ones You Love

http://www.cdc.gov/SafeChild/about.htm

 This is a CDC initiative to raise parents‘ awareness about the leading causes of child injury in 

the US and how they can be prevented. This site includes a number of resources to help 

parents keep their children safe from injuries (e.g., fact sheets, podcasts, media outreach 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

32

guides, et cetera). There are specific materials pertaining to drowning, burns, falls, 

poisoning, and road traffic injuries.

 Demonstrating Your Program‘s Worth (Evaluation)

http://www.cdc.gov/ncipc/pub-res/demonstr.htm

 This is a short book that shows how to demonstrate the value of programmatic work to the 

public, peers, funding agencies, and people served. This book explains how to conduct a 

simple evaluation, how to use evaluation to improve programs, and how to incorporate 

evaluation into the activities of an intervention program itself. 

 Injury Framing Guide

http://www.cdc.gov/injury/CDCFramingGuide-a.pdf

 This is a communication tool for talking about injury. This guide incorporates framing 

theories, message development techniques, and vehicles for explaining important public 

health statistics. The information and tools provided in this guide can be used to build 

messages that can be included in press releases, speeches, annual reports, and research 

articles to help professionals better communicate with their audiences.

 Injury Center Publications and Resources

http://www.cdc.gov/injury/publications/index.html 

This link includes all of the resources available from NCIPC.

In closing, Dr. Ballesteros shared his contact information, which is as follows:

Mick Ballesteros, PhD

Work Number: 770-488-1308

Fax Number: 770-488-1317

Email: mballesteros@cdc.gov

Division of Violence Prevention

Alex Croby, MD, Epidemiologist

Division of Violence Prevention (DVP)

National Center for Injury Prevention and Control (NCIPC)

Centers for Disease Control and Prevention (CDC)

Dr. Crosby pointed out that CDC has a strong tradition of partnering with other agencies, like the 

Department of Justice (DOJ), to make a measurable impact on the health and well being of 

Americans. As noted, the mission of DVP is to prevent injuries and death caused by violence. 

This mission is accomplished mission in four steps, following the public health approach to 

prevention as shown in the following model:
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

33

Assess the 

Problem

What‘s the

problem?

Identify the 

Causes

Why did it happen?

Develop & 

Evaluate

Programs

& Policies

What works?

Implementation

& Dissemination

How do you

do it?

The Public Health Approach to 

Prevention

First, DVP assesses the problem using sound science and epidemiology. Next, they identify the 

causes of violence that need to be addressed in prevention programs and policies. Then, they 

evaluate interventions and policies to determine which approaches are working. Finally, they 

encourage widespread adoption of programs and policies based on scientific evidence. The 

public health approach is very dynamic in that each stage is intended to provide the knowledge 

and information to inform the next step. The public health approach is basically a way to 

systematically examine any health problem or disease. This applies across the range of various 

diseases that CDC or any public health agency may address. It is a very logical approach and a 

very effective one.

With respect to the magnitude of the problem, Dr. Crosby shared the following tables which 

reflect the leading causes of death by ethnicity in the US in 2006, and the leading causes of 

death among AI / AN by selected ages in the US in 2006. 2006 is the most recent year for 

which there are full national data:

Leading causes of death by ethnicity –

United States, 2006

Source: CDC Vital Statistics 

Rank White Black

American 

Indian/AN Asian Latino

1 Heart Disease Heart Disease Heart Disease Malignant 

Neoplasms

Heart Disease

2

Malignant 

Neoplasms

Malignant 

Neoplasms

Malignant 

Neoplasms

Heart Disease Malignant 

Neoplasms

3

Chronic Low 

Respiratory

Cerebro

Vascular

Unintentional 

Injuries

Cerebro

vascular

Unintentional 

Injuries

4

Cerebro

vascular

Unintentional 

Injuries

Diabetes 

Mellitus

Unintentional 

Injuries

Cerebro

vascular 

5 Unintentional 

Injuries

Diabetes 

Mellitus

Liver Disease Diabetes 

Mellitus

Diabetes 

Mellitus

6

Alzheimer’s 

Disease

Homicide Cerebro

Vascular

Influenza and 

pneumonia

Liver Disease

7 Diabetes 

Mellitus

Nephritis Chronic Low 

Respiratory

Chronic Low 

Respiratory

Homicide

8

Influenza and 

pneumonia

Chronic Low 

Respiratory

Suicide Nephritis Chronic Low 

Respiratory

 

Leading causes of death among AI/AN, 

Selected Ages, US, 2006

Rank 10-19 years 20-29 years 30-39 years 40-49 years 50-59 years

1 Unintentional

Injuries

Unintentional

Injuries

Unintentional

Injuries

Unintentional

Injuries

Malignant

Neoplasms

2 Suicide Suicide Suicide Heart 

Disease

Heart 

Disease

3 Homicide Homicide Heart 

Disease

Liver Disease Unintentional

Injuries

4 Congenital 

anomalies

Heart 

Disease

Liver Disease Malignant

Neoplasms

Liver Disease

5 Malignant

Neoplasms

Malignant

Neoplasms

Homicide Suicide Diabetes

Mellitus

Source: CDC vital statistics

As reflected in the tables, homicide and suicide rank in the top 8 for several populations. 

Among AI / AN, suicide ranks as the 8th leading cause of death; however, this is not the whole 

story. When assess by selected ages, suicide disproportionately affects young people. It is the 

second leading cause of death among those 10-19, 20-29, and 30-39 years of age. Suicide is 

the 5th leading cause of death in those 40-49 years of age. Based on the 5 major racial and 

ethnic groups, there is a distinct pattern among several groups in terms of where suicide rates 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

34

are the highest, with the rates highest especially among AI / AN adolescents and young adults, 

after which the rates begin to drop. While not the same magnitude, that pattern is very similar 

among African Americans, particularly among males. Understanding where the different 

patterns are helps to focus prevention programs. 

The suicide picture is also very different looking across some of the regions and different tribes, 

from very high rates in the Aberdeen Area and Alaska to very low rates in Nashville. Where 

suicide is a problem cannot be cast with a broad brush. The following map reflects this by IH S 

regions:

Suicide rates by region for persons aged 0-

19 years – U.S., 1989-1998 (U.S. average rate 3.03)

WA

OR

ID

Portland 7.70

MT

WY

Billings 8.08

ND

SD

NE

Aberdeen 19.07

MN

IA

WI

MI

IN

PA

NY

ME

Percentile

Bemidji 8.94

Phoenix 7.71

CA

California 3.48

Tucson 18.25

Navajo 7.31

Albuquerque 7.25

T X

OK

KS

Alaska 23.77

Nashville 2.54

LA

MS AL

95-100

75 -94

50 - 74

0 - 49 FL

TN NC

SC

NV UT

AZ

CO

NM

Oklahoma City 3.11

AK

Looking across the public health approach, selected CDC activities in violence prevention 

among Native Americans fall in some of the following areas:

 Problem Description / Surveillance

 National Violent Death Reporting System

 Sexual violence assessment among minority women, including AI / AN

 Program evaluation

 Enhanced evaluation of tribal youth suicide prevention program (G. L. Smith 

Memorial Act with Substance Abuse and Mental Health Services Administration, 

which funds 17 tribes); DVP entered into an agreement, along with SAMHSA, to 

conduct a more focused evaluation of a particular project in the Portland Area: The 

Native American Rehabilitation Association that works with 8 federally recognized 

tribes in Oregon. 

 Multiple activities with

 Tribal Epidemiology Centers

 Health disparities in adolescent suicidal behavior

NVDRS began in 2002 and currently operates in 18 states: Alaska, Colorado, Georgia, 

Kentucky, Massachusetts, Maryland, Michigan, North Carolina, New Jersey, New Mexico, Ohio, 

Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin. One of the 

benefits of this system is that it allows communities to examine information on violent deaths 

(e.g., homicides, suicides, firearm injuries, undetermined deaths) in more detail than a death 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

35

certificate. This system links data from police, coroner, medical examiner, crime lab, and death 

certificates. NVDRS includes demographic and other information about the decedent (e.g., age, 

sex, race, marital status, employment status, occupation, veteran status, pregnancy status, etc.

Information about suicide event); place, date and time of injury, and method used; 

circumstances of suicide (e.g., mental health and treatment; intent [note, stated intent, 

attempts], and precipitating circumstances).

DVP will soon undertake the prevalence of sexual violence assessment. The purpose of this 

effort is to assess the characteristics, circumstances, and help-seeking behavior related to 

sexual violence among African American, Hispanic, and AI / AN women. Some older surveys, 

though decades old, suggest that these three populations are probably at higher risk than the 

majority population. This is a pilot project to determine the feasibility of paper-and-pencil, faceto-face interviews in collecting sexual violence-related data. AI / AN data collection is proposed 

to occur in Seattle.

With respect to the enhanced evaluation of the Garrett Lee Smith funded suicide prevention, 

SAMHSA initially funded 13 states and 1 tribe with funds from the Garrett Lee Smith Memorial 

Act. CDC is funding 3 of these sites to conduct an enhanced evaluation. One of the 3 

conducting enhanced evaluation is the Native American Rehabilitation Association (NARA) of 

Oregon. The NARA program will be evaluated to determine whether it utilizes culturally 

appropriate strategies and community mobilization, and addresses reservation-based Native 

American youth. They are working with 8 federally recognized tribes in Oregon, and strategies 

are being built by the tribes themselves. They have developed their own adolescent health 

behavior survey to examine risk and protective factors, and have been willing to share this 

information with other tribes who are trying to engage these types of assessments.

In terms of collaboration with the Tribal Epidemiology Centers, these are small groups of 

scientists, mainly epidemiologists, located around the US. They provide technical assistance to 

the tribal governments on health studies. Routine conference calls are convened with the Tribal 

Epidemiology Centers, CDC, and IHS to discuss injury-related subjects, including suicidal 

behavior. 

DVP convened a Health Disparities Meeting in September 2009. This meeting was a 

collaboration between CDC, IHS, and SAMHSA. The meeting was convened to address 

adolescent suicide among American Indian / Alaska Native and Hispanic / Latino youth aged 

10-24 years to try to develop recommendations to improve / support comprehensive prevention 

efforts for suicidal behavior among those populations. DVP is in the process of revising those 

recommendations to be much more strategic and specific, along the lines of the public health 

approach, for those populations.

Evidence-Based Programs Implemented in Tribal Communities

CDR Holly Billie, Senior Injury Prevention Specialist

National Center for Injury Prevention and Control (NCIPC)

Centers for Disease Control and Prevention (CDC)

CDR Billie briefly described the motor vehicle evidence-based programs that were implemented 

in four tribal communities: San Carlos Apache (SCA), Tohono O‘odham Nation (TON), White 

Mountain Apache Tribe (WMA), and Ho-Chunk Nation (HCN). Basically, known effective 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

36

strategies for reducing motor vehicle-related injuries were tailored and implemented in these 4 

tribal communities. Motor vehicle-related injuries are a major problem among American Indians

/ Alaskan Natives. Motor vehicles crashes are the leading cause of death overall for Native 

Americans aged 1 to 44, and the 4th leading cause of death for all ages. On average, two AI /

AN are killed every day in crashes in the US, which is the reason NCIPC decided to focus some 

of their motor vehicle efforts in tribal communities.

Starting in the fall of 2004, the CDC injury Center awarded approximately $72,000 to each of 

these four tribes to design, implement, and evaluate effective injury prevention programs to 

reduce motor-vehicle related injuries and deaths among members of their own communities. 

Over the course of their 5-year grants, staff implemented interventions selected from The Guide 

to Community Preventive Services, a systematic review of community-based interventions. This 

initiative began as a 4-year grant, but a fifth year was added. The tribes selected at least two 

effective strategies to increase restraint use, including seatbelts and car seats, and to address 

driving while intoxicated (DUI). The tribes hired a coordinator to work with local police 

departments and others in their communities to increase seatbelt and car seat use, and to 

reduce DUI. The two following tables reflect the focus areas of each program, and the results:

Program Focus

Tribe Increasing 

Seatbelt Use

Increasing 

CSS Use

Reducing 

DUIs

SCA   

TON   

WMA   

HCN   

 Strong Focus  Some Focus

 

Results

Tribe Increasing 

Seatbelt Use

Increasing 

CSS Use

Reducing 

DUIs

SCA Up 46% 

Passed law

Arrests up 52%

Passed .08 BAC

TON From 43% to 74.5% Passed .08 BAC

WMA From 13% to 54% 24 checkpoints

HCN Up 38% From 26% to 

76%

Although these are simple illustrations, considerable work went into implementing these 

programs by the tribes. The interventions included major media campaigns, car seat education 

and distribution, working to pass new laws in the communities, conducting enforcement 

checkpoints, et cetera. As reflected in the second table, all four tribes experienced pretty 

remarkable results. All four tribes were successful in increasing seat belt use, one tribe 

increased car seat use, and two tribes were successful in passing stronger laws. These were 

major improvements in the communities in terms of addressing motor vehicle crashes. 

It is important to note that sustainability is always an issue. If there is a good program in a 

community, it is important to keep it there as long as possible. This is difficult to do when 

funding runs out; however, all four of these tribes had some level of sustainability after their 

funding ending in the past fall. For example, the San Carlos Police Department decided to 

continue funding their program. Tohono O‘odham Nation will continue data collection and some 

media as they search for new funding. White Mountain Apache Police Department has decided 

to hire a coordinator to continue some of their activities. Early on, the Ho-Chunk Nation

reported their successes to their Tribal Council, which incorporated the entire program into the 

tribal budget. Successes of these tribes are currently highlighted on the CDC injury webpage 

at: http://www.cdc.gov/Motorvehiclesafety/native/research.html CDR Billie indicated that she 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

37

would also share written materials and posters that the tribes developed when they presented 

their successes during a major highway safety conference that is convened on an annual basis.

With respect to next steps, the University of North Carolina (UNC) Injury Prevention Center 

helped several of the funded tribes with evaluation. UNC will be providing a final evaluation 

report that will include statistical results and challenges and barriers the tribes experienced in 

implementing their programs. This report will assist in CDC‘s plans to develop a manual that all 

tribes can use to implement strategies to reduce motor vehicle injuries in their own communities. 

The motor vehicle program continues to seek ways to work with tribes in the area of motor 

vehicle injury prevention, because this is an important focus of DUIP.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

38

CDR Billie also reported on a new initiative that began in the fall of 2009 to more closely 

examine AI / AN elder fall prevention. She and Dr. Judy Stevens, CDC Elder Fall Expert, are 

involved from NCIPC. This year‘s objectives are to:

 Develop a data monograph reflecting key information about fall-injury in the elderly, 

including AI / AN-specific data, general population data that provides perspective on AI / AN 

population.

 Identify interventions with strong evidence for reducing fall-injury in the elderly, clustered 

thematically as: Clinical, Public Health, and Community-Based

 Develop an inventory of current efforts in Indian Country, including public health injury 

prevention, clinical fall risk assessment and intervention, tribal home modification programs, 

and AoA Title VI (Senior Center)-based programs.

There are some prevention materials that are native-specific. For example, the National Fire 

Protection Association (NFPA) has a native-specific program called Remembering WhenTM for 

which they use all native photographs. NCIPC uses this resource frequently when working with 

tribes. The URL is as follows:

 

http://www.nfpa.org/categoryList.asp?categoryID=203&URL=Safety%20Information/For%20pub

lic%20educators/Education%20programs/Remembering%20When

CDC is also involved in an effort to collaborate with other agencies charged with addressing 

Native American highway safety including IHS, BIA, and NHTSA. During the last CDC TCAC 

meeting held in Anchorage in August 2009, Tribal Leaders wondered why there was not much 

Native American-specific information on CDC‘s web pages. In response, NCIPC‘s Motor 

Vehicle Team worked to post the tribal motor vehicle successes and also the following general 

Native American Road Safety page:
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

39

Discussion Points

 Mr. Franklin indicated that last year, his grandfather died from a fall. He was 81 years old 

and Mr. Franklin was on the road working; whereas, usually he is home. He went to college 

to become a paramedic and his family would look to him for those types of questions when 

his grandfather fell. Unfortunately, he did not receive the phone call until four days later. By 

that time, so much blood had accumulated on his brain, he had a stroke, went into a coma, 

and passed soon after that. Mr. Franklin always thought it could have made a difference if 

there were posters in their clinic or some type of outreach indicating what to do for an elder 

who falls. He knew that after a certain age, someone should be taken in after a fall just in 

case. His grandfather is stubborn and felt that he did not need treatment, but if Mr. Franklin 

had known, he would have insisted. He encouraged NCIPC, in consultation with the TCAC, 

to develop some culturally appropriate posters, signage, and handouts that deal directly with 

elder falls if they do not already exist.

 Dr. Ballesteros responded that there is a website that includes a plethora of resources 

available from NCIPC directly geared toward older adult falls (e.g., posters, brochures, et

cetera). While he was not sure if there were already culturally appropriate materials for 

tribes, there are at least materials readily available at this point. He thought the pictures 

spanned the population of the US, and noted that internally they could speak further about 

how to make some of the materials more appropriate for specific populations.

 CDR Billie added that NCIPC is working on culturally appropriate materials for the elder 

population that focus on Native Americans. Since coming to CDC, she realized that the 

agency‘s native-specific photographs and media are limited, so she began contacting tribal 

members to request photographs and media that they may be able to share. All of the 

photos that CDC uses must be cleared and released to CDC to use. She thought that most 

people were interested in showing their tribes in a positive way, so CDC is very interested in 

obtaining photos and media of happy, healthy families. This message has been 

disseminated through the Tribal Epidemiology Center conference calls as well.

 Lori de Ravello indicated that while she was not directly involved in this project, but the 

Immunization Program and HPV Team at CDC were developing Native American-specific 

materials. As part of that they did a photo shoot in Albuquerque of youth and families, for 

which they collected releases. There are books and CDs that can be reviewed. The photo 

shoot was focused primarily on youth immunizations, but there are numerous family 

photographs as well, including multi-generational families. 

 Bridget Canniff mentioned that three of the Tribal Epidemiology Centers have been funded 

under a cooperative agreement from CDC through the Office of Minority Health and Health 

Disparities. They have produced an injury prevention toolkit that is Native American-specific 

that covers motor vehicles, child safety seats, fire and home safety, elder falls, and a fifth 

topic. This was a collaborative project between the Northwest Tribal Epidemiology Center, 

the California Tribal Epidemiology Center, and the Southern Plains Tribal Epidemiology 

Center. The entire toolkit is available on the CRIHB website.

 Mr. Petherick inquired as to whether anyone had considered drilling down into why the 

accident rates are so much higher than the rest of the population. It seemed like a lot of the 

focus had been on individuals and their need to wear seat belts and drive safely. Perhaps 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

40

there are other contributors, such as the roads being in poor condition or not being marked 

very well, people having to drive long distances to get to their jobs or purchase food, et 

cetera. It is important to better understand and document those reasons and take them 

forward to Congress, et cetera. If it is unsafe to walk somewhere, people are also not going 

to risk their lives working on other health issues (e.g., diabetes, obesity, inactivity).

 CDR Billie agreed, indicating that they had also listed some of the major risk factors on the 

website and the references because this is important to understand. While they focus on 

personal behavior quite a bit, it is also true that changing environmental conditions can 

greatly decrease injuries. On the Navajo Reservation between Gallup and Window Rock, 

New Mexico, there was a large number of pedestrian fatalities for decades. Rather than 

focusing on personal behaviors that were contributing, they put up lights. Based on the 

crash reports, they realized that the number one reason for a lot of the pedestrians being hit 

was that drivers could not see them. By adding the lights, the pedestrian fatalities dropped 

such that in some years there were none. It is important to understand the risk factors. 

 Mr. Valdo shared a local example regarding collaborations between IH S, SAMHSA, CDC, 

and tribal programs. He comes from a small community of 3,500 tribal citizens on the 

reservation and 5,000 total enrolled in the community. In 2009, they experienced 9 

successful suicides out of 18 attempts that they know of. This is a high number. Many tribal 

communities are very cultural, spiritual, and close knit. The US Census shows that tribal 

communities do not have a homeless population because they take in anyone. Families are 

highly multi-generational. However, there is something wrong when this many people under 

the age of 30 take their own lives, particularly knowing the support that they have. He 

agreed that they needed help, but also cautioned that many of these people who committed 

suicide were referred to IH S, were referred out, but then were referred back because there 

are no human resources or infrastructure. They can use BIA services in Albuquerque, but 

that is a 75-mile drive one-way. Some people do not even have vehicles. The federal 

government seems to continually pull back on their responsibilities to Native Americans. 

The federal government tells tribes to take over their 638 programs, yet they do not allocate 

the dollars to provide the services, and to some extent, they do not provide those services to 

tribal communities anyway. There is an increasing trend to place more of the support and 

financial burden on tribes, and it is called nice, flowery things like ―638‖ or ―selfdetermination.‖ While tribes want to do things for themselves, they still need help. There is 

a great report on the sexual trade of Native American women in Minnesota, which discusses 

historical trauma and all of the things that Native Americans have gone through: 

extermination, assimilation, infertilization, et cetera. There is a history that Native American 

people have gone through that they must get through [Shattered Hearts: Sexual Trafficking 

of American Indian Women and Girls in Minnesota; Published August 2009 by Minnesota 

American Indian Women's Resource Center]. It is important to develop trust locally, and to 

understand that there is a major hurdle already before every entering Native American 

communities. He acknowledged that representatives from CDC have good hearts and 

minds and want to help, but there are barriers that will limit what they are able to do. He 

echoed the importance of cultural sensitivity. Mr. Valdo works for a non-profit group that has 

its own fire safety video, and they use Remembering WhenTM. They helped develop their 

own fire safety video with their own languages and their own local faces because people in 

the small communities respond better to this. Tribal communities are oral and visual, so it is 

somewhat different from the Western model. Having tribal partners and reaching out to ask 

for assistance is important, but there are 565 federally recognized tribes and over 200 are in 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

41

Alaska alone. There is not one mass communication model available. It must be done in 

multiple streams and multiple systems. 

 Dr. Crosby agreed that the NVDRS would definitely not pick up all of the suicides, and he 

agreed that more could definitely be done in terms of collaboration. NCIPC has worked with 

the IH S and SAMHSA on various projects, and has been involved in more intensive 

evaluations of communities that definitely have demonstrated that historical trauma, the 

magnitude of unemployment in communities, substance abuse, et cetera play a role in 

suicidal behavior among adolescents and young adults. Consideration must be given to 

how to address these issues in terms of what resources are available, what programs have 

been demonstrated to work, what programs have been developed specifically for American 

Indian communities. It is a small number, but there are a few. NCIPC worked with IH S to 

develop a natural helpers program for an Apache Tribe in Dulce, New Mexico. It is a matter 

of expanding the menu of programs that are known to work and finding resources to do it. 

 Ms. Hughes thought the on-going discussion about collaboration and getting more minds 

working on the same issue was one of the themes they would hear repeatedly, and they are 

beginning to observe more progress in dealing with various issues. There is a constant 

reminder about resources as well. They have heard in other meetings that CDC has a lot of 

resources, and the tribes need to remind themselves to go to the CDC website to learn what 

is available that can be adapted. Even all tribes are different. One product is not going to 

work in all 565 federally recognized tribes, but there is a source to tap that can be modified 

for each tribe.

 Mr. Franklin requested that CDC work to place a link on the CDC and NIHB websites for the 

Remember WhenTM materials. 

 Regarding collaboration, CAPT Snesrud agreed that helping tribes to better understand the 

resources available at CDC was critical (e.g., materials, points of contact, SMEs, et cetera). 

CDC is trying to be more accessible. She stressed that anyone who needed information 

should not hesitate to contact her or Dr. Bryan, who have the ability to connect people.

 Tim Gilbert noted that during the last TCAC meeting in Atlanta, there was an injury breakout 

session. Regarding the research agenda, if they saw something that aligned with Alaska‘s 

priorities, he wondered how they would go about working on a project together with NCIPC. 

Related to that, the position they find themselves in in Alaska for intentional and 

unintentional injuries is that the funding for their programs has been on a slow declined. 

They are compact in Alaska, so a tribal leader in the Alaska Tribal Health system may find 

himself or herself trying to decide what to invest in (colorectal screening, diabetes, injury 

prevention, or another problem). The numbers speak for themselves. They once had 22 

designated FTEs addressing injuries in Alaska, and now have 4 or 5. It is probably a local 

problem, but he wondered how NCIPC might help. Alaska has great data. They have a 

trauma registry that they tap into, but what they do not have is the ability to make a case for 

injury prevention—a marketing campaign to raise the awareness of the importance of 

investing in this problem. Tying that back to what types of projects they might work on in 

partnership with NCIPC, he wondered how NCIPC invests in projects such as that.

 Dr. Ballesteros suggested that he look at NCIPC‘s Injury Framing Guide, which was one of 

the resources listed in Dr. Ballesteros‘s presentation. While not specific to Native 

Americans, the intent of that was about making the case for injury as a public health 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

42

problem. Even NCIPC is still trying to make that case, and have struggled with this for 

decades. The Framing Guide was NCIPC‘s attempt to get a collective, consistent message 

across about the issues of injury. Regarding the research agenda, the way NCIPC uses the 

agenda is that when they have funds available specifically for research (versus programs), 

they make sure that what they fund aligns with the research agenda. They consistently stay 

on that path in order to give their best effort to addressing the topics they deemed important 

in that agenda. Many of those will relate to tribal communities. When FOA‘s are published, 

tribes are eligible to apply for these funds. NCIPC has published some announcements that 

were specifically for tribes, and continue to look for opportunities to do that. 

 With respect to who to call, CDR Billie stressed that she, CAPT Snesrud, and Dr. Bryan 

would be happy to help direct them in the right direction. Part of CDC‘s role is to provide 

technical assistance to anyone in the country who wants it. 

 Dr. Crosby added that Alaska could coordinate its Injury Atlas with the Injury Framing Guide. 

Part of making the case is the magnitude of the injuries (e.g., morbidity, mortality, and cost). 

The Injury Framing Guide helps to package existing information to make the case. 

 Dr. Antone inquired as to when the recommendations were expected to be published from 

the health disparities meeting that addressed adolescent suicidal behavior among American 

Indians / Alaska Natives and Latinos that Dr. Crosby mentioned.

 Dr. Crosby responded that SAHMSA offered to develop a specific password access website 

to which only the participants could contribute in terms of the recommendations. Originally, 

the recommendations were very general at the close of the meeting. The raw data will be 

entered into the website so that the participants can provide comments and make revisions, 

in order to develop more specific recommendations. He was not sure what the timeline 

would be, but expected the website to be set up within the next few weeks. Then it would 

be a matter of the participants providing their input.

 Mr. Antone pointed out that collaboration needed to occur in the federal and tribal 

communities. There is a consultation in March with HHS. From what he understood, a 

number of groups had sparked the focus on suicide. They need to come together to 

address this. Some things stood out to him regarding the health disparities meeting that 

addressed adolescent suicidal behavior among American Indians / Alaska Natives and 

Latinos. There was the idea of historical trauma hundreds of years ago, plus the infiltration 

of various religions, particularly Catholicism. There has been a loss of tradition, and there 

are differences between families. In December, they lost someone to suicide and the family 

did not want it to be known that that was the cause. However, everyone knew. They are 

considering putting something through Health Research Advisory Council (HRAC) as an 

addendum. 

 Dr. Crosby inquired as to whether Mr. Antone received a copy of the original 

recommendations that came out of the meeting. Since the timeline for refining these may 

be too long, perhaps he could utilize the raw recommendations to refine himself. He offered 

to provide a copy to Mr. Antone of all of the original recommendations. He recognized that 

there is stigma in some families that is associated with shame. Not addressing it can 

contribute to the grief, and there are healing processes that a family or community have to 

go through if nobody wants to talk about it.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

43

 Larry Curley observed that in all of the discussions he had heard throughout the day, there 

was constant reference to websites. There appeared to be an assumption that everyone 

and every tribe has access to the Internet. In Nevada, there are 27 tribes that are located in 

one of the most isolated parts of the country. One clinic in the last two weeks had a stock of 

H1N1 vaccines go bad because a power source went out. They had to scramble to find 

another source. Applying that to the Internet, the Internet relies on a reliable power source, 

but when that power goes down, there is no access to the Internet and all of the websites in 

the world are not going to come to you. He thought there was overreliance on technology, 

and that there was an underlying assumption that it was available everywhere. Regarding 

prevention, although there are 15 tribal clinics in Nevada and 13 are tribally managed and 

administered, there are no IH S hospitals in the state at all. As a result, the tribes in Nevada 

are highly dependent on contract health services funds. Those funds are received in 

October and are depleted by the end of February of each year. There was a meeting with 

the clinic health directors recently who were talking about people who presented for cancer 

treatment who were approved for initial treatment under Priority 1, but were denied follow-up 

treatments. Prevention is an oxymoron. It is not occurring in Nevada. He wondered of the 

statistics that were being collected how many of the deaths could be classified intentional 

because of denial of health care to their people who require follow up prevention care. 

 Ms. Hughes noted that the first disparity that always came to the forefront in Indian Country 

was the funding disparity. Many of their problems could be made better if there was simply 

funding. Tribes know they are nowhere near having the funding needed to do what needs to 

be done, which brings them back to the collaboration discussion. They must ensure that 

they build contacts with all federal agencies to help them deal with the issues in Indian 

Country. In her lifetime, she does not expect to see the health disparities issues brought 

into alignment with the rest of the country, but a good goal would be for cardiovascular 

disease in Indian Country to be the same as for the rest America. She would like to see 

Indian Country receiving the same amount of funding that state and federal penitentiaries 

receive for their inmates. The incongruence in dollars for others versus dollars for American 

Indians / Alaska Natives comes up in every consultation. 

Overview

Wayne Giles, MD, Acting Deputy Director

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Giles extended his welcome to everyone on behalf of NCCDPHP. During this session, he 

discussed the burden that chronic disease has and the impact it can have in Indian Country, 

offered an over view of NCCDPHP, and highlighted some of the tribal collaboration and 

consultation efforts. Dr. Giles reported that chronic diseases are responsible for 7 of every 10 

US deaths. Nearly half (49%) of Americans suffer from one or more chronic diseases. Chronic 

diseases cause major limitations in daily living for 1 in 10 Americans, and cause significant 

racial / ethnic disparities in health [Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: final data 

for 2005. National Vital Statistics Reports 2008;56(10). Available from: http://www.cdc.gov/

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

44

nchs/data/nvsr/nvsr56/nvsr56_10.pdf; Wu S, Green A. Projection of Chronic Illness Prevalence 

and Cost Inflation. RAND Corporation, October 2000; Anderson G. Chronic conditions: making 

the case for ongoing care. Baltimore, MD: John Hopkins University; 2004; Kung HC, Hoyert DL, 

Xu JQ, Murphy SL. Deaths: final data for 2005. National Vital Statistics Reports 2008;56(10). 

Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf; and National Center 

for Health Statistics. Health, United States, 2007. With chartbook on trends in the health of 

Americans. Hyattsville, MD: National Center for Health Statistics; 2007. Available from: 

http://www.cdc.gov/ nchs/data/hus/hus07.pdf].

Chronic diseases are also costly. They account for about 75% of annual US medical care 

costs, and 98% of Medicare spending and 83% of Medicaid spending is for people with chronic 

conditions. That is, nearly every dollar of Medicare spending is for people with chronic 

conditions. Health care coverage costs for people with a chronic condition average $6,032 

annually, which is five times higher than for those without such a condition [Partnership for 

Solutions, Chronic Conditions: Making the Case for Ongoing Care. September 2004 Update. 

Anderson G. Chronic conditions: making the case for ongoing care. Baltimore, MD: John 

Hopkins University; 2004]. Based on both the burden and cost data, the urgent reality of 

chronic diseases cannot be ignored. The investment in chronic disease prevention programs is 

essential in order to successfully address the nation‘s health care crisis.

It is known that AI / AN community has its own language, culture, and history. It is also known

that over 60% now reside principally in urban settings, and that as a whole, they are younger 

and poorer than the average US population. The five leading causes of death in AI / AN 

populations are: Heart disease (19.1%), Cancer (17.7%), Unintentional Injury (11.7%), 

Diabetes (5.9%), and Stroke (4.5%). These are followed by: Chronic Liver Disease and

Cirrhosis (4.3%), Chronic Lower Respiratory Diseases (3.7%), Suicide (2.8%), Influenza and

Pneumonia (2.5%), and Kidney Disease (1.9%) [Source: Health United States, 2008]. Although 

chronic diseases are among the most prevalent and costly health issue in the nation, they are 

preventable. Four key risk factors that contribute to most chronic diseases include tobacco use, 

poor nutrition, physical inactivity, and obesity and overweight. It is known that American Indians 

and Alaska Natives smoke more, engage less in physical activity, and have increasing obesity 

rates.

To address chronic diseases, the NCCDPHP organizational structure is as follows:

NCCDPHP Organizational Chart

Ursula Bauer, Ph.D., M.P.H. 

Director

Barbara Bowman, Ph.D.

Associate Director for Science

John Moore, Ph.D., R.N. 

Acting Associate Director 

for Public Health Practice

Jeff McKenna, M.S.

Associate Director for

Communication Science

Sean Cucchi, M.H.A. Associate 

Director for Policy

Dara Murphy, M.P.H.

Management Officer 

David McQueen, Sc.D

Associate Director for

Global Health Promotion 

Vacant

Chief Medical Officer

Wayne Giles, M.D., M.S.

Acting Deputy Director

Health Communication 

Science Office

Global Health Unit

Office of Planning, 

Evaluation and Legislation

Program Services Branch

Office of Informatics and 

Information Resources 

Management

Program Integration, 

Evaluation, and Worksite 

Health Promotion

Preventing Chronic Disease

and Extramural Research 

Office 

Jason Bonander, M.A.

Associate Director

Elijah West

Senior Advisor
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

45

NCCDPHP is 21 years old. Notably about the center is that divisions are disease-focused, risk 

factor-focused, or population / setting-focused. The disease-focused divisions include: Division 

of Cancer Prevention and Control (DCPC), Division of Diabetes Translation (DDT), Division for 

Heart Disease and Stroke Prevention (DHSP), and Division of Oral Health (DOR). The risk 

factor-focused divisions include: Division of Nutrition, Physical Activity, and Obesity (DNPAO), 

Office on Smoking and Health (OSH), and Office of Public Health Genomics (OPHG). The 

population / setting divisions include: Division of Adolescent and School Health (DASH), 

Division of Adult and Community Health (DACH), and Division of Reproductive Health (DRH).

In thinking about the public health strategy, the burden associated with that, and the population 

impacted, NCCDPHP likes to use the following illustration to stress that prevention cuts across 

the entire life from cradle-to-grave: 

Our Public Health Strategy

Infant Child Adolescent Adult Older Adult

Prevention

Early Detection

Control

NCCDPHP‘s first priority is to prevent or delay disease, disability, and the associated costs. 

This can be done by avoiding tobacco use, increasing physical activity, improving nutrition, and 

maintaining normal weight. The second priority is early detection in order to find disease early 

and halt or reverse its course. This is done through cancer early detection, heart disease early 

warning signs, and addressing pre-diabetes. The third priority is effective disease management

of conditions such as high blood pressure, high cholesterol, A1C, and obesity. Strategies 

include addressing lifestyle behaviors, self-management, preventive health care, and 

medication compliance.

NCCDPHP‘s contribution to public health and the AI / AN community includes tribal grants, 

formal and informal tribal consultation processes, interagency agreements with HIS, and 

collaboration with the NIHB. Approximately 3% of NCCDPHP‘s budget directly supports tribes 

or tribal organizations. The center‘s engagement with AI / AN populations through IHS, direct 

tribal grants, through networks like the NIHB and the formal and informal Tribal Consultation 

process also helps to ensure that their investment is as collaborative, meaningful, and culturally 

appropriate as possible. NCCDPHP‘s interagency agreements with IHS since 1990 involve 

DACH, DCPC, DRH, DHDSP, DNPAO, OSH, and DOH. Across the center, total funding to 

tribes is approximately $26.4 million on an annual basis. Compared with other centers, 

NCCDPHP is please to be on the high end of funding, and clearly understands the major impact 

that these dollars can have and the importance of addressing health disparities within AI / AN 

communities.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

46

Division of Cancer Prevention and Control

Marcus Plescia, MD, MPH, Director

Division of Cancer Prevention and Control (DCPC)

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Plescia indicated that he was fairly new in his role as Director of DCPC, having come to 

work at NCCDPHP about six months previously. Prior to this, he worked in chronic diseases in 

North Carolina. 

He reported that DCPC provides national leadership in developing and implementing a 

comprehensive, public health approach to cancer control, from primary prevention to end-of-life 

palliative care; focuses on risk-reduction, early detection, surveillance, cancer survivorship, 

education, and reducing health disparities; and collaborates with partners (e.g., state, tribal, and 

territorial health agencies; voluntary and professional organizations; academia; other federal 

agencies; and the private sector). In FY 2010, DCPC was appropriated $370 million for its 

cancer prevention and control activities, including four national programs and two national 

education campaigns. Approximately $14 million are provided through CDPC for projects that 

serve AI / AN communities, largely because they run fairly large screening programs. 

The National Program of Cancer Registries (NPCR) provides data for 96% of the population. 

Along with NCI‘s SEER, 100% of the population is covered. Misclassification of AIs / ANs has 

created under-representation of disparities in cancer data. In 2008 and 2009, CDC linked 

NPCR and IHS patient registration data to produce more accurate AI / AN cancer incidence. 

This allows tribal organizations to plan and implement cancer control efforts. This has been so 

successful, they are now considering linking the IH S patient registration data with the National 

Death Index (NDI).

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) includes 

screening programs that are funded in all 50 states, DC, 4 US territories, and 12 American 

Indian / Alaska Native organizations. These programs provide breast and cervical cancer 

screening and diagnosis to low-income, uninsured, and underinsured women. Services include

clinical breast examination; mammograms; pap tests, diagnostic testing for women with 

abnormal results; surgical consultation; and referrals to treatment. Approximately 5% of women 

screened through NBCCEDP are AI / AN women. This program also offers technical assistance 

to increase breast and cervical cancer screening for tribes and states with large native 

populations. NBCCEDP targets low-income women with little or no health insurance. Racial 

and ethnic minority women comprise priority populations in the program, which has helped to 

reduce disparities in cancer screening and health outcomes. From 2003 to 2007, pap smears 

were provided for 84,000 AI / AN women and about 45,000 women received mammograms. 

This program has a lot of reach, particularly for those who do not have ready access to IH S 

services. 

The Colorectal Cancer Control Program (CRCCP) funds programs in 26 states and 4 tribal 

organizations. CCCP utilizes a population-based approach to increase screening rates to at 

least 80% by 2014. The program is integrated with a public education campaign, Screen for 

Life, to increase awareness of the importance of screening. In 2005, AIs / ANs had the second 

highest incident rate for colorectal cancer. Routine screening can prevent cancer. FY 2010 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

47

funding for colorectal cancer-related activities will be $44 million. Four tribal organizations 

received funding for CRCCP: Alaska Native Tribal Health Consortium, the Arctic Slope Native 

Association, South Puget Intertribal Planning Agency, and the Southcenteral Foundation.

The number of new colorectal cancer cases could be reduced by 76% to 90% if all 

precancerous polyps, abnormal growths in the colon or rectum, were identified using screening 

tests and removed before turning into cancer. However, only half of all US adults aged 50 or

older have been screened appropriately for colorectal cancer. While screening rates are slowly 

increasing, disparities still exist in screening test utilization. It is important to integrate efforts 

with other chronic disease prevention efforts.

The funding will support screening and diagnostic follow-up care, patient navigation, data 

collection and tracking, public education and outreach, provider education, and an evaluation to 

measure the clinical outcomes, costs, and effectiveness of the program. The population-based 

approach covers low-income, uninsured, and underinsured men and women between 50 and 

64, as well as the insured.

The Tribal Comprehensive Cancer Control Program (TCCCP) offers an integrated, coordinated 

approach across the cancer continuum. Tribal Cancer Plans have been developed in 7 tribes 

and tribal organizations, the purpose of which is to assess the cancer burden; address the 

needs of at-risk populations; create cancer prevention priorities; and build infrastructure to 

increase AI‘s / ANs‘ access to cancer screening and treatment. The steps include plan 

implementation and fostering collaborations with partners.

DCPC AI / AN-focused activities include data linkages in NPCR to improve cancer burden data; 

research on AI‘s / ANs‘ experience with cancer prevention and treatment; work with Fond du 

Lac, White Earth, Red Lake tribes and the Alaska Native Medical Center to survey prostate 

cancer patients‘ experience with care in urban health centers; colorectal cancer prevention 

projects with Tribal Epidemiology Centers; and provision of tribal liaisons to provide technical 

assistance to CCC, BCC, and CRC grantees and to work with key partners, including HIS.

Opportunities include continued work with NPCR and IHS to link cancer incidence data for AIs /

ANs in order to gain greater insight into the cancer burden for AIs / ANs; provide support for 

tribe and tribal organization cancer prevention and control programs (especially breast, cervical, 

and colorectal cancer prevention programs; and integration with tribal comprehensive cancer 

control plan efforts); and continue research into AI / AN cancer disparities (e.g., burden of 

disparities, causes, and effective interventions to reduce disparities).

The issue of survivorship is a new area that NPCR is working on. At this juncture, people with 

cancer can be effectively helped and cured. But again, as with many underserved populations, 

people go through a great deal of pain and suffering in being treated for cancer and an 

enormous amount of money is spent on treatment, and they survive. But then they are 

forgotten, are lost in the system, and return to no having very good access to care. This is a 

public health problem that they want to deal with. There are 50 million cancer survivors across 

the US today, which is an area NPCR is interested in engaging in with AI / AN in an effort to be 

more effective.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

48

Discussion Points

 Mr. Trudell wondered how many AI / AN men over the age of 50 have actually received 

colonoscopies, because it is a contract health issue and probably will not be paid for.

 Dr. Plescia responded that a couple of their epidemiologists, who are physicians, are in 

some of the tribal areas. They have used various providers for those services. He agreed 

that is an issue to obtain a colonoscopy, particularly for people who are in more remote 

areas where there are no services. This is a major challenge, with which the division 

continues to struggle.

 Mr. Petherick said he appreciated the slide pertaining to opportunities. He is with the 

Cherokee Nation, which operates one of the Comprehensive Cancer Control Plans. Not 

only within their plan, but also within the IH S budget formulation process, a problem they 

have experienced is that cancer ranks high in health priorities. However, when having to 

make tough budget choices, it is not a budget priority. It would be helpful to understand the 

true cost of cancer in Indian Country so that they could all be better advocates for cancer 

prevention and control in Indian Country. 

 Dr. Plescia replied that their division is engaged in a number of research activities, and have 

begun to put together a team of economic researchers. He will take this suggestion back to 

them.

 Mr. Valdo indicated that his mother was diagnosed with Stage 4 colorectal cancer about 

seven months previously, and is currently receiving chemotherapy. It was clear that the 

division is aware of the issues (e.g., lack of resources, lack of testing, lack of screening). 

They are fortunate that his mother worked for an enterprise that provides 100% of medical 

benefits, yet she never got tested. She went to IH S and complained of symptoms, but was 

never tested even though she had insurance. There is also a contract health issue. The 

system is broken. It is difficult to allocate resources adequately and in the best locations to 

try to prevent diseases. He wonders how he failed his mother. She is 54 years old with 

Stage 4 cancer, so this is very near and dear to him. With that in mind, Mr. Valdo reiterated 

the importance of collaboration and coordination. He also wondered how they could fix a 

system that does not talk to each other, does not utilize all of the resources that are 

available, tries to push people off elsewhere even if they have coverage, et cetera. When 

the IH S facility is the only facility within 60 miles, as many complaints as there are about it, 

that is where people are going to go. When IH S is not providing necessary services, such 

as screening, there is something wrong. 

 Dr. Plescia thanked Mr. Valdo for sharing his personal story. He said he thought that 

approximately 50% to 60% of people were taking advantage of the screening tests. 

Obviously, many people are still slipping through the cracks. It is not just ability to pay. 

People who have good insurance are not getting their colorectal screening exams. There 

are many reasons for that, which need to be better understood. The division is fortunate to 

be able to use those screening funds much more broadly, and to really look at all barriers, 

not just cost. Hopefully, this will help to increase the rates of screening, which remain widely 

underused.

 Ms. Hughes indicated that the Bemidji area is also very low in rates of accessing screening 

programs. Colorectal cancer is very high in this area. Even if people have access to IH S, 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

49

people are not going in for any of these specific tests. The Oneida Tribe is a highly 

populated area. They have access to a lot of medical services. The IH S clinic is not the 

only option. However, tribal members will primarily go to the IH S clinic before they will go to 

private clinics and hospitals. So, they instituted a program almost a year ago in which they 

issue a card to anyone who comes in who is over the age of 50, which has a standard 

checklist of what everyone should get on an annual basis (e.g., colonoscopy, mammogram, 

tuberculosis test, et cetera). There is an incentive for people who check off a certain 

percentage of the items on the card to receive a gas card. Still, the awareness factor 

continues to be an on-going battle. Everyone knows what is available, but until it becomes 

personal, people do not pay attention to the consequences. But, it is so easy to prevent in 

the first play. It is an on-going communication issue that must be addressed over and over.

 Ms. Manuel said she thought that overall in Indian Country, people do think, ―It won‘t happen 

to me, or my family, or that‘s not an Indian thing.‖ In her area, they have educators but it is 

still difficult to convince people to go to screenings until it happens to someone in their 

family. She has an aunt who has had cancer three times. She has finally gotten involved in 

the activities, and got the family involved. Because of this, they found out how many family 

members had cancer and did not know until the last minute when nothing could be done to 

save them. Her aunt is now involved in the American Cancer Society (ACS) walks to collect 

funding and has encouraged the rest of the family to get involved. Ms. Manuel said that 

even though screenings are offered free, they hardly see anyone take advantage of this 

opportunity. Recently, they had a mammogram clinic in which they took a van out to the 

community. Only 32 people out of 100 women who were called showed up. That was sad 

to see. When she spoke to some of the people there and told them to go to the van 

because many people had not shown up, some of the people said they did not really need it. 

They must start educating in some other way so that they understand that this can happen 

to them. 

 Mr. Secataro indicated that in September, his wife was diagnosed with cancer. Just like Ms. 

Manuel said, unless someone has been through it, they will not think much about it. His wife 

had to go through treatments and she was placed in isolation. People at home do not think 

about it. At his clinic, the no-show rate is about 60%. Even he has not shown up for 

screenings. They wanted to check his ears, and he put it off three times. The CHR kept 

demanding that he be seen. Finally, he went to the VA who told him he could not hear. 

Because he is a veteran, he is now receiving disability compensation. They have tried many 

times to figure out why people do not show up for screenings. Still, they must keep trying. 

 Mr. Trudell pointed out that everyone in the room and at the table had probably been 

touched by cancer. It is a shared fault because people do not use the IH S facilities the way 

that they should, not because they do not want to, but because they believe it will not do 

them any good anyway because there will be follow-up treatments that are not paid for. It is 

going to a continuing theme that people can go for all of the screenings they like, but if they 

need follow-up exams and / or treatment, they will not receive these. Aberdeen Area has a 

good breast screening program. A van comes to the clinics and hospitals. Sometimes 

those notices come out really early, but if a visit has to be postponed, by the next visit 

people have forgotten and have not been notified about changes. That accounts for some 

of the 60% no-shows. Because of the priority system under which the IH S and all of the 

tribal clinics have to operate, if someone is not a Priority 1, they will not receive service. 

They may receive drugs, but if they need a referral out and are not a Priority 1 for other 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

50

screening or further determination of the seriousness of a disease or potential disease, they 

will not receive it. This is why people simply do not go back to IH S. 

 With regard to reasons for not taking advantage of screenings, Mr. Valdo indicated that CHS 

dollars are paying for screening. IH S facilities are not even doing this. Many people see 

their tribal facility as being their medical home, yet they are sent for something that they are 

very uncomfortable doing already outside of their medical home. He has heard his own 

cousin make the excuse, ―Well, I‘m not going to get checked, because who is going to pay 

for it if I find out it‘s there? I would rather just let it take its course.‖ If they cannot educate 

their own families to get screened, he does not know what to do. Even as the Chair of the 

NIHB, he has no answers. The California Area Office may authorize funds if someone is on 

their death bed. Unfortunately, that is a reality. The other problem is that these things do 

not get checked for so long. When his nephew was diagnosed with leukemia at the age of 

one. He is now two years old, and there has been a huge burden on the family. His parents 

have to take him about two hours away for treatment, and often have to stay for a month. 

Anytime his nephew even catches a cold or infection, the whole family must figure out how 

to help. This is not an Indian-friendly facility. They must travel to Oakland Children‘s 

Hospital, which is about as far away from Northern California Indian Country as they could 

possibly be. When his grandmother went to visit his nephew, she stepped on a hypodermic 

needle on the sidewalk of the facility. This is a reality of what his people put up with. Mr. 

Valdo said he also thought they were not doing enough for their young men, in terms of 

educating them about screening. They have to reduce the stigma. Outreach and education 

cannot just be to the IH S facility, because many areas simply do not have such facilities. 

There must be more creative ways to get messages out to people. 

 Ms. Begay mentioned that cancer is the third leading cause of death in the Navajo Nation. 

The Navajo healing ceremonies coincide with Western medicine of prevention and wellness. 

She appreciated the number of Navajo people working at CDC. She was very pleased and 

touched to hear some Navajo voices at this meeting. The Navajo culture, way of life, and 

the blessing ceremony are very closely tied to healthy living. The activities within the 

blessing ceremony are all about walking in beauty. For women who are pregnant, the 

ceremony is about prenatal care, childhood, adolescents, and puberty. There are many 

chants and blessing all the way through the later years of life praying for the good way, 

quality of life, and long life. In terms of cancer, there are barriers to accessing health care 

for men and women. She believes the greatest obstacle in Indian Country, and specifically 

for Navajo people, is fear of being told that they have early signs of cancer or may have 

cancer. Navajo people were sent elsewhere for screening, treatment, and continued care 

until 2007 when a cancer center was built in Gallup, New Mexico. It is still a great distance 

for people in the Western part of the nation to travel there or elsewhere. Another issue is 

that there is no family support. Contract health service program and tribal resources are 

limited, but family support is needed. CDC needs to understand that the blessing and 

cultural healing programs are critically essential, but Medicare and Medicaid do not cover 

these. This needs to be considered. She noticed one of the bullets in the presentation 

spoke to that, and that it needed to be followed through on. 

 Ms. Hughes stressed the importance of creating awareness so that prevention and cure 

could occur.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

51

Division for Heart Disease and Stroke Prevention

Nell Brownstein, PhD

Applied Research and Evaluation Branch (AREB)

Division for Heart Disease and Stroke Prevention (DHDSP)

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Brownstein reported that DHDSP‘s mission is to ―Serve as the nation‘s public health leader 

for achieving cardiovascular health for all and eliminating the disparities in the burden of heart 

disease and stroke. CDC is a ―science-based‖ organization, meaning that they have access to 

public health data and need to use this information to propose informed solutions. DHDSP has 

achieved much of its work through its connections, and value its partnerships and opportunities,

such as this meeting, to share the division‘s thoughts and information. DHDSP‘s programs 

translate science into action. They can further define these pieces of their perspective into the 

following core functions: science (surveillance, research, evaluation), connections 

(partnerships, resources), and action (programs). 

The division‘s organization structure is as follows:

Office of the Director

Planning, Partnerships and 

External Relations

Policy Team

Communications Team

Coordinator, 

Global CVD Health

Associate Director for 

Research

Associate Director for Science

Administrative Office

Applied 

Research and 

Evaluation 

Branch

Epidemiology 

and Surveillance 

Branch

Program 

Development 

and Services 

Branch

Our Structure

DHDSP has three branches. They have staff who analyze and detect problems, and they are 

planning to do much more intense work on data in order to better understand what is occurring 

in Indian Country. They also have staff who translate science into practice and help to evaluate 

the division‘s programs. The program services staff assist with the WISEWOMAN and state 

heart disease and stroke prevention programs.

Program priorities are to control high blood pressure, control high blood cholesterol, improve 

emergency response, improve quality of care, increase awareness of signs and symptoms of 

heart attack and stroke and the need to call 9-1-1, and eliminate disparities. Strategies for 

addressing priorities include focusing on policy and systems change; affecting population-based 

change; ensuring cultural competency; engaging partners; and working at policy and systems 

levels within settings (e.g., worksites; health care; community; schools.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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The heart disease problem in Indian Country is very large, which is of great concern. Diabetes 

increases the risk for heart attacks as well. The number of people in Indian Country who have 

heard disease (16.4%) is much higher than in any other population in the US: Black (9.9%), 

Asian (7.5%), and Hispanic (7.4%) [MMWR, Vol 52, Number 47, REACH Data, Nov. 28, 2003. p 

1148-1152]. In addition, more people in Indian Country die earlier from heart disease than any 

other group in the US, as illustrated in the following graphic:

Percentage of Premature Heart Disease 

Deaths by Ethnicity

0

2

4

6

8

10

12

14

16

18 Percent

0 - 34 35 - 44 45 - 54 55 - 64

Age (in years)

White Asian/PI Hispanic Whites Hispanic Blacks Black AI/AN

MMWR, February 28, 2004

Data pertaining to age-adjusted prevalence of self-reported myocardial infarction by sex, race, 

and education level in the entire US adult population aged > 18 years show that males have a 

higher prevalence of myocardial infarction than women. American Indian / Alaska Natives and 

multi-racial respondents had the highest prevalence of myocardial infarction. Blacks and Whites 

had similar overall prevalence estimates. Asian and Hispanic respondents reported less 

myocardial infarction than Whites, although the estimates were not statistically significantly 

lower. Roughly twice the proportion of those with less than 12 years of education reported 

myocardial infarction when compared to college graduates. The prevalence of myocardial 

infarction increases with advancing age. The following chart shows the prevalence of 

myocardial infarction:

% ≥18 Years CI

Sex Male 5.4 5.3–5.6

Female 2.9 2.8–3.0

Race White 4.0 3.9–4.1

Black 4.0 3.7–4.4

Asian 2.8 1.7–4.5

Hispanic 3.4 3.0–4.0

AI or AN 7.5 6.0–9.4

Multiracial 6.4 5.5–7.4

Educ. < 12 yrs. Educ. 6.0 5.6–6.4

High School 4.5 4.3–4.7

Some College 3.9 3.7–4.1

College Grad 2.9 2.8–3.1

Overall 4.1 4.0–4.2

Prevalence of Myocardial Infarction
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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DHDSP has had the good fortune to work with staff at the Native American Cardiology Program 

as their partners on the Native American Time to Treatment Intervention Evaluation Study 

(NATIVE Study). Dr. Rick Brody noticed that people from Indian Country were presenting very 

late after having a heart attack. While ―time is money‖ for a heart attack ―time is everything.‖ 

Following a heart attack, parts of the heart begin to die because they are not getting enough 

oxygen and nutrients, but if an ambulance is called, they can begin treatment right away, which 

can make the difference between life and death. Of the 145 patients that Dr. Brody followed at 

the Cardiology Clinic, he noticed that 17 people did not report until 12 to 24 hours after having a 

heart attack, and 34 people did not come in until after 48 hours. When he followed up to learn 

the reason for their delays, he found out that some people went to traditional healers, others 

had mild symptoms, and misunderstanding the signs of a heart attack. Other reasons included

denial, lack of telephone, personal transportation issues, hospital / EMT delay).

DHDSP has a wide variety of programs, such as the WISEWOMAN Tribal Programs in Alaska 

and South Dakota. Montana has also been very active as one of DHDSP‘s funded states. They 

have conducted a very specific heart attack campaign on the Crow Reservation, a very specific 

stroke campaign on the Flathead Reservation, and are conducting blood pressure and 

cholesterol work with patients at three Urban Indian Clinics. Oklahoma is working to collect 

more information on blood pressure and cholesterol among Native Tribes so that they can better 

provide prevention activities (e.g., CVH Examination Survey). Minnesota has a CHW

intervention to improve blood pressure control.

DHDSP shares the WISEWOMAN program with the NBCSP. In addition to cancer screening, 

native women are also screened for cardiovascular risk factors (e.g., blood pressure, 

cholesterol, weight, blood sugar, and smoking status), and they also receive assistance in 

healthy eating and increasing physical activity in ways that are more like their ancestors. The 

WISEWOMAN flow of services is illustrated in the following graphic: 

WISEWOMAN: Flow of Services

Recruited 

from 

NBCCEDP 

Program 

Cardiovascular

risk factor

screening and counseling

Lifestyle 

intervention

for diet, physical 

activity and

tobacco

Risk

factors

prevented

Abnormal

Medical 

referral, diagnosis, 

and follow-up

Lifestyle 

intervention

Risk

factors

reduced
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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The WISEWOMAN Alaska program has implemented a statewide media campaign for native 

women about the warning signs of heart attacks, which can be found at the following address:

http://www.partners.hss.state.ak.us/takeheart/AlaskaWomenTakeHeart.htm. This is one of their 

posters:

The program has a toolkit that includes book marks, bingo cards, event planning activities, and 

radio spots. Alaska has won some major media awards for its products, as has Montana.

Montana Department of Health and Human Services launched a campaign with the American 

Heart Association on the Ft. Peck Reservation. The following is a poster with Harry Three 

Stars, who is a known pow wow dancer, urging others to know the signs of a heart attack and 

call 9-1-1:
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Dr. Brownstein then discussed some research in which she has been engaged, Reducing Time 

to Treatment for Myocardial Infarction (MI) for Rural American Indians and Alaska Natives, that 

offers an opportunity. They were interested in better understanding why tribal people did not 

know all of the signs of a heart attack and why they were presenting for care so late following a 

heart attack. The contractor for this project is an Indian-owned company. The first phase is 

underway, which includes interviews with tribal health care providers, community leaders, and 

individual community members and focus groups with community members to get their 

perspectives on delays to treatment, key myocardial infarction messages to AI / AN populations, 

and recommendations for healthcare providers. 

The stories they are hearing are very rich. She had heard that heart attack was not even ―on 

the radar screen‖ for people in Indian Country because they are too busy. That is simply not 

true. All of the community members had members of their extended families who had died from 

a heart attack or who were disabled as a result of a heart attack. People really opened up and 

told their stories. The primary message they heard was that they did not want other people to 

go through what they had. Some of the stories people told regarded poor relationships with 

their providers. Providers were not even asking them about their history of heart disease or 

heart attacks, or telling them about any signs of heart attacks other than chest pains. An elder 

who went for a walk every day of his life did not go out one day for his walk. His family asked 

him why, and he told them that he did not feel that he could make it home due to terrible fatigue. 

He had a heart attack. Not much is being done for people after they have a heart attack either 

by their primary care providers. One women confided that her doctor never told her whether 

she could have relations with her husband following a heart attack. 

The barrier for not getting in quicker after a heart attack seems to be distress to the system. 

One suspicion providers have is that people are coming in claiming to have chest pains 

because they want to acquire pain medications. Another area that elicits a lot of distress is that 

when people do come in, they are transferred to hospitals far away, they have no transportation 

to get back home, and their families have no transportation or funds to stay in a hotel near 

where they are hospitalized. Mr. Franklin alluded to that issue when he talked about how it took 

four hours for his family to get to cancer treatment. Though they are not finished analyzing the 

data, it appears that health care providers need recommendations for improvement at IH S and 

Tribal Clinics. Because it is known that tribal members have not been getting all of the 

information about the signs of a heart attack, DHDSP wants to improve that. They look forward 

to working with and getting feedback from the TCAC on this project. Another product this 

division has produced is a community health worker source book, which is a training curriculum 

for preventing heart disease and stroke.

Discussion Points

 Ms. Hughes emphasized that education and awareness was an important component. This 

needs to move beyond the consumer level. The provider needs to ask the appropriate 

questions. Unfortunately, Tribal Clinics are so overwhelmed, it is difficult to get into any 

department because the waiting list is always long. Even with a triage department, it is 

difficult to get a short turnaround because the intake person asking the question is not 

asking enough or the right questions, so situations are not being diagnosed as something 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

57

that needs to go to triage immediately. That occurs in private hospitals when people call or 

go to the emergency room. This is an area where they need to have the professional 

people who are trained asking the questions. She knows chest pains mean there is the 

possibility of a heart attack, but she does not know all of the other symptoms. However, if 

someone asked her the right questions, she would respond appropriately and perhaps there 

would be a quicker trip in for the necessary treatment. 

Division of Reproductive Health

Myra Tucker, Tribal Liaison

Division of Reproductive Health (DRH)

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Tucker noted that she attended the first TCAC meeting, and was excited to see the work 

moving forward and the process of educating CDC and garnering CDC resources to work on 

behalf of tribes in an effective manner. This group also has personal meaning for her in that, 

since the last time they met, she became the Tribal Liaison for her division because CAPT 

Snesrud assigned that to her name on the agenda and it stuck. 

For those wondering why DRH was housed in NCCDPHP, the honest answer is that it was a 

political decision. At the same time, there is a good rationale for reproductive health to be 

considered in the whole circle of life or the life cycle. DRH deals with women before, during, 

and after pregnancy; infants; and children. They are increasingly learning that physiologically, 

pregnancy‘s stress to a woman‘s body offers a window into a woman‘s health and an 

opportunity to affect her lifelong health (e.g., gestational diabetes) and infancy and childhood as 

the foundations of health. Thus, in many ways, NCCDPHP turns out to be a good fit for DRH.

DRH‘s mission is to ―Promote optimal reproductive and infant health and quality of life. There 

are numerous resources and tools at CDC and in DHR that are relevant to developing public 

health infrastructure and epidemiologic capacity within tribal health organizations.‖ Resources 

can be found at the following web address: http://www.cdc.gov/reproductivehealth/. To 

accomplish its mission, DRH works with partners to conduct epidemiologic research and 

surveillance; support scientific and programmatic development within states and tribes; provide 

technical assistance and consultation; and translate research findings into health care practice, 

public health policy, and health promotion. 

As evidenced by the following table, there is a lot of work to be done with tribes:
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

58 Selected US Health Indicators, US White and 

American Indian Populations

US Whites AI/AN

Life expectancy 78.3 74.5

Infant mortality 5.8/1000 8.1/1000

Maternal mortality 9.9/100000 12.5/100000

No PNC, 1st trimester 11.1% 30.1%

% Smoking in pregnancy 13.8% 18.2%

SIDS death rate 55.4/100000 111.6/100000

Based on these data, life expectancy for AI/AN is about four years shorter than for Whites in the 

US. Infant mortality is higher, maternal mortality is higher, lack of prenatal care is more than 

twice as high, smoking during pregnancy is higher, and death from sudden infant death 

syndrome (SIDS) is twice as high.

DRH‘s previous work with tribes includes 30 Tribal Behavioral Risk Surveys and research titled: 

Risk Factors for Sudden Infant Death Syndrome among Northern Plains Indians. Current work 

with tribes includes capacity-building, surveillance, research, and emergency response. Crosscutting themes include working with tribal entities for all activities; and providing appropriate 

data / enhancing the knowledge base. An important effort DRH is making is to determine how 

to acquire more local data for local decision making. CDC has a lot of expertise in these areas, 

and wants to work closely with its tribal partners to ensure that tribal organizations have that 

expertise and capacity as well.

Examples of the kind of tribal work the DRH is engaged in include the publication of a Maternal 

and Child Health Journal special AI/AN issue titled, ―Research for Maternal and Child Health 

Practice in American Indian and Alaska Native Communities.‖ In reviewing the scientific 

literature on AI/AN maternal and child health five years ago, DRH found that the literature 

relating to AI/AN was that less than 1% of the data even mentioned American Indians or Alaska 

Native mothers and infants. When they were mentioned, it was usually in the context of what 

Dr. Tucker refers to as ―awfulizing,‖ meaning a lot of descriptive data about what is wrong and 

what the disparities are. The purpose of the special journal was to increase the amount of 

relevant studies, moving beyond descriptive studies to include evaluations of interventions. It is 

known that the disparities exist, but something must be done about it. This journal includes 

input from tribal partners regarding avenues for intervention in order to shift the discussion to 

address what is working and how to move forward. Dr. Tucker stressed that her excitement 

about the tribal consultation process was because TCAC, more than any other advisory group 

she had observed at CDC, brought the issues right down to the personal level and what 

happens to people related to the work that CDC does.

The largest surveillance system in DRH is the Pregnancy Risk Assessment and Monitoring 

System (PRAMS), which is conducted in 35 states. A survey goes to new mothers that asks 

them about their experience during pregnancy and the health of their babies. This is one of the 

only sources of population-based data about new mothers and their babies in the US that is 

available for American Indians. In the 10 states that have 5% or more American Indians in their 

population, American Indian women generally are not high responders. The response rates are 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

59

about 60%, with the exception of Alaska and Oklahoma. Therefore, one of the discussions they 

have been having in the division over the last five years regards how PRAMS can work more 

effectively with tribal communities so that these data can be available for local use. South 

Dakota Tribal PRAMS showed people how to do that. They won an award in 2009 for a point in 

time PRAMS led by the Yankton Sioux Tribe. The South Dakota Tribes and the Yankton Sioux 

have provided a template for what works effectively with tribes by obtaining data locally and 

then returning those data for local use. Dr. Tucker said she was proud to report that the South 

Dakota PRAMS project had a response rate from American Indian women of over 70%. Part of 

DRH‘s work pertains to how to use what was learned from this experience to ensure that CDC 

surveillance systems in these states work on behalf of tribes. There is now a model, and it is 

within their reach.

With respect to future directions, Dr. Tucker believes that CDC should maximize the use of 

existing data systems on behalf of AI/AN maternal and child health; and that tribal data systems 

and tribal epidemiology programs should be developed.

Division of Adolescent and School Health

Linda Crossett, PhD

Research Application Branch (RAB)

Division of Adolescent and School Health (DASH) 

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Crossett indicated that she had recently been given the lead for enhancing previous, yet 

minimal, AI/AN activities with partnerships within DASH, outside of CDC, and with all of the 

tribal units throughout the country.

DASH is somewhat unique at CDC in that it is one of the few divisions that funds education 

agencies throughout the country instead of health departments. When funds directly go to an 

agency in each state that is funded, they do have to have a memorandum of agreement with the 

state health department, and then a person is funded in that agency through DASH as well, so 

that there are two people at fairly high levels in the education and health agencies to address 6 

categories of risk behaviors for young people that in unintentional injuries and violence; alcohol 

and other drug use; sexual behavior; tobacco use; dietary behavior; and physical inactivity.

Many people think of school health as being only health education, but DASH does much more 

than that. DASH enables partners to plan and implement effective policies and programs; 

synthesize and apply research; monitor health risk behaviors and school health policies and 

programs; and evaluate the effectiveness of policies and programs. DASH has three 

surveillance systems: Youth Risk Behavior Survey (YRBS), School Health Policies and 

Programs Study (SHPPS), and School Health Profiles (SHP). Like the theme echoed 

throughout the day, DASH has limited national data on American Indians / Alaska Natives. 

They have pockets of data, but is in its infancy in collecting these data. DASH views this as one 

of their priorities. 

DASH believes in a coordinated school health approach and has developed numerous tools to 

help schools implement science-based, effective programs. Other divisions within CDC, other 

federal agencies, such as USDA, and national non-profit organizations have also developed 

high quality tools to help schools make a difference. The bottom line is that DASH has a strong, 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

60

research-based agenda for action and there is now a wealth of technical assistance resources 

available to help schools take action. So there are no good excuses really for failure to take 

action. The following are just a few examples:

With respect to specific activities addressing risk behaviors among American Indian and Alaska 

Native youth, through a series of contracts with Westat, CDC provides comprehensive technical 

assistance to sites conducting the YRBS, including the Bureau of Indian Affairs (BIA) and 

Navajo Nation (or near the reservation if enrollment was at least 50% Navajo), working with the 

Indian Health Service. The BIA first conducted a YRBS in 1994 among students enrolled in 

grades 9 through12 in BIA-funded schools. Since that date, the BIA high school YRBS was 

conducted in 1997, 2001, 2003, and 2005. The BIA middle school YRBS (grades 6 through 8) 

was conducted in 1997, 2000, 2003, and 2005. The Winnebago Tribe and Cherokee Nation of 

Oklahoma have received funding support for administration of the YRBS. They also hope that 

these two groups will be models for other tribes. For the first time, DASH is also funding tribal 

governments to implement school health programs. The Nez Perce Tribe in Idaho received 

funds for DASH‘s coordinated school health program, and the Cherokee Nation of Oklahoma

received HIV education funding and YRBS funding. All of the activities are supported through 

state education agency cooperative agreements. DASH also offers training in many of its 

evidence-based tools that will help schools address these risk behaviors. They have a 

professional development consortium. Several of the states, and recently the Cherokee Nation, 

have taken advantage of some of DASH‘s professional development training. 

DASH was part of the recent Expert Panel: ―Adolescent Suicide: Addressing Disparities through 

Research, Programs, Policy, and Partnerships‖ in September 2009. In addition, DASH has an 

article in clearance titled ―Health Risk Behaviors among American Indian and Alaska Native 

High School Students in the United States, 2001-2007.‖ DASH is very proud of this article. 

They originally intended to develop a website, but then realized that they did not have 

comparable data from various areas, so they combined years and data and have some 

methodologies that are explained in the article. They are publishing this article first so that they 

can explain how this was done due to lack of a broad spectrum of risk behavior data. 

Opportunities include training and professional development; expansion of funding opportunities 

to support implementation of the YRBS and school health programs; and collaboration with 

other divisions and offices across CDC. Dr. Crossett stressed that DASH is prepared to 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

61

collaborate stronger with tribes. Most information about resources available from DASH (e.g., 

tools, regional training, et cetera); however, she appreciated the comment made earlier by Mr. 

Curley about some areas not having internet access. Therefore, she indicated that she would 

inform CAPT Snesrud, Dr. Bryan, and TCAC through other means as well. 

Division of Oral Health

William Kohn, DDS, Director

Division of Oral Health (DOH)

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Kohn indicated that CDC‘s Division of Oral Health (DOH) is currently a very small group, 

with 28 employees with a wide range of responsibilities nationwide. DOH consists of four 

essential, interrelated components that support the efforts of states to strengthen oral disease 

prevention and health promotion programs and to ensure the safe delivery of dental care.

DOH‘s vision is ―A nation where all people enjoy good oral health that contributes to leading 

healthy, satisfying lives‖ and its mission is to ―Prevent and control oral diseases and conditions 

by building the knowledge, tools and networks that promote healthy behaviors and effective 

public health practices and programs.‖ 

Dentistry separated itself from medicine years ago, so they are always trying to remind people 

that the mouth is part of the body and that one is not completely healthy unless they have good 

oral health as well. DOH is a good fit within NCCDPHP because oral disease is a chronic 

disease. Dental decay is the most chronic disease of childhood. Once in the permanent teeth, 

it can be repaired, the damage is for life. DOH‘s focus is really on the prevention of oral disease 

first, followed by control. They primarily focus on tooth decay, gum disease, and oral cancer. In 

some ways it is easy, but can be very complicated moving across all of the implications of those 

diseases. 

DOH does not implement programs. Its primary activities are to strengthen the nation‘s oral 

health infrastructure; build the evidence base for and extending the use of proven strategies to 

prevent oral diseases; enhancing efforts to monitor oral diseases and conditions; disseminate 

effective prevention practices to health professionals and the public; and provide guidance on 

infection control in clinical dental settings. The public health infrastructure in states and in 

Indian Country has really suffered, and the oral health departments tend to be cut first when 

there are budget crunches. This has always been a struggle, so DOH provides grants to states 

to help build up their oral health infrastructure. They have primarily worked with water 

fluoridation programs and school-based sealant programs. DOH is the national authority on 

infection control in dental offices. This division‘s history has really been in water fluoridation and 

infection control. It has only been in the last 10 years that DOH got more involved in research 

on prevention intervention and collecting data, so its impact is yet to be felt in some areas. 

Activities and programs include the state department of health infrastructure development

cooperative agreements; guidelines and recommendations; national oral health surveillance 

systems for oral health indicators, state synopsis, and oral health questions in surveillance 

systems (e.g., NHANES, BRFSS, PRAMS, NHIS, MEPS, and Healthstyles); and Healthy 

People 2010 / 2020. Most of DOH‘s tribal activities have been with IH S. Specific AI/AN efforts 

have included work on Healthy People 2010 / 2020 objectives; assistance in 2009 developing 

the Alaska YKHC Epi-Aid on caries in children; provided funds for water fluoridation 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

62

improvement (circuit rider); provided $50,000 to improve fluoridation in Alaska (bought in line 

fluoridation monitors and improved quality control); helped with accreditation of the IHS 

Residency Program; provided DOH speakers at conferences; and was represented from 2004-

2008 on the IHS National Health Promotion / Disease Prevention Committee.

In terms of the results that DOH has found nationwide among AI/AN children, they have found 

that children 4 to 5 and 6 to 11 years of age from non-fluoridated villages had 3 times and 1.5 

times the number of dental caries in primary teeth than children from fluoridated villages, 

respectively. Children 6 to 11 and 12 to 15 years of age from non-fluoridated villages had twice 

the number of dental caries in permanent teeth as children from fluoridated villages. The 

frustrating thing is that most dental caries are completely preventable from primary prevention 

mechanisms, so if they can just do a better job of getting information about self-care, 

fluoridation, and sealants, in a generation a significant amount of tooth decay could be 

eliminated. Some people do not trust fluoridation, so this can be problematic. As an aside, Dr. 

Kohn noted that January 25, 2010 was the 65th anniversary of community water fluoridation in 

the US. It began in Grand Rapids, Michigan on January 25, 1945. Since that time, there have 

been many studies and expert reviews about the safety of the safety and effectiveness of 

fluoridation.

Opportunities include surveillance consultation and inclusion of tribal disease data on the 

National Oral Health Surveillance System (NOHSS) and telling success stories; assistance with 

remote monitoring of fluoridated water systems; and quality assurance monitoring of tribal water 

systems through the CDC Water Fluoridation Reporting System (WFRS). DOH received some 

addition funding this year and will soon publish and FOA for four more state infrastructure 

grants. These will be advertised to tribal organizations, which will be eligible for cooperative 

agreements to help build infrastructure. This is an opportunity to have someone with a sole 

focus on administrating the program, collecting data, managing the quality of fluoridation and 

sealant programs, et cetera.

Discussion Points

 Mr. Franklin inquired as to when the FOA would be published.

 Dr. Kohn replied that this would be in the coming cycle, for which the budget process is just 

now unfolding.

 Ms. Hughes noted that dental care is second or third in the list of priorities in Indian Country. 

Need is great. There are fluoridation and sealant programs, but because the inconsistency 

of being able to provide service, the problem that has been created over the years is still not 

being dealt with. By the time youth are in high school, they have dental problems that 

should have been corrected sooner. The waiting list to get in to dental clinics is extremely 

long.

 Ms. Sebattus indicated that USET has a dental support center. When they were seeking 

more data on dental health at the tribal level, the most recent data they were able to find 

was from 1999. There have not been funds to duplicate this survey that was Indian 

Countrywide. For the national area tribes, USET conducted a similar survey and used 

similar parameters that the state used to obtain data for tribes. It would be beneficial to 

duplicate this throughout Indian Country.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

63

 Dr. Kohn noted that one of the requirements of the cooperative agreement that will be 

published is the collection of data at least every five years. DOH can also provide technical 

assistance. Dental surveys can be very resource-intensive because there is so much data. 

DOH develop a basic screening survey for children, which is a much simpler surveillance 

tool: decay / no decay; untreated / treated; et cetera. DOH can provide this assistance 

even to those who are not funded.

 Mr. Franklin complimented Dr. Giles and his staff for the very respectful tone they were 

using in their presentations. He liked what was said earlier about shifting from ―awfulizing‖ 

to action. He also noted that the information being presented could actually fill an entire 

day, and that he would like them to consider presenting at the NIHB conference in May 2010 

in Albuquerque and perhaps the annual consumer conference. While this is good 

information for TCAC members to hear because they will take it back to their communities, 

tribal leaders will want to hear this discussion as well. Moreover, they will offer awesome 

input. 

Division of Nutrition, Physical Activity, & Obesity

Rosanne Farris, PhD

Program Development and Evaluation Branch Chief

Division of Nutrition, Physical Activity, & Obesity (DNPAO)

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Farris reported that obesity continues to be a major problem in the US, with one third of 

adults obese and 16% of children ages 2 to 19 obese. To address this issue, the vision of 

DNPAO is ―A world where regular physical activity, good nutrition, and healthy weight are part of 

everyone's life‖ and its mission is to, ―Lead strategic public health efforts to prevent and control 

obesity, chronic disease, and other health conditions through regular physical activity and good 

nutrition.‖ The goals of DNPAO are to increase health-related physical activity though 

population-based approaches; improve dietary quality most related to population burden of 

chronic disease and unhealthy child development; and decrease prevalence of obesity through 

prevention of excess weight gain and maintenance of healthy weight loss.

State programs need to develop strategies to leverage resources and coordinate statewide 

efforts with multiple partners to address all of the following DNPAO principal target areas. CDC 

sees these six target behaviors as key to preventing and reducing the prevalence of obesity: 

increase breastfeeding initiation, duration, and exclusivity; increase physical activity; increase 

consumption of fruits and vegetables; decrease consumption of sugar sweetened beverages; 

reduce consumption of high energy dense foods; and decrease television viewing.

Congress provided specific funding to CDC to address the public health problem of obesity 

starting in 1999. Six programs were funded in the first year and grew in numbers over the 

years. As illustrated on the following map, DNPAO currently funds 25 states (shown in blue) for 

it nutrition, physical activity, and obesity prevention state program. In addition, all states and 

territories will receive funding in January 2010 for two-year recovery act funds for policy and 

environmental initiatives related to nutrition, physical activity, and tobacco prevention:
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Several programs are on-going in Montana, including the following:

 Blackfeet Tribe has a program with a focus on breastfeeding (Destiny Anderson of Indian 

Health Service will assist with this effort)

 Ft. Bellknap has a program with a focus on physical activity in Head Start (the Fort Belknap 

Indian Reservation is the homeland of the Gros Ventre and Assiniboine people)

 Rocky Boy has a program with a focus on physical activity in the Boys and Girls Club (the 

Rocky Boy Reservation is homeland of the Chippewa and Cree)

 Flathead has a program with a focus on physical activity and some nutrition in its after 

school program (the Flathead Reservation is the homeland of the Confederated Salish and 

Kootenai Tribes)

Cathy Edgerly, a Program Specialist, is working for the Inter-tribal Council of Michigan. She 

represents the Council and works on the Healthy Weight Partnership and State Planning Group. 

The tribes working with Inter-Tribal Council of Michigan include the following:

 Bay Mills Indian Community (Sault ste. Marie Tribe of Ojibwe)

 Grand Traverse Band of Ottawa and Chippewa Indians

 Hannahville Indian Community (Potawatomi)

 Keweenaw Bay Indian Community (Ojibwe)

 Lac Vieux Desert Band of Lake Superior Chippewa Indians

 Little Traverse Bay Bands of Odawa Indians

 Match-E-Be-Bash-She (Gun Lake Tribe, Potawatomi)

 Nottawaseppi Band of Huron Potawatomi

 Pokagan Band of Potawatomi Indians

 Saginaw Chippewa Indian Tribe
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Three pueblos in New Mexico (Pueblo of Cochit, Pueblo of Santa Clara and Pueblo of San 

lldefonso ) are working on obesity plans.

There is quite a lot going with the Ojibwe and Chippewa tribes in Minnesota. They are in the

planning stages of a breastfeeding supports and challenges assessment. They are conducting 

focus groups with several priority populations, including Native American Indians, to learn more 

about needs and ways to approach increasing breastfeeding rates. The following reservations 

are involved in this effort:

 Leech Lake Reservation (Ojibwe)

 Grand Portage Reservation (Ojibwe) 

 Bois Forte Reservation (Ojibwe)

 Fond du Lac Reservation (Ojibwe)

 Mille Lacs Reservation (Ojibwe)

 Red Lake Comprehensive Health Services

 White Earth Reservation (Ojibwe)

DNPAO funds the states‘ breastfeeding teleconferences. DNPAO-Breastfeeding Work Group 

partners with the United States Breastfeeding Committee to provide training and opportunities 

for networking for coalition members. The teleconferences also provide an opportunity for 

interactions and discussion on a wide variety of topics related to breastfeeding support. A topic 

covered during one of the teleconferences was breastfeeding legislation.

The Navajo Nation Breastfeeding Coalition members worked diligently to pass the pivotal 

Healthy Start Act in 2008. This Act requires Navajo Reservation employers to provide: 1) a 

flexible work schedule for breastfeeding or milk expression, 2) a private room for breastfeeding 

or breast pump usage for milk expression.

There are a number of opportunities to continue to work together. One is to increase the 

number of health promotion program examples in AI/AN communities to show case (limited 

examples exist in the literature now). This will serve as an example for other tribes to use and 

learn from. There are also opportunities for AI/AN communities to tailor interventions to their 

specific culture and health priorities. The program characteristics include culturally competent 

and community-driven approach to decrease obesity and chronic disease such as diabetes. 

There is very little work in health promotion programs that involves AI/AN communities. 

Through support and technical assistance, Indian Tribal Organizations can learn to assess, 

develop plans, locate resources, ensure ways to measure progress, use data, and complete 

program evaluation. The process will also enhance their capacity to work on other community 

health concerns or issues. Capacity to work on obesity is limited.

For more information regarding DNPAO resources, contact information is as follows:

Claire Heiser, DNPAO Program Team Lead, 770-488-5284

Lorraine Whitehair, Public Health Nutritionist 770-488-5704

http://www.cdc.gov/obesity/stateprograms/index.html
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Office On Smoking and Health

Dianne May, PhD

Program Services Branch (PSB)

Office On Smoking and Health (OSH)

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. May indicated that the mission of OHS is as follows, ―As the lead federal agency for 

comprehensive tobacco prevention and control, OSH develops, conducts, and supports 

strategic efforts to protect the public‘s health from the harmful effects of tobacco use.‖ OSH‘s 

goals are to prevent initiation, promote cessation, eliminate secondhand smoke exposure, and 

identify and eliminate tobacco-related disparities. 

OSH currently funds 50 states and DC, 8 Territories, 6 National Networks, and 6 Tribal Support 

Centers. OHS has an MOU with Indian Health Service which is approximately $75,000 per year

to fund staff activities. These activities include providing data analysis on American Indian Adult 

Tobacco Survey (AI ATS); developing tribal funding recommendations; and conducting strategic 

planning.

The American Indian / Alaska Native National Network is in year 2 of a 5-year cooperative 

agreement at about $400,000 per year that is allocated to the Inter-Tribal Council of Michigan, 

which is the lead. National network activities include training and technical assistance for tribes 

and tribal organizations on implementing the AI ATS, analyzing and using AI ATS data, planning 

communications and media, developing policy; and convening a national advisory board. When 

a tribe conducts the AI ATS, the tribe owns the data.

Tribal Support Centers are in year 5 of a cooperative agreement, with a new cooperative 

agreement announcement to be funded at some point. There are 6 funded grantees and 7 

cooperative agreements of about $1.6 million per year. The centers are shown on the following 

map:

CDC Funded Tribal Support Centers

2005 through 2010

National Network, 

funded under 

Currently Funded

under PA AA066

2005 - 2010

Black Hills Center for 

American Indian Health

Winslow, AZ

Indigenous People

Task Force

Minneapolis, MN

Cherokee Nation

Tahlequah, OK

Muscogee Creek Nation

Okmulge, OK

Inter Tribal Council of MI

Sault Ste. Marie, MI

CA Rural Indian

Health Board

Sacramento, CA 

SE Alaska Regional

Health Consortium

Sitka, AK
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

67

The purpose of the Tribal Support Centers includes: 1) capacity-building programs lead tribal 

efforts to reduce abuse of commercial tobacco and secondhand smoke exposure; and 2) 

implementation programs to implement and evaluate tobacco control strategies. Capacitybuilding is being done with the Black Hills Center for American Indian Health, California Rural 

Indian Health Board, Cherokee Nation, and Indigenous Peoples' Task Force. Implementation is 

being done with California Rural Indian Health Board, Muscogee (Creek) Nation, and Southeast 

Alaska Regional Health Consortium.

There are a number of Tribal Support Center activities. Tribes working with Tribal Support 

Centers tend to have higher tobacco taxes than other tribes. In some instances, the tribal taxes 

are higher than state taxes. As a result of Tribal Support Center work, several tribes are 

working with states to measure secondhand smoke levels in tribal casinos. Several of the tribes 

in Oklahoma are working with the Oklahoma Department of Health and the University of 

Oklahoma to measure second hand smoke levels in the casinos. Muscogee Creek Nation 

penalties are more stringent than the State of Oklahoma‘s for selling commercial tobacco 

products to minors. Tribal Support Centers are also using findings from the AI ATS to develop 

culturally appropriate interventions. Tribal Support Centers and the National Native Commercial 

Tobacco Abuse Prevention Network (NNCTAPN) are working with Legacy, RWJF, and other 

partners to expand surveillance systems and implement culturally appropriate interventions and 

evaluations. Muscogee Creek Nation, Cherokee Nation (which just completed the AI ATS), 

CRIHB, the former Tribal Support Center Intertribal Council of Michigan all have developed 

commercial tobacco abuse interventions that were informed by AI ATS findings. CDC‘s national 

partners have funded several projects for the Tribal Support Centers in the areas of surveillance 

systems and culturally appropriate interventions and evaluations. Tribal Support Centers are 

working with the NNCTAPN on a REACH-US initiative that seeks to integrate tobacco control 

with chronic disease programs in tribal health systems. Tribal Support Centers and the 

NNCTAPN are working with local governments in areas with large AI/AN populations to adopt 

no commercial tobacco policies and smoke-free work policies.

Discussion Points

Mr. Petherick pointed out that the tobacco and health sides needed to be balanced. He 

expressed hope that this would be communicated in the activities being undertaken, especially 

working with states and local governments that do not always understand the tribal side. Tribes 

were put in a situation where they had a zero economic base and had to develop an economy. 

Unfortunately, tobacco issues have always been a part of that. They always say, ―We want you 

to buy tobacco. Just don‘t use it.‖ 

Division of Adult and Community Health

Lynda Anderson, PhD, Acting Director

Division of Adult and Community Health (DACH)

National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Anderson reported that DACH is charged with providing cross-cutting chronic disease and 

health promotion expertise and support to CDC‘s NCCDPHP as well as to states, communities,
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

68

and other partners. DACH also manages several important chronic disease prevention and 

control programs for specific chronic diseases, assesses new and emerging chronic disease 

issues, and launches new programs for NCCDPHP. DACH spending on activities that target 

AI/AN populations is $4,908,199.

In terms of centerwide services, several programs within DACH serve as bases for delivering 

epidemiologic support, prevention research, and flexible program funding in states that support 

all of NCCDPHP‘s programs. These programs include the Prevention Research Centers

(PRCs) and the Preventive Health and Health Services Block Grant. With respect to crosscutting approaches, DACH manages several programs that address an array of issues related 

to chronic disease prevention and health promotion for specific populations. The division also 

provides expertise and national leadership in health education and promotion, both of which are 

tools widely used in chronic disease prevention efforts. Such efforts include Healthy Aging, 

Healthy Communities Program, Health-Related Quality of Life, and REACH. 

Regarding emerging issues, DACH is also charged with undertaking innovative scientific 

research on emerging and cross-cutting chronic disease and health promotion issues for CDC. 

These research initiatives define the extent and public health impact of emerging issues and 

develop the scientific basis for public health solutions. These programs include ACE, Alcohol, 

Alzheimer‘s, Mental Health and Social Determinants of Health. DACH launches new and 

growing programs for NCCDPHP, some of which have historically become separate divisions as 

they have matured. Major chronic disease programs and initiatives currently being launched by 

DACH are Arthritis and Epilepsy.

DACH‘s REACH US program funds 40 communities throughout the country to advance the 

prevention and elimination of health disparities among racial and ethnic minority groups, and to 

understand and spread successful strategies for achieving significant changes at the community 

level. Forty REACH US Communities include 18 Centers of Excellence in the Elimination of 

Health Disparities (CEEDs) and 22 Action Communities. CEEDs have expertise in working with 

specific ethnic groups and widely disseminating effective strategies. The REACH US 

Communities are depicted in the following map: 

African-American/

Blacks

American Indian/

Alaska Native

Asian

Native Hawaiian/

Other Pacific Islanders

Hispanic/Latinos

Multi-Ethnic

Action Communities

CEED Communities

REACH U.S. Communities

Under the REACH US program, CDC awarded 6 entities targeting the elimination of health 

disparities in American Indian communities. All six are fully engaged in intervention activities. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

69

Two of these entities, Oklahoma State Department of Public Health and the University of 

Colorado at Denver and Health Sciences Center, are functioning as CEEDs and serving as 

resource centers on effective interventions in addition to working in their home communities.

Oklahoma State Department of Public Health–Southern Plains REACH US (SPRUS) has 

chosen to work with American Indian Tribal Communities in the Southern Plains Region (e.g., 

Oklahoma, Texas, and Kansas) to reduce the risk of diabetes and CVD through activities 

related to nutrition, physical activity, and tobacco control prevention. Current funding totals 

$844,284. The University of Colorado at Denver and Health Sciences Center works to reduce 

CVD risk among urban American Indians through community and clinically based interventions. 

Current funding totals $738,938.

Four entities (e.g., Choctaw Nation of Oklahoma, Eastern Band of Cherokee Indians, InterTribal Council of Michigan, and Northern Arapaho Tribe) are funded as Action communities. 

They are implementing and evaluating successful approaches with specific communities that 

impact AI/AN populations. The Choctaw Nation of Oklahoma received a Core Capacity Building 

under the REACH 2010 program. After successfully building their capacity and infrastructure, 

they are now implementing their Lifetime Legacy Project with REACH US. The project focuses 

on healthy priority area of cardiovascular disease as well as the intervening variables of 

childhood obesity, tobacco and substance abuse, specifically methamphetamine use. The 

Eastern Band of Cherokee Indians (EBCI) works to reduce the risk for Type 2 Diabetes in the 

EBCI communities by promoting physical, emotional, and cultural well being. 

The Inter-Tribal Council of Michigan continues to implement community-based intervention 

activities to reduce cardiovascular disease and diabetes related disparities that are culturally 

tailored to each of three tribal communities, while providing overall technical assistance to the 

tribes and disseminating results of the culturally tailored interventions among consortium 

partners. The Northern Arapaho Tribe Wind River Indian Reservation (WRIR) plans to reduce 

the rate of infant mortality among American Indians on the WRIR through community based 

approaches. These approaches include increasing community awareness and commitment to 

eliminating infant mortality disparities through coordinated and multi-organizational action. 

Current funding for these four entities is as follows:

 Choctaw Nation of Oklahoma $415,390

 Eastern Band of Cherokee $415,390

 Inter-Tribal Council of Michigan $415,390

 Northern Arapaho $398,807

The Healthy Communities Program began in 2003, and was formerly the Steps Program. To 

date, more than 200 communities have received funding and technical support to mobilize 

communities with a focus on Diabetes, Heart Disease, and Obesity Prevention; and Physical 

Activity, Nutrition, Tobacco Use Prevention. This program directly funds and supports 

communities through city health departments, and rural local health departments through states, 

tribes, and community organizations with national reach.

The Sault Saint Marie Tribe of Chippewa Indians and the Cherokee Nation are entering into the 

second year of a five-year cooperative agreement to develop and implement policy, systems, 

and environmental changes addressing chronic disease risk factors of physical inactivity, poor 

eating and nutrition, and tobacco use and exposure to reduce the burden of chronic diseases 

such as obesity, diabetes, cardiovascular disease. Four communities from the Sault Saint 

Marie Tribe are participating in this initiative: Sault Saint Marie, St. Ignace, Manistique, and 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

70

Munising. Four counties across the Cherokee Nation are participating as well: Cherokee 

County, Mayes County, Sequoyah County, and Adair County. Each tribe receives $400,000.

The PRCs are a national network of 35 academic research centers that conduct communitybased participatory research (CBPR) and partner with communities, health care providers, and 

state and local public health agencies. Centers that target AI/AN populations, with current 

funding for 2009 of $790,000 per center, include the following:

 Oregon Health and Science University, Center for Healthy Native Communities evaluated 

onsite eye exams and telemedicine to diagnose and treat diabetes-related eye disease and 

vision problems among American Indians in the Pacific Northwest. This center was 

approved and funded for the 2010-2014 program cycle and will create a hearing loss 

prevention program for American Indians and Alaska natives.

 University of New Mexico, Center for Health Promotion and Disease Prevention tested the 

effectiveness of school- and community-based interventions for identifying and reducing 

psychological distress among American Indian youth who witness or experience violence. 

This program is called Teen Health Resiliency Intervention for Violence Exposure (THRIVE). 

Data are being evaluated to determine the successfulness of increasing participants‘ coping 

skills, reducing the symptoms of trauma, and of maintaining positive effects over time. The 

center has been approved and funded for the 2010-2014 program cycle.

The American Recovery and Reinvestment Act (ARRA) Communities Putting Prevention to 

Work (CPPW) grants total $450 million, which includes $373 million FOA, evaluation, and 

community support. The goal of the CPPW grants is to reduce risk factors and prevent / delay 

chronic disease and promote wellness in both children and adults at the local level via cities, 

states, and tribes. Addressing risk factors includes reducing obesity through improved nutrition 

and physical activity; and reducing tobacco use. Interventions include policy and environmental 

change at the local level through evidence-based strategies in the areas of media, access, point 

of decision, price, and social support. Objective reviews took place January 11-15, 2010 and 

awards are expected to be made soon for a two-year funding period.

Discussion Points

 Mr. Gilbert inquired as to whether the two PRCs mentioned were the only two funded, or 

were the only two with an AI/AN focus.

 Dr. Anderson clarified that there are 35 PRCs throughout the country. The two she 

mentioned focus their core research specifically on tribal issues.

 Mr. Gilbert said they believe they have good capacity at the Alaska Native Medical Center 

(ANMC) to conduct research that is tribally owned and driven. They interact with CDC on 

different levels, and as they went through the list, he could think of three or four projects that 

they have with DCPC, OSH, and a couple of others. ANMC feels that they have a good 

handle on their basic data and regard themselves as a health system somewhat like Kaiser, 

with cradle-to-grave care and access to data at different points in people‘s lives. Over the 

last couple of years, they have thought about the value of having a PRC to translate what 

they have into evidence-based action. With that in mind, he wondered whether there would 

be opportunities to establish PRCs in the future, and if so, whether tribal programs would be 

eligible instead of universities as the applicants of those grants.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

71

 Dr. Anderson responded that the way this was set up, certain entities are eligible for the 

core infrastructure, but there are opportunities for collaborations with already funded PRCs 

through special interest projects. The division would be happy to inform ANMC where those 

may be located nearby to help make some linkages to existing PRCs, and to discuss other 

opportunities as well.

 Mr. Gilbert indicated that some of those present had successes with the NARCH programs. 

This is not exactly full tribal ownership of research, but it leans toward that and requires a 

partnership with an academic institution. However, it is a two-way street and is not 

necessarily academia coming to his backyard with an idea. Speaking for Alaska, he loved 

the idea of PRCs that are more tribally owned and operated. 

 Dr. Giles responded that something unique about the PRCs was the link between what is 

occurring in the community and what is occurring in the academic centers. All of them have 

a Community Advisory Board (CAB), which drives the research and specifies the topics they 

believe are important to address in the community. The PRCs were recently competed, 

which is done on a five-year cycle. Thus, it will be several years before the next round. 

However, there may other opportunities through other mechanisms such as REACH or 

special interest project. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

72

Division of Diabetes Translation

Dawn Satterfield RN PhD

Native Diabetes Wellness Program (Team Lead)

Division of Diabetes Translation (DDT)

National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)

Centers for Disease Control and Prevention (CDC)

Dr. Satterfield indicated that DDT‘s vision is ―A world free of the devastation of diabetes‖ and 

that its mission is ―To reduce the preventable burden of diabetes through public health 

leadership, partnerships, research, programs and policies that translate science into practice. 

The division‘s goals are to prevent diabetes; prevent complications, disabilities, and burden 

related to diabetes; eliminate diabetes-related health disparities; eliminate disparities, which are

starkly revealed by diabetes in Indian Country.

In the past decade basically, 1995 to 2004, trends in diabetes increased in both US and 

American Indian and Alaska Native populations. However, in 2004, the age-adjusted 

prevalence of diagnosed diabetes among AI/AN adults was 2.5 times that of US Whites (16.3% 

versus 6.5%). Throughout the period, prevalence in the AI/AN population was more than 2

times that of Whites [Source: 1995–2005 IHS user population data and National Diabetes 

Surveillance System]. Dr. Pyone Cho is working on data to determine the actual number and 

rates of children across the country who are developing Type 1 and Type 2 diabetes.

In the face of this stark reality that many tribal leaders know only too well, DDT epidemiologists 

have encouraging trends to report. End state renal disease related to diabetes decreased in all 

race / ethnicity groups with the exception of Hispanics. American Indians and Alaska Natives

had the most dramatic drop, which is cause to celebrate, as the IH S Diabetes Program has 

pointed out. The hard work of tribal communities, with the support of the SDPI, has surely been

a major reason and should be honored. 

With a 2010 appropriation of $66 million, DDT strives to identify trends in diabetes incidence, 

prevalence, and mortality; and translate science to action by communicating evidence-based 

prevention messages and implementing effective public health programs. The Move It!

campaign is a national diabetes education program that was developed with the American 

Indian and Alaska Native Work Group of the National Diabetes Education Program and the 

American Association of Indian Physicians. More recently, they have had the good news that 

diabetes often can be prevented with modest weight lost, attention to healthy foods, and 

physical activity. In addition, 171 American Indians contributed to the landmark study that now 

allows them to say to the world that diabetes can very often be prevented with these types of 

activities and nutrition. DDT also implements effective public health programs. All 50 states 

and 9 territories have diabetes programs. The Native Diabetes Program works with the 6 USassociated Pacific Islands as well. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

73

DDT specifically turned their attention to American Indian / Alaska Native disparities in diabetes 

to address those with communities, and with grounding principles of social justice with respect 

for both Native and Western science. They dream every day of a life of balance, a community 

of support, a program of prevention, and a message of hope. The goals of the Native Diabetes 

Wellness Program are to support sustainable ecological approaches to restore traditional foods 

and activities in communities; share messages about traditional ways of health that are 

remembered, retold, and talked about in homes, schools, and communities; and support 

meaningful tribal consultation at state and federal levels. 

Dr. Satterfield highlighted some examples of support to restore traditional foods and share 

messages of traditional ways of health. Since 2001, the National Institutes of Health, NIDDK, in 

partnership with the Tribal Leaders Diabetes Committee, CDC Native Diabetes Wellness 

Program, the Indian Health Service Division of Diabetes Treatment and Prevention, and eight 

tribal colleges and universities (TCUs), have developed the K-12 science- and culturally-based 

Health is Life in Balance Diabetes Education in Tribal Schools (DETS) curriculum. Originally, 11 

programs were funded. Based on the Tribal Diabetes Leaders Committee report that they could 

have the $1 million more for 2010 / 2010, and the division‘s support, an additional 6 programs 

were funded. Samples of the curriculum were placed on the information tables outside the 

conference room. The eight TCUs are: Cankdeska Cikana Community College (Fort Totten, 

ND), Fort Peck Community College (Poplar, MT), Haskell Indian Nations University (Lawrence, 

KS), Keweenaw Bay Ojibwa Community College(Baraga, MI), Leech Lake Tribal College (Cass 

Lake, MN), Northwest Indian College (Bellingham, WA), Stone Child College (Box Elder, MT), 

and Southwestern Indian Polytechnic Institute (Albuquerque, NM). 

All partners worked with school sites throughout the US to test the curriculum in three evaluation 

phases. Sister sites were also included in the last evaluation phase to include parts of the 

country not originally in the eight TCUs areas. In addition to funding, CDC assisted with the 

DETS evaluation format and scientific oversight for the project. The Eagle Books are included 

as part of the K-4 lessons plans. The curriculum was rolled out in November 2008 at the 

Smithsonian National Museum of the American Indian in Washington, DC. The roll out 

coincided with the Eagle Books original watercolor art exhibit at the same locale. From FY 

2009-2011, all partners are providing education outreach and teacher development training in 

all states that have AI/AN populations. NDWP is leading a DETS impact evaluation case study 

in four communities each year through 2012. These case studies are to provide communityspecific information on the DETS curriculum use and acceptance as well as the impact of the 

Eagle Books in classroom and community. These materials are available to tribes in any 

amount they would like. They also have the potential to make templates available to tribes 

through DETS for those who want to translate the books into their own languages. Several 

versions already exist, and they recently heard that Creek Nation is interested in developing a 

translation.

For the Traditional Foods project, 11 grantees were originally funded at $100,000 each. The 

good news is that due to the Tribal Diabetes Leaders Committee recommendations to Congress 

for the program to receive $1 million through 2011, DDT continued to receive support from IHS. 

As a result, DDT was able to fund 6 more grantees. The following map depicts the funded sites:
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

74

To date, Indian Country Today has published three articles about this project. One of the 

articles featured the Standing Rock Diabetes Program: Native Gardens Project, which has had 

some early success in just the year that they have been able to incorporate this project into 

what they already had underway. They partnered with USDA‘s Nutrition Program for Seniors, 

and now have vouchers that are going to elders. These have been cashed in at a rate of 50% 

just in the first year (e.g., $17,000 worth of local foods have been cashed in). They also have 

three functional farmer‘s markets. 

DDT grantees meet twice a year. Their second grantee meeting was convened in November 

2009 in Albuquerque. Rewarding words are heard from the grantees. For example, Tammi 

Meissner of the Southeast Alaska Health Care Consortium said, This program is so important 

because in addition to traditions being kept alive, "we" are reclaiming the sense of community...” 

These are the things that keep them going on the rough days. DDT is also mapping out their 

schedule for the coming years, and wondered whether there might be an interest in coinciding 

their 2011 meeting with TCAC‘s Atlanta meeting. 

Mr. Robert Curlee, Deputy Director

Financial Management Office (FMO)

Centers for Disease Control and Prevention (CDC)

Mr. Curlee showed several tables representing CDC / ATSDR resources committed to programs 

that benefit American Indian / Alaska Native (AI/AN) populations and communities from 2009 

compared to 2008. Fiscal information was summarized in the data presented according to 

organizational and disease-specific programs, and by defined funding allocation categories. 

Recovery act funding was not included in this information, nor had 2010 information been 

prepared at this time, although Mr. Curlee noted that there are some efforts underway.

CDC Budget and AI / AN Resource Allocations
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

75

Total CDC / ATSDR funding with VFC (73%) is $168,275,464. Total funding without the VFC is

$46,009,312 (27%). Excluding ATSDR, total funding with VFC is $167,637,959 and without is 

$45,371,807. Funding resources aligned with coordinating centers is reflected in the following 

table:

Improving Financial Management for a stronger CDC 

Funding Resources Aligned with Coordinating Center Total Funding 

FY2009 w/ VFC

Total Funding 

FY2009 w/o VFC Center/Institute/Office (CC/CIO)

Coordinating Center for Infectious Diseases $129,574,394 $7,308,242 

NCVZED $106,000 $106,000 

NCHHSTP $3,542,458 $3,542,458 

NCIRD$45,371,807

$122,605,845 $339,693 

NCPDCID $3,320,091 $3,320,091 

Coordinating Center for Health Promotion $27,568,187 $27,568,187 

NCBDDD $200,000 $200,000 

NCCDPHP $27,368,187 $27,368,187 

Coordinating Center for Health Information and Service $1,665,361 $1,665,361 

NCHS $1,665,361 $1,665,361 

Coordinating Center for Environmental Health and Injury Prevention $2,240,561 $2,240,561 

NCEH $788,371 $788,371 

NCIPC $1,452,190 $1,452,190 

National Institute for Occupational Safety and Health $322,140 $322,140 

Coordinating Office for Terrorism Preparedness & Emergency 

Response $4,651,716 $4,651,716 

Office of the Director $1,615,600 $1,615,600 

OWCD $496,079 $496,079 

OMHD/OD $1,119,521 $1,119,521 

CDC-CC/CIO Grand Total $167,637,959 $45,371,807 

ATSDR Total $637,505 $637,505 

CDC/ATSDR Grand Total $168,275,464 $46,009,312 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Funding resources aligned with disease specific programs (with ATSDR) are shown in the 

following table: 

Improving Financial Management for a stronger CDC 

CDC Funding Resources Aligned with Disease Specific 

Programs (with ATSDR): A Comparison

FUNDING LEVEL

FY 2008

FUNDING 

LEVEL

FY 2009

Percent 

of Change

Chronic Disease Prevention and Health Promotion $ 25,884,960 $ 27,286,210 5%

Cancer $11,502,097 $14,077,332 22%

Cross-cutting Programs $7,178,202 $5,613,762 -22%

Diabetes $3,349,585 $4,039,402 21%

Tobacco $2,162,395 $2,064,618 -5%

Heart Disease and Stroke Prevention $1,010,000 $975,000 -3%

Maternal Child Health $292,584 $147,749 -50%

Adolescent and School Health $390,097 $368,347 -6%

Infectious Diseases $ 7,715,374 $ 7,390,219 -4%

Infectious Disease Prevention (new category for FY 

09) N/A $46,000 N/A

Infectious Diseases in Alaska Natives $2,631,565 $3,380,091 28%

HIV/AIDS $3,194,327 $2,493,544 -22%

STDs $1,117,005 $898,891 -20%

Vaccine-preventable diseases (non-VFC funds) $321,477 $339,693 6%

Viral Hepatitis (not reported for 09) $217,000 $232,000 7%

Other $234,000 $0 -100%

Public Health Emergency Preparedness $ 5,192,034 $ 4,651,716 -10%

Public Health Capacity, Strategic Partnerships and Training (OD) $ 1,612,545 $ 1,627,600 1%

Environmental Health $ 614,686 $ 788,371 28%

Environmental Public Health Services/Research $614,686 $788,371 28%

Health Statistics $ 1,424,746 $ 1,665,361 17%

Injury Prevention $ 581,920 $ 1,452,190 150%

Unintentional Injuries $435,920 $150,000 -66%

Violence Prevention $146,000 $1,302,190 792%

Birth Defects/Developmental Disabilities $ 250,000 $ 200,000 -20%

Occupational Health $ 310,140 $ 310,140 0%

Health Marketing $ 229,000 $ - -100%

CDC Total w/o VFC $ 43,815,405 $ 45,371,807 4%

Vaccines for Children $ 64,263,901 $ 122,266,152 90%

CDC Total with VFC $108,079,306 $167,637,959 55%

ATSDR $ 682,470 $ 637,505 -7%

CDC/ATSDR Grand Total with VFC $108,761,776 $168,275,464 55%

Funding for disease-specific programs with VFC and without VFC is illustrated in the following 

pie charts:

Improving Financial Management for a stronger CDC 

Vaccines for Children 

(VFC), $122M, 73%

Chronic Disease 

Prevention and

Health Promotion, 

$27M, 16%

Infectious Diseases, 

$7M, 4%

Public Health 

Emergency

Preparedness, $4M, 

3%

Training and Strategic 

Partnerships $1.6M, 

1%

Environmental Health, 

$788K, 1%

Health Statistics, 

$1.6M, 1%

Injury Prevention, 

$1.4M, 1%

Birth Defects and 

Developmental

Disabilities, 

$200K, 0.4% 

Occupational Health, 

$310K, 0.7%

CDC Funding for Disease Specific Programs (with VFC)

 

Improving Financial Managementfor a stronger CDC 

Chronic Disease 

Prevention and

Health Promotion, 

$27M , 60%

Infectious Diseases, 

$7M, 16%

Public Health 

Emergency

Preparedness, $4M, 

10%

Training and Strategic 

Partnerships, $1.6M, 

4%

Environmental Health, 

$788K, 2%

Health Statistics, 

$1.6 , 4%

Injury Prevention, 

$1.4M , 3%

Birth Defects and 

Developmental

Disabilities, 

$200K, 0.4%

Occupational Health, 

$310M, 1%

CDC Funding for Disease Specific Programs (w/o VFC) 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

77

Funding allocation categories include the following:

AI/AN Awardees (Direct)

Competitively awarded programs (i.e., grants, cooperative agreements) where the awardee is a 

tribe / tribal government, tribal organization, tribal epidemiology, Alaska Native organization, 

tribal college, tribal university, or urban Indian Health program.

Intramural AI/AN

Intramural programs, the purpose of which is to primarily or substantially benefit AI/AN.*

*This category would include costs (e.g., salary, fringe, travel, et cetera) associated with

CDC staff or contractors whose time / effort primarily or substantially (50% or better) benefit 

AI/AN.

Extramural AI/AN Benefit

Competitively awarded programs for which the purpose of the award is to primarily or 

substantially benefit AI/AN.

Federal AI/AN Benefit

Federal Intra-Agency Agreements wherein the purpose of the agreement is to primarily or 

substantially benefit AI/AN.

Indirect AI/AN

Service programs for which funding for AIs / ANs can reasonably be estimated from available 

data on the number of AIs / ANs served** 

**This category applies only to the Vaccines for Children program and to NCHS. 

In comparison to 2008, 2009 indirect AI/AN awards (with VFC) increased from $65 million to 

$123 million. Funding allocation categories aligned with disease-specific programs (with VFC)

and a comparison of allocation categories for fiscal years 2008 and 2009 are reflected in the 

following tables:
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

78

Improving Financial Management for a stronger CDC 

CDC Funding Allocation Categories Aligned with 

Disease Specific Programs (with VFC)

Disease Specific Programs AI/AN

Awardees

Intramural 

AI/AN

Extramural 

AI/AN

Federal 

AI/AN

Indirect 

AI/AN

Vaccines for Children (VFC) $122,266,152 

Chronic Disease Prevention 

and Health Promotion $20,590,186 $1,166,791 $3,931,499 $1,679,711 

Infectious Diseases $2,295,195 $3,993,353 $485,000 $534,694 

Public Health Emergency

Preparedness $4,651,716 

Training and Strategic 

Partnerships (OD) $596,905 $878,585 $124,140 $27,970 

Environmental Health $230,209 $552,270 $5,892 

Health Statistics $1,665,361 

Injury Prevention $141,717 $1,160,473 $150,000 

Birth Defects and 

Developmental

Disabilities $200,000 

Occupational Health $310,140 

CDC Funding Allocation

Categories - Grand Totals $23,854,212 $6,790,999 $10,662,968 $2,398,267 $123,931,513 

 

Improving Financial Managementfor a stronger CDC 

CDC Funding Allocation Categories 

for FY 2008 and FY 2009

Funding Allocation With VFC Percent Without VFC Percent 

Category FY 2008 FY 2009 Change FY 2008 FY 2009 Change

AI/AN Awardees $22,839,514 $23,854,212 4% $22,839,514 $23,854,212 4%

Intramural AI/AN $6,856,724 $6,790,999 -1% $6,856,724 $6,790,999 -1%

Extramural AI/AN $10,687,986 $10,662,968 -0.20% $10,687,986 $10,662,968 -0.20%

Federal AI/AN $2,006,435 $2,398,267 20% $2,006,435 $2,398,267 20%

Indirect AI/AN $65,688,647 $123,931,513 89% $1,424,746 $1,665,361 17%

CDC Grand Total $108,079,306 $167,637,959 55% $43,815,405 $45,371,807 4%

The following pie charts reflect the AI/AN 2009 funding allocation categories with the VFC and 

without the VFC: 

Improving Financial Management for a stronger CDC 

AI/AN Awardee, 

$23M, 14%

Extramural AI/AN, 

$10M, 6%

Federal AI/AN, 

$2M, 2%

Intramural, $6M, 

4%

Indirect, 

$123M,51%

AI/AN FY 2009 Funding Allocation Categories 

(with VFC)

 

Improving Financial Management for a stronger CDC 

AI/AN Awardees 

, $23M, 53%

Intramural 

AI/AN, 

$6M, 15% Extramural 

AI/AN, 

$10M, 23%

Federal AI/AN, 

$2M, 5%

Indirect AI/AN, 

$1M , 4%

AI/AN FY 2009 Funding Allocation Categories 

(w/o VFC) 

AI/AN Fiscal Year 2009 funding (with VFC) in the amount of $168 million represents 2% of the 

total CDC / ATSDR budget, while the $45 million in AI/AN funding represents 1% of the total 

CDC / ATSDR budget. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Grants to tribes broken down by state, by HHS area, and by IHS area are reflected in the 

following three maps respectively:

Improving Financial Management for a stronger CDC Improving Financial Management for a stronger CDC Improving Financial Management for a stronger CDC 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

80

In the above maps, green boxes represent the Tribal Epidemiology Centers and the stars are 

the actual project locations of the awarded tribal programs. These maps depict only those funds 

that are directly awarded to tribal government, tribal organizations, Alaska Native health 

corporations, urban Indian organizations, and tribal colleges.

TCAC CDC / ATSDR strategic funding direction is to engage in sub-budget committee 

collaboration; expand division-based involvement for health impact across CDC / ATSDR; 

engage in program project initiatives with CDC / ATSDR Financial Strategies Committee; 

increase visibility in budget submission health initiatives; align with CDC / ATSDR health goals 

and objectives for performance- and results-based management; and collaborate further with 

HHS and operating division (OPDIV) shared resource initiatives.

While unable to gain any information on the American Recovery and Reinvestment Act (ARRA) 

funding before this session, Mr. Curlee said he would hopefully be able to provide further 

information on this later. Though Mr. Curlee said he was also not certain what would be taking 

place regarding 2010, Dr. Frieden has alluded to a separate track regarding tribal activities, and 

that further information would be provided regarding that issue once some firm decisions were 

made regarding awards. Funding has been worked out the HHS on some of the ARRA funding 

activities that NCCDPHP will be managing. 

Based on the comments throughout the day, it was clear that consideration must be given to 

how to make awareness of the tribal health activities funded by CDC more recognized. As 

evident in the funding provided previously, there is a cross-cutting network of activities with the 

CDC centers. While NCCDPHP is certainly a major contributor in that process, other centers 

are also engaged and involved. Early planning is very important. 

Mr. Curlee noted that in a few days, the Fiscal Year 2011 budget would be rolled out by 

President Obama, which would include the HHS and CDC budgets in the huge package that 

would be provided for the public to see. Unfortunately, they were past the point for adding 

anything to the 2011 budget. However, FMO will soon be working on the 2012 budget 

initiatives, and CDC‘s 2012 budget will be provided to HHS by the end of May 2010. FMO will 

soon begin to work with CDC‘s program offices and centers to develop strategies. This 

represents another opportunity to approach health awareness for tribal nations and try to 

provide AI/AN activities in the process. The challenge is trying to put that together into a

template and narrative that can be understood and can make a difference in health activities, so 

that CDC can review and consider that as they move forward in the budget process. This will 

begin with HHS initiatives that will be provided in the early submission. Hearings will also take

place. During the summer, the Secretary‘s Budget Council will take place, which Dr. Frieden 

will be a part of. Later in September, CDC‘s submission request will be provided to the Office of 

Management and Budget (OMB). OMB will respond to CDC after working with HHS. About this 

time next year, the 2012 budget will be submitted for rollout as well. The budget cycle is a 

major process with a number of timing aspects. Mr. Curlee emphasized that tribal leaders give 

thought to potential initiative project-type areas that CDC could work with and work with tribes in 

considering moving forward.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

81

Discussion Points

 CAPT Snesrud pointed out that this year there are 78 cooperative agreements, while last 

year there were 76. At a time when dollars available have decreased, Tribes have 

increased awards received. There were two additional Tribal grantees and $1 million 

increase over FY 2008. That said, there is also great diversity in the type of awards made to 

Tribes and Tribal organizations. Several of the major program categories ended and new 

ones developed as heard from NCCDPHP, so the players have changed. But in a time of 

having to do more with less, Tribes grantees have been able to increase both in the number 

of awards and in the total amount of resources. 

 Ms. Hughes thought it was good to have the opportunity to consider submission of a project 

for 2012. The HHS consultation will be in March in Washington, DC but it is too late to have 

any serious impact there. However, they hope to be on the front in for the 2012 budget and 

to have some real-time input into the budget planning process. If they could think of some 

type of project initiative for consideration, that would be really great.

 CAPT Snesrud added that CDC and TCAC have been having this discussion about the 

budget for some time. The relationship between CDC and TCAC has been evolving both in 

understanding each other better and in building trust to enable us to work together more. 

We have now reached a juncture at which Tribes need to process and determine how to 

utilize the tools FMO spoke of to influence CDC‘s budget planning. A few TCAC members 

previously tried to establish a TCAC Budget Subcommittee but it seemed that Tribes 

knowledge of how to they could influence CDC‘s budget was yet not fully understood. 

Although it is true that all federal agencies have the same federal budget timeline, CDC is 

unique in that we address the public health needs of the whole nation, including AI/AN 

Tribes and people. What she heard Mr. Curlee and Mr. Franklin saying was that they are 

available as resources to answer questions, work with TCAC, and provide examples of 

projects that CDC has supported in the past. She encouraged TCAC to consider the reestablishment of that budget subcommittee. 

 Ms. Hughes expressed her appreciation of the presentations they had heard, because there 

are many programs within CDC that tribes are not aware of on a routine basis. Even when 

they do receive funding, they still fall within that one focused category for five years and do 

not necessarily know about all of the other resources that are available. Gaining a 

grassroots understanding of what CDC has to offer is very important for TCAC. 

 Ruth Ojanen indicated that Norton Sound Health Corporation, where she is a board 

member, is in Northwestern Alaska. She stressed that during the last TCAC meeting, while 

the site visit to Anchorage to the beautiful medical center may have given some the 

impression that tribes have it really good there, the only travel into her area of Little 

Diomede is by airplane. Their roads are more like trails than roads, and they are closed in 

the summer. They were without passenger service for four months in the Bering Strait. 

While they had some helicopter services, there are regulations. The only way they could get 

off of the island was in a medical emergency, and the National Guard had to come. They 

had an outbreak of H1N1, so a team of doctors and other professionals did travel there by 

helicopter and worked around the clock for two days to treat those patients and immunize 

others. They took four patients back with them, but then at some point the patients needed 

to get back to Little Diomede. That is, Alaska is not Anchorage. There are high rates of 
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suicide in certain areas, but based on the resources on the map, it is all centered in 

Anchorage. While they appreciate Anchorage and the medical center, access is not easy 

for many rural residents. She stressed that she meant no disrespect to the Anchorage 

facility because she herself would go there, but she wanted to drive home the point that 

many people are remote and have few if any services. 

 Ms. Hughes said that brought to mind what the Aberdeen Area was experiencing with the 

snow storms.

 Dr. Bryan pointed out that on the map shown by Mr. Curlee that made it appear that 

resources were all centered in Anchorage, the green box was simply the Tribal 

Epidemiology Center because they wanted to point out where that was located. The stars 

represent several places outside of Anchorage. From what he knows about the funding 

stream from CDC to Anchorage, virtually all of the resources go to fund activities outside of 

Anchorage. He suggested that perhaps they could develop a different map to better 

illustrate where the resources are, and stressed that they realize that Anchorage is not all of 

Alaska.

 Regardless of the programs through which funds are allocated to tribes, Mr. Finkbonner 

pointed out that in the State of the Union Address, the President would announce that he 

plans to fix the FY 2010 budget for the next 10 years. He wondered what impact that would 

have on resources for the tribal programs. Shifting allocations could pose a greater concern 

for tribes. It is important to be mindful of the AI/AN health disparities, and if they really want 

to make a difference in the overall US health disparities, it is important to focus on the 

populations that have the greatest disparities. 

 Mr. Valdo said that while it was great to see the $1 million increase, it was not enough. He 

always becomes depressed during these meetings when he sees American Indians at the 

top in the categories even though they have the least numbers in terms of population. He 

took one of Mr. Curlee‘s statements as an open invitation to offer an idea for a study that 

perhaps could be incorporated into the budget. He would like to see that the overall budget 

allocated to tribes doubled. Their number one wish is to have their own Tribal Block Grant 

so that they are not fighting with the states anymore. This is currently a major hurdle. It was 

very good to hear the support from each of the groups which spoke regarding getting more 

support to the tribes. That is a major shift. To hear FMO say that as well was very 

enlightening. However, while it is nice to be screened, what then? What good is a test 

result when there is no one to take care of the results? Consideration must be given to 

ways to develop sustainable long-term programs within tribal communities. He requested 

further input from FMO about what might be a good initiative to put forth for the next budget 

cycle.

 Mr. Franklin agreed that it would be beneficial to have further input from FMO to offer some 

details about what a suggestion might look like. Should it be a wish list or something that 

has been implemented in a previous funding cycle that should have a tribal add-on?

 Mr. Curlee responded that they would provide, through CAPT Snesrud and Dr. Bryan, some 

type of template and some ideas to use as a framework. They can also provide good data. 

CDC‘s major mission is about prevention. He challenged TCAC to step up in order to take 

advantage of the opportunity to be considered in the budget cycle above where they have 
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been to date. A lot has to do with how ideas are presented and what catches the eyes and 

ears of Congress. 

 Regarding current fiscal funding, Ms. Hughes inquired as to what CDC does with unspent 

dollars and whether there was a way that tribes could be considered for access to the 

unspent dollars.

 Mr. Curlee replied that at times, some programs do not spend all of their funds. The 

challenge for year-end spending is that proposed activities much be able to be processed 

through the Procurement and Grants Office (PGO) rapidly. A new grant will not get through 

this process. A supplemental is a possibility, as is a contract option that could be modified 

quickly that does not require a competition period. The agency sets priorities for any 

possible funding that might be available, how it can be utilized, and the conditions it can be 

met on. Sometimes this is related more to infrastructure activities at CDC because they are 

easier to process in a hurry. For example, information technology is very important at CDC, 

so they are sometimes able to make quick purchases for IT network equipment and such. 

They would probably also work through the national centers‘ program offices to consider 

priorities that they may have for any available funds that could take place in September as 

well. For example, working through NCCDPHP, perhaps something could be brought to 

light and if funding was made available and could be rapidly process, it would be 

considered. 

 Dr. Bryan pointed out that year-end funds are typically problematic. They always think that 

there is a windfall, and it is great, and they should jump on them. However, there are the 

practical issues of moving them out the door—spending them. Consideration must be given 

to how CDC spends the funds as an agency, who they should send them to, who can 

receive them efficiently, whether they are restricted from appending these funds to an 

existing cooperative agreement, et cetera. Then there is the issue that these are one time 

funds, so it is difficult to build programs and hire staff based on those funds. While it is not a 

bad idea and such requests are always considered, there are realities. For $10,000 to 

$20,000 it is not worth the effort unless there is a very easy niche for those dollars. This is 

becoming increasingly more difficult to do. While he understands how wasteful it is if they 

cannot spend year-end funds, he has a dismal opinion of these funds just because of the 

practicalities. They must think creatively together about the realities of using those funds 

and getting them out the door.

 A CDC representative suggested that to alleviate some of the rush, they have a couple of 

one-page ideas already prepared. Her program funded a great project in Alaska with yearend funding of $150,000 to conduct a self-collected screening project. It is one-time, but it is 

still a good thing to do on a proactive basis.

 Mr. Trudell pointed out that there are a number of studies, best practices, et cetera. They 

must think about how to tie all of those together and assess them and assess communities 

so that these can be implemented to other communities. Each community is different. 

Perhaps they could develop a plan to put together a team of health educators who would 

visit the communities to help them conduct an assessment to implement these things. If the 

communities do not know how to implement programs and do not have the funds to do it 

themselves, why not use some of the year-end funds to have teams work on this.
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 Dr. Bryan noted that if they had some boilerplate, ready-made plans, perhaps they could 

include some language in new FOAs being published that would offer some flexibility for 

moving money out if it became available. They would have to clear this with PGO. There 

are a couple of FOAs in the works that will target Indian Country. It will require being ready 

to receive. If they have cooperative agreements with national organizations, coalitions, or 

groups of tribal organizations of some sort with a pretty broad initiative, this could be a place 

for a legitimate tag on should funds become available. 

 Mr. Curley indicated that the Indian Health Board receives PHEP funds through the State of 

Nevada, and has a great relationship with them. One problem they have experienced in 

Nevada with the carry forward funds at the end of the year is that the program year begins in 

August of each year. They begin developing their applications in January, submit them on 

time, but do not receive the notice of award until December or January of the following year. 

This gives them only about four months within which to spend a tremendous amount of 

funds, and then they are told they can only carry a certain amount over, or that they are one 

time funds that cannot be carried over. They have to spend the previous year‘s carry over 

first. That puts programs back. Things that should have occurred in the beginning are 

having to be carried forward. Funds become mixed and it is then unclear how to carry these 

forward. The timing of when funds are dispersed creates these types of issues, at least in 

Nevada. Recently funds came out and the IHS was requested by the state to match these 

funds with tribal funds. They submitted a plan that said they would use 638 funds to match 

those funds. It took three months to correct the misperception that those were federal 

dollars and federal dollars cannot be matched with federal dollars. Somewhere within CDC, 

there are people who need to understand that 638 funds can be matched with CDC dollars.

He wished they could find a way to streamline the financial award system so that they do not 

have to constantly make carry forward requests.

 Mr. Curlee responded that they have been reviewing this for some time, particularly with 

respect to the preparedness grant that goes out late in the year. There is an initiative 

underway within CDC currently. One of the objectives is to try to move many of the fourth 

quarter activities at least into the third quarter, and sooner if possible. This has been raised 

before the Management Council. This will take a significant amount of work in terms of 

making changes in performance periods, grant periods, and going through recycle areas. 

As they engage in this process, they will work on communications with partners as well. It 

takes time, but if done correctly, award and funding announcements can come out earlier in 

the process. This is a major goal at CDC. While he could not say that it would be 

accomplished within this year, the goal is to make major steps this year. He indicated that 

he would take these comments back to the committee. 

 Ms. Begay expressed the same concerns stated by Mr. Curley. Navajo Nation receives 

funding through two states, New Mexico and Arizona. Those two states have their own 

complex financial systems. When the funds finally get to the Navaho Nation, the Navaho 

nation as a tribal government has its own complex financial system. The timeline gets even 

longer due to this. Their bioterrorism preparedness program has had to deal with those 

situations. The Navaho Nation has developed recommendations and expressed concerns 

about this situation; therefore, the Navajo Nation has submitted numerous concerns and 

position statements to CDC through various forums requesting consideration for direct 

funding to the tribes rather than through the states. This is a great concern and the Navajo 

Nation intended to express this during the consultation with Dr. Frieden on January 28, 

2010.
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During this session, the group attempted to set a time for the next TCAC teleconference and a 

location / host for the next face-to-face meeting. CAPT Snesrud suggested institutionalizing 

regular times of the year for face-to-face, as well as a standard timeframe for teleconferences. 

It was agreed that Fridays during the 1:00 PM EST timeframe seemed to work best for the 

teleconferences as a rule, while the end of January to the end of February and August worked 

best for the two face-to-face meetings. Given the number of other meetings already scheduled 

and a variety of conflicts, it was agreed that everyone would return home, review their 

schedules, and email CAPT Snesrud with their availability for the next teleconference. A 

suggested date of the second week of February was made for the next teleconference. CAPT 

Snesrud stressed the importance of scheduling a teleconference as soon as possible to address 

the issue raised by Mr. Curlee regarding the possibility of submitting a special project for 

funding. Ms. Sebattus offered to check whether Niagara could host the next face-to-face 

meeting. 

With no further comments, questions, or business posed, the meeting was officially recessed 

until 8:00 AM EST the next day. 

Wednesday, January 27, 2010

CAPT Snesrud called the meeting to order, followed by which Mr. Secataro offered the morning 

prayer. Ms. Hughes requested that everyone sign the Talent / Consent Waiver to be submitted 

to Natalie Greene from MTC, given that photographs would be taken during the consultation on 

January 28, 2010.

Annabelle Allison, PhD

Tribal Liaison / Lead Public Health Scientist

Office of Tribal Affairs (OTA)

National Center for Environmental Health (NCEH)

Agency for Toxic Substances and Disease Registry (ATSDR)

Centers for Disease Control and Prevention (CDC)

Dr. Allison indicated that the Agency for Toxic Substances and Disease Registry (ATSDR) was 

created by Superfund Law in the 1980s to protect health and environment from hazardous 

substances. ATSDR is really known and recognized for conducting various types of public 

health assessment of waste sites, health consultations, health surveillance, registries, and 

Open Discussion / Recess

Call to Order and Opening Prayer

NCEH / ATSDR
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

86

training / outreach. The National Center for Environmental Health (NCEH) is part of CDC. 

About four years ago, NCEH and ATSDR merged to some extent because they both address 

environmental health topics. NCEH is the lesser known of the two entities, and is really known 

for its research to investigate effects of environment on health in the laboratory and the field. 

They also conduct some surveillance and engage in environmental emergency response and 

education and training.

The past year has been very busy. Dr. Allison has been in the Office of Tribal Affairs (OTA) just 

under two years. Much of what she has been doing has pertained to gaining visibility and 

conducting outreach on behalf of her program and NCEH / ATSDR. She has attended several 

conferences, meetings, and forums to advocate for a tribal voice and input into the NCEH / 

ATSDR national conversation and has very active in coordinating efforts with the Navajo Nation 

and others regarding uranium assessment and remediation. This year was the last year of a 

five-year cooperative agreement with two Tribal Colleges and Universities: Turtle Mountain 

Community College in North Dakota and Dine College in New Mexico. One of her efforts during 

2010 will be to find additional funding to continue OTA‘s efforts with Tribal Colleges and 

Universities. She hopes to increase the number of AI/AN in public health and environmental 

health careers, and to work with Tribal Colleges and Universities to further their accreditation 

programs. Related to visibility will be collaborating internally and getting herself known to the 

various divisions within NCEH and ATSDR and working with them on various projects.

The most recent announcement is that effective January 15, 2010, Dr. Howard Frumkin, who 

was the Director for NCEH / ATSDR, accepted a new role as Special Assistant to the Director 

for Climate Change and Health. Temporarily in his place is Dr. Henry Falk, who is serving as 

the new Acting Director for NCEH / ATSDR. A search for a permanent replacement is 

underway.

For 2010, Dr. Allison has activities planned regarding the NCEH / ATSDR National 

Conversation, the goal of which is ―To create an action agenda for strengthening our nation‘s 

approach to protecting the public from harmful chemicals.‖ This will be 18 months in length and 

includes a myriad of partners and the public. In mid 2009, Dr. Frumkin and others created this 

National Conversation to go across the country to determine how they could improve the 

services that NCEH / ATSDR offer. Dr. Allison has strongly advocated for tribal representation. 

She met with national tribal organizations on 9/11/09 in DC to share information about the intent 

of NCEH / ATSDR and to hear about ways they could get the word out to Indian Country about 

the National Conversation. The National Conversation has six workgroups and tribal 

representatives, which are as follows:

 Scientific Understanding: Susan Hanson, Shoshone Bannock Tribe

 Policies & Practices: Kristin Hill, Great Lakes Inter-Tribal Epi Center

 Chemical Emergencies: Syndi Smallwood, Pechanga Band of Luiseno Indians

 Serving Communities: Steve Crawford, Passamaquaddy-Pleasant Point Tribe

 Education & Communication - Rosemary Ahtuangaruak, Inupiat Community of the Arctic 

Slope

 Monitoring: Nancy John, Cherokee Nation

OTA‘s goals and strategies or the National Conversation is to develop a national tribal 

environmental health group to be composed of the six workgroup representatives, tribal 

professionals, national tribal organizations, and federal agencies. The purpose of this group will 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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be to provide support to the six workgroup representatives and assist OTA with identifying 

priorities of tribes and develop a strategic plan.

Regarding the health and environmental impacts of uranium on the Navajo Nation, in which Dr. 

Allison has been heavily involved, mining was done on the Navajo Nation from 1944 to 1986. 

Approximately 4 million tons of uranium ore were mined and milled. There are 500+ abandoned 

uranium mines, 4 inactive milling sites, former dump site, contaminated groundwater, and 

structures built with contaminated materials. There have been Congressional hearings since 

the 1990s. In October 2007, testimony was offered before the House Oversight & Reform 

Committee. Representative Henry Waxman (CA) and select committee members requested 

five federal agencies (e.g., EPA, IHS, BIA, DOE, NRC) to develop a five-year plan to assess 

and remediate. They meet every six months to provide updates on their progress. In 2008,

CDC / NCEH Health Studies Branch provided technical support to the EPA and IHS on a water 

and urine sample study at certain households. In September 2008, Representative Waxman 

requested NCEH / ATSDR to participate in the progress report meetings. 

In December 2008, as part of the NECH / ATSDR efforts to assist the IHS, they conducted 

Grand Rounds Training at five IHS clinics to inform physicians about the impacts of uranium on 

the Navajo people and to give them some guidance on how to diagnose and screen for patients 

who suspect that they have been exposed to uranium. In July 2009, shortly after a couple of 

water studies were conducted and sample analyses were finalized, NCEH / ATSDR provided 

training to CHRs who have been crucial in helping to get the word out about the on-going 

studies and informing the various communities about the impacts of uranium and what it means 

for them, and recruiting them to participate in the water sampling and urine sample collection. 

The training focused on how to disseminate sample results back to the community members. In 

preparation for this training, NCEH / ATSDR developed a booklet that the CHRs take to 

households as they talk about uranium. The book includes CHR talking points and information 

that the household members will see. This is a very effective tool, and the concept was to give 

the CHRs information that they could feel comfortable about discussing. Much of the 

information was translated into the Navajo language. 

In FY 2010, there is potential funding coming down the pike for ATSDR to conduct an 

epidemiological study of non-occupational health impacts from past mining and milling 

operations. They are waiting now for confirmation. Once that occurs, they will release an FOA. 

The majority of the funds will be allocated externally for an entity to conduct the epidemiological 

study. While ATSDR will not conduct the study, they will offer guidance and oversight regarding 

the design and implementation. Because this is an epidemiological study, they are hoping to 

have continued funding for at least three years. However, this will depend on the amount of the 

funding allocation.

In closing, Annabelle Allison said she hoped to get out to Indian Country more during 2010 to 

visit with tribal communities. She also shared her personal contact information: 770-488-3991; 

AAllison@cdc.gov.

Discussion Points

 Mr. Secatero indicated that in the village next to where he lives called, trains were being 

filled up and moved out without covers, so the wind blew dust on the grass. The animals 

were exposed to it. Years later, many people complained about stomach pains and there 
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are many stomach cancers due to this mining. He wondered whether Dr. Allison had heard 

anything about reopening some of the mines.

 Dr. Allison responded that a couple of exploration companies have gone back to New 

Mexico to see if they can find uranium to mine. There is political controversy because they 

are thinking of exploring or have explored areas near the Grand Canyon, which is adjacent 

to the Navaho Nation. The New Mexico Legislature has had meetings about this beginning 

in the Fall of 2009. They are thinking about trying to do something similar to what the 

Navajo Nation is doing in terms of assessing the impacts of mining. There are numerous 

issues the pueblos are dealing with, and she expressed her hope that they would be able to 

find the funding to conduct further assessments. As far as exploration goes, it is back and 

forth in terms of support. For economic reasons, people in the area need jobs and they 

have to balance that with some of the environmental concerns that surface as a result of 

that. It is up in air in terms of whether mining will move forward.

 Ms. Begay indicated that this was the first time she had met Dr. Allison, although she had 

been to the Navaho Nation numerous times. Navaho people call the uranium ―yellow cake.‖ 

There are numerous horrific stories about the tragedy and death this yellow cake has 

brought upon the Navaho people and the Navajo Nation. They have heard stories about 

children who have played in contaminated water, and spouses whose husband worked in 

the mine and came home and shook off their clothing, the dust from which their families 

inhaled, causing pain and suffering. They have also heard of children playing the mines that 

were left open when companies moved away. Overall, the Navaho Nation has staunchly 

opposed anymore uranium mining on the Navajo National. The Navaho Nation President, 

Joe Shirley, has offered a great deal of testimony. The Navajo Nation Division of Health 

Director has submitted numerous written testimonies and offered oral testimony. It took a 

combination of efforts on the Navajo Nation by numerous bodies of Navaho groups, and 

people adversely affected by uranium. Dr. Klaus has offered endless technical and 

professional expertise. Their attorneys have collectively worked together to cease any 

further discussion about uranium mining on the Navajo Nation and to request a long-term 

study assessment on the adverse effects of uranium on the environment and on human 

health. Therefore, she was very encouraged to hear about this potential funding to conduct 

assessments. They have requested that CDC and ATSDR engage and be part of the five 

federal agencies to play in a central role in conducting research and assessments. The 

Navajo Nation has requested that these two agencies also prepare a five-year coordinated 

plan and budget development to support the five-year Waxman plan. She said she was 

encouraged to hear this report and indicated that she would take the information back to the 

Navajo Nation. 

 Dr. Klaus added that the Navajo Nation CHRs did a fantastic job. They conducted every 

single interview in a very short time. She did not know any other group of people in world 

who were called on regularly to put aside their own work to do all of these extra things. 

 Mr. Valdo expressed his hope that the study would include the neighboring communities, 

because not only Navajos, but also others worked in the mines. There have been over 200 

applications by mining companies for pilot programs to locate the best quarries. He did not 

think these companies would spend money for 200 pilot wells for nothing. Uranium ore 

used to be over $1,000 per pound, so it is very lucrative. Ultimately, they would like to be 

able use the results of the study to fight the mines. It has been an ugly battle and racial 

tensions have escalated. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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 Mr. Antone inquired as to what CDC had done following their commitment to Alaska to help 

the Navaho Nation.

 Dr. Allison responded that in August 2009 during the last TCAC meeting, there were 

representatives from the NCEH Health Studies Branch who have conducted the most 

comprehensive studies on ATSDR‘s behalf. They continue to be committed to work with the 

EPA on additional water sampling at unregulated wells that have been identified. There are 

several on the reservation, and as they talk to families are finding out about ones they 

missed in the first round of sample collection. They have visited those additional wells and 

have offered to collect additional urine samples from individuals who are interested in 

learning whether they have been exposed. She indicated in the CDC Recommendations 

and Responses, #24 speaks specifically to the Navajo Nation, and that in their briefing 

books there was a longer summary of two studies conducted thus far. They have not been 

able to make a connection between what is in water and human health exposures to 

uranium, so there are other things causing exposure. There are many pathways that are not 

necessarily thought of that are out of the box, like workers bringing the dust home on the 

clothes they wear, the family members who washed those clothes, children playing on the 

floor where a person walked and dropped materials, children playing on tailing piles, et 

cetera. Different about ATSDR‘s study is that they are focusing on non-occupational 

exposures. They also anticipated additional work with EPA and IHS related to uranium. In 

terms of Alaska, the Health Studies Branch also presented on some of the work they would 

like to do in that area, and that is moving forward as well.

 Kristin Hill, the Policies and Practices Work Group representative of the National 

Conversation work groups, said she was pleased to have the support of Kathy Hughes, who 

advanced her name forward to apply for this role. She was honored and pleased to be 

selected for the role. The Policies and Practices Work Group has have had several phone 

conversations, and their first in-person meeting convened in November in Washington, DC. 

They have developed the charge, which she believes almost has the support of the full 

group. This has been a challenge to listen to the multiple perspectives of all of the various 

agencies, advocacy groups, business interests, et cetera. These groups can be highly 

charged and there are a lot of smart, energetic people on all sides trying to hash out these 

issues. This group has sense that they will achieve some common ground. She has been 

thinking about how to talk to the TCAC more about policies and practices, and requested 

input regarding how she might connect with them in a two-way conversation.

 Dr. Allison said that the creation of the Environmental Health National Group she was 

hoping to establish would provide additional input and feedback on some of the views and 

perspectives. It really is meant to be a two-way support system.

 Mr. Antone said they are beginning to see mines coming back like the Rosemont Copper 

Mine and the possibility of exploration in the Grand Canyon, so there is a multitude of issues 

across Indian Country. This is a good time to bring that working group together.

 Steven Matles from the Indian Health Board of Nevada thanked Dr. Allison and said that she 

sold herself short. ATSDR helped them with a methamphetamine summit. One of the major 

takeaways from that summit for the folks from the tribal clinics and the CHRs pertained to 

the secondary effects of methamphetamine in children. It has helped a number of tribes in 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

90

his area with early detection so that appropriate interventions can be instituted fairly early, 

particularly in that population.

 Dr. Allison indicated that ATSDR has regional representatives who share space with 

different EPA regions. There are 10 regions and ATSDR has representatives in all of them. 

Libby Vianu is the Region 9 representative. She is very passionate about working with 

tribes in her area. Dr. Allison indicated that she would pass along Nevada‘s appreciation to 

her. She has kept Dr. Allison updated on the activities, and Dr. Allison was happy to hear 

that the experience was positive.

 Mr. Franklin said it was disturbing to hear 1950s Indian policies coming back into Indian 

Country. He encouraged tribes to help fight it on that front to help Dr. Allison, and that the 

NIHB would what they could, as would California to contribute to the effort (e.g., resolution, 

et cetera) he encouraged ATSDR to reach out and let them know, especially NIHB. It is 

even scarier to hear that the issue is being pushed. The Supreme Court made their 

decision and they can contribute as much as they want now. All tribes must support each 

other.

 Ms. Hughes reminded them that the previous day, a reference was made as tribal status for 

treatment as a state under the EPA. That is also a very effective tool. A company wanted 

to open a mine in Upper Michigan. Through the formal process with EPA and the status of 

treatment as a state, the tribe had their input and was able to prevent it. More tribes need to 

take advantage of that policy and practice.

 Mr. Trudell reminded everyone that there are also uranium and mining problems in Western 

South Dakota stemming from mining in the Black Hills. He requested that ATSDR keep this 

in mind as they conduct their studies.

 In response to Mr. Franklin‘s comments, Dr. Hill said that the tone and nature of the work 

group participants is going is to be proactive, with policies to examine potential impacts 

before they occur. That is, they want issues addressed in the form of health impact studies 

before mining or any other environmental issue takes place, rather than spending money to 

assess something after it has already occurred.

 Ms. Hughes inquired as to how CDC / NCEH / ATSDR could be a formal participant on the 

Waxman group.

 Dr. Allison responded that a request would have to go to Representative Waxman and the 

committee. Despite their informality, they are participating actively. Regarding some of 

NCEH / ATSDR activities, she has 16 pages of various activities, but she wanted to keep 

her presentation short. However, she did not want to sell short the fact that NCEH and 

ATSDR representatives are working diligently on various tribal projects. She said she was 

very happy to report that in 2010, all of the divisions within NCEH and ATSDR have some 

tribal projects, which she thought was great. In response to Dr. Hill‘s comment about 

examining issues before they occur, Health Impact Assessments (HIAs) are becoming very 

popular. These assess the impacts of public health prior to the development of a facility, 

plant, et cetera. These are often being conducted in conjunction with National 

Environmental Policy Act (NEPA) studies. Europe has used HIAs pretty effectively over the 

past few years. This practice is beginning to be adopted in the US more. Alaska has used 

the HIA process to assess potential mining sites. It is information currently in that there is no 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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rule or regulation that mandates this, but there can be a push to look at public health impact 

proactively. 
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Dr. Ralph Bryan, Senior Tribal Liaison for Science and Public Health

Centers for Disease Control and Prevention (CDC) /

Agency for Toxic Substances and Disease Registry (ATSDR)

CAPT Mike Snesrud, Senior Tribal Liaison for Policy Evaluation

Centers for Disease Control and Prevention (CDC) /

Agency for Toxic Substances and Disease Registry (ATSDR)

Dr. Bryan explained that the document provided to TCAC members titled ―A Summary Report 

for the 4th Annual CDC Consultation January 28, 2009: Resource Allocations, Strategic 

Partnerships, and Capacity-Building‖ is basically the CDC component of the HHS annual report 

just packaged separately for TCAC‘s use. This is a comprehensive highlight similar to the 

presentations delivered the previous day of all of the activities across the agency that deal with 

Indian Country. The first page of this document is a synopsis of what was presented the 

previous day by Mr. Curlee of FMO about CDC‘s resource allocation. This is a nice overview of 

CDC‘s general responsiveness to TCAC and the Tribal Consultation Sessions convened over 

the years. Not everything is listed, but it is fairly comprehensive. The document provided to 

TCAC members titled ―CDC Tribal Consultation Advisory Committee (TCAC) Update on 

Recommendations / Response January 2010‖ lists 24 of the cumulative formal 

recommendations since the inception of TCAC in 2006. The recommendations are listed more 

or less chronologically. He and CAPT Snesrud will continue to add to this list as formal 

recommendations are delineated during TCAC meetings and Tribal Consultation Sessions. No 

recommendations have been removed from the list to date as completed and done, because 

many of the activities, once implemented, are on-going. Some of the activities are partially 

implemented, in progress, or in transition. Of the 24 formal recommendations, a number have 

been implemented and are on-going. During this session, he and CAPT Snesrud wanted to 

give TCAC members an opportunity to respond this document, offering feedback with regard to 

whether this format is the most useful versus more succinct, tabular type matrixes presented in 

the past, which are shorter but contain less detailed information about what CDC has been 

doing in response to the recommendations.

CAPT Snesrud added that what they mean by ―CDC having an open door policy‖ is that 

although they do convene two specific bi-annual Tribal Consultation Sessions during which 

testimony can be provided by any and all tribal leaders, Tribal leaders still have the option to 

provide testimony and/or consult with CDC at any of the HHS regional and national sessions, 

and any individual Tribe can choose to request a program specific or broader consultation to 

address their questions and concerns. As in the past, Tribes can always submit inquiries, 

testimony, or recommendations if unable to attend the in-person TCAC meetings or Tribal 

Consultation Sessions. Regarding the previous day‘s discussions about where the proponent 

for Tribal Affairs will be within CDC and the proposed new OSLS, she referenced participants to 

the bottom of page 3 of the ―CDC Tribal Consultation Advisory Committee (TCAC) Update on 

Recommendations / Response January 2010.‖ She also drew their attention to pages 8 and 9 

of this document regarding specific resources that are building on an orientation to tribal leaders 

to understand more about CDC. 

CDC in Response to TCAC Recommendations / Organizational Improvements
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Discussion Points

 Responding to an inquiry from Mr. Franklin, CAPT Snesrud indicated that since April 2008, 

the Office of Minority Health and Health Disparities was in the Office of the Chief of Public 

Health Practices of which Dr. Bailey was the Chief. She noted that they would hear more 

later in the day during the overview about the CDC reorganization and proposed new 

organization of the agency.

 Mr. Trudell expressed concern that typically when there is reorganization, the entire 

education process must start over in terms of the tribes‘ positions, feelings, what they are 

trying to attain, et cetera and tribes must relearn everything about the new organization. It 

seems as though every time tribes begin to make headway, the ―rug is jerked out from under 

them.‖

 CAPT Snesrud replied that Tribes ―hit the ground running,‖ and were picking up momentum 

in the journey of assisting CDC and the Tribes to work and partner together. In particular, 

the TCAC has greatly lead this effort. CDC is gaining a much greater knowledge and 

understanding of the sovereignty of tribes and the government-to-government relationship

and has come a long way to increasing Tribal access to is resources. 

 To allay Mr. Trudell‘s concern, Dr. Bryan added that the agency was undergoing what was 

termed an ―Organizational Improvement Process,‖ so it is not a reorganization per se. It is 

just an enhancement of the existing organization. That is a nuance, not a dodge. In terms 

of the OSLS, TCAC‘s recommendation early on to consider a Tribal Office has been taken 

very seriously in this process. He said he thought they would be pleased with the results 

when they heard more about what was in the works in terms of more formally establishing a 

Tribal Office, unit, entity, and organizational structure within the OD family of offices at CDC 

that includes a commitment from the agency to provide additional staff and adequately 

resource that office so that they can do a better job of serving tribes. He assured them that 

much of what was occurring was because of TCAC‘s input to date. Dr. Bryan and CAPT 

Snesrud are fairly optimistic and pleased with the way things are currently headed. 

 CAPT Snesrud stressed how vital TCAC members are in this process, now and throughout 

the journey. She acknowledged that collectively much progress has been achieved since 

2001 when CDC first began hosting Tribal meetings to get guidance and assistance at CDC 

in terms of how CDC works with Tribes. Nevertheless, she said she understood their 

distrust of CDC as another federal agency that tribes were continuously having to educate 

and hold accountable.

 Mr. Finkbonner said he liked the ―CDC Tribal Consultation Advisory Committee (TCAC) 

Update on Recommendations / Response January 2010‖ document as it helped to put into 

context some of the efforts they were trying to address around the table. It will also help him 

when he returns to his delegates to seek a primary delegate to serve on TCAC rather than 

him as the alternate delegate because it gives them something to work with. To reframe the 

concept, it is not so much distrust as it is that CDC and public health both tend to be 

abstract thoughts with tribal leadership. They do not quite understand what it is, so this 

document will help to put TCAC / CDC efforts into context. He thought the document was 

moving very much toward a strategic plan, which he completely supported. Sometimes the 

process of developing a strategic plan is more valuable than the document itself. What is 

also great about strategic plans is that when there is a change in leadership, such as with 
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new political appointees, the strategic plan stays in place and gives them the institutional 

history that went into building up those efforts. 

 Dr. Bryan replied that the previous Monday afternoon, he and CAPT Snesrud met with 

OSLS Deputy Director Karen White. They spoke with Dr. White and Kristen Brusuelas

about the need for rapid action in terms of strategic planning on this front.

 Mr. Antone noted that he had been one to hound CAPT Snesrud and Dr. Bryan because 

sooner or later the tribes are going to ask them what they are doing. He thought the 

document was something they could move on, and which could help them gauge what was 

being done and what was not. At this point, they must identify who will be the recipients of 

the report. While some tribes have direct funding, there are 564 tribes, so TCAC / CDC 

have barely scratched the surface. Most of the tribes that have received grants from CDC 

have some capacity, but there are many that do not. This document should be submitted to 

Dr. Frieden, and he should be educated about tribes. 

 CAPT Snesrud acknowledged Dr. Bryan for pushing through, partly as a result of the H1N1 

crisis, the formation of the AI/AN Population Team within CDC‘s Director‘s Emergency 

Operation Center (DEOC). Drs. Bryan and Tom Hennesey are the team leads, and CAPT 

Craig Wilkins and Myra Tucker are the critical players who have operationalized that team. 

While this has been specific and germane to the H1N1 initiative, it truly has gotten tribes ―on 

the map‖ in a very prominent way that will be utilized in many other efforts. Referring to 

page 15 of the recommendations document, and incredibly exciting, CAPT Snesrud noted 

that ―Knowledge to Action Science Clips‖ had been developed as well in response to the 

best practices recommendation. 

 Ms. Hughes said she thought the recommendation document would help to keep them on 

task. She expressed her hope that if this led to the development of a strategic plan, to her 

that would be a more formal document. She hoped that this was the plan.

Stacey Ecoffey, Principal Advisory for Tribal Affairs

Intergovernmental Affairs

Department of Health and Human Services (HHS)

Ms. Ecoffey reported that generally, many changes are underway at HHS department-wide. 

She did not think the changes were to be feared. More so, the changes are positive for Indian 

Country and should elevate tribal issues the HHS agencies. There are many new political 

leadership members who have been around Indian Country for a long time. This has made their 

interaction in the Office of the Secretary much easier. They have a lot more access, movement 

on issues, et cetera. They played a lot of defense in the last administration; whereas, this time 

there is more positive action. The Secretary plans a lot of interactions with Indian Country. Ms. 

Ecoffey hopes to have a lot more staff in her office, which should enable them to spend much 

more time with the tribal consultation groups in various agencies. She said she thought they 

had some good career staff at CDC.

Updates from OS / Intergovernmental Affairs
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With respect to the Budget Consultation, she encouraged tribal leaders to join the calls to help 

plan the agenda. Some of the issues HHS would like to discuss include the consultation 

process, and how HHS does things with consultation as an overall department. President 

Obama sent out a memo about Executive Order 13175: Consultation and Coordination With 

Indian Tribal Governments. HHS has always taken very seriously and complied with this order. 

There are areas for improvement, and they evaluate the process every few years. It is time to 

evaluate this now. HHS‘s memo back to OMB and the White House is in the clearance process. 

The White House has not decided whether they want to share all of the plans from the agencies 

or how that will work, but HHS is very open to sharing what their plan is and the comments that 

they received from Indian Country on HHS‘s policy.

Though somewhat different for the tribes this year, HHS is setting the dates for the consultations 

and is focusing primarily on the consultation policy process, the agency policies, and open tribal 

leader comments on consultations in general. HHS will convene one-day sessions throughout 

the country in each region, with the exception of Regions 9 and 10 which will have two sessions 

given the large number of tribes in those two regions. She hoped the Secretary would have a 

letter soon and that she would be able to share the dates by the next week. These meetings 

will be convened from the end of March through the beginning of May 2010. They also plan to 

visit Indian Country during that time frame as well. The plan is to look at a few tribes in each 

region, and then to build up to some larger HHS trips throughout the year. They plan to form a 

Federal Tribal Work Group that will meet over the summer. They will ask for nominations from 

the tribes for that work group in May or June, and will convene the first meeting of that group in 

July to review all of the comments heard internally and externally because this is a partnership 

and develop a better plan and determine which agencies need to be targeted to develop 

consultation policies. CMS‘s plan is moving forward, and there are some really good people in 

the Administration for Children and Families (ACF), so some good things should come out of 

that office for Indian Country. They also plan to target NIH and AOA soon to develop 

consultation policies, and will probably wait to target FDA so that it is not overwhelming to HHS 

and the tribes.

In early summer, HHS hopes to convene a meeting with the Chairs and the Co-Chairs of the 

four Tribal Advisory Groups and the Secretary and Chief of Staff and Ms. Ecoffey‘s boss. This 

is now agreed upon, and they hope to plan this so that tribal leaders are not traveling to DC for 

anything extra. It will be important to prepare to discuss tribal priorities with the Secretary and 

Chief of Staff. They will most likely create a Secretary‘s Tribal Advisory Committee, but the 

charters must be in order with the groups. The attorneys are likely to scrutinize this closely, so 

they hope to have all of the charters and policies in place. Hopefully in the fall, they will be able 

to roll out and start this process. In the meantime, the charters and policies must be completed. 

HHS is excited because they will be the first federal agency to have a group such as this.

There will soon be a budget roll out, for which there should be a webcast. Ms. Ecoffey indicated 

that she would get the link for that to everyone so that they could see it. There will be 

documents on the budget that she will also share with TCAC members. She said that she was 

thoroughly enjoying the new leadership at HHS. It is a lot different to have a Chief of Staff who 

is very Indian-friendly. She stressed that when the tribal leaders were developing their 

testimonies for the budget consultation, they would not have to do a 101 this time. She 

suggested using concrete tribal-specific examples, such as ―If the budget is not improved in this 

area, X will increase‖ so that HHS can see where they need to target specific items in the 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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budget for programs that will benefit Indian Country. While they could do somewhat of a 101, 

this time there would be some Indian-friendly faces who do not need this.

While she could not always guarantee the secretary, Ms. Ecoffey encouraged tribal leaders to 

visit HHS. Either HHS is doing their job really well or tribes just have not requested it, but not a 

lot of people have come in to meet with the new leadership. They really enjoy the tribal advisory 

committees and talk about them in staff meetings, with regional offices, et cetera. The regional 

offices are also going to be much more engaged with tribes. Some tribes have good 

relationships with the HHS regions, but they should see more. They have been encouraging the 

regions to meet with everyone in their areas and talk about things that they can do in their 

regions specifically with the states that they serve and the HHS programs that fall in those 

states, and how they can improve interactions between the tribes, the states, and HHS.

The consultation report should be published by the end of March. The HHS website is being 

improved. The agenda will include a lot of information about H1N1. There has been a lot of 

good movement and collaboration between the internal agencies to outreach to Indian Country, 

as well as with the Department of the Interior and Homeland Security. It has been nice reaching 

out to all of them, especially Homeland Security, because they really want to be a part of the 

process and be helpful to Indian Country. They just do not know quite how to do that, but the 

President‘s memo has made it a lot easier for the inner agencies to talk to each other about how 

to do consultation. 

Discussion Points

 Ms. Hughes found the possibility of a Federal Tribal Advisory Committee directly to the 

Secretary of HHS to be very exciting. Having a voice at that level is an issue of great 

importance to tribes. Although it is a challenge for the tribal leaders to participate in all of 

the consultations, expanding these relationships is very important for Indian Country. It is 

good to see progress with policy, funding, et cetera because of the voice at so many tables 

now. 

 Mr. Secataro wondered how TCAC was doing, and what else they needed to do. There was 

a question about by-laws and designating committee members, and he wondered if that had 

been resolved. 

 Ms. Ecoffey responded that it is a policy issue. Each of the advisory committees do things 

so different, one cannot be compared to another. All four of the committees do some 

amazing things. It just depends upon the issue. For the most part, all of the committees are 

on equal footing. Some of them have been established longer. Some work on more 

technical issues, some work on broader issues, some focus more on funding, and some 

focus more on programmatic issues. With respect to the question about the by-laws, it is 

very important to keep good records. Some of that does fall back on the HHS agencies. 

Some have not been keeping official records consistently. A major issue regarded how a 

representative at the table is designated. This has been ironed out. HHS does not care 

who sits at the table. They simply need the person to be designated by a tribal leader. That 

has not been done in some cases. Another issue is that HHS does not want to contract out 

their inherent government responsibility to a contractor. The agencies should have direct 

relationships with the tribes. In moving forward, the Directors of HHS‘s agencies should be 

sending letters directly to the tribal leaders. They should not have to go through the Indian 

Health Service and the Area Directors. Because they have advanced in their relationships 
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97

with tribes, HHS wants to improve that process and have that direct relationship. They have 

not had that in the past. 

 Ms. Hughes indicated that every TCAC member had a letter from an elected official 

designating them to be on board. There is some paperwork that needs to be completed to 

solidify this.

 Mr. Trudell pointed out that sometimes they forget to commend their young people as they 

move up the ladder. He commended and congratulated Ms. Ecoffey for moving up the 

ladder, and told her to keep up the good work and keep opening the doors.

 Regarding agencies having to funnel letters or other communications through the IHS, Ms. 

Begay pointed out that each tribe is different and each tribal government is different. They 

operate their protocols differently. There has been some concern about how those letters 

are disseminated to the Navajo Nation. The Navajo Nation has a three-branch government. 

There has been some confusion and there was some concern with the recent IHS Director 

―Dear Tribal Leader‖ letter asking for designation to her advisory group. There was some 

conflicting designation from the Executive Branch and Legislative Branch of the Navajo 

Nation government. She wondered how this current worked from the HHS‘s standpoint in 

terms of how letters are sent. This can be a sensitive issue, and there can be competition.

 Ms. Ecoffey responded that currently the process for HHS is that from the Secretary, the 

letter goes to the Tribal Chairman of every tribe. For federal agencies such as HHS, it is not 

feasible to have 565 individual processes for every tribe in the US. They also utilize 

Regional Directors, her list, and national organizations to get these out. Consideration must 

be given to how to determine a mechanism that works for everybody. This will likely be 

negotiated out once they receive all of the comments over the summer. 

 Mr. Valdo reminded everyone that under the Federal Advisory Committee Act (FACA), the 

designated representative is an elected official who can have alternates who are not 

elected. They also must remember that consultation is not staff to government, it is 

government to government. Some organizations have forgotten why these committees 

were created, which is to serve the Indian people. 

 Unlike the Navajo Nation with 88 representatives, Ms. Hughes indicated that Oneida only 

has 9 and they still have challenges occasionally. Everything basically does come into the 

chair‘s office. Their internal process requires the chair‘s staff to distribute to the rest of the 

government. From a federal perspective, it is too challenging to know what all of the tribes 

are doing. She believes that part of the responsibility will rest with the TCAC. When there 

are vacant positions, each council member takes the responsibility of trying to fill those. 

Every advisory council must take this type of responsibility to ensure that areas are 

represented, even though HHS sends the letters. They all have a national presence 

because of their participation, and they have contact that they need to use because of that. 

 Mr. Franklin said that he is a single issue elected councilman. His tribe elected him to 

represent them as their health delegate, so he wears a number of hats and is pulled in every 

direction. Even though he is elected just to represent health, he does not have time enough 

for that. He sees the wisdom and importance of having a letter from a tribal government for 

an elected tribal official that gives someone a seat at the table to speak on behalf of 

federally recognized tribes, but they need the leeway to appoint someone to attend on their 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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behalf should they have to prepare for other activities. The most important thing is to ensure 

that the area is represented in the way that the tribal leaders see fit. He commended Ms. 

Ecoffey on her efforts. California has many issues, and they took the liberty of visiting HHS, 

which has been very rewarding for them. In the previous administration, talking to the White 

House was a dead issue and everyone knew it. With this administration, that is no longer 

true. Tribes need to take advantage of this. He encouraged everyone to keep in mind that 

this could all change again, so if they do not place everything that has been built up for 

tribes on solid foundations, they could be knocked down again. FACA is the foundation.

 Ms. Ecoffey agreed, stressing that during this window of opportunity, they must attempt to 

put as many concrete, sustainable things in place as possible. Tribes benefit from being 

FACA-exempt committees. The tide could change if they do not follow some of the 

guidelines set forth in the legislation that authorized FACA. There are always negotiations 

and there should always be back and forth between the tribes and the governments in order 

to come to compromises, but there are also some things that cannot be compromised 

because of the way legislation was passed and how things have been signed into law. 

Ultimately, they want to improve the lives of Indian Country.

Transition Overview

Walter Williams, Director

Office of Minority Health and Health Disparities (OMHD)

Centers for Disease Control and Prevention (CDC)

Dr. Williams thanked the TCAC Co-Chairs, the TCAC members, other tribal leaders in the room, 

CDC, and other special guests for their presence, and expressed his delight at being able to 

address them during this session. He said that his purpose was to formally announce the 

transition of tribal affairs activities, including work on CDC‘s tribal consultation policy and 

working with TCAC and related affairs, from the Office of Minority and Health Disparities 

(OMHD) to the Office of State and Local Readiness (OSLS). In part for him this is a celebration 

of many accomplishments since they began their journey together in 2005. His recollection was 

that CDC was the first HHS agency to establish an agency tribal consultation policy. This work 

began in 2004 and the policy was actually adopted in 2005. Abundant work has been 

accomplished since that time, including the establishment of the TCAC. In 2008, OMHD was 

transitioned from its position in the Office of Strategy and Innovation (OSI) to the Office of the 

Chief of Public Health Practice (OCPHP). That transition occurred after a transition from an 

office that reported directly to the CDC Director, which had been in existence for 14 years. They 

had to deal with some of the concerns raised throughout this meeting with respect to position 

within the organization, when they found themselves having to report through another person to 

get information and action items to the CDC Director. 

Transition of Tribal Affairs from OMHD to OSLS
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99

With the new organizational design, OMHD has now been moved to the Office of the Associate 

Director for Programs (OADP), a new office established in the recent organizational redesign. 

In making decisions about where to place OMHD, the agency undertook a review of important 

functions in relation to the new proposed organizational structure. This was done through a 

very intensive process that took into consideration current functions, staffing, budget authority, 

et cetera, and asking critical questions with regard to the new CDC Director‘s priorities. It was 

determined that the tribal activities aligned best with OSLS. Most activities that are important to 

the programs that support Indian Country have not been affected, and others that are mission 

critical are continuing in other organizational components at CDC. There has been a ―mixing of 

the bowl‖ so to speak, but the critical efforts to help CDC achieve its mission continue. 

In September 2009, Dr. Frieden indicated that the Secretary of HHS and Congress had 

approved the proposed organizational improvement proposal that was submitted. Currently 

underway is the actual administrative process that must take place in order to officially establish 

all of the organizational entities. Effective January 1, 2010, it was Dr. Frieden‘s intent that all of 

the new organizational structures would be operational. Thus, CDC is currently operating under 

the new structure as the administrative packages move forward for final approval. Regarding 

the transition of responsibilities as a proponent for the CDC tribal consultation policy and work 

with TCAC from OMHD to OSLS, a primary focus is enhancing support for public health 

activities in tribal, state, and local communities. Dr. Williams said he personal perceived this as 

an opportunity for enhanced synergy with regard to state and tribal collaboration and enhancing 

state and tribal relationships. He is looking forward to Dr. White and her group moving forward 

with activities to make that real. He is personally looking forward to continuing to work with the 

CDC Tribal Liaisons. CAPT Snesrud and Dr. Bryan have been a part of his office for a number 

of years, so he is suffering from a little empty nest syndrome and separation anxiety that came 

with the knowledge that two of his valued colleagues are now moving to another office. 

Nevertheless, he is excited about where they are going and what portends to be a good location 

for enhanced action at CDC. The intent of OMHD is to continue its critical support of the critical 

areas in which they are partnering with TCAC to support. 

Discussion Points

 Mr. Antone expressed gratitude to Dr. Williams for all of his support over many years, 

acknowledging that he had been instrumental over the years in the ultimate foundation of 

the TCAC. Public health issues have made them all a part of each other, and they have 

continuously worked together to address issues for all tribes. He presented a beautiful vase 

and bowl to Dr. Williams as a symbol of how all of the tribes fit together, what the problems 

are, and what can be done to assist as they begin to weave strategies to move forward to 

hold the nations together. He indicated that the gift of the bowl and vase to Dr. Williams was 

to honor the efforts that he had made over the years on behalf of tribes. 

 Dr. Williams thanked Mr. Antone for the gift and his gracious and kind words. He said that 

for him, the opportunity to come to know many of the tribal leaders, visit parts of Indian 

Country to see the communities first hand, and meet the tribal leaders‘ families members 

had been a very important personal journey. 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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 Dr. Bryan noted that he began to work for Dr. Williams in 1999, while CAPT Snesrud came 

on board in 2002. Over the last decade not only did Dr. Williams create their positions, but 

also the consultation policy endeavor ensued and the TCAC was created and established 

under his leadership. Dr. Bryan stressed the importance for everyone to understand the 

critical role that Dr. Williams and his office played in getting them to their current status. He 

said it had also been a personal journey for him, and he presented Dr. Williams with a gift as 

well. Not only is there trepidation and separation anxiety, but also there is a large degree of 

personal appreciation. 

 Dr. Williams expressed his gratitude, noting that he was not expecting any of this. He said 

he really appreciated the acknowledgement of the efforts they had made through his office, 

stressing that it had been the results of the effort of many people. When Dr. Bryan and 

CAPT Snesrud came on board, it gave his office the nidus for some very important work that 

they pushed forward at CDC. He stressed that any successes he achieved had been on the 

backs of Dr. Bryan and CAPT Snesrud. He thanked them again for their kind words, but 

emphasized that they had been the ones who executed on many of the efforts that got them 

to where they were. There is still a long way to go, and he said he looked forward to their 

continued journey together.

Office of State and Local Support Welcome

Karen White, Acting Director

Office of State and Local Support (OSLS)

Centers for Disease Control and Prevention (CDC)

Dr. White highlighted the work that had been done over the last several years in OMHD, and 

what that mean to CDC. Having a separation between OMHD and tribes to move into OSLS 

has been a long time coming. This is to be celebrated because finally tribes are being 

recognized as a separate entity—that tribes should be working at the same level as state and 

local health departments and territories versus being within an umbrella of other work at CDC. 

Dr. Williams has worked a very long time to help people understand, and Dr. Bryan and CAPT 

Snesrud have supported this endeavor over the years. The challenge of working in the 

administration over the last decade or so has really not permitted that to occur in a way that 

many at CDC believed it should. It is very important to note the immediacy with which Dr. 

Frieden and this administration made this change. It was very quickly on his agenda during the 

summer to move forward with an emphasis on states, locals, tribes, and territories. She 

perceived this transition as a relay in the journey that Dr. Williams discussed. This is the next 

step and OSLS has been charged with the obligation and responsibility to ensure that this 

occurs. She made a promise to those present that this would move forward, and that she, Dr. 

Bryan, and CAPT Snesrud had already engaged in some discussions regarding what the next 

steps would be immediately following this TCAC meeting. She expressed her gratitude to Dr. 

Williams for the work he has done to bring this program this far, indicating that she would pick 

up the baton and move forward from there.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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During this session, Ms. Hughes indicated that this marked the end of the official TCAC 

meeting. She reminded everyone that the business left pending from the previous day was to 

contemplate a potential project to submit for inclusion in the 2012 CDC budget, which would be 

a priority for their first teleconference. The date of the first teleconference was proposed for the 

second Friday in February, but everyone planned to check their calendars, with a final decision 

to be made via email. Based on the discussion earlier in the morning, additional work needs to 

be done to the TCAC charter and there needs to be recognition of delegates and alternates to 

serve on this council. 

The following subcommittees were established:

Budget Charter

Joe Finkbonner Joe Finkbonner

Kathy Hughes Reno Franklin

JT Petherick

Roger Trudell

Derek Valdo

The entire TCAC will be notified about these two subcommittees so that anyone who is 

interested may participate.

Dr. Bryan confirmed that no formal recommendations were made during this TCAC meeting, 

and CAPT Snesrud reminded TCAC members to submit their written reports as soon as 

possible. She also reminded everyone that CDC has developed its own distribution list, which 

will be updated at least twice a year. She requested that names be emailed to her of others 

TCAC members would like to be included on the distribution list.

Discussion Points

 Dr. Tucker indicated that about four years previously, when Dr. Gerberding was the CDC 

Director, she and the then Secretary had a handshake deal. The Secretary had an initiative 

to address infant mortality, and Dr. Gerberding indicated that CDC would give IHS $1.5 

million per year to address infant mortality. The Maternal and Child Health (MCH) Director 

for IHS contacted Dr. Tucker to suggest that they provide MCH Epidemiologists for tribes to 

build capacity just as they had done for states. Thus, the funds that Dr. Gerberding 

awarded were allocated to the Tribal Epidemiology Centers, of which there were 7 at the 

time. MCH Epidemiologists were employed at these centers. Dr. Tucker said that of all of 

the programs she had seen in her career, this one did the most. These epidemiologists 

found and began collecting and analyzing data that there had never been before for local 

use. There began to be a liaison between states and tribes because the Tribal 

Epidemiology Centers could affect those liaisons and began to get the data flowing for use 

on the part of tribal and state governments. That project sunsetted in 2009. She hopes that 

some of that work will go forward, and stressed that any opportunity she gets to promote this 

Wrap Up / Adjournment
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

102

program, she does. She has great faith in TCAC. Some of the work that CDC can and 

wants to do will be accomplished because of external pressure, because tribes demand it 

and CDC responds to that demand.

 Ms. Hughes thanked Dr. Tucker for her comments, acknowledging that it was sometimes 

difficult when working on advisory councils such as the TCAC to see the progress being 

made. It sometimes feels that for every step forward they take two steps back. Hearing 

about the success stories and the improvements being made is very good.

 Mr. Finkbonner reported that John Pipe, Councilman of the Fort Peck Tribe and member of 

the National Diabetes Indian Coalition (NDIC), passed on January 23, 2010 having 

succumbed to the complications of diabetes. This brought home the efforts that the TCAC 

was engaged in around the table, and called attention to the public health messages and 

prevention programs that they want to put in place. Mr. Pipe was one of many Native 

Americans who have passed as a result of complications of diabetes. His passing 

represents a great loss for Indian Country. He was a quiet man, but there was great wisdom 

in the words he did speak because he chose them selectively. With that in mind, Mr. 

Finkbonner asked that as everyone bowed their heads to say the closing prayer they lift up 

Mr. Pipe, his family, and the community who lost a great leader.

With no further questions, comments, or business posed, Mr. Antone offered the closing prayer 

following which the meeting was officially adjourned.
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

103

CDC Tribal Consultation Advisory Committee (TCAC) 

Update on Recommendations/Response

January 2010

1. Continue to fully implement the procedures of the CDC Tribal Consultation Policy 

(TCP); Status: Implemented/ongoing

The CDC/ATSDR Tribal Consultation Policy provides guidance for working effectively with 

American Indian and Alaska Native (AI/AN) Tribes, communities, and organizations, as well as 

enhancing AI/AN access to CDC and ATSDR programs. The policy identifies when CDC 

programs should involve Tribal leaders and outlines specific responsibilities regarding program 

activities, including mutual participation in setting program and budget priorities. Since the 

policy was released in October of 2005, both Dr. Gerberding and Dr. Frieden (CDC Directors) 

have supported its implementation to strengthen Tribal partnerships through increased 

opportunities for tribal input into CDC decision-making processes. 

CDC believes this policy to be the foundation for effective government-to-government 

relationships. The TCP provides procedural guidance for CDC staff to ensure that more tribes 

and tribal organizations benefit from CDC expertise and resources by eliminating barriers and 

enhancing tribal access to CDC programs by assuring tribal eligibility for all CDC program 

announcements unless authorizing legislation and programmatic regulations restrict eligibility. 

The TCP outlines several venues for tribal consultation and information exchange with CDC: 

 Biannual CDC tribal consultation sessions that are open to all tribal leaders – Sessions were 

held on Feb. 28, 2008; Nov.20, 2008; Aug. 12, 2009, and one is planned for Jan. 28, 2010. 

 Establishment of the CDC Tribal Consultation Advisory Committee (TCAC) – done Nov. 

2006

 Ongoing CDC participation in HHS-sponsored national/regional tribal consultation sessions 

– CDC leadership has participated in each HHS national session and a majority of regional 

consultations since their inception 

 Other requested meetings between the CDC Director (or designee) and elected tribal 

leaders (or their designees) – some examples of meetings that have occurred:

2007

o OSH met with Muscogee (Creek) Nation; Cherokee Nation; Aberdeen Area Tribal 

Chairmen‘s Health Board; California Rural Indian Health Board; Intertribal Council of 

Michigan; Big Pine Band of Paiute during April and Nov. 2007 to gain information to 

enable CDC to more fully understand approaches, measures, and tools for promoting 

tobacco cessation efforts among AI/ANs and next steps to be taken in prevention efforts. 

Appendix A
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o Native Diabetes Wellness Program, Division of Diabetes Translation, met with 

representatives from across the 12 IHS areas through the IHS National Tribal Leaders 

Diabetes Committee twice each in 2007 through 2009 about CDC‘s ongoing diabetes 

projects (including the Eagle Books) and the development of a new Funding Opportunity 

Announcement, "Using Traditional Foods and Sustainable Ecological Approaches to 

Promote Health and Prevent Diabetes in American Indian and Alaska Native 

Communities."

o In collaboration with CDC‘s Global Health Odyssey Museum and the Native Diabetes 

Wellness Program, the TCAC participated in an opening reception for the first exhibit of 

the original art work, "Through the Eyes of the Eagle: Illustrating Healthy Living for 

Children‖, October 12, 2006-January 5, 2007. The exhibit has since traveled to the 

Smithsonian National Museum of the American Indian and is traveling to other native 

and non-native venues through 2012.

2008

o The Native Diabetes Wellness Program responded to a thoughtful question by TCAC 

leadership in 2008 about the relationship of the program with the Special Diabetes 

Programs for Indians (SDPI) administered by IHS. Program leaders responded that our 

mission seeks to complement the ongoing work and respect traditional knowledge about 

health in tribal communities, working closely with our federal partners. The Eagle Books 

represent a collaborative effort used by many SDPIs and these are distributed through 

the warehouse of the IHS Division of Diabetes Translation, along with resources for the 

"Health is Life in Balance" K-12 Diabetes Education in Tribal Schools curriculum, led by 

NIH. Plans for the "Traditional Foods" FOA were described, with hopes of funding 

approximately 10 tribes or tribal organizations to further their efforts to restore local, 

traditional foods in their communities. The program awarded 11 tribal grantee partners 

in 2008, and with the assurance of continued financial support through IHS and the DDT, 

funded an additional six in FY2009 for a total of 17 funded partners in the Traditional 

Foods cooperative agreement.

o CDC Leadership met with 6 Tribal leaders from Tohono O‘odham Nation in Jan. 2008 to 

consult about budget allocations, communication, marketing, public health capacity, 

environmental public health, STEP, diabetes, cancer, tobacco, STD & HIV infection, and 

public health emergency preparedness activities. 

2. Assure adequate staff and resources are available within the Office of the Director 

(OD) to support TCP implementation. Provide OD support for Senior Tribal Liaisons 

(STLs) in implementation of their roles, responsibilities, and scopes of work; Status: 

Partially implemented/in transition 

The Office of the Director (OD) manages and directs the activities of the CDC; provides overall 

direction to, and coordination of, the scientific/medical programs of CDC; and provides 

leadership, coordination, and assessment of administrative management activities. 

CDC‘s Senior Tribal Liaisons (STLs) have been part of the Office of Minority Health and Health 

Disparities (OMHD), Office of the Chief of Public Health Practice (OCPHP), Office of the CDC 

Director. The CDC STLs continue to provide leadership and subject matter expertise needed to 

help monitor progress and ensure agency-wide adherence to the TCP. 
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 OMHD has been the administrative base for CDC‘s two STLs who, along with OMHD 

Director, Dr. Walter Williams, were designated by the CDC Director to be the primary 

agency points of contact for tribal affairs. 

 STLs are knowledgeable about the agency‘s programs and budgets, have ready access to 

senior program leadership, and are empowered to speak on behalf of the agency for AI/AN 

programs, services, issues, and concerns. Position descriptions were written (2007) and 

have directed the work of these Liaisons. 

 The OD/National Center of Environmental Health and Agency of Toxic Substances and 

Disease Registry recruited and hired an experienced & knowledgeable environmental public 

health professional to be the primary point-of-contact for environmental health issues. 

(2008) 

 CDC strives to manage our fiscal and personnel resources in a manner that maximizes 

impact on the health and safety of AI/AN people, accurately monitor resources allocated to 

benefit AI/AN communities, and make this information readily available to tribal leaders 

annually. 

CDC‘s ability to implement effective management of activities with AI/ANs tribes depends upon 

an appropriate balance of staff and resources within the OD. In FY 2008, Dr. Stephanie Bailey, 

Chief of the Office of Public Health Practice (OCPHP), submitted a request to the OD to 

establish an Office of Tribal Affairs (OTA) in the CDC Office of the Director with staff increases 

as budget constraints allowed. 

During FY 2009 and continuing in FY 2010, CDC embarked upon a major Organizational 

Improvement (OI) process to better support CDC priorities and operate more efficiently. 

 As part of that OI process, the OCPHP no longer exists, and the STL positions will become 

part of the new Office of State and Local Support (OSLS). ―State and local‖ in this context is 

inclusive of Tribal and Territorial governments and communities. Proposed critical functions 

for OSLS include:

o Provide guidance, strategic direction and oversight for the investment of CDC 

resources and assets in local1public health agencies

o Develop and oversee a cross-agency system of performance and accountability that 

assures that CDC resources at local public health agencies are positioned to achieve 

and advance the public health outcomes intended and supported by CDC

o Strengthen local public health capacity to support the provision of programs, policies, 

and practice that will improve the health status of all Americans

o Provide guidance and strategic direction for the recruitment, development and 

management of field staff provided to local public health agencies by CDC direct 

assistance (DA) funding

o Enhance shared leadership of public health policy and practice with local public health 

agencies through increased collaboration and communication

 As the OI process continues, CDC leadership has committed to the establishment of an 

appropriately staffed and funded organizational unit within OSLS that is devoted to Tribal 

public health. CDC‘s STLs are closely involved in the planning for this unit. 

 

1

“Local” refers to state, local, tribal, and territorial public health agencies
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3. Assure that CDC Director and other executive leadership respond in a timely and 

effective manner to the recommendations made by TCAC; Status: Partially 

implemented/in transition

See Organizational Improvement (OI) summary in #2 above. As part of the OI process and 

establishment of a new organizational unit for AI/AN program activities within OD, new 

procedures and lines of communication will be established to maintain timely and transparent 

responsiveness to TCAC recommendations. Past procedures, primarily written and verbal 

reports to Tribal leadership during TCAC and Biannual Consultation meetings, will continue as 

well. In addition, CDC‘s Annual Tribal Consultation and Budget Report contains comprehensive 

fiscal and programmatic information regarding CDC‘s many activities to address public health 

issues in Indian country. That Report is also made available, separate from the HHS report, to 

Tribal leaders/stakeholders via posting on CDC websites. At the January 2010 CDC Biannual 

Tribal Consultation Session, this Report will be included in participants‘ meeting package. 

4. Expand efforts to ensure that funds currently awarded to state health departments 

through CDC cooperative agreements are appropriately benefiting American Indian 

Alaska Native (AI/AN) people in those states; Status: Implemented/ongoing

Official policy to support this recommendation was established in 2005 with the release of 

CDC‘s Tribal Consultation Policy, which includes language specific to this recommendation:

 ―Project officer responsibility in such cases includes ensuring appropriate benefit to AI/AN 

populations from CDC funds awarded to states . . . Documentation of this benefit should be 

included in awardees‘ reports required under cooperative agreements. Further, if tribal 

populations are included as justification in a state‘s grant application, states must provide 

documentation that tribes were involved in the development of that application and will be 

involved in the proposal‘s implementation. Also included in this responsibility is an overall 

effort to help serve as a ―bridge‖ between states and AI/AN governments and organizations 

and to inform state colleagues about federal protocol for working with AI/AN communities, 

about concerns expressed, and about approaches suggested by the CDC TCAC.‖

Since that time, three of CDC‘s major funding streams to state health departments have 

implemented procedures in support of this recommendation: Public Health Emergency 

Preparedness (PHEP)/Public Health Emergency Response (PHER) awards; Immunization 

Grant Program (Section 317) funds; and STD control program funds awarded to states from 

NCHHSTP. All have implemented guidance to state awardees requiring tribal 

engagement/partnerships. These procedures will serve as models for other CDC programs so 

that similar approaches are used across all major funding awards to states from CDC. 

5. Provide authoritative guidance within funding opportunity announcements (FOAs) on 

how states should work with tribes, specifically requiring that applicants who use tribal 

populations to justify proposals document tribal involvement in both design and 

implementation of proposed activities; Status: Implemented/ongoing

See #4 above and existing clause in CDC‘s Tribal Consultation Policy. In addition, the CDC 

Procurement and Grants Office (PGO) has issued guidance across CDC specifying that "CDC 

substantial involvement" activities for funded programs include fostering outreach and specifying 

goals for reaching AI/AN populations. In November 2009, PGO templates for all CDC Funding 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Opportunity Announcements (FOAs) were updated to reflect these and other requirements 

relevant AI/AN populations for FOA applicants/awardees. 

Guidance for state awardees regarding CDC expectations for working with tribal partners is now 

commonplace in many FOAs, for example: 

 ―As with previous PHER awards, CDC expects that a significant portion of the funds will be 

distributed and utilized at the local and tribal level.‖

In addition, other CDC programs are taking proactive steps to support state-tribal cooperation: 

 In August 2008, the CDC Native Diabetes Wellness Program (NDWP) launched a new 

initiative to encourage and support working relationships between state programs and the 

respective tribal nations in each State. Initiative has support from CDC‘s TCAC and the 

Tribal Leaders Diabetes Committee. Partnerships include all state programs with an initial 

emphasis on ―model‖ programs demonstrating innovation in their relationships with tribal 

partners and tribal nations. State-based programs have received guidance to seek 

opportunities for tribal consultation with tribes in their states. 

 In 2009, the NDWP presented on several occasions to Division of Diabetes Translation staff, 

as well as to the state Diabetes Prevention and Control Program Directors, implementing 

elements of the NDWP State-Tribal relationship initiative. In August 2009, Traditional Foods 

cooperative agreement partners responded overwhelmingly their desire to meet with 

respective state Diabetes Prevention Control Program coordinators. 

6. Implement standardized language for CDC Funding Opportunity Announcements 

(FOAs) that specifies tribal eligibility unless precluded by authorizing language, single 

eligibility approval, or similar contingencies; Status: Implemented 

Standardized tribal eligibility language was established during FY2007-2008 and since then the 

PGO Technical Information Management Section (TIMS ) has monitored new FOAs (both nonresearch and research) to ensure compliance with tribal eligibility guidance. Tribal eligibility is 

specified as follows: 

 Federally recognized or state-recognized AI/AN tribal governments

 American Indian/Alaska Native tribally designated organizations

 Alaska Native health corporations

 Urban Indian health organizations

 Tribal epidemiology centers

7. Increase tribal stakeholders’ knowledge of CDC Funding Opportunity Announcement 

(FOA) and how to obtain TA during the grant application process; assist TCAC in 

establishing a technical subcommittee to evaluate how FOAs and the grant application 

process could be modified to encourage more tribal applicants and to help ensure that 

tribal applicants have equal opportunities to compete successfully; Status: 

Implemented/ongoing

CDC utilizes cooperative agreements and grants to assist other health-related and research 

organizations that contribute to CDC‘s mission of health promotion through health information 

dissemination, preparedness, prevention, research, and surveillance.
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Through various mechanisms (e.g., emails, meetings, web postings) CDC has informed Tribal 

leaders and other AI/AN stakeholders about information available on the PGO website: 

http://www.cdc.gov/od/pgo/funding/grants/faq_main.shtm) -- information that supplements that 

available at www.grants.gov . The PGO website provides useful information on finding and 

responding to CDC FOAs. Most awards are made through a competitive application process; 

however, if either Congress or CDC determines that a single organization is the best resource 

for the public service activity, a grant may be awarded without competition. 

PGO has committed to increased outreach activities and training sessions for AI/AN tribes, tribal 

organizations and stakeholders as funding permits. Recent examples include training and 

technical assistance sessions in conjunction with CDC TCAC Meetings and Biannual Tribal 

Consultation Sessions in July 2008 (Florida); November 2008 (Arizona), and August 2009 

(Alaska). 

8. Within selected CDC programs, explore the possibility of designating a certain 

proportion of cooperative agreement funds as intended for tribes/tribal organization as 

awardees. Involve TCAC in discussions across Centers on expanding these approaches; 

Status: Implemented/ongoing

Several CDC programs currently allocate funds in this manner and the approaches taken by 

these programs are shared across CDC. Examples include the following:

 The Division of Cancer Prevention and Control (DCPC) National Breast and Cervical Cancer 

Early Detection Program (NBCCEDP) funds 12 AI/AN tribes/tribal organizations and two 

National Tribal Organizations. DCPC also funds 7 Tribal Comprehensive Cancer Control 

Programs and 4 Tribal Colorectal Cancer Screening Programs. 

 Under the REACH US Program, CDC awarded six entities targeting the elimination of health 

disparities in Native communities; all are fully engaged in intervention activities. Two of 

these entities (OK State Department of Public Health; University of Colorado at Denver) are 

functioning as Centers of Excellence for the Elimination of Health Disparities (CEED) and 

serving as resource centers on effective interventions in addition to working in their ―home‖ 

communities. 

o Four entities (Choctaw Nation of OK; the Eastern Band of Cherokee Indians; the InterTribal Council of Michigan; the Northern Arapaho Tribe) are funded as Action 

Communities; they are implementing and evaluating successful approaches for 

eliminating health disparities in tribal communities. 

 The Division of Diabetes Translation (DDT) Native Diabetes Wellness Program (NDWP) 

released an FOA to tribes/tribal organizations for 5-year cooperative agreements to support 

community use of traditional foods and sustainable ecological approaches for diabetes 

prevention and health promotion in AI/AN communities. The funded programs engage 

communities in identifying and sharing the stories of healthy traditional ways of eating, being 

active, and communicating health information and support for diabetes prevention and 

wellness. 

o From a pool of 60 AI/AN applications, 11 cooperative agreements were awarded in 

2008, with an additional six in FY 2009 to tribes/tribal organizations across the nation at 

approximately $100,000 each per year for a total of $1.7 million per year through FY 

2013. 

 CDC‘s Office on Smoking and Health funds seven tribes/tribal organizations. In November 

2009, during a meeting initiated by the Black Hills Center for American Indian Health 
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109

(BHCAIH) and co-sponsored by CDC, NACCHO, and NALBOH, the Navajo Nation Division 

of Health announced it will take the lead on efforts to pass strong comprehensive clean air 

legislation and provide leadership for the Navaho Nation‘s tobacco control and prevention 

efforts. 

 CDC's Office on Smoking and Health also funds the National Native Commercial Tobacco 

Abuse Prevention Network. OSH and the national network are collaborating on a series of 

trainings tailored for tribes who wish to implement their own AI/AN Adult Tobacco Survey.

o The training stresses the importance of tribal-specific surveillance in informing and 

improving comprehensive commercial tobacco prevention and control at the tribal health 

system level and provides the knowledge and tools that allow tribes to implement this 

surveillance system. 

o Tribes served by the Inter-Tribal Council of Michigan, the Aberdeen Area Tribal 

Chairmen‘s Health Board, Muscogee (Creek) Nation and the Tribal Support Centers for 

Tobacco Programs are committed to work collaboratively on these trainings that will be 

held at least twice per year. Ongoing technical assistance for tribes in the area of 

surveillance implementation and data analysis will also be provided. 

9. Provide culturally appropriate training for project officers assigned to States with 

established AI/AN communities; Status: Implemented/ongoing

During the past few years, multiple programs at CDC, such as the Division of Cancer Prevention 

and Control, the Office on Smoking and Health, the Division of Diabetes Translation, the 

Division of Unintentional Injuries, the Division of STD Prevention, and the Office of Workforce 

Development have regularly offered training opportunities for new project officers and training in 

additional competencies for all project officers (Atlanta and state-based). Content specific to 

tribal relationships, TCP, etc. is included in these trainings. 

10. For competitive applications responsive to AI/AN-focused program announcements, 

seek objective review panel members who are knowledgeable about working with AI/AN 

communities; Status: Partially implemented/efforts ongoing

PGO has committed to working assertively with all CDC programs to ensure that, whenever 

possible, AI/AN professionals and/or others with subject matter expertise and experience in 

Indian country serve as objective review panel members and chairs of objective review panels. 

An agency-wide data base listing individuals with knowledge and skills of this type is planned, 

but not yet completed. 

11. Assist in the orientation of TCAC members and other tribal leaders to CDC and 

ATSDR by developing and distributing a directory of CDC and ATSDR services and 

resources; Status: Implemented

CDC leadership and staff have offered a ―Tribal Leaders Orientation to CDC‖ at the past two 

Atlanta-based Biannual Tribal Consultation Sessions (2008 and 2010). 

The CDC publication ―Rx for Health,‖ which explores the wealth of informational products and 

services that CDC offers, was distributed at the Biannual Tribal Consultation Session in Atlanta 

in February 2008 and posted on the National Indian Health Board (NIHB) website. It is 

accessible here also: http://www.cdc.gov/about/stateofcdc/pdf/rx_for_health2008.pdf
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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CDC Divisions and funded Tribal Programs have been sharing ―best practices‖ at the NIHB 

Public Health Summit, the NIHB Annual Consumers Conference, the IHS Health Summit, and at 

multiple CDC sponsored conferences and Grantee Meetings for state funded programs to help 

inform all public health partners of effective practices. 

―The State of CDC‖ found at http://www.cdc.gov/about/stateofcdc/ has been distributed 

annually. This report goes behind the scenes with the nation's premier public health agency to 

explore stories of health protection, cutting-edge research, and real-world disease investigation 

that CDC is conducting every day. In addition CDC has also made other publications available 

to help stakeholders understand more about CDC. These publications include: 

 Public Affairs in Health (PAH)

Public Affairs in Health (PAH) is a peer-reviewed electronic journal established to provide a 

forum for public affairs professionals working in public health to share study results and 

practical experience. The journal is published by the Office of Enterprise Communication 

within CDC. PAH is published biannually in April and October. Articles published in PAH 

include editorials, essays, original research reports, best practices, milestones in public 

health (MPH), and announcements. 

 Pandemic Influenza Storybook

This year marks the 90th anniversary of the 1918 influenza pandemic. That pandemic killed 

more than 50 million people worldwide including an estimated 675,000 people in the United 

States. The stories related in the Pandemic Influenza Storybook will make you cry, some will 

make you laugh, but all serve as reminders of the primary reason why preparedness is so 

important — saving human lives. This first edition contains 50 stories from 26 states. 

 CDC: 60 Years of Excellence

A look at CDC's 60 Year Legacy of Excellence in protecting the health of the public.

12. Continue discussions with CDC’s Financial Management Office (FMO) to establish 

guidelines and a timeline to allow tribal stakeholders to provide annual input into the 

CDC budget formulation process. Monitor and track where tribal recommendations have 

influenced CDC priorities and goal process, and have enhanced tribal access to CDC 

resources; Status: Partially implemented/efforts ongoing

The FMO Deputy Director and/or designee have regularly attended CDC TCAC meetings and 

Consultation Sessions to brief TCAC and other tribal leaders on the CDC budget and budget 

formulation process. 

 FMO has advised the TCAC that a FMO designee will serve as a resource to the TCAC 

Budget Subcommittee to answer questions and increase transparency for Tribes in order to 

assist them in providing concrete recommendations to CDC about budget allocations and 

formulation. 

 Beginning in 2005, FMO has worked closely with OMHD to prepare the CDC Annual Tribal 

Budget and Consultation Report each December. Along with this comprehensive budget, 

FMO annually develops a slide deck to compare and contrast overall agency categorical 

allocations with those specific to AI/ANs. 

13. Re-analyze the CDC AI/AN Resource Allocation Portfolio such that resource 

allocations are: a) stratified by categorical programs that are of high priority to Indian 

country; and, b) stratified geographically; Status: Implemented/ongoing
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During the FMO briefings to tribal leaders, FMO provides a comprehension breakdown of CDC 

allocations benefiting tribes by state, IHS Areas, and HHS Regions. CDC strives to manage its 

fiscal and personnel resources in a manner that maximizes impact on the health and safety of 

AI/AN people, accurately monitor CDC resources allocated to benefit AI/AN communities, and 

make this information readily available to tribal leaders. 

 CDC is using a portfolio management approach to its resources devoted to AI/AN health 

issues. This approach improves how CDC tracks and displays its AI/AN resource 

commitments and enables CDC to more closely monitor funds distributed to state health 

departments via CDC grants and cooperative agreements to help ensure that AI/AN 

communities receive appropriate benefit from these funds. 

 In FY 2009, total funds allocated through competitively awarded grants and cooperative 

agreements to tribal partners approached $24 million ($23,854,212). Compared to FY 2008, 

total funding in this category increased in the amount of $1,014,698 or 4 percent. 

 CDC estimates its total FY 2009 resource allocation for AI/AN program to be approximately 

$168 million. The total figure ($167,637,959) represents a 55 percent increase compared to 

AI/AN allocation in FY 2008, an increase that is consistent with an overall increase in VFC 

funds received by CDC in FY 2009. If VFC funds are not included, CDC estimates its total 

FY 2009 allocation for AI/AN programs to be $45 million, 53 percent of which goes directly 

to tribal partners and 76 percent overall is expended outside of HHS2. The total figure 

($45,371,807) represents a 4 percent increase over non-VFC AI/AN allocations in FY 2008.

14. Develop a CDC-wide AI/AN action plan that will strategically integrate AI/AN –

focused policies, resources, and programs; align these activities with CDC’s Health 

Protection Goals; and serve as a roadmap and portfolio management tool for CDC’s 

overall efforts to optimally impact the public health of AI/AN people and communities; 

Status: Not implemented 

Although this recommendation has been discussed within CDC OD during past administrations, 

no definitive action has taken place thus far. It is anticipated that this recommendation will be 

given due consideration under new CDC leadership and as the Organizational Improvement 

process moves forward in FY 2010. 

15. Reconsider recent decisions regarding funding for HIV and STD prevention 

programs in Indian country; Status: Implemented (reconsidered in 2007). Again in 2009, 

AI/AN Tribes have requested CDC to reconsider funding decisions for HIV/AIDS. 

/Activities are being implemented in response to this. 

Dr. Gerberding received a letter from the Northwest Portland Indian Health Board (NPAIHB) 

requesting reconsideration regarding funding of the Red Talon Project during FY 2007. Dr. 

Gerberding responded to NPAIHB on January 17, 2007. 

CDC remains committed to developing and supporting culturally-specific best practices that 

effectively and appropriately address HIV and STD prevention in diverse Native communities. 

NCHHSTP will continue to support national initiatives like the annual Native AIDS Awareness 

Day and other National HIV/AIDS AI/AN conferences. NCHHSTP supports HIV and STD 

prevention programs in Indian country in a variety of ways:

 

2

Extramural and Direct funds
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112

 NCHHSTP funds Tribes and organizations that successfully compete for FOA awards (9 in 

2007; 10 in 2008; and 8 in 2009). 

 In addition to the direct awards to tribes and tribal organizations, NCHHSTP also had 

maintained an Interagency Agreement (IAA) with IHS supported by the Division of Sexually 

Transmitted Diseases Prevention (DSTDP).

o This IAA supports two senior public health staff assigned to the IHS Division of 

Epidemiology to maximize resources and collaborations across Indian country. 

o DSTDP plans to maintain this IAA to support and enhance STD prevention and control 

efforts in AI/AN populations. This IAA assists DSTDP to raise awareness of STDs 

among AI/AN as a priority health issue, supports partnerships and collaborations with 

multiple public health partners (state STD programs, IHS, tribal, and urban Indian health 

programs (I/T/U), and support improvement of STD programs for AI/ANs. 

o The IAA has also supported STD outbreak response efforts and integration of STD, 

HIV/AIDS, TB, and hepatitis prevention and control activities. The DSTDP has funded 

ANTHC to assess the acceptability, feasibility, and impact of self-collected specimens on 

reducing barriers to health-care-seeking behaviors and increasing STD screening 

opportunities among Alaska Natives in both rural and urban settings. 

 For two successive years, the NCCDPHP/Division of Reproductive Health (DRH) 

successfully competed for Minority AIDS Initiative funds from HHS Office of HIV/AIDS Policy 

and are using monies from this funding stream to focus on adapting training and technical 

assistance tools for providers of AI/ANs. Pilot projects are underway in CA and AK. 

 CDC/IHS National STD Program provided funding to the IHS Bemidji Area Office (BAO) who 

partners with the Great Lakes Inter-Tribal Epi Center (GLITEC) to provide mini-grants to one 

tribe or tribal organization in each of the three states of Michigan, Minnesota, and Wisconsin 

to work on local needs. . 

o Collaborations and technical assistance will be provided as they work with tribes and 

tribal organizations to complete their projects. 

o DSTDP is also partnering with IHS, Project Red Talon, and Mercer University School of 

Medicine in a project called Native Students Together Against Negative Decisions 

(NativeSTAND)—a peer education curriculum for healthy decision-making for Native 

youth. 

 Since 1989, CDC has funded the National Native American AIDS Prevention Center 

(NNAAPC) to provide capacity building assistance (CBA) to organizations providing services 

to AI/ANs nationwide. 

o With these funds, NNAAPC provided CBA to CBOs and health departments serving 

Native populations, emphasizing the integration of Native principles, beliefs, and 

communication styles into HIV prevention activities. 

 Just recently under a new FOA, NCHHSTP funded two non Native organizations to 

strengthen organizational infrastructure, interventions, strategies, monitoring and evaluation 

for HIV prevention, to deliver CBA to community-based organizations serving all high-risk 

and racial/ethnic minority populations, including Native communities. 

 In addition, NCHHSTP also funded two other organizations, Aberdeen Area Tribal 

Chairmen‘s Health Board (AATCHB) and Colorado State University to focus on 

strengthening community access to and utilization of HIV prevention services in Native 

communities. 

o AATCHB will provide culturally appropriate CBA to tribal HIV and STD prevention 

personnel on reservations and urban centers in Colorado, Iowa, Illinois, Indiana, Kansas, 

Minnesota, Michigan, Missouri, Montana, North Dakota, Nebraska, Ohio, South Dakota, 

Utah, Wisconsin, and Wyoming to reduce health disparities currently existing for AI 

populations. 
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o Colorado State University will continue to strengthen the capacity of CBOs serving 

Native people to develop and implement regionally specific and community-specific 

strategies to address HIV/AIDS

16. Strengthen the relationship between the Division of Adolescent and School Health 

(DASH) and tribal stakeholders to maximize resources and opportunities to address 

issues facing AI/AN youth; Status: Implemented

Following meetings between DASH staff and the CDC TCAC, DASH convened an internal 

working group to identify collaborative strategies and activities for working more effectively with 

Tribes. In FY 2007, for the first time in DASH history, Tribes were included as eligible 

applicants for the Coordinated School Health FOA.

 Three tribes (Cherokee Nation, Nez Perce Nation, and the Winnebago Tribe of 

Nebraska) were funded in FY2008 and other State Education Programs are now reaching 

out to tribes and working collaboratively with them in the development and implementation 

of programs benefiting AI/ANs in their school districts.

 On an ongoing basis, DASH‘s Surveillance and Evaluation Research Branch provides 

technical assistance to the Bureau of Indian Education and the Navajo Nation to conduct the 

Youth Risk Behavior, which is conducted every 3 years to collect data on students in 

Bureau-funded schools to determine the prevalence of health-risk behaviors and assess 

trends in these behaviors to more effectively target and improve programs.

17. Bring SAMHSA and CDC leadership together to consider programming in Indian 

country with an agenda to increase investment in Suicide Prevention and other priority 

issues where there might be strengthened outcomes by collaborative work; 

Status: Implemented/ongoing

During FY 2008, the CDC Adolescent Health Goal Team prioritized the need to explore further 

suicide prevention activities in AI/AN and Hispanic/Latino youth. DASH, along with the National 

Center for Injury Prevention and Control (NCIPC)/Division of Violence Prevention, multiple 

divisions from within NCCDPHP, and OMHD participated in an internal day long session on how 

to use the limited CDC funds available to address this issue. 

 CDC along with SAMHSA and HIS convened a meeting in Washington, DC over September 

21 – 23, 2009 wherein subject matter experts met to assess topics such as prevalence, risk 

and protective factors, prevention strategies, policy and legal implications, and 

dissemination needs. The group identified knowledge gaps, research and program needs, 

and key recommendations. Findings from this meeting of experts have been synthesized 

and will help to inform next steps in addressing suicide in Indian country. As recommended 

by the CDC TCAC, several Native youth did participate in the meeting. Proceedings from 

this meeting will be shared with TCAC and Tribal leaders broadly as soon as available. 

 The Native Diabetes Wellness Program, together with SAMHSA, has made available a 

reprint of the ―Guide To Build Cultural Awareness – American Indian and Alaska Native‖, for 

distribution nationwide through SAMHSA, CDC, and the Indian Health Service. SAMHSA 

secured HHS clearance, and CDC provided funding and printed 115,000 cards, which were 

delivered to SAMHSA in March 2009. To date, requests are coming in for at least 6,500 

cards per month. 
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18. Work together with tribes and tribal organizations to ensure AI/AN Tribes are 

included in the planning of public health emergency preparedness activities and events 

to assure a coordinated and effective public health response; Status: 

Implemented/ongoing 

CDC has been working to strengthen federal/state/tribal relationships such that tribal 

governments and organizations have access to funds awarded to the states (e.g., see 

Recommendations #4 and #5 above). Highlights of multiple efforts across CDC to respond to 

this recommendation include: 

 

 Since the beginning of the Public Health Emergency Preparedness (PHEP) Cooperative 

Agreement program, many states have worked with tribal organizations in improving 

preparedness. Tribal participation, including receipt of resources from states, has been 

encouraged and expected; over the past 3 years tribal concurrence with statewide 

preparedness plans and activities has been required. 

 Beginning in FY07, there has been a requirement in the CDC PHEP program guidance that 

promotes tribal engagement. A letter from either the individual tribes within a state‘s 

boundaries, or an appropriate tribal health board or tribal leaders‘ coalition representing 

those tribes, is required. The letter specifies that the tribes or their legitimate representatives 

have been engaged in planning, and are in substantial agreement with the plan and the 

methodology for distributing Cooperative Agreement funds across a given state. This 

language included in the guidance was developed with the assistance of the CDC Tribal 

Consultation Advisory Committee.

 Each year the Division of State and Local Readiness (DSLR) conducts a state-by-state 

review of PHEP Continuing Applications, monitors for Tribal inclusion, concurrence, 

involvement in planning, and implementation of activities. They share research and 

information on Tribal Capacity and Tribal Preparedness Plans at annual grantee meetings.

 Awardees for the CDC Centers for Public Health Preparedness (CPHP) program host 

national and regional conferences that provide an effective forum for discussing 

preparedness-building activities and opportunities for establishing collaborative capacitybuilding activities among and between tribal, state, and local governments and other 

agencies. The conferences are intended to stimulate the sharing of ideas, resources, and 

information on public health capacity building as a way to enhance public health 

preparedness programs that target and involve tribal people.

 CDC‘s Division of Strategic National Stockpile (DSNS) sponsored a webcast entitled: Mass 

Antibiotic Dispensing-Partnering with Tribal Governments and Communities. The broadcast 

is archived on the CDC website for current viewing. Continuing Education Credits are 

available to viewers of the broadcast through March 3, 2012.

 DSNS, in partnership with OMHD/OD/CDC and IHS, developed a brochure: Preparing Tribal 

Nations to Receive Strategic National Stockpile Assets. This brochure is available here: 

http://www.cdc.gov/h1n1flu/pdf/preparing_tribal_national_stockpile.pdf

 In December 2009, 55 tribal communicators from 29 unique tribes across the United States 

participated in this training course. The CERC/Pandemic Influenza course is a 11⁄2 day 

training that offers a combination of influenza communication tabletop exercises and 

informative group discussions. CERC is an approach used by scientists and public health 

professionals to provide information that allows an individual, stakeholders or an entire 

community, to make the best possible decisions about their well-being, under nearly 

impossible time constraints, while accepting the imperfect nature of their choices. The 

CERC training program draws from lessons learned during public health emergencies, and 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

115

incorporates best practices from the fields of risk and crisis communication. With this 

comprehensive training program, the CDC has moved forward in meeting the needs of 

partners and stakeholders in preparing for, responding to and recovering from the threat of 

bioterrorism, emergent diseases, and other hazards. 

o This training session was the third to be offered specifically to tribal communicators. The 

first CERC training course for communicators to tribal nations was held April 10-11, 2007 

in Phoenix, Arizona and the second was held in San Antonio over October 29-21, 2007.

During the December 2009 training session, tribal attendees took part in the CERC 

"Basic" and "Pandemic Flu" training modules. In addition, all attendees participated in a 

tabletop exercise based on the current H1N1 pandemic. Because this training session 

took place in Atlanta, a number of participants took advantage of an opportunity to 

tour the CDC Global Health Odyssey Museum 

( http://www.cdc.gov/gcc/exhibit/default.htm) and the CDC Emergency Operations 

Center (http://emergency.cdc.gov/cotper/eoc/). For more information on CDC's CERC 

program and access to on-line training modules, please 

visit: http://emergency.cdc.gov/cerc/index.asp .

CDC‘s ongoing efforts address emergency preparedness and response in Indian country is 

exemplified by the multiple activities recently implemented in response to the 2009 H1N1 

influenza pandemic. 

 To develop, facilitate, and coordinate many of these activities, CDC established an AI/AN 

Populations Team (AAPT) in the CDC Emergency Operations Center (EOC), co-led by the 

CDC Senior Tribal Liaison for Science and Public Health and the Director of CDC‘s Arctic 

Investigations Program. AAPT activities have included:

o Technical assistance to the Indian Health Service (IHS), including an evaluation of the 

IHS Influenza Awareness System (IIAS) confirming its high sensitivity and specificity for 

detecting influenza-like illnesses (ILI)

o Support for the publication and dissemination of the MMWR article documenting 

increased H1N1-death rates among AI/AN: 

http://www.cdc.gov/h1n1flu/statelocal/keyfacts_deaths.htm

o Confirmation of increased rates of Alaska Native hospitalizations due to H1N1

o Raising and maintaining awareness of CDC leadership in regard to the impact of H1N1 

on AI/AN populations

o Establishing a dedicated section of CDC‘s H1N1 website for information of importance to 

Tribal Health Officials: http://www.cdc.gov/h1n1flu/statelocal/ 

o Production of video and radio PSAs with AI actor, Wes Studi: 

http://www.cdc.gov/h1n1flu/statelocal/aian_psa.htm

 Other tribal-related H1N1 activities at CDC have included: 

o Disseminating H1N1 information directly to tribal constituents and stakeholders, 

including IHS, via web postings and direct e-mail distribution

o Providing updates to tribal leadership on H1N1 during national and regional tribal 

consultation meetings, NIHB Annual Consumers Conference, NCAI, and the CDC 

Consultation Session in Anchorage, AK over August 11-13, 2009

o Working with states and tribal governments to ensure tribal benefit from federal funding 

streams intended to support H1N1 preparedness and response. 

o Published an article on vulnerable populations in tribal communities in the American 

Journal of Public Health
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116

o Developed, in partnership with IHS, a guidance document on H1N1 issues in Indian 

country that accompanied a letter from Secretary Sebelius to Tribal leaders: 

http://www.cdc.gov/h1n1flu/statelocal/DTLL_H1N1_Guide_10-7-09.pdf

o Posted useful legal documents on CDC‘s Public Health Law Program website: 

http://www2a.cdc.gov/phlp/mutualaid/MutualResources.asp#

o Developed, with IHS, and distributed a vaccination poster for tribal audiences: 

http://www.cdc.gov/h1n1flu/additional_print.htm#nativeamerican

 

19. CDC should consider developing a tribal training center and utilize a clearinghouse 

approach so that the “best practices that are being developed in CDC collaborative work 

with tribes” can be mimicked in other new program areas of tribal importance. CDC 

should share these “best practices” at upcoming AI/AN conferences to help inform and 

train tribal leaders and tribal health staff. CDC needs to provide more technical 

assistance in the public health arena so that tribes are able to implement these programs 

at the local level; Status: Implemented/ongoing

Many of the responses noted above are consistent with the  ̳clearinghouse‘ concept and making 

information readily available to tribal leaders and public health officials (see particularly 

responses to #s1 and 11 through 18). In addition, beginning the week of January 25, 2010, 

CDC will release the inaugural special subject issue of its e-mail and web-based newsletter, 

―Knowledge to Action Science Clips,‖ dedicated to AI/AN and indigenous health publications. 

The Clips series focusing on AI/AN health will recur biannually and will highlight 

work/publications by CDC staff and their partners in other organizations. A more 

comprehensive list of publications of this type are included in CDC‘s contribution to the HHS 

AI/AN Health Research Advisory Council (HRAC) annual report. 

Other CDC activities relevant to this recommendation include:

 CDC staff served as faculty for the Summer Research Training Institute for American Indian 

and Alaska Native Health Professionals in Portland, OR, June 15 - July 2, 2009. The 

Institute curriculum is designed to meet the needs of professionals who work in diverse 

areas of American Indian and Alaska Native health...from administrators to community 

health workers, physicians, nurses, researchers, program managers...almost anyone who 

works in Indian health care and wants to take advantage of new skill-building opportunities. 

Because our courses emphasize research skills and program design and implementation, 

those professionals who seek training opportunities related to research will find relevant 

courses in this program. 

 In FY 2008, CDC staff addressed racial misclassification, a major barrier to accurate AI/AN 

cancer data, by conducting linkages, at low cost, between the IHS patient registration 

database and central cancer registries in all states. CDC staff led efforts to publish ―Annual 

Report to the Nation on the Status of Cancer, 1975–2004, Featuring Cancer in American 

Indians and Alaska Natives” in the October 2007, journal CANCER. 

 In February 2008, CDC center leadership met with representative of NIHB and Tribal Epi 

Centers to educate and establish a relationship and identified points-of-contacts to 

periodically share information about public health activities and initiatives. 

 In May 2007 (Anchorage, AK), 20 participants from tribal governments, Tribal EpiCenters, 

tribal health boards, Alaska Native health corporations, and the NIHB met with 21 other 

participants of state, and federal public health professionals and consultant legal experts to 

discuss the current status of public health legal preparedness in Indian country, identify 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

117

gaps in public health legal foundations, and develop an initial plan of action to address these 

gaps. 

 CDC in consultation and collaboration with Northwest Portland Area Indian Health 

Board/Project Red Talon; participating schools, tribes, and health care facilities; corporate 

partners Beckton Dickson and GenProbe, and IHS STD staff worked together to implement 

school-based STD screening in schools serving AI/ANs. 

 CDC NCBDDD in collaboration with SD Department of Health, University of SD, ND Fetal 

Alcohol Syndrome Center met with American Indian communities in Standing Rock, Turtle 

Mountain, and Pine Ridge to develop a media campaign to promote a community-based 

intervention for women of childbearing age to either reduce their drinking or to improve 

family planning.

20. Strongly recommend that NIHB hold a “CDC Day” at their annual conference, or 

highlight CDC in the morning and another agency in the afternoon. Simply having the 

Public Health Summit does not create the visibility needed for tribes to understand CDC 

and what it has to offer AI/AN tribes; Status: Not implemented/other activities apply

CDC has communicated to NIHB our interest in supporting a ―CDC Day‖ at their Annual 

Consumer‘s Conference. In the meantime, CDC professionals and leadership have continued 

to participate in numerous regional and national tribal meetings – prominent examples include: 

NIHB Public Health Summit, NIHB Annual Consumer‘s Conference, IHS Public Health Summit, 

Tribal Epicenters Meetings, Association of American Indian Physicians Annual Conference, 

AI/AN Health Research Conference, National Congress of American Indians Annual 

Conference, and HHS Regional Tribal Consultation Sessions. 

21. Allow tribal organizations to have access to some of the expertise that CDC has as 

tribes develop methodologies to collect and analyze data, and develop statistical reports, 

it would be ideal to have an expert verify the work for flaws; Status: 

Implemented/ongoing

The responses to recommendation #19 above are also germane to this recommendation. In 

addition to the examples already cited, CDC staff in Albuquerque, NM remains ready to assist 

tribal organizations as described in this recommendation. Subject matter experts (SMEs) in 

epidemiology, statistics, policy analysis, racial misclassification, health disparities, cancer, 

immunizations, and STDs work full-time on tribal health issues in close collaboration with IHS. 

These SMEs maintain close working relationships with a number of Tribal Epi Centers. 

Similarly, CDC SMEs with the Arctic Investigations Program in Anchorage maintain ongoing and 

robust collaborations with many Alaska Native health organizations across Alaska. Examples of 

these many collaborations can be found in the annual update, ―Centers for Disease Control and 

Prevention: Highlights of AI/AN-Focused Activities, FY 2009, A Summary Report for the 4th

Biannual CDC Tribal Consultation Session, January 28, 2010, Atlanta, GA.‖

22. Develop an annual report that will describe recommendations that have been made 

within the last two years, and the status of each; Status: Implemented/ongoing

This report, ―CDC Tribal Consultation Advisory Committee (TCAC) - Update on 

Recommendations/Response, January 2010,‖ will be updated annually. In addition, the report 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

118

mentioned in response to recommendation #3 above will also be issued annually as it provides 

a more comprehensive overview of CDC program activities relevant to Indian country. `The title 

of that report is, ―Centers for Disease Control and Prevention: Highlights of AI/AN-Focused 

Activities, FY 2009, A Summary Report for the 4th Biannual CDC Tribal Consultation Session 

January 28, 2010, Atlanta, GA.‖

23. Schedule COTPER/DSLR project officers to present at the next TCAC meeting to 

address CDC state guidance policies as they related to tribes. Require states that 

receive PHEP funding to make a formal report to share with TCAC and other tribal 

leaders; Status: Implemented/ongoing

In addition to the detailed responses outlined under recommendations #4, 5, and 18 above, 

COTPER Leadership and DSLR project Officers met with Tribal leaders during the February 

2008 Biannual Tribal Consultation Session and again at the 2010 Tribal Leaders Orientation to 

CDC session, both in Atlanta.

23. Develop a strategic budget plan to determine what options are available for FY2011 

and FY2012; Status: Not implemented

Similar to the response above to recommendation #14, no definitive action has taken place thus 

far. It is anticipated that this recommendation will be given due consideration under new CDC 

leadership and as the Organizational Improvement process moves forward in FY 2010. 

24. Gain commitment of CDC/NCEH and ATSDR to assist the Navajo Nation with 

environmental and pollution issues; Status: Implementation in progress

Several activities are underway or planned that address this recommendation: 

 NCEH is assisting investigation of Drinking Water Exposures in Unregulated Water 

Sources at the Navajo Nation (NN). 

o Water hauling is widespread on NN. Approximately 25% households on NN are not 

connected to a public water system and must haul drinking water from outside, often 

untreated sources. Connected households may still choose to haul water from untreated 

sources. The extent to which Navajo people consume untreated water has not been 

quantified. The exposures and health risks associated with this practice are unknown. 

o As a first step in addressing this knowledge gap, NCEH/ Health Studies Branch (HSB) 

conducted a study of 199 untreated water sources (livestock wells and springs) used for 

drinking water in the NN in August 2006 and September 2007. This study showed 

widespread bacterial contamination and water sources exceeding EPA limits for uranium 

and arsenic. The study identified 5 high risk communities where water arsenic and 

uranium were concentrated. In order to assess the extent of human exposure to drinking 

water contaminants in the 5 high risk communities, HSB also conducted a crosssectional household study in October 2008 (see next topic). In the fall of 2009, HSB 

conducted additional sampling of unregulated wells that had been identified from the 

household survey. Sample results from these wells are pending.

 NCEH/HSB conducted a household survey of drinking water sources and contaminant 

exposures at the NN. 

o Cross-sectional household surveys of 296 households (with and without access to 

potable water) were randomly selected from five NN communities. HSB interviewed one 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

119

member of each household on water hauling practices, tested for urine biomarkers of 

exposure to 18 chemicals, and analyzed one drinking water sample for chemical and 

bacterial contaminants. Of 296 water samples collected, 34 (11%) samples exceeded 

safe drinking water standards for arsenic and 8 (3%) samples exceeded safe water 

standards for uranium. Ninety-two (35%) of the drinking water samples tested positive 

for total coliform and 22 (8%) tested positive for E. coli. Of the 244 urine samples 

collected, 103 (42%) had high uranium levels (>95th % of levels seen in the US 

population as defined by NHANES). The study population had urine levels higher than 

usual for national levels but comparable to other regional study levels, though none at 

levels known to cause health effects. Uranium contamination of water sources does not 

appear to be the primary cause of increased uranium levels found in urine. Bacterial 

contamination was found in water samples which could indicate a public health risk. In 

the fall of 2009, additional urine testing of participant family members was offered and 

conducted as a public service. 

o Additional activities related to the two projects above included visiting each study 

participant in-person to discuss study results, presenting results at Chapter meetings 

and to community groups, preparing physician education for clinics in the study area to 

understand study results and potential health concerns, referring participants to the 

Indian Health Services‘ (IHS) screening program, and labeling unsafe water sources.

 House Committee on Oversight and Government Reform Bi-Annual Meeting to Discuss 

Updates Regarding the Five-Agency, Five-Year Plan to Address Health and Environmental 

Impacts of Uranium Contamination at the NN.

o Since September 2008, representatives from NCEH and ATSDR have attended biannual meetings with congressional representatives of the House Committee on 

Oversight and Government Reform which is overseeing efforts to address health and 

environmental impacts of uranium contamination at the NN. Five federal agencies 

including the Environmental Protection Agency (EPA), Department of Energy (DOE), 

IHS, Bureau of Indian Affairs (BIA), and the Nuclear Regulatory Commission (NRC) 

have each been tasked with responsibilities for assessment and remediation related to 

uranium exposure and contamination. NCEH and ATSDR have been actively providing 

technical support to EPA and IHS for numerous activities related to environmental public 

health.

 The House Committee on Oversight and Government Reform requested that the BIA, DOE, 

NRC, EPA, and IHS develop a coordinated five-year plan to address the health and 

environmental impacts of uranium contamination in the NN. ATSDR and NCEH have 

participated in congressional briefings on this subject.

o In support of the 5 agency, 5-year plan, ATSDR conducted Grand Rounds training for 

medical professionals at the NN. The subject of the training was uranium exposure, but 

also touched on arsenic in drinking water which is of concern to the tribe. The training 

was conducted through the Division of Toxicology and Environmental Medicine‘s 

(DTEM) cooperative agreement with the American College of Medical Toxicology 

(ACMT) and included technical input from the ASTDR Division of Health Assessment 

and Consultation (DHAC) and the ATSDR Division of Regional Operations (DRO). A 

physician with board-certification in toxicology was selected by ACMT to conduct the 

training which took place in December 2008 at four IHS clinics located in the Navajo 

communities of Tuba City, AZ; Kayenta, AZ; Chinle, AZ; and Shiprock, NM. The 

development of this training was an interdisciplinary effort with input from the IHS, EPA, 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

120

ACMT, NCEH, NN, University of New Mexico (UNM), Southwest Research and 

Information Center (SRIC), and others.

 On July 13-14, 2009, Community Health Representatives (CHRs) from the NN Health 

Clinics were provided training to prepare them to deliver individual bio-monitoring results to 

approximately 300 households that participated in a 2008 investigation of drinking water 

exposures. The drinking water study was conducted by the NCEH/HSB and the NN 

Environmental Protection Agency (NNEPA). The 2008 investigation focused on the extent to 

which non-regulated water sources represent a public health threat to members of the NN. 

The water study investigation protocol required that each participant be provided their 

individual bio-monitoring results through a personally delivered letter. ATSDR‘s Division of 

Health Assessment and Consultation (DHAC) and Division of Toxicology and Environmental 

Medicine (DTEM) collaborated with the HSB and the NCEH/ATSDR Office of Tribal Affairs 

to develop the specialized training.

o The CHR training provided information on 1) the biomonitoring laboratory results and the 

potential health effects of those laboratory findings on the health of individuals who 

participated in the bio-monitoring study; and 2) background information on bacteria and 

chemical water contamination found in non-regulated Navajo Nation wells and springs 

that were potential threats to public health when used as a drinking water source. The 

third aspect of the training was to promote safe water hauling practices that included 

steps necessary to sanitize water containers as well as types of containers appropriate 

for the hauling and storage of drinking water. The training was designed to provide 

opportunities for the CHRs to translate the materials into Navajo. Education examples 

were developed that reinforced the importance of only using water from regulated wells 

or springs for cooking and drinking as a way to protect and improve individual and family 

health. A two-sided desktop flip chart was developed as a job-aid for use by the CHR‘s 

when individual results were delivered to tribal members. 

o More than 50 CHRs and NNEPA staff participated in the 2-day workshop. The CHRs 

were then better prepared to educate the families associated with the 300 participating 

households involved in the study. Dissemination of the individual test results to tribal 

members began soon after the conclusion of the workshop.

 In June 2009, ATSDR‘s Division of Toxicology and Environmental Medicine (DTEM), with 

assistance from the CDC National Center for Health Marketing developed, recorded, and 

produced the Environmental Medicine Grand Rounds ―Uranium for the Navajo Nation Health 

Clinics.‖ The Grand Round reviews some of the history of uranium mining, uranium health 

effects and medical care, and provides some information on water sampling activities 

conducted by the NNEPA and NCEH. These materials support the work of NNEPA, NCEH, 

IHS, and EPA in addressing uranium contamination of Navajo land by past mining and 

milling activities. Past and ongoing exposure has negatively impacted the health of some 

tribal members.

o Recognizing the difficulties in providing in-person, local training to widely dispersed 

health professionals and their staffs, the ―Uranium for the Navajo Nation Health Clinics‖ 

Grand Rounds DVD was developed with a DTEM environmental medicine physician 

presenting critical information on uranium health effects to the health professionals 

caring for tribal members who may suffer health effects from exposure to uranium waste. 

This training product allows local physicians and their staffs the flexibility to receive 

continuing education at times and places convenient with their schedules and locations. 

This format provides additional opportunities to educate new staff and for all staff to use 

as a refresher to reinforce their learning experience. The ―Uranium for the Navajo Nation 
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

121

Health Clinics‖ Grand Rounds will be available on DVD to Navajo Nation clinics and 

health professionals. ATSDR offers free continuing education credits to physicians, 

nurses, and health educators who complete this Environmental Medicine Grand Rounds 

training and posttest as a service to assist these NN health professionals to maintain 

their medical and health credentials.

 ATSDR anticipates FY 2010 funds for ATSDR to conduct an Epidemiological Study at the 

NN. The ATSDR Division of Health Studies is projected to design and begin epidemiologic 

studies of health conditions caused by non-occupational exposures to uranium released 

from past mining and milling operations on the NN. 

 Technical Support and Data Analysis for Ft. Wingate Army Base Closure and Transfer of 

Lands to the Navajo Nation and Pueblo of Zuni 

o The Fort Wingate Army Depot, located about eight miles east of Gallup, NM, closed in 

January 1993 after nearly a century and a half of military uses, first as a cavalry post, 

then as a munitions depot. Environmental investigation and cleanup efforts, including 

munitions clearance, have been made on a nearly continuous basis since 1994. Major 

environmental concerns at this site include munitions hazards and groundwater 

contamination by explosives and nitrates. On December 31, 2005, the New Mexico 

Environment Department's (NMED) RCRA permit came into effect, establishing a 

scheduled cleanup of the facility.

o In November 2008, an ATSDR Site Remediation and Assessment Branch (SRAB) 

representative and the NCEH/ATSDR Tribal Liaison participated in a meeting with the 

US Army, NN representatives, Pueblo of Zuni representatives, and the NMED that was 

held in Gallup, NM. SRAB was asked to review various documents and to provide input 

on the environmental public health exposure pathways that have the potential to impact 

future land use options. The US Army is conducting a phased assessment of soil, water 

and other media in preparation for the transfer of lands to the Bureau of Indian Affairs 

(BIA) who will then facilitate the distribution of lands to the Navajo Nation and Pueblo of 

Zuni. 

o SRAB provided input to the Department of Defense (DOD) during 2009 on the sampling 

and risk assessment methodology for the site and continues to collaborate with the two 

tribes, the US Army, and NMED to ensure their environmental health concerns are 

addressed.
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Tribal Consultation Advisory Committee (TCAC) Members 

Chester Antone, Tucson, TCAC Chair (Tohono O‘odham Nation, Councilman)

Roselyn Begay, Navajo Nation (Division of Health, Program Evaluation Manager)

Joe Finkbonner, Portland (Northwest Portland Area Indian Health Board, Executive Director)

Reno Franklin, California (California Rural Indian Health Board, Chairman)

Kathy Hughes, Bemidji, TCAC Co-Chair (Oneida Business Committee)

Cynthia Manuel, NIHB (Tohono O‘odham Nation, Councilwoman)

Michael Peercy, Tribal Self-Governance Advisory Committee, Choctaw Nation of Oklahoma, 

Epidemiologist

J.T. Petherick, Oklahoma (Cherokee Nation, Health Legislative Officer)

Alicia Reft, Alaska (Karluk Ira Tribal Council)

Dee Sabattus, Nashville (United South and Eastern Tribes, Inc., Interim THPS Director)

Lester Secatero, Albuquerque (Albuquerque Area Indian Health Board, Chairman)

Roger Trudell, Aberdeen (Santee Sioux Tribe of Nebraska, Chairman)

Derek Valdo, NCAI (from Pueblo of Acoma, National Congress of American Indians)

Other Elected Tribal Leaders

Cathy Abramson, Sault Tribe of Chippewa Indians, Board Member 

Candida Hunter, Hualapai, Councilwoman

Joyce Jones, Karluk IRA Tribal Council, Vice-President

Andy Joseph, Jr., Colville Tribes, Northwest Portland Area Indian Health Board Chair, HHS 

Chair Tribe Council, NIHB

Buford L. Rolin, Poarch Band of Creek Indians, Tribal Chairman

Other Tribal Organizations / Tribal Health Boards / Tribal Health Professionals 

Stacy Bohlen, NIHB, Executive Director

Michael Bristow (Osage Tribe of Oklahoma) 

Jessica Burger, NIHB, Deputy Director 

Bridget Canniff, Northwest Portland Area Indian Health Board, Tribal Epi Center Consortium, 

Project Director 

Kristal Chichlowska, Colville Confederated Tribes, California Tribal Epidemiology Center, 

Director 

Alan Crawford (former AI CDC employee) 

Feliciano Cruz, Pascua Yaqui Tribe, Public Health Emergency Preparedness Coordinator

Larry Curley, Indian Health Board of Nevada, Executive Director

Elaine Dado, Northwest Portland Area Indian Health Board 

Maria Garcia, Pascua Yaqui Tribe, Program Manager Alternative Medicine 

Tim Gilbert, Alaska Native Tribal Health Consortium, Senior Director, Community Health

Kristin Hill, Great Lakes Inter-Tribal Epidemiology Center, Director 

Lyle Ignace, Coeur D‘Alene, Indian Health Service, Medical Officer

Luke Johnson, Fort Mojave Indian Tribe, Public Health Emergency Preparedness Coordinator 

Angela Kaslow, CRIHB, Director, Family and Community Health Services 

Deborah Klaus, Navajo Division of Health, Director / Senior Epidemiologist, Navajo Epi Center 

Attendant Roster
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Steven Matles, Indian Health Board of Nevada, Deputy Director 

Jackie McCormick, Northwest Portland Area Indian Health Board

Ruth Ojanen, Board Member, Norton Sound Health Corporation

Michael Peercy, Choctaw Nation of Oklahoma, Epidemiologist

Geoffrey Roth, National Council of Urban Indian Health, Executive Director

Paul Saufkie, Hopi Tribe, Public Health Emergency Preparedness Coordinator 

Audrey Solimon, NIHB, Senior Advisor, Public Health Programs

Berda Willson, Norton Sound Health Corporation, Board Secretary

Centers for Disease Control and Prevention

Larry Alonzo, Commander, US Public Health Service

Annabelle Allison, Environmental Health Specialist, NCEH / ATSDR

Lynda Anderson, DACH / NCCDPHP / CDC

Mick Ballesteros, Associate Director for Science, National Center for Injury Prevention and 

Control

Holly Billie, Senior Injury Prevention Specialist, National Center for Injury Prevention and 

Control

Nell Brownstein, AREB/DHDSP/NCCDPHP/CDC

Kristen Brusuelas, Chief of Government Relations, State and Local Services

Ralph Bryan, Senior Tribal Liaison for Science and Public Health

Pyone Cho, Epidemiologist, NCCDPHP

Alex Crosby, Epidemiologist, Division of Violence Prevention, NCIPC

Linda Crossett, DASH/NCCDPHP/CDC

Larry Cseh, ATSDR, Environmental Health Scientist

Sean Cucchi, Associate Director for Policy, NCCDPHP

Rob Curlee, Deputy Director, Financial Management Office

Lori de Ravello, IHS / Division of Epidemiology & Disease Prevention, Public Health Advisor

Roseanne Farris, NCCDPHP / DNPAO, Branch Chief

Michael Franklin, Senior Public Health Analyst, Financial Management Office

Larry Gilbertson, Public Health Advisor, NCCDPHP

Wayne Giles, Acting Deputy Director, National Center for Chronic Disease Prevention and 

Health Promotion

William Kohn, DDS, Director, DOH/NCCDPHP/CDC

Christine Kosmos, Director, Division of State and Local Readiness

Dianne May, PSB/OSH/NCCDPHP/CDC

Marcus Plescia, Director, DCPC/NCCDPHP/CDC

Dawn Satterfield, Native Diabetes Wellness Program

Mike Snesrud, Senior Tribal Liaison for Policy and Evaluation

Stephen Thacker, Acting Deputy Director, Office of Surveillance, Epidemiology, and Laboratory 

Services

Myra Tucker, Tribal Liaison

Karen White, Acting Deputy Director, Office of State and Local Support

Lorraine Whitehair, Division of Nutrition, Physical Activity, and Obesity / NCCDPHP

Craig Wilkins, AI/AN Team

Walter Williams, Office of Minority Health and Health Disparities
Tribal Consultation Advisory Committee (TCAC) Minutes of the Meeting January 26-27, 2010

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Other Guests

Stacey Ecoffey, Principal Advisory for Tribal Affairs, Intergovernmental Affairs, HHS

Brenda Granillo, Director, Arizona Center for Public Health Preparedness

Ronald Demaray, IHS, Acting Director, Office of Direct Service and Contracting with Tribes