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Tribal Consultation on Centers for Disease Control and 

Prevention and Agency for Toxic Substance and Disease 

Registry’s (CDC/ATSDR) 

CDC Moving Forward Initiative

12/13/2022 - 02/24/2023

On February 9, 2023, the Centers for Disease Control and Prevention (CDC) and the Agency for Toxic

Substances and Disease Registry (ATSDR) hosted a tribal consultation on how to strengthen relationships 

during the implementation of the CDC Moving Forward Initiative, how the agency can better engage with 

Indian Country through meaningful consultation, tribes' priorities as we transition out of the COVID-19 

public health emergency, and on how CDC/ATSDR can better support tribes and tribal communities in the 

future. Written comments were accepted until 5:00 pm (EST) on February 24, 2023.

Table of Contents

Tribal Consultation on CDC Moving Forward Initiative ................................................................................. 1

Introduction................................................................................................................................................... 2

Detailed Responses to Tribal Leaders’ Summary of Recommendations Regarding CDC/ATSDR’s CDC 

Moving Forward Initiative ............................................................................................................................. 3

1) CDC Moving Forward............................................................................................................................ 3

2) Accountability ....................................................................................................................................... 5

3) Health Equity ........................................................................................................................................ 7

4) Data....................................................................................................................................................... 11

5) Funding ................................................................................................................................................. 13

Next Steps ..................................................................................................................................................... 15

Appendix A: Consultation: Written, Oral, and Other .................................................................................. 16

Consultation Transcript (Oral Testimony) ............................................................................................... 16

CDC/ATSDR Tribal Testimony Chat Comments........................................................................................ 29

CDC/ATSDR Tribal Consultation – CDC Moving Forward Initiative PowerPoint Presentation ...............32

Written Testimony .................................................................................................................................. 50

Appendix B: List of Participants— February 9, 2023, Tribal Consultation...................................................115

Appendix C: Current CDC/ATSDR Tribal Consultation Policy (dated 2020) .................................................121

Appendix D: Dear Tribal Leader Letter for CDC/ATSDR December 15,2022, Tribal Consultation ...............130

Appendix E: Federal Register Notice for CDC/ATSDR December 13,2022, Tribal Consultation..................133
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Introduction 

On February 9, 2023, CDC/ATSDR hosted an in-person and virtual government-to-government 

consultation with tribal leaders to receive input and guidance on how to strengthen relationships 

during the implementation of the CDC Moving Forward Initiative, how the agency can better 

engage with Indian Country through meaningful consultation, tribes' priorities as we transition 

out of the federal COVID-19 public health emergency declaration, and how CDC/ATSDR can better 

support tribes and tribal communities in the future. 

This tribal consultation provided an opportunity for leaders from tribal nations and CDC/ATSDR to 

engage in government-to-government discussion to advance CDC/ATSDR support for and 

collaboration with American Indian and Alaska Native (AI/AN) tribal nations and to improve the 

health of AI/AN communities. There were 226 participants, including tribal leaders, CDC/ATSDR 

senior leaders, and other tribal partners. Comments were accepted from December 13, 2022, to 

February 24, 2023, 5:00 pm (EDT). 

CDC/ASTDR issued a Federal Register Notice on December 13, 2022, announcing the consultation, 

which included the purpose and details of the meeting. A Dear Tribal Leader Letter (DTLL) was 

sent to tribal leaders on December 15, 2022, inviting them to the consultation. Additionally, 

CDC/ATSDR shared information about the virtual consultation session and comment period with 

various tribal partners according to the CDC/ATSDR Tribal Consultation Policy. The current 

CDC/ATSDR Tribal Consultation Policy is available on CDC’s Tribal Health website. 

Specifically, CDC/ATSDR sought feedback from tribal leaders on the following topics: 

1. How can the agency strengthen relationships during the implementation of the CDC 

Moving Forward Initiative? 

2. How can the agency better engage with Indian Country through meaningful consultation? 

3. What are your tribes' priorities as we transition out of the COVID-19 public 

health emergency and how can CDC/ATSDR better support tribes and tribal 

communities moving forward? 

This report provides tribal leaders with a summary of recommendations and input received during 

the consultation period. 

CDC received input from seven federally recognized tribes and one tribal partner during the 

consultation period. 

CDC/ATSDR recognizes the need for ongoing and continued education and training of CDC staff 

working with tribal nations and is committed to working with agency leaders to ensure training is 

appropriate and available. CDC has summarized tribal leaders’ responses to the questions above

and provided initial responses to the most frequent comments. The agency will use this 
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information to continue to update the policies and practices around the implementation of the 

CDC Moving Forward Initiative.

Detailed Responses to Tribal Leaders’ Recommendations During the February CDC/ATSDR Tribal 

Consultation

This section addresses recommendations made by tribal leaders (or their designees) at the 

CDC/ATSDR Tribal Consultation held on February 9, 2023, and during the written comment period 

ending on February 24, 2023. The comments and recommendations received are organized under 

the following themes: 1) CDC Moving Forward Initiative; 2) Accountability; 3) Health Equity; 4) 

Data; and 5) Funding.

1) CDC Moving Forward Initiative

Tribal leaders recommended that CDC/ATSDR better inform and continuously inform tribal 

leaders about CDC Moving Forward. Comments were received concerning the need for 

CDC/ATSDR staff to be trained on working with tribal nations, how COVID-19 messaging is being 

sent to tribal nations, and how CDC/ATSDR can learn from tribes. 

Summary of CDC Moving Forward Initiative Recommendations:

Tribal leaders specifically identified a need for CDC/ATSDR staff to be aware of and trained in 

working with tribal nations. Tribal leaders recommend that training be provided to all CDC/ATSDR 

staff on tribal sovereignty, the nation-to-nation relationship, federal trust responsibility, and other 

core concepts and CDC/ATSDR’s role in fulfilling them.

Tribal leaders are concerned that tribal priorities may not be reflected in the CDC Moving Forward 

Initiative, and there is a need for greater accountability to ensure their input is reflected in the 

Moving Forward efforts. Tribal leaders reminded CDC/ATSDR of their trust responsibility and the 

importance of engaging tribal leaders at the beginning of and often prior to actions being taken, 

such as CDC Moving Forward. One tribal leader summarized this sentiment as “we say, say 

nothing about us, without us.” 

Tribal leaders reminded CDC/ATSDR that the best way to move forward and make progress on 

public health goals is to hear directly from tribes via tribal consultation, because it benefits all 

tribes. Tribal leaders believe that early and regular engagement puts CDC/ATSDR in a better 

position to serve tribal nations, fulfill the federal trust responsibility, and achieve meaningful 

health equity in Indian Country.

Tribal leaders stated that the reorganization of CDC/ATSDR is the perfect time to hit reset, come 

together and work in tandem. Strengthening cross-cutting functions identified in CDC Moving 

Forward and improving personnel resources, expertise, and funding is a welcome step forward. 

Tribal leaders have acknowledged that there has been improvement in information sharing and 

CDC/ATSDR’s relationship with tribes is getting stronger, but concerns remain about the 
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timeliness of the communication regarding the CDC Moving Forward Initiative. Specifically, 

leaders expressed concern about receiving information after implementation began, and they 

hope CDC/ATSDR will take tribal comments into full consideration, even if it means rethinking 

decisions that have already been made in planning the reorganization.

Tribal leaders acknowledged CDC/ATSDR’s priorities but asked CDC/ATSDR if they were aware of 

some of tribal leaders’ priorities (e.g., data sharing, missing or murdered Indigenous persons, 

electronic health records systems, etc.), and if additional consultation will occur on CDC Moving 

Forward. In addition, tribal leaders stated that they see the reorganization of CDC/ATSDR as a 

chance to implement necessary systemic and cultural changes that can effectively address the 

root causes of health inequities, paving the way towards a more equitable future.

Tribal leaders stated that the reorganization of CDC/ATSDR should prioritize a strengths-based 

organizational culture and focus on cultural humility.

Tribal leaders have emphasized the importance of clear communication from CDC/ATSDR 

regarding COVID-19, as well as ensuring that all recommendations, guidance, and advice are 

based on science. Tribal leaders have stated that they have worked hard to protect populations 

who have high comorbidity rates and susceptibility to infection, therefore, information needs to 

be accurate. Tribal leaders also stated that it makes their job much harder when they make 

declarations of guidance and behavior to their tribal citizens and CDC/ATSDR is not as forceful.

Tribal leaders expressed concern about the transition out of the COVID-19 pandemic and inquired 

about how CDC/ATSDR is taking tribal priorities into consideration as it transitions out of the 

public health emergency declaration, in addition to how CDC/ATSDR will prepare for the next 

pandemic. Tribal leaders emphasized the need for tribal leaders and CDC/ATSDR to learn from 

each other; questioning what and how the agency is learning from tribes when tribes are not 

consulted at the beginning of the process. 

Tribal leaders expressed concern that the administration intends to end the public health 

emergency without consultation; especially because there is more than one national emergency 

declaration for the COVID-19 pandemic. In addition, tribal leaders expressed concern about how 

CDC/ATSDR will collaborate with HHS and sister agencies to ensure that tribal nations are 

informed of health care coverage, surveillance activities, vaccine programs, etc., that are available 

to their communities. 

Response to CDC Moving Forward Initiative Recommendations:

CDC/ATSDR acknowledges the recommendations made by tribal leaders on the CDC Moving 

Forward Initiative. CDC/ATSDR also recognizes the importance of engaging tribal nations early and 

often in the CDC Moving Forward Initiative. CDC is committed to working to continue 

strengthening our relationship with tribes as we further implement CDC Moving Forward. Early in 

the implementation of the CDC Moving Forward Initiative, CDC engaged the CDC/ATSDR Tribal 

Advisory Committee (TAC) during the December 2022 TAC Conference Call and Dr. Mary 
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Wakefield presented on the CDC Moving Forward work being done to modernize and reorganize

the agency. Dr. Wakefield discussed efforts to prepare a more response-ready workforce 

equipped to respond to future public health emergencies and optimize CDC’s web-based content 

to enhance utility and equity for CDC’s public health partners and the people we serve. To that 

extent, CDC/ATSDR will continue to use the Tribal Advisory Committee (TAC) and other tribal 

engagements to seek input and guidance from tribal leaders throughout this process.

CDC/ATSDR recognizes the need for ongoing and continued education and training of CDC/ATSDR 

staff working with tribal nations and is committed to working with agency leaders to ensure 

training is appropriate and available. CDC/ATSDR also understands the importance of workforce 

development and is partnering with the National Network of Public Health Institutes (NNPHI),

Indigenous Public Health Leaders Program. The program is currently training its second cohort of 

50 emerging AI/AN public health professionals who are working with tribal organizations and 

communities. This six-month program focuses on core public health competencies, including 

mental health, emergency preparedness, and collaboration amongst stakeholders, to better serve 

tribal populations.

The CDC Office of Tribal Affairs and Strategic Alliances (OTASA) will continue to recommend 

training materials and programs produced by tribes as well as work with other agency initiatives 

to improve tribal engagement across CDC/ATSDR. CDC/ATSDR also recognizes the significance of 

building relationships at the tribal staff and leadership levels and will continue to improve 

coordination and communication between partners.

CDC/ATSDR recognizes and appreciates tribal leaders’ concerns around the ending of the federal 

COVID-19 public health emergency declaration. While CDC/ATSDR continues to refine how it will 

support tribal nations, tribes and partners should reach out to OTASA with any questions or 

concerns. OTASA will continue to keep tribal nations informed as CDC/ATSDR updates and 

transitions the emergency response.

2) Accountability

Tribal leaders recommended that CDC/ATSDR ensure they are accountable to tribal priorities and 

input. Comments were received concerning the need for CDC/ATSDR to be accountable and 

uphold the federal trust responsibility. 

Summary of Accountability Recommendations:

Tribal leaders recommend accountability include measures of effectiveness and evaluation of 

CDC/ATSDR’s work. Tribal leaders also stated that accountability must occur bidirectionally, and 

tribes are committed to providing direct communication to CDC/ATSDR about the agency’s work 

in Indian Country. Tribal leaders stated that with two-way communication there can be 

meaningful consultation; reminding CDC/ATSDR that tribal consultation must occur with leaders 

who have decision-making authority in the agency. In addition, tribal leaders reminded 

CDC/ATSDR that appropriate follow-up must occur in order to make the engagement meaningful. 

Tribes indicated a desire and willingness to engage with CDC/ATSDR in a framework of equal 
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partnership, emphasizing that the relationship between tribal governments and CDC/ATSDR 

should not be paternalistic.

Tribal leaders stated that CDC/ATSDR must take active measures to ensure AI/AN people and 

tribes are visible in the creation of policies and data as part of its trust responsibility; this includes 

sharing information in a timely manner, such as the status of the implementation of the 

recommendations made by the Government Accountability Office (GAO) in its 2022 report on 

enhancing HHS data access for Tribal Epidemiology Centers (TECs) or details on how CDC/ATSDR 

plans to end the COVID-19 public health emergency. 

Tribal leaders have stated that CDC/ATSDR and their programs do not always consider tribal 

needs and funding; this lack of transparency elicits questions about CDC/ATSDR’s commitment to 

upholding their trust responsibility.

Response to Accountability Recommendations: 

CDC/ATSDR appreciates the recommendations and acknowledges the need for greater 

accountability in reporting and following up on tribal leaders’ recommendations. CDC/ATSDR will 

continue to prioritize providing updates to the CDC/ATSDR TAC and HHS Secretary’s Tribal 

Advisory Committee (STAC) through regular TAC conference calls and quarterly STAC meetings, as 

well as a summary report of the tribal leaders’ recommendations received at tribal consultation 

and CDC/ASTDR’s response.

Dr. Leslie Ann Dauphin, the Acting Designated Federal Official for the CDC/ASTDR TAC, stated in 

her March 2023 CDC updates to the HHS STAC that one of the motivations for the CDC Moving 

Forward Initiative is to increase transparency and accountability. CDC/ATSDR is also working to 

conduct a landscape analysis of all CDC/ATSDR funding opportunities to see where and how the 

agency can reduce administrative burden, increase technical support, and disburse funding more 

efficiently to partners.

CDC/ATSDR recognizes the need for transparency and will continue to share information widely, 

and seek input from the CDC/ATSDR TAC, STAC, tribal leaders and tribal serving organizations that 

may be impacted by CDC/ATSDR’s actions. Additionally, CDC/ATSDR sends information on funding 

opportunities, resources, conferences, and other tribal news to tribal leaders, national tribalserving organizations, grantees, and others through a biweekly email and other ad hoc 

communications to ensure timeliness. CDC/ATSDR also asks our HHS sister agencies and national 

tribal partners to share information with their network to ensure information is distributed as 

widely as possible.

CDC/ATSDR acknowledges the need to report to tribal leaders on the CDC Moving Forward work 

and the reorganization as we progress and will strive to improve on the shortcomings identified 

with the CDC Moving Forward Initiative and upholding our trust responsibility. CDC/ATSDR 

intends to pursue tribal input on key areas of the Moving Forward Initiative through continued 

engagement with the TAC as well as continued collaboration with national tribal partners.
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CDC/ATSDR also continues to prioritize engagement with tribes more generally. For example, 

during the August 2022 TAC meeting in Tahlequah, Oklahoma, the CDC National Center for 

Environmental Health (NCEH) shared plans to hold several regional tribal environmental health 

summits throughout the nation to address issues raised by tribes during listening sessions and 

previous engagements with tribes over the last few years. NCEH will hold these summits in 

partnership with tribal health organizations, the first summit is expected to occur in July 2023. 

Primary environmental health topics include climate and health, solid waste, and safe water.

CDC/ATSDR is committed to tribal consultation and has increased the number of consultations 

compared to past years. For example, CDC participated in HHS-led tribal consultation on data 

sharing on October 13 and October 19, 2022. A summary report of the oral and written comments 

received from the HHS-led tribal consultation was finalized in January 2023 and is now included 

on CDC’s Tribal Public Health Data website. The CDC’s National Institute for Occupational Safety 

and Health (NIOSH) recently hosted a consultation in February 2022 to obtain public feedback on 

the AI/AN Worker Safety and Health Strategic Plan, and the final plan was published March 2023.

Furthermore, the CDC National Center for Injury Prevention and Control will hold a consultation 

on the Rape Prevention and Education Program on July 12, 2023. For further information please 

see CDC/ATSDR Tribal Consultation website. 

3) Health Equity

Tribal leaders recommended that CDC/ATSDR continuously apply a health equity lens when 

working with tribal nations and tribal serving organizations. In their recommendations, tribal 

leaders identified several health equity topics including cultural humility, COVID-19, life 

expectancy, and respecting tribes’ experience and knowledge about their communities’ health.

Summary of Cultural Humility Recommendations(a):

Tribal leaders commented on health inequity as a major issue facing tribal nations. Tribal 

communities are experiencing some of the worst health outcomes in the U.S. According to the 

NCHS Data Brief on life expectancy, AI/AN populations are experiencing a significant reduction in 

life expectancy compared to the general population. To improve health inequities, power must be 

returned to tribal nations. Flexibility and tribal control should be at the center of the federal 

government’s funding structures. Health inequity is a problem that is best solved within the 

community, led by tribes, and supported by CDC/ATSDR. 

Tribal leaders acknowledge that the relationship between tribes and CDC/ATSDR is getting 

stronger. Tribal leaders recommend that CDC/ATSDR always approach health equity with cultural 

humility, while dismantling structures of inequality. The agency should strive for an organizational 

culture that is strengths-based, recognizing that solutions should come from within the 

community. 
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Tribal leaders recommended that CDC/ASTDR should not worry about getting it “all perfect” but 

should make sure that they are respectful about tribal nations’ cultures, norms and values, and 

not assume to know better than tribes about tribes. Tribes know their people, communities, 

social and historical context, needs, and strengths best; tribes are the experts in charting a path to 

health equity for their people. Tribal leaders recommend that nothing should be done without 

CDC/ATSDR and tribes working together, including sharing of information and providing the 

flexibility for the implementation of culturally appropriate public health initiatives for tribes. 

Listening to and understanding tribes should be a foundation for CDC/ATSDR staff working in 

Indian Country. 

Response to Cultural Humility Recommendations (a): 

CDC/ATSDR recognizes and acknowledges that cultural humility should be at the forefront of all 

engagement with tribal nations. CDC/ATSDR agrees the recommendation that CDC/ATSDR and 

tribes need to work together and share information in an open and learning environment. 

CDC/ATSDR is committed to working internally to improve cultural awareness and humility. 

CDC/ATSDR will offer training, resources, and consulting services to CDC programs to enhance 

their comprehension of the distinctiveness of tribes and the government-to-government 

partnership that establishes the basis for our collaboration with tribes. Additionally, CDC/ATSDR is 

committed to providing more opportunities to seek and receive tribal input on CDC activities. 

CDC acknowledges that in order to provide support in improving the health equity and public 

health outcomes of AI/AN communities, the CDC workforce has to better reflect the communities 

it serves. In November 2022, CDC hosted its first American Indian, Alaska Native, and Native 

Hawaiian (AIANNH) Career Day, where AIANNH professionals learned about fellowships, 

internships, and other pathway programs to begin public health careers at CDC. Additionally, CDC

looks forward to supporting future cohorts of the Indigenous Public Health Leadership Program to 

train public health leaders on core public health competencies, with a focus on key issues 

affecting tribal communities. 

Summary of COVID-19 Recommendations (b):

Tribal leaders enthusiastically commented on their successful and effective role in organizing and 

administering all aspects of the COVID-19 response in their communities. Many tribal leaders 

describe the extraordinary commitment of tribal nations throughout the United States on the 

prevention of COVID-19 infection in their communities, including vaccination, and timely and 

effective messaging. 

Tribal leaders are concerned about the transition out of the COVID-19 public health emergency 

and the need for tribal nations, CDC/ATSDR and other federal agencies to work together to learn 

from each other to prepare for the next pandemic. There is much to learn from tribal nations and 

by treating tribal nations as equal partners, health equity can be obtained. Partnering and 

identifying what worked will benefit the 574 federally recognized tribes and our nation as a 

whole. 
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Tribal nations also expressed concerns about how they will receive COVID-19 vaccines, treatment, 

and other supplies that may be needed as the number of cases continue to increase. 

Response to COVID-19 Recommendations (b): 

CDC/ATSDR applauds the work that tribal nations did to respond to the COVID-19 pandemic; lives 

were saved, and tribes were at the forefront of emergency response activities. CDC/ATSDR would 

like to thank tribes, tribal serving organizations, and others who not only assisted with COVID-19 

prevention, treatment, and vaccination in their communities, but also reached out to and 

supported communities nearby. 

CDC/ATSDR recognizes that many tribal members were and are at high risk and the commitment 

and dedication of tribal leaders and tribal public health officials should not be ignored. 

CDC/ATSDR would also like to acknowledge the need for clear and concise guidance on how, 

tribes and tribal serving organizations will receive the technical assistance, supplies, vaccines, and 

treatments they need to protect their communities as the COVID-19 public health emergency 

declaration transitions. CDC/ATSDR is in the process of updating their tribal support activities and 

identifying who will be responsible for COVID-19 activities moving forward. At this time, OTASA 

(tribalsupport@cdc.gov) continues to serve as the primary point of contact for tribes. 

CDC/ATSDR’s COVID-19 landing page Coronavirus Disease 2019 (COVID-19) | CDC also has 

resources and information on COVID-19, as well as up-to-date guidance. As more information 

becomes available, OTASA will distribute this information through our bi-weekly email updates.

Summary of Life Expectancy Recommendations (c):

Tribal leaders expressed their concerns with the findings in CDC/ATSDR’s Vital Statistics Rapid 

Release, Number 023 (August 2022) (cdc.gov), which described the disparities in deaths and other 

health outcomes experienced by AI/AN individuals. Tribal leaders demand a swift and profound 

response since the inequities are overwhelming and are worsening at alarming rates. 

Response to Life Expectancy Recommendations (c): 

CDC/ATSDR agrees with tribal leaders' comments on the life expectancy of AI/AN peoples. The 

findings have our attention. CDC/ATSDR recognizes the unique public health needs of AI/AN 

communities and is committed to working with tribes to improve and protect the health of tribal 

communities. CDC/ATSDR also recognizes that such health disparities within Indian Country speak 

to the importance of enhancing health equity among AI/AN tribal communities and AI/AN persons 

living in urban areas. CDC/ATSDR continues to work internally and with other federal agencies on 

how to address this issue. Ensuring representation, particularly in the tribal public health 

community, is paramount to addressing health disparities and inequities experienced by AI/AN 

communities and across the nation. CDC/ATSDR will continue to work to improve these efforts 
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and ensure that our public health workforce is representative of the communities they serve, 

including tribal communities. 

Summary of Recommendations about Respecting Tribes’ Experience and Knowledge (d):

Many tribal leaders stated that tribes know their communities best and CDC/ATSDR can learn 

from tribes. In particular, tribes stated that not all of the 574 federally recognized tribes possess 

the same level of tribal public health resources, capacity, or needs. However, each tribe has 

unique knowledge and experiences to offer to CDC/ATSDR and other tribes, highlighting the 

importance of collaboration and knowledge-sharing within the public health community. 

CDC/ATSDR needs to garner this knowledge and leverage it in its work. Regarding using CDC’s 

support to share their expertise, one tribal leader stated that “we want to take that equitable 

approach across the board, which is tough, because that's a lot of work.”

Tribes stated that they are willing to meet with CDC/ATSDR and mentor other tribes to share 

successes and failures. They suggested that CDC/ATSDR hold consultation or listening sessions to 

develop a process for this knowledge exchange. 

Tribal leaders were adamant that CDC/ATSDR “look out and see what a tribe can do with the 

dollar” and understand how they implement their resources; a prime example is the COVID-19 

pandemic, during which, many tribes were the first to act to save lives. 

Tribal leaders recommended that CDC/ATSDR work closely with tribal nations to prepare for the 

next pandemic as each has something to offer; tribes make decisions for themselves on the best 

way to set priorities and design programs tailored to the needs of their communities. “Tribes

know their people, communities, social and historical context, needs, and strengths best – tribes

are the experts in charting a path to health equity for their people.”

Tribal leaders strongly recommended that they need to be included in planning and decisionmaking processes; specifically, nothing that affects tribal communities should be discussed, and 

nothing should happen without tribal leaders at the table. One tribal leader stated, “we say:

nothing about us, without us.” 

Tribal leaders also commented that they wanted sufficient flexibility and support for tribes to

design their public health priorities and interventions. This would be both more effective in

advancing health equity and more respectful of tribal sovereignty.

Response to Recommendations about Respecting Tribes’ Experience and Knowledge (d):

CDC/ATSDR agrees with tribal leaders’ comments. CDC/ATSDR can learn much from tribal nations. 

CDC/ATSDR recognizes and understands that with 574 federally recognized tribal nations, tribal 

cultures, norms, traditions and values are distinct so we must partner with and listen to tribes. 

CDC/ATSDR is committed to engagement with tribal nations early and often when proposed 

actions may affect tribal nations. The agency is also committed to providing more opportunities to 

engage in discussion and knowledge exchange with tribes and tribal partners. 
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4) Data

Tribal leaders stated that CDC/ATSDR needs to do a better job in assuring that tribal nations have 

access to their own data. In addition, they emphasized that TECs are public health authorities, as 

designated in the 2010 Indian Health Care Improvement Act and should have access to requested 

data. Tribal leaders pointed to the GAO report on enhancing data access for TECs to highlight this 

need for data access. 

Summary of Tribal Data Access Recommendations (a):

Tribal leaders reiterated that no one should speak on behalf of a tribe and when it comes to tribal 

data, tribes need access to their own data. Tribes are sovereign nations and CDC/ATSDR must 

provide data to the tribes as they are public health authorities. Without data about their 

communities, tribes cannot keep themselves safe and cannot develop appropriate health policies

and interventions. Tribal leaders reminded CDC/ATSDR that tribes must have the same access to 

data as do other public health authorities.

Tribal leaders wanted to remind HHS that the GAO report on enhancing data access for TECs 

specifies activities that should be performed, including developing guidance and procedures for 

providing data access to TECs. 

Tribal leaders also recommend that HHS, CDC/ASTDR, and the Indian Health Service (HIS) extend 

the GAO recommendations to all IHS tribal health care clinics and consortiums to improve the 

relationships between these facilities and the TECs.

Response to Tribal Data Access Recommendations (a): 

CDC/ATSDR acknowledges the comments regarding the need for tribes to have public health data 

about their own communities. CDC/ATSDR has worked closely with HHS and IHS on setting up an 

interim system where tribes can request datasets that CDC/ATSDR maintains. 

While CDC/ATSDR does not currently have tribe specific data, CDC/ATSDR is actively exploring

ways to gather and incorporate such data in the future. It is important to ensure that all 

communities, including tribal communities, are properly represented and accounted for in data 

analyses and decision-making processes. 

On December 30, 2022, CDC/ATSDR launched the Tribal Public Health Data website to provide 

tribes and TECs with a more streamlined way to identify and request data with AI/AN 

indicators. CDC/ATSDR will continue to improve tribes’ and TECs’ access to public health data for 

decision-making in their communities. 

Summary of GAO Report Recommendations (b):

Tribal leaders support and strongly encourage CDC/ATSDR to continue to implement the 

recommendations issued in the GAO report entitled Tribal Epidemiology Centers: HHS Actions 
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Needed to Enhance Data Access. In addition, tribal leaders encourage the quick implementation 

of the GAO report’s recommendations, not just for the twelve TECs, but extending that 

opportunity for tribal health consortiums and other tribal health care facilities.

Response to GAO Report Recommendations:

CDC/ATSDR agrees with the findings and recommendations in the GAO report and has worked 

closely with HHS and IHS on implementing the recommendations and publishing the CDC/ATSDR 

Tribal Public Health Data website. CDC/ATSDR recognizes the importance of having accessible, 

timely, and quality data for making decisions about how to protect and improve our communities’ 

health; the status of TECs as public health agencies; and the sovereign status of tribal nations and 

how it factors into the collection, analysis, and use of their members’ public health data.

CDC/ATSDR also recognizes that with any data sharing or access provision, CDC/ATSDR needs to 

examine the type of data, their provenance, and any statutory or legal protections that may apply 

to their management. Given that each data system is unique in terms of data ownership, 

applicable laws/policies, sharing agreements and content, and because CDC/ATSDR is not the 

data owner in many cases, CDC/ATSDR must work with state health departments to identify the 

best processes to share data with federally recognized tribes on a system-by-system basis. 

CDC/ATSDR is working to balance these considerations and it will take time to work through this. 

CDC/ATSDR has fulfilled its role in responding to the GAO recommendations report with the 

publication of the Tribal Public Health Data Website and guidance document; for further 

information on data modernization please visit the CDC Data Modernization Initiative website. 

Summary of Tribal Epidemiological Data Recommendations(c):

Tribal leaders recommend that CDC/ATSDR provides accessible data to tribal nations and that the 

data analyses CDC/ATSDR conducts include AI/AN data that has not been erased by racial 

misclassification. 

In addition, tribal leaders stated that they cannot develop effective health policies without 

effective and accurate data. High-quality, meaningful AI/AN health data are essential for 

identifying disparities, setting priorities, designing strategies, and highlighting successes related to 

health equity. 

Tribal leaders also commented on H.R. 1397 “Tribal Health Data Improvement Act of 2021,” which 

expands tribal access to public health care data and public health surveillance programs, and 

reauthorizes the National Center for Health Statistics to take certain actions in the collection and 

availability of health data for AI/AN people. This bill requires CDC/ATSDR to develop guidance 

around birth and death record data for state and local health departments on AI/AN people; fund 

tribes, tribal organizations, Urban Indian Organizations, and TECs via cooperative agreements to 

analyze and address AI/AN inaccuracies in birth and death records; standardize health data 

collection on race and ethnicity; and encourage states to enter into data sharing agreements with 

tribes to improve data accuracy. 
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Tribal leaders also recommended that CDC/ATSDR address how national surveillance systems 

deployed during the COVID-19 pandemic will continue to operate. 

Response to Tribal Epidemiological Data Recommendations:

CDC/ATSDR acknowledges the tribal leaders’ recommendations and is working towards making 

sure that tribes not only have access to the CDC/ATSDR datasets that they need to protect the 

health of their communities, but that the datasets are accurate, high quality, and complete. In 

January 2023, CDC/ATSDR obtained feedback from the TEC consortium on the Tribal Public Health 

Data website and is working to incorporate that feedback by adding additional information on 

racial and ethnic classifications in the data available at CDC. This information will be accessible 

within the tribal access to data chart on the website in summer 2023. 

Additionally, in March 2023, CDC/ATSDR and other federal agencies provided input and 

recommendations to the Office of Management and Budget on the proposed revisions of OMB’s 

Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal 

Data on Race and Ethnicity, that CDC/ATSDR anticipates will help address several issues related to

racial misclassification in public health data. 

CDC/ATSDR plans to develop and pilot test a capabilities-based assessment instrument and 

method to document data modernization-related capabilities and needs appropriate for use by 

tribes and tribal public health partners. This will involve establishing a Tribal Expert Working 

Group to provide feedback, conducting listening sessions to collect tribal input, and pilot testing 

the tool in nine sites before finalizing and disseminating it across tribal public health 

organizations. CDC/ATSDR has also taken other actions, such as updating data sharing policies and 

providing guidance for accessing tribal public health data, to address recommendations and 

improve data sharing with tribal partners.

CDC/ATSDR launched the Tribal Public Health Data Request Form to help facilitate tribes’ access 

to the data available from CDC/ATSDR. This service is for tribal nations, TECs, and Urban Indian 

Health Centers. Others may request information from CDC-INFO.

Information about CDC /ATSDR’s relevant data sets is available on the Tribal Public Health Data

website. If you cannot find your answer there, please contact OTASA by using the Tribal Public

Health Data Request Form. OTASA will provide an answer or triage your request to the relevant 

CDC/ATSDR program for response.

5) Funding 

Tribal leaders recommended that CDC/ATSDR prioritize and simplify tribal funding. Tribal leaders 

reiterated the need for CDC/ATSDR to invest more directly in tribal public health, have set aside 

funds, and for CDC/ATSDR to develop and implement Notices of Funding Opportunities (NOFOs) 

that prioritize tribal sovereignty. 
14

Summary of Funding Set Aside and Tribal Prioritization Recommendations (a):

Tribal leaders recommended that CDC/ATSDR invest in tribal public health with sustained public 

health infrastructure funding; suggesting that for every $1 spent directly funding tribal public 

health infrastructure, there is a $5 return on the investment. Furthermore, tribal leaders 

emphasized that one cannot put a price on a life. Tribal leaders also reiterated that there are 

generations of health inequity stemming from the piecemeal funding approach; this has been 

demonstrated in the recent report on the decreased life expectancy in AI/AN people.

Tribal leaders recommended that through the CDC Moving Forward Initiative, and in all future 

work, all of CDC/ATSDR must prioritize tribes. Tribal leaders reemphasized their past 

recommendation for a 10% set aside, as it is in line with the federal trust and treaty 

responsibilities. Tribal leaders stressed that these funds should not come through competitive 

grants, because tribes should not be made to compete against each other. Rather, public health 

funding to tribes should be broad-based and formula driven. 

In addition, tribal leaders remain concerned about not being deemed eligible for preparedness 

funding, as well as the unreliable and administratively burdensome grant cycle.

Response to Funding Set Aside and Tribal Prioritization Recommendations (a):

CDC/ATSDR cannot commit to enacting a 10% set aside for tribes. However, CDC is taking the 

intent of this recommendation under consideration as the agency continues to explore better 

ways to provide resources and other CDC support for tribal public health. A major barrier to 

implementing this recommendation is the current structure of CDC/ATSDR’s budget. The agency’s 

budget, which is directed by Congress, is structured based on disease or public health issue area, 

and not specific population. While there remains room for improvement, direct funding to tribal 

nations for tribal public health has increased in recent years. Setting aside 10% of every 

CDC/ATSDR Center, Institute, and Office’s (CIO) budget for tribal nations may have the challenge 

of disproportionate distribution among tribal nations because of the disparate status and 

variations of tribal health infrastructures across Indian Country.

Summary of Direct Funding Recommendations (b):

Tribes recommended that CDC/ATSDR provide direct funding to tribes so that they have the 

opportunity to determine how the funding will be spent and tailor programs to their unique 

needs. Tribal leaders suggested that if CDC/ATSDR looked to see what tribes are capable of doing 

in their communities, the agency would understand that the return on investment would be 

enormous.

Tribal members reminded CDC/ATSDR of their government-to-government relationship with the 

federal government. Therefore, in order for CDC/ATSDR to uphold their trust and treaty 

responsibilities funds must flow directly to tribes through the appropriate channels, not through

state and local jurisdictions or other partners. 
15

Response to Direct Funding Recommendations (b):

CDC/ATSDR acknowledges and respects the government-to-government relationship that the 

federal government holds with the 574 federally recognized tribes. CDC is taking this 

recommendation under consideration as the agency continues to explore better and more 

efficient ways to provide resources and other CDC support for tribal public health.

CDC/ATSDR strives to maximize its extramural investments as much as possible. In fact, most 

CDC/ATSDR funding is provided to the field (approximately 78%). However, the agency’s budget, 

which is directed by Congress, is structured based on disease or public health issue area, and not 

specific population.

Where possible, CDC/ATSDR continues to support tribal specific funding, such as the National 

Center for Chronic Disease Prevention and Health Promotion’s Healthy Tribes program and the 

National Center for State, Tribal, Local, and Territorial Public Health Infrastructure and 

Workforce’s new cooperative agreement, CDC-RFA-TO-23-0001: Strengthening Public Health 

Systems and Services in Indian Country. Strengthening Public Health Systems and Services in 

Indian Country is a new, five-year cooperative agreement with an expected project start date of 

August 31, 2023. The anticipated base funding for this cooperative agreement is $5 million for 25 

recipients, an 800% base funding increase from the previous cooperative agreement’s base 

funding (OT18-1803: Tribal Capacity Building Umbrella Cooperative Agreement).

Summary of NOFO Recommendations (c):

Tribal leaders strongly recommend that all CDC/ATSDR staff who develop and implement NOFOs 

understand and account for tribal sovereignty in their NOFOs. Tribal leaders ask for all NOFOs to 

be reviewed by experts, including OTASA staff, who understand and respect tribal sovereignty. In 

addition, tribal leaders stated that simply listing tribes as eligible for a NOFO is not enough. As 

sovereign nations, separate NOFOs should be written specifically for tribes. 

Response to NOFO Recommendations:

CDC/ATSDR acknowledges and respects tribal sovereignty. CDC/ATSDR is working with all CIOs to 

ensure that the development and clearance of all NOFOs includes thorough review by staff with 

the expertise to recognize and address tribal concerns and eligibility, as applicable. However, it is 

important to note that at times, Congress limits how funds can be allocated and used; CDC/ATSDR

will continue to work with our CDC Washington Office, our TAC, and others to make all grants as 

inclusive and flexible as possible. 

Next Steps:

For next steps, CDC will work to incorporate the recommendations and input into the CDC Moving 

Forward Initiative. After the comments have been incorporated, CDC/ATSDR will provide an 

update to the CDC/ATSDR TAC. As CDC Moving Forward continues, CDC/ASTDR will use these 

recommendations as a resource to ensure that tribal nations are part of the solution.
16

Appendix A: Consultation: Written, Oral, and Other

CDC/ATSDR’s Tribal Consultation on CDC Moving Forward Initiative 

February 9, 2023

Tribal Consultation Transcript (Oral and Chat Box Testimony)

Dr. Houry: [Good to be] with you today. My name is Dr. Deborah Houry, and I am CDC’s Chief Medical 

Officer and the Deputy Director for Program and Science. CDC would like to acknowledge the Muscogee 

Nation and Cherokee Nation whose indigenous lands we are on at CDC.

I want to start off by reaffirming our government-to-government relationship. The CDC is committed to 

working with tribal governments on a government-to-government basis and we strongly support and 

respect the sovereignty and self-determination of tribal governments in the United States.

Your verbal and written testimony will be fully considered, and we thank you in advance.

Additionally, this Zoom meeting is being recorded for record-keeping purposes only. If you do not wish to 

be recorded, you can disconnect now.

Thank you for this opportunity to hear from you. I will now turn the meeting over to Councilman Nate 

Tyler, of the Makah Nation, a member of the CDC/ATSDR Tribal Advisory Committee, and co-facilitator of 

today’s consultation. Thank you.

Chat Message: Thank you for joining today’s Tribal Consultation. Please note, the chat function is to be 

used by tribal leaders and CDC leaders only.

Councilman Nate Tyler: All right. I appreciate that. My name is Nate Tyler, Makah Tribal Council.

My Indian name is Či-lap. Či-lap means warrior. My grandfather gave me that name after returning from 

the first Gulf War. It’s a pleasure to welcome you guys, to welcome everybody here, to take part. 

You know I am happy to be co-facilitator of this, but to take part of a CDC/ATSDR Tribal Consultation on 

the CDC Moving Forward initiative, tribal priorities as we transition out of COVID-19 public health 

emergency, as well as, how the CDC can better support tribes and tribal communities in the future. And, 

for myself, you know I’d like to start off with prayer. I know you know there are a lot of different religions 

out there. I grew up as a youth studying in the Baha’i faith. So, I’m going to read a Baha’i prayer. You don’t 

need to stand, but I do want to read this prayer. It’s on traveling.

This is my first time, too, so, first time being put in this position, so:

I have risen this morning by Thy grace, O my God, and left my home trusting wholly in Thee, and 

committing myself to Thy care. Send down, then, upon me, out of the heaven of Thy mercy, a blessing 

from Thy side, and enable me to return home in safety even as Thou didst enable me to set out under Thy 

protection with my thoughts fixed steadfastly upon Thee.

There is none other God but Thee, the One, the Incomparable, the All-Knowing, the All-Wise. 

Bahá’u’lláh
17

So once again, welcome.

I'd like to turn the meeting over to Dr. Dauphin, CDC’s Acting Designated Federal Official for the Tribal 

Advisory Committee.

Chat Message from Charity Sabido-Hodges: Kleco, kleco Cousin Nate...That was very good.

Dr. Dauphin: Thank you. Councilman Tyler,

As Councilman Tyler mentioned, I am Les Dauphin, Acting Designated Federal Official of CDC Tribal 

Advisory Committee and Director of the proposed National Center for State, Tribal, Local, and Territorial 

Public Health Infrastructure and Workforce. I will talk briefly about the internal CDC reorganization, 

recently announced as part of the CDC Moving Forward initiative, as it relates to CDC tribal work and 

engagement. Then Dr. Mary Wakefield will present the CDC Moving Forward initiative’s goals, and next 

steps. We will then proceed with consultation.

Before I do so, however, I want to acknowledge there remains work to be done on how and when we 

engage and work with our tribal partners. Our goal is continually improving tribal engagement. CDC 

Moving Forward is CDC’s effort to take concrete lessons from the COVID-19 response, and how we work 

with our public health partners, including tribes, and our responses in the way we do our work.

This means not just looking at what we do well, but where we have opportunities to improve. At the heart 

of CDC Moving Forward is accountability. We have to look unflinchingly at how we operate and ask how 

we can do better.

CDC honors the government-to-government relations with tribal nations and the work we've done to 

support tribes. But unquestionably there's room for improvement. CDC is committed to positioning

ourselves as a true partner to tribal nations to help you build the public health infrastructure needed to 

protect all tribal citizens from health threats. 

In that spirit of accountability, I want to acknowledge that parts of the Moving Forward initiative, like the 

internal reorganization announced last month by CDC, have been moving internally, and tribal partners 

have not been kept up to date, as they should have been on each of these internal steps. Making major 

changes to an agency as a large as CDC is hard, and there will be missteps and miscommunication; we 

acknowledge and are accountable for that.

But I also want to emphasize that the internal reorganization steps happening are only one part of the 

Moving Forward effort, and the most important part of this initiative is still ahead of us. The way we truly 

strengthen our government-to-government relationship is not through changing boxes on the chart. It's in 

the day-to-day commitment to listen, build trust, and deliver on what tribes want, and need from CDC.

And that is what you'll get from me and from CDC as we enter this next phase of Moving Forward; not 

perfection, I want to be clear, not perfection, but a daily commitment to building, trust and delivering the 

services, resources, and information tribes need to protect American Indians and Alaska Natives in every 

community in the United States.
18

That is why consultation is so crucial, but also just the first step in a renewed effort to strengthen our 

government-to-government relationship. So briefly for an overview of the reorganization relevant to the 

TAC and tribes. [Screen shares organizational chart] CDC Staff, please make sure that we have that circled. 

Okay perfect. 

The most relevant part of the CDC reorganization for CDC’s tribal work, is CDC is establishing the center 

that I mentioned previously: the National Center for State, Tribal, Local, and Territorial Public Health 

Infrastructure and Workforce. This will combine the critical functions related to supporting tribal, state, 

local and territorial public health, infrastructure, and workforce, such as our major CDC tribal and 

jurisdictional grants and cooperative agreements, our partnership and technical support, and key 

workforce activities.

To create this proposed center, we consolidated functions that currently exist, in the Center for State, 

Tribal, Local, and Territorial Support, or CSTLTS, and the infrastructure and workforce related functions 

from the Center for Surveillance, Epidemiology and Laboratory Services, or CSELS. I'm honored to have 

been asked to serve as Director for this new proposed center, which, like CSTLTS will be the home of CDC’s 

tribal work, the major cooperative agreements supporting tribes, and CDC’s Office of Tribal Affairs and 

Strategic Alliances, which you see circled at the top right in the slide. And, I'm pleased to be joined today 

by Dr. Seh Welch, who will continue to serve as the Acting Director of this office, OTASA. I'm glad to have 

Dr. José Montero, formerly CSTLTS director, and the long-time Designated Federal Official of the TAC by 

my side. The two of us have committed to working together. We pledge to continue to build on the 

previous work accomplished in the years to come.

As we move forward, we will be listening to you, engaging with you, and elevating your voices at the level 

that we haven't done before. And this consultation today is just the beginning of this renewed 

commitment. I'm now honored and happy to introduce Dr. Mary Wakefield, who will provide a brief 

overview of the CDC Moving Forward initiative. 

Chat Message: Thank you to everyone for joining the Tribal Consultation today. Please note, the chat 

feature is reserved for Tribal Leadership and elected officials only.

[CDC Moving Forward Slides Projected]

Dr. Wakefield: I was sent to speak from up here, although frankly, I’d be much more comfortable speaking 

from where Les was speaking, but I’m banished to this podium. So here I am. 

It's, as I said, a pleasure to be here and talk with you about the work that we have underway. I'll take the 

next slide, please. Whomever is controlling that. Thanks. So, Les talked about some of the work that has 

been underway at the agency related to CDC Moving Forward. This is an initiative that I’m sure

from different sources many of you have already heard about, even certainly before today. Maybe in the 

media, maybe from colleagues, et cetera. I’m going to just highlight a few of the key areas of activity that 

we, that have already occurred, and that we are driving toward over the next months and frankly, years. 

And I really want to underscore that this is a process within CDC, and in collaboration with tribal leaders, 

and tribal communities, and others, that will not be done this month, or three months from now or six 

months from now. This is a long-term initiative to make significant changes and improvements in the way 
19

this organization does its work. We have opportunities for improvement, and that's the aim of CDC Moving 

Forward. Just by way of timeline, earlier last year the director initiated a review of the agency, and it was 

those reviews that were conducted that actually were the trigger for us, one of the major triggers for us 

being here today talking about this initiative. Les has already spoken to what you see on the right side of 

this timeline. That is the reorganization effort that has been underway, and that we're now in the process 

of implementing. 

My very few moments with you are going to focus on the far-right side of this timeline. That is, the work of 

improving our processes, not just our structure to the reorganization, but improving our processes within 

the agency. That's the work that we are focused on in addition to reorganization, right now. Clearly, 

consultation with you is critical. As we continue this work, the [re]organization is just a piece of it. How we 

engage to meet the mission of this agency is equally challenging to improving our structure, and it's where 

consultations like this, and this is not going to be the last consultation, I'm sure around CDC Moving 

Forward. We need your input to ensure that we are meeting your expectations of us in improving this 

agency. So again, my comments have to do with the right side of this chart, and that is the process 

improvement activities that we have underway.

Over the last couple of months, we have convened teams across the agency, across CDC. We call them 

priority action teams. They have taken the work of the data that was collected and informed the Director 

to actually establish CDC Moving Forward. They've taken all of that input, they have talked with external 

groups and including groups that represent tribes through September, October, November, and that time 

frame. As well as other outside partners, state health departments, local health departments, and other 

groups to inform the work of improving processes within the organization. So those priority action teams 

were stood up, they developed action plans, and now, where we are in January, February is the 

implementation of those plans. So, we're starting to do the real work through CDC Moving Forward of 

taking all of that input and beginning to operationalize it. The implementation plans are being led by CDC’s 

senior leaders. 

So, as I mentioned the priority action teams were comprised of people from across the agency, looking at 

solutions to the problems that have been identified in April through July. And now those solutions that 

have been recommended, are being assigned to senior leaders for implementation. But truth be told, this 

is the work of everyone within CDC. It's not the senior leaders that are leading it, but this work going 

forward will involve everyone. Take the next slide, please.

These are our top areas for improvement and in consultation with you today. These are the areas we're 

focused on, and where your suggestions, and observations, and recommendations to us will be extremely 

important. With the areas that we're focused on for improvement, are these: first of all, to get the science, 

the research, the data out much faster, so that it informs whether we're talking about a pandemic, an 

epidemic, or injury prevention. Every part of the work of the agency we are looking at and thinking about 

how we can get our scientific findings and data out faster, not just to healthcare providers, but also to the 

public, to tribal communities, as well as tribal leaders. For example, enhancing laboratory science and 

quality. Another area of focus. I won't go into that. 

And I’ll make a couple of additional comments about a few of these key areas. Translating science into 

guidance and policies that are understandable and are usable by tribal communities, and usable by tribal 
20

health and tribal leaders, is another priority area. Prioritizing our communications, so that we are speaking 

clearly and in venues that people go to for information is another area for improvement. 

And the last two areas developing a workforce within CDC and across the country that is prepared for 

future emergencies. We know this pandemic is not the last pandemic. We have, and we'll have other 

emergencies in the future. So, we have a sharp focus on improvement in this area. And, finally promoting 

partnerships with our external partners, that are results-based focused on achieving outcomes and having 

impact. And that's why consultation from our perspective is so critically important. That we're engaging 

with you in ways that are meaningful, and eventually have significant outcomes that are positive 

outcomes. 

The next slide. I’ll say just a couple of quick words before I wrap up on just a few of those top areas of 

improvement. First in terms of sharing, excuse me, sharing scientific findings faster. In this area we're 

looking at, not just speed, but also partner input early on in the process. We're looking at how we can, 

within the agency, build in tribal input, and other external input to inform even the priorities of the 

research that we're conducting, not waiting to just release science on the back end. But hearing from you 

about what we should be focused on in the science itself. What should the research questions be that CDC 

should be following and studying, and then producing results that are meaningful and useful to you to 

improve tribal health. How can we be supportive of your efforts in, in strengthening tribal health. So, 

science, so sharing, scientific, faster, but also ensuring that they are on point and meeting community's 

needs.

Next slide, please. Just shifting to one of the other top areas for improvement. This is again focused on not 

just getting it out faster but ensuring that the policies that are implemented based on that science are 

practical. They're relevant, and they are easy to understand.

Next slide, please. Next slide, please. And the last area that I wanted to just mention very briefly is the area 

of promoting results-based partnerships. We know, as Les indicated, that we have opportunity and need 

for early engagement with our partners, and certainly with tribal leaders because of our government-togovernment relationship. We need to be active in that engagement with our partners to develop and hear 

your priorities and goals, which is what makes meetings like this so critically important. And we need an 

institutionalized, organized way of receiving timely and meaningful feedback, so we can ensure that our 

partnerships produce the results in tandem with you, that help us to meet mission and meet your needs as 

well. We are working, very directly, on health equity within our work as well. 

And in all of these areas that I've just described and gone through very quickly, we are looking at metrics--

measures of performance. So, this is not in our minds, is not talking about what we aim to do, but it's also 

measuring, to ensure that we're having impact in these meaningful areas. So bottom line in in terms of 

producing science, with our partnerships, with the development of our workforce, we are looking for early 

engagement, substantive input and acting on that in a very a conscientious and deliberate fashion to 

inform our work as we go forward. So again, changes here are not just about the reorganization. There's 

more to come on that. It's very much a focus on how we can improve our processes and engagements to 

get even better outcomes for the public's health, and certainly that is true, very much for a tribal 

community health as well. 
21

So, I’ll stop there with that. That this is the fastest overview I've ever provided on Moving Forward, and I 

was told not to speak fast, which is my nature. So, this was especially a challenging for me, but I appreciate 

the opportunity, and certainly to see some familiar faces in the room today as well. Thank you for the 

opportunity to share just a few highlights of Moving Forward.

Dr. Dauphin: Thank you very much, Dr. Wakefield. We appreciate that overview. And, it was brief, but it 

was very thorough, and we thank you for it.

Okay, at this time, I would like to give a few logistical overviews. First, for participants who have joined by 

Zoom. Please ensure that your tribal position and tribe are included in your display name. We put 

instructions on how to do this, change your name, in the chat.

Chat Message (OTASA): Welcome to the CDC/ATSDR Tribal Consultation Session. Please include your tribal 

position and tribe in your displayed name. How to Change Your Zoom Display Name:• Go to the top right 

corner of your Zoom displayed box• Click on the ellipses (three dots)• Select ‘Rename’• Enter a new screen 

name (name, tribal position, tribe)• Select ‘OK’• Done OR• Click on name in “Participant’s List”• Select 

‘More’ or the ellipses (three dots)• Select ‘Rename’• Enter a new screen name (name, tribal position, 

tribe)• Select ‘OK’• Done

Dr. Dauphin: All right. We are soliciting your consultation on three things: strengthening relationships 

during the implementation of the CDC Moving Forward initiative, how the agency can better engage with 

Indian Country for meaningful consultation and tribes’ priorities as we transition out of the COVID-19 

public health emergency, and on how CDC can better support tribes and tribal communities in the future.

So, I’m going to provide additional meeting logistics. This consultation session, according to the current 

CDC/ATSDR tribal consultation policy, will be held between federally recognized tribes represented by the 

tribal president, tribal chair, tribal Governor, or an elected or appointed tribal leader, or their authorized 

representative and the CDC Director ATSDR Administrator's designee, Dr. Houry. The order of speaking will 

run as follows: First, Tribal Presidents, Chairpersons, and Governors. Second, Tribal Vice presidents, vicechairpersons, Lieutenant Governance. Then, elected or appointed tribal officials. And finally, designated 

tribal officials.

When you begin, please announce your name, title, and tribal nation you are representing for the record. 

Those who wish to submit written testimony, or who may not have an opportunity to respond during our 

time today, please email your written comments, or testimony, no later than 5:00 p.m.

February 24, 2023, to tribalsupport@cdc.gov. And that will be provided in the Zoom in the chat as well.

I will now turn the meeting over to Councilman Nate Tyler to facilitate the discussion.

Councilman Nate Tyler: Okay, once again, appreciate that Dr. Dauphin for the overview, and the 

information that you're shared about logistics. We're getting ready to start the discussion portion of this. I 

know we're really short on time here. Hopefully, everybody can get a chance to give their testimony on 

behalf of their tribe. I think that's really important to do that. So, if there is any

tribal leaders ready to give testimony, raise your hand, and if you're in the room, turn your mic on and 

offer your testimony, please.
22

Councilman Nate Tyler: Oh, yeah, to start your testimony, state your name, title, and the tribe you are 

from, and then also give your testimony, or let the panelists know that you're going to submit your written 

testimony via email. So, we'll open it up for your testimony at this time.

Chat Message (Councilman Nate Tyler): Can you put the Tribal Leader Title after your name please.

Councilman Nate Tyler: Deputy Warner, so I know the CDC is asking you to answer one question, come 

back and answer the second, come back, come back to answer the third. But, if you're prepared to offer 

testimony and full for your testimony, and full at this time

Deputy Principal Chief Warner: All right, thank you. Bryan Warner, Cherokee Nation, Deputy Principal 

Chief, and again, thank you, Councilman Tyler, thank you Dr. Houry, Dr. Dauphin and Dr. Wakefield, I really 

appreciate the overview. And, for me I'll try to, I'll try to be as succinct as I can on this, but I really, one, 

one piece for me is what I appreciate the approach and what we've already had a couple of times that 

we've had to have you to come in, and you've told us about what was going on, and I appreciate the speed 

of your speech, ma'am. I really love that so, don't, don't ever stop, you know. Yes, ma'am; but when I, 

when I think about institutional effectiveness and assessment, I really think about a man by last name of 

Hummingbird told me, it's essentially this, Bryan. It's: What are you doing? How are you doing it, and how 

are you going to do it better? So, and then with that I feel like if we're really all here together to look at 

that assessment and that effectiveness, you know we're getting ready to implement this. So, we're going 

to see some results on the other end. But if we're, if we're tethered to that that institutional effectiveness 

and assessment, then we're not going to miss good by trying to be perfect. You know, and I think that is 

something that as we move forward, you know a lot of people, they want to worry about being perfect, I 

think, as far as tribal consultations, you know the relationship, the relationship between tribes and the CDC 

is getting stronger. That's my opinion.

I do have the seat as the TAC chair, and being on the TAC for a few years, and I have seen some 

improvement. As I, and my team sitting behind me, they assure me that we will continue to reach out and 

to because accountability is a two-way street, it's not just one way, so the tribe as the CDC is, we're asking 

you to be accountable in your measures and your effectiveness, and what you're doing. We will also be 

accountable in giving you the direct communication. I think, when we start to look about this Moving 

Forward as we kind of as we kick this can down the road, and these things start to implement, you come 

back and give us these updates. We will always be inviting you to come at any TAC meeting to give us 

these updates, but consultation...sometimes we have a little more than a handful of tribes now that are 

public health accreditation; that it went through the that process. I think, reaching out to some of those, 

some of the others that are in this process where they're at the infancy stages, they're in the middle, or 

they're getting towards end, I think, coming in and touching base with them. I don't want to leave any of 

the other tribes out at all, because I would be willing to say as a consultation, the Cherokee nation, I know 

the Chickasaw Nation is in this process. We would be willing to put something together to come in and 

consult with those tribes around, and to see, hey? That so you know, as tribes are growing, the CDC is 

growing. 

So, a reorganization is something that it's just part of the growth process. So, I see that being able to be 

improving. Maybe as you start to look at some of the smaller tribes and the medium-size, and the larger 
23

tribes, and you know we don't want to leave anybody out. We want to take that equitable approach across 

the board, which is tough, because that's a lot of work.

But then I think you can come back after you've had some initial, maybe one-on-one, one to ten meetings 

with ten to fifteen different tribes. Maybe we have something at a national level where we come in, and 

we have a consultation or a listening session to do something like that.

Better engage. You know that that talks about number two ah priorities. As we transition out, we need 

boots on the ground. You know we need, when we talk about public health infrastructure and what we're 

doing, we're, you know we're, we're also building a template for our other divisions within the Cherokee 

Nation to look at and understand public health, and I think, in order to do that, you know I've got, I've got 

the A-Team at the Cherokee Nation, our Public Health Department. We have reorganized that group. They 

used to be stacked up underneath health. We've moved them out from health, they are on their own. So 

that is a, for me, that's a historical thing that we've done, and it may not have been done without the 

pandemic. I know the, the leadership there. I've always had their ear, and they’ve always had mine, and 

that's something that I felt very strong about, because I believe in what they do. I believe in public health 

because we're all living entities of public health, so that continuation, but direct, you know, when you look 

at coming out of COVID. Some of the things that you're going to continue to hear is that direct funding to 

the tribes. We're not trying to leave any organizations out or any technical assistance groups, but we want 

to make sure that our, our tribes have that opportunity to tailor that money.

Because, as Councilman Tyler says, I love this, look out and see what a tribe can do with the dollar, you 

know, and understanding that. And we know that when we invest money into public health, it used to be 

like it, was it for every dollar we spent, the return on investment was five dollars. It may be even more 

today. You look at that, but you really can't put a price on life out there. You can't, you know, and our 

communities are living entities, and within those entities are the human beings that that live there that 

make things happen. They, they are the commerce, they are the economic development drivers and 

different things. And, as you've seen throughout the pandemic without the tribal nations across the United 

States, and in particular, I know for sure, in Oklahoma, the efforts to get out vaccines, the efforts to get out 

the messaging. We were, as everybody we were all working, and as a symphony as you guys were putting 

out your message, we were putting out tribal related messages so that our people understood those things 

and everything. So, I think there that you know, as I told Dr. Walensky today, there's a really good time to 

hit that reset button, and you know we're not going to scratch everything that we've done. But let's come 

together, and we will work in tandem, so Wado, Councilman Tyler. That is testimony. Thank you.

Chat Message (OTASA): Attendees, please update your Zoom display name to include your tribal position 

and tribe. Thank you.

Councilman Nate Tyler: Appreciate that Deputy Warner, Chief Deputy Warner. Is there anybody else in the 

room wanting to give testimony? [Pause] Any Chairman, Presidents, Chiefs on Zoom that wants to give 

testimony?

Chat Message (OTASA): Please note, the chat feature is reserved for Tribal Leadership and elected officials 

only. 
24

Chat Message (OTASA): Welcome to the CDC/ATSDR Tribal Consultation Session. Please include your tribal 

position and tribe in your displayed name. How to Change Your Zoom Display Name:• Go to the top right 

corner of your Zoom displayed box• Click on the ellipses (three dots)• Select ‘Rename’• Enter a new screen 

name (name, tribal position, tribe)• Select ‘OK’• Done OR• Click on name in “Participant’s List”• Select 

‘More’ or the ellipses (three dots)• Select ‘Rename’• Enter a new screen name (name, tribal position, 

tribe)• Select ‘OK’• Done

Chat Message (Councilman Nate Tyler): Will Micklin, who are you representing?

Councilman Nate Tyler: Okay. Will Micklin, Vice President Tlingit and Haida, I'm going to turn it over to you 

if you can turn your camera on, if you're able to. If you have the bandwidth to do that, please turn your 

camera on and give your testimony.

Will Micklin: [Speaking in indigenous language] Can you hear me?

Councilman Nate Tyler: Yes.

Will Micklin: [Speaking in indigenous language] My Tlingit name is Yaan Eesh. My English name is, Will 

Micklin. I am Fourth Vice President for the Central Council of Tlingit and Haida Indian tribes of Alaska. We 

are the regional tribe in Southeast Alaska, thirty-five thousand, one hundred and thirty-eight square miles, 

all of Southeast Alaska, East of the one hundred and forty-first meridian, thirty-five thousand plus tribal 

citizens, and Richard J. Peterson, is our President. Thank you for the opportunity to speak. I'll, I'll be brief.

I just have two recommendations. One is for continued attention to implementing the GAO report on 

Tribal Epidemiology Centers, entitled HHS Actions Needed to Enhance Data Access.

It's geared to the 12 Tribal Epidemiology Centers in Indian Country and the essential recommendation is to 

develop guidance on how TEC's, Tribal Epidemiology Centers should request data and develop agency 

procedures on responding to those specific requests. HHS concurred on those recommendations and their 

expedited implementation, which is important, not just for the 12 TECs, but extending that opportunity for 

tribal health consortiums.

There are many in Southeast Alaska, the Southeast Alaska Regional Health Consortium that represents 

tribes in Southeast Alaska, and the opportunity to participate in that program is important and making 

sure that data is both accessible and provided and incorporated in CDC analyses is of critical importance.

Secondly, and this is specific to the epidemiology recommendation, that the role of CDC with tribes; with 

the example of the current COVID-19 pandemic is clear in the expression of recommendations based on 

CDC analysis and journal science in support of those conclusions. The example I provide is the nonpharmaceutical interventions that are critical to epidemiological measures to control community 

transmission and mitigate a pandemic that includes masking, physical distancing, the limited travel, and 

avoidance of congregate situations wherever possible, and of course, quarantine and isolation where

required. But also, guidance for building operations during this and other pandemics, ventilation in 

buildings, upper-room ultraviolet germicidal irradiation, the UVGI or UVC as is currently in deployment, 

and that as well, the UVGI for healthcare settings. All these are important and important, based on clear 
25

declarations of guidance and advice. We have worked hard to protect our populations, who have high 

comorbidity, susceptibility to infection. 

We have demonstrated high rates of infection and impact of current infection and long COVID situations, 

and it makes our job much harder when we make declarations of guidance and behavior to our tribal 

citizens and the CDC is not as forceful. And where we require masks, the CDC may say it's a matter of 

personal choice. All these are important because we are trying to mitigate harm to our tribal citizens, and 

we think the science supports the affirmative position of CDC and other considerations, we think are not as 

important as the consequence of harm to our populations. If we don't apply what is our accepted 

epidemiological measures for control of a pandemic, whether epidemic or endemic. So those are our 

specific recommendations. We thank you for the opportunity, and we will endeavor to provide written 

remarks. Thank you. [Speaking in indigenous language].

Councilman Nate Tyler: Thank you for your comments, Vice President Micklin. You can email your 

comments to tribalsupport@cdc.gov by February 24th, 5:00 p.m. Eastern. Are there any other tribal 

presidents, chairman, vice-chairman, vice presidents, governors, or chiefs, willing to offer testimony at this 

time?

Chat Message (Kameron Runnels): How am I able to make a comment not sure if my video or audio is 

working.

Councilman Nate Tyler: Kameron Runnels, you have your hand raised. I see you in the chat not knowing if

you're able to have the capacity to offer testimony.

Kameron Runnels: Hello!

Councilman Nate Tyler: We can hear you. What? What is your title?

Kameron Runnels: Hi! My name is Kameron Runnels. I'm the Vice Chairman of the Santee Sioux Nation 

Tribal Council in Nebraska and I’m also Vice Chairman of the Great Plains Tribal Leaders’ Health Board, and

I just wanted to make a comment on the kind of mirroring what the last gentleman just spoke on about 

access to data.

I spoke about this, you know, a couple months ago, to the IHS Director. You know tribes, you like, you can't 

develop effective health policies, for there are people without accurate data. You know HHS is required by 

law to provide this data to tribes. It's an epidemiology centers, but they have not, or they, they don't, and 

this reluctance to allow tribes to access this data required by law prevents tribes from addressing health 

problems in their communities. When HHS does not follow their own rules for data sharing, our 

communities suffer. You know we can't manage disease, and ultimately, ultimately more of our people die 

before their time. And the solution is simple, must follow existing law and provide tribes with the data we 

need to protect our members. HHS should give tribes the same access to data as it does other public 

health authorities. I'll just, I'll leave it at that. And thank you, and that's it.

Councilman Nate Tyler: Thank you Vice Chairman Runnels. At this time is there anybody else? [pause] In 

the waiting room or participants actually ready to offer testimony? [pause] 
26

The floor is now open for anybody that wants to offer testimony.

Connie Barker. 

Legislator Connie Barker: Thank you. Connie Barker, Tribal Legislator for the Chickasaw Nation, and I 

would just like to just actually skip down to number three, first. And when we're talking about tribes’

priorities and now that the COVID-19 public health emergency, and how it is transitioning out. What I think 

tribes would like to see is, how do we prepare for the next pandemic? And what are what are we 

partnering with the CDC to do, to learn from each other, not only to learn from the agency, but what are 

the agencies learning from the tribes? And, as we said yesterday, or maybe it was this this morning, when 

we were visiting with Dr. Walensky, some of the Oklahoma tribes were the first to act, and they outworked

the State of Oklahoma, when it came to sending out PPE, vaccines, keeping our hospital doors open, clinics 

open, to where we could treat patients saving the lives of a lot of tribal members that maybe would have 

died if they hadn’t have that tribal hospital to go to. And so, it's a share of information, not just sitting and 

listening to the experts here, because, like what Dr. Walensky said this morning, this is the first pandemic 

that's happened since the inception of the CDC.

So, we were all caught off guard but, maybe how to prepare for the next one. And as she said this morning, 

it's not just going to be, if, but it could be when--you know when the next one. So just a sharing of 

information, I think, would kind of help us both move forward through a partnership of doing what's best 

for not only tribal members, but for our nation as a whole.

Councilman Nate Tyler: Thank you, Connie Barker, Appreciate that. So, it is open. Anybody willing to give 

testimony?

Dr. Sharon Stanphill.

Dr. Sharon Stanphill: Thank you. And Sharon Stanphill, Chief Health Officer Cow Creek Band of Umpqua 

Tribe of Indians, a tribal representative. One of the things I want to address is number one. As we were just

shared the great presentation of the Moving Forward initiative and about the Center, and we saw the org 

chart, and where we are on the org chart at the tail end of the timeline. I'm hoping that tribes were 

brought in quite early, that as you developed at the org chart, and all of the positions. I didn't see any tribal 

liaisons with the divisions. But yet there were no other positions added as of yet. So, I just want to make a 

statement that in the State of Oregon, whereas our homeland, we have a phrase, and we say, say nothing 

about us, without us. Right? You hear that. And, the State of Oregon does an amazing job with assuring 

that the nine tribes and our Urban Indian Health Service, NARA, that we all are included, and that nothing 

gets past the tribes from the very, very beginning; before legislation is started before anything happens.

And so, I just want to say I saw the six top areas of improvement, and they're wonderful. But I’m 

wondering how the tribes given you, do you have our lists of every single one of those things, whether it's 

data sharing, infrastructure, which, by the way, the tribes of the Northwest, I think one hundred percent of 

all of them are just wanting to make sure that happens. All of our electronic health record systems, all the 

things that you're already aware of. Missing and murdered indigenous women, all of the things that are 

our top priorities, and how you'll restructure here, have we come in, way at the beginning, so that you are 
27

aware of all these things, and you'll plug those in and continue to have consultation on those. So, it's kind 

of an overarching, how your relationship with us could be better? 

And that goes into number two. The consultation, that you would have it very, very early, so that you 

haven't planned your org chart, you haven't put your whole department together, and you've got your top 

six priorities that we're integrated into every one of those way from the beginning. And I’ll close by saying 

again, in the state of Oregon, we have tribal liaisons at every single level, so we always, always have 

somebody; just in case, you get a little step ahead we'll slow you down and say, “Wait, we haven't 

consulted the tribes yet,” and we're way at the beginning, so that would my request. Thank you.

Councilman Nate Tyler: Thank you, Dr. Stanphill. Any other participants on the Zoom, raise your hand if 

you're willing to offer testimony. 

[pause]

Written testimony can be submitted by February 24th, 5:00 p.m. Eastern. Email your written 

documentation to tribalsupport@cdc.gov. 

Councilman Nate Tyler: And in your email note that this is for consultation. Any other participants on the 

Zoom, raise your hand if you want to give consultation...public comments. 

[pause]

Chat Message (OTASA): If any tribal leader wants to submit written additions to the Tribal Consultation 

Session, please email your comments no later than 5:00 pm (EST) February 24, 2023, to 

tribalsupport@cdc.gov. Thank you.

Councilman Nate Tyler: All right. If there is no other testimony, at this time, prior to turning it back over to 

Dr. Dauphin, I'd like to thank everybody that took part in this testimony. I think it's really important to

advocate for your tribe, when you advocate for your tribe, you're advocating for all tribes, so I think that's 

important to know, and it has been said that Dr. Stanphill said it best I think, you engage tribes at the 

earliest moment, if it's going to affect us. Any adverse effect, bring us in early, so appreciate you stating 

that. At this time, I'll turn it over to Dr. Dauphin. Thank you.

Dr. Dauphin: Thank you Councilman Tyler. I want to thank you all for your testimony today. And as another 

reminder, all tribal nations are welcome to submit written testimony by February 24th at 5:00 p.m. EST to 

tribalsupport@cdc.gov.

We appreciate your time and thoughtful input. And Councilman Tyler, I want to thank you for facilitating 

this. We really appreciate it, and I will turn it back over to you for some closing remarks.

Councilman Nate Tyler: All right. I sure do appreciate it. I gave my closing remarks a minute ago,

but I’ll say it, and I’ll say it once again. It's really important to bring us in at the earliest convenience. Well, 

not even convenience. It's not even convenient. If it affects tribes bring us to the table at the highest level. 

As sovereigns, consultation is at the highest level. And that is an expectation from tribes. We don't want to 
28

meet with, I know it's it was brought up about tribal liaisons, but we don't want to meet, you know, tribal 

leader - tribal liaison. I would want to meet tribal leader to the director or assistant director, and that's 

that, you know. That's the only way we can get any kind of movement you hear directly from the tribes. 

And it means a lot to tribes when it happens that way. So, I do appreciate all tribal leaders that took part in 

this. 

Like I said it, it doesn't just benefit your tribe, it benefits all tribes. Not all five hundred and seventy-five 

tribes are going to take part in this consultation. I wish even half would do it. If half the tribes in the United 

States did take part in this, I think it would go a long ways, but I do truly appreciate it, and I think 

everybody else does appreciate those that are taking part, those that have been taking part, during this 

last year and a half through this consultation process across the board. 

And one other thing tribal leaders on the phone or on the Zoom, if you want to take part in these advisory 

committees, sign up, submit, we do need help across the board, not just in CDC, but other advisory 

committees. When you do that, you know it goes a long ways, puts you at the table, puts you at the 

highest level, lets you advocate for your people, lets you advocate for your tribes and hammer home the 

issues that do impact us as sovereign nations. 

So once again I do appreciate the CDC, appreciate the CDC for the last two days. It's been a good two- day 

get together for us as tribal leaders at the table. So once again, you appreciate it, and I will once again 

close in prayer. And once again, you don't have to stand. Like I said I did grow up as a young kid taking part 

in the Baháʼí Faith. That was when I was a kid, I haven't done it since I was a little kid, so you know it's been 

quite a while, but I do want to close with a prayer for protection.

"Immeasurably exalted art Thou, O Lord!

Protect us from what lieth in front of us and behind us, above our heads, on our right, on our left, below 

our feet and every other side to which we are exposed. Verily Thy protection over all things is unfailing.” -

The Báb. 

So once again appreciate it. Safe travels to everybody and see you guys, at the next meeting. 

Adjourned. Thank you.

Dr. Dauphin: This consultation session is now closed. Thank you, Councilman Tyler.
29

*************************************************************************************

CDC/ATSDR Tribal Testimony Chat Comments:

Julie Shasteen, CDC to Everyone:

Welcome to the CDC/ATSDR Tribal Consultation Session. Please include your tribal position and tribe in 

your displayed name.

How to Change Your Zoom Display Name:

• Go to the top right corner of your Zoom displayed box 

• Click on the ellipses (three dots)

• Select ‘Rename’

• Enter a new screen name (name, tribal position, tribe)

• Select ‘OK’

• Done 

OR 

• Click on name in “Participant’s List”

• Select ‘More’ or the ellipses (three dots)

• Select ‘Rename’

• Enter a new screen name (name, tribal position, tribe)

• Select ‘OK’

• Done

Julie Shasteen, CDC to Everyone:

Thank you for joining today's Tribal Consultation. Please note, the chat function is to be used by tribal 

leaders and CDC leaders only.

Charity Sabido-Hodges to Everyone:

Kleco, kleco Cousin Nate...That was very good

Julie Shasteen, CDC to Everyone:

Thank you to everyone for joining the Tribal Consultation today. Please note, the chat feature is reserved 

for Tribal Leadership and elected officials only.

Julie Shasteen, CDC to Everyone:

Welcome to the CDC/ATSDR Tribal Consultation Session. Please include your tribal position and tribe in 

your displayed name.

How to Change Your Zoom Display Name:

• Go to the top right corner of your Zoom displayed box 

• Click on the ellipses (three dots)

• Select ‘Rename’

• Enter a new screen name (name, tribal position, tribe)

• Select ‘OK’
30

• Done 

OR 

• Click on name in “Participant’s List”

• Select ‘More’ or the ellipses (three dots)

• Select ‘Rename’

• Enter a new screen name (name, tribal position, tribe)

• Select ‘OK’

• Done

Councilman Nate Tyler to Everyone:

Can you put the Tribal Leader Title after your name please

Julie Shasteen, CDC to Everyone:

Attendees, please update your Zoom display name to include your tribal position and tribe. Thank you.

Councilman Nate Tyler to Charity Sabido-Hodges and all panelists:

thanks, where are you from

Julie Shasteen, CDC to Everyone:

Please note, the chat feature is reserved for Tribal Leadership and elected officials only.

Julie Shasteen, CDC to Everyone:

How to Change Your Zoom Display Name:

• Go to the top right corner of your Zoom displayed box 

• Click on the ellipses (three dots)

• Select ‘Rename’

• Enter a new screen name (name, tribal position, tribe)

• Select ‘OK’

• Done 

OR 

• Click on name in “Participant’s List”

• Select ‘More’ or the ellipses (three dots)

• Select ‘Rename’

• Enter a new screen name (name, tribal position, tribe)

• Select ‘OK’
31

 • Done

Julie Shasteen, CDC to Everyone: 

If any tribal leader has written additions for the Tribal Consultation Session, you are encouraged to submit 

them to TribalSupport@cdc.gov before Feb 24 at 5 pm (EST).

Councilman Nate Tyler to Everyone: 

Will Micklin, who are you representing

Will Micklin to Hosts and panelists: 

Will Micklin, Vice President, Tlingit&Haida

Kameron Runnels to Everyone: 

how am I able to make a comment not sure if my video or audio is working

Julie Shasteen, CDC to Kameron Runnels and all panelists: 

Raise your hand and you will be invited to speak. If you cannot use your audio, please add a comment in 

the chat.

Rasha Al Rawi, CDC to Kameron Runnels and all panelists: 

Please use the "raise hand" feature and state your tribe

Julie Shasteen, CDC to Kameron Runnels and all panelists: 

Thank you for your comments. They are being recorded and will be incorporated as part of this Tribal 

Consultation summary.

Julie Shasteen, CDC to Everyone: 

If any tribal leader wants to submit written additions to the Tribal Consultation Session, please email your 

comments no later than 5:00 pm (EST) February 24, 2023 to tribalsupport@cdc.gov. Thank you.

Julie Shasteen, CDC to Everyone: 

If interested - email tribalsupport@cdc.gov 

Julie Shasteen, CDC to Everyone: 

Thank you all
32

CDC/ATSDR Tribal Consultation – CDC Moving Forward Initiative PowerPoint Presentation
CDC/ATSDR Tribal Consultation – 

CDC Moving Forward Initiative

February 9, 2023

4:00 ‒ 5:00 pm (EST)

1
Welcome and Opening Remarks

2
Consultation Participants and Roles

The government-to-government relationship between the United 

States and federally recognized Indian Tribes dictates that the principal 

focus for consultation by CDC is with Indian Tribes, individually or 

collectively. 

3
Overview of CDC Moving Forward 

Initiative

4
Office of the Director

Office of Program Strategy and Accountability

Office of Data Reporting and Evaluation

Office of Recipients Support and Coordination

Proposed National Center for State, Tribal, Local and 

Territorial Public Health Infrastructure and Workforce 

5

Office of Tribal Affairs and 

Strategic Alliances

Division of Jurisdictional Support

Office of the Director

Branch 1

Branch 2

Branch 3

Division of Partnership Support 

Office of the Director

Branch 1

Branch 2

Division of Workforce Development

Office of the Director

Public Health Associate Program Branch

Education and Training Services Branch

Epidemiology Workforce Branch

Population Health Workforce Branch

Office of Rural 

Health
CDC Moving Forward

February 9, 2023

6
CDC Moving Forward: Timeline

Ongoing feedback from CDC leaders and staff, as well as external partners, to refine and execute plans

April 2022

Director initiated CDC 

review

April- July

Data collection, 

informational 

interviews, and 

report submitted 

Aug

CDC Moving Forward 

launched

Sept

Reorganization 

planning initiated

Oct

Process 

improvements 

initiated

Nov

Reorganization plan 

submitted

Dec

Process improvement 

plans submitted

Jan – Feb 2023

Process improvement 

implementation
Top Areas for Improvement

▪ Share Scientific Findings and Data Faster

▪ Enhance Laboratory Science and Quality

▪ Translate Science into Practical, Easy-to-Understand Policy

▪ Prioritize Public Health Communications

▪ Develop a Workforce Prepared for Future Emergencies –

CDC and Nationwide

▪ Promote Results-Based Partnerships

8
Share Scientific Findings and Data Faster 

▪ Reduce, streamline, and expedite scientific clearance process

▪ Deploy standard language clarifying current level of scientific understanding; use of 

various strategies for getting information out for public and public health use and 

consider a new CDC platform to share preliminary findings

▪ Work collaboratively with tribes' jurisdictions to facilitate data collection, 

interoperability, and reporting

9
Translate Science into Practical, Easy-to-Understand 

Policy

▪ Implement standardized policy development process for guidance documents, 

including an engagement strategy with external partners

▪ Consider guidance using best available science and examine implementation 

benefits, harms, equity impact, feasibility, and external partners and 

community considerations, resulting in actionable public health guidance

10
Promote Results-Based Partnerships

▪ Establish agency-wide grantee satisfaction survey to identify needed 

improvements

▪ Develop common reporting standards and equity focus for funding opportunities 

and promote peer-to-peer technical assistance

11
Presentation/Speaker Protocol

The order in which we will follow is:

1. Tribal Presidents/Chairpersons/Governors

2. Tribal Vice-Presidents/Vice-Chairpersons/Lt. Governors

3. Elected or Appointed Tribal Officials

4. Designated Tribal Officials

12
Etiquette

Guidelines for

Tribal Consultation

• All attendees must keep their mic on mute during the meeting 

unless speaking.

• Members of the public must keep their video camera off and 

may not speak during meeting proceedings.

• For those on the phone, to unmute your phone press *6.

• When asking a question or making a comment, click the 

‘Participants’ button at the bottom of the Zoom screen and 

select the ‘Raise Hand’ option located on the right-hand side of 

the screen.

13
Guided Questions 1. How can the agency strengthen 

relationships during the implementation of 

the CDC Moving Forward Initiative?

2. How can the agency better engage with 

Indian Country through meaningful 

consultation?

3. What are your tribes' priorities as we 

transition out of the COVID-19 public health 

emergency and how can CDC/ATSDR better 

support tribes and tribal communities 

moving forward?

Guided Questions

14
Tribal Testimony

15
Summary and Closing

16
Thank you

Please submit written comments by 

February 24, 2023, by 5:00 pm (EST) to

tribalsupport@cdc.gov

17
32

CDC/ATSDR’s Tribal Consultation on CDC Moving Forward Initiative

February 9, 2023

Written Testimony
February 24, 2023

Director Rochelle Walensky

Centers for Disease Control and Prevention

C/O Office of Tribal Affairs and Strategic Alliances

Center for State, Tribal, Local, and Territorial Support

tribalsupport@cdc.gov

Director Walensky,

Thank you for this opportunity for consultation on the CDC Moving Forward initiative. The 

CDC is critical for advancing the government’s trust responsibility towards the health and 

wellness of our people.

At Cherokee Nation, we are especially focused on improving public health and working 

effectively with the CDC. We operate the largest Tribal health care system in the nation and are 

one of six Tribes with an accredited Public Health Department. My administration has made 

health and wellness one of our top priorities, and Cherokee Nation Deputy Principal Chief Bryan 

Warner serves as chair of the CDC’s Tribal Advisory Committee.

I appreciate the work being done in the CDC Moving Forward plan to strengthen the agency’s 

cross-cutting functions, including health equity, science, communications, and policy, and to 

break down silos among CDC CIOs that may interfere with clear communications and rapid 

response to public health threats. Improving the personnel resources, expertise, and funding 

support for cross-cutting functions is a welcome step forward.

In that same regard, Tribal relations and support should be viewed as a cross-cutting function 

that is just as important as any other. 

While in the past we have had excellent relations with some CIOs within CDC, others rarely if 

ever consider Tribal needs. The current lack of integration is reflected in the latest OMB Native 

American Crosscut totals for the CDC’s FY 2022 appropriations, which showed only 0.79% of 

CDC funding is for programs that benefit Native Americans. Even worse, the CDC has not 

reported an increase in funding for the Native American Crosscut in several years. This means 

we are doing worse than maintaining Tribal resources; we are losing ground.
That is unacceptable when Indian Country experiences many of the worst public health outcomes 

in the U.S. According to the CDC’s most recent report on life expectancy of American Indians 

and Alaska Natives, we are now expected to live 6.6 years less than in the 50 years preceding the 

report. AI/AN life expectancy today is the same as it was for the general U.S. population in 

1944. From the standpoint of both health equity and overall health, these metrics reveal deep 

deficiencies in meeting the trust responsibility and the most basic CDC mission to protect health 

and well-being.

That is why in this reorganization and on an ongoing basis, CDC needs to prioritize integrating 

support for Tribal Nations across all parts of the agency. For example, the proposed Executive 

Board to assess and recommend agency priorities each year should include permanent 

representation of an expert on Tribal priorities and sovereignty.

To give a specific example of how the disconnect between CIOs and Tribal nations is felt, we 

often see Notices of Funding Opportunities that, even when they do mention Tribes are eligible 

for funding, do not account for the unique position of Tribes as sovereign nations. They may 

include requirements such as a letter from a state chronic disease director or other state officer, 

which is never appropriate to ask of a Tribe with sovereignty that is fully independent of state 

sovereignty. Listing Tribes as eligible for a NOFO is not enough if we are lumped in with nonsovereign organizations.

To address this issue, I ask that the reorganization make sure that all NOFOs from the CDC are 

reviewed before release by an expert in best practices for respecting tribal sovereignty.

In the bigger picture, Tribes need sustained public health infrastructure funding that takes a 

holistic view of health, including social determinants of health. The piecemeal approach is not 

effective at addressing generations of health inequities. At present, Tribes have not even been 

deemed eligible for preparedness dollars, much less offered sustained funding outside of an 

unreliable and administratively burdensome grant cycle.

It is concerning that this opportunity for Tribal consultation has come far along into the CDC’s 

reorganization process. For this to be a meaningful consultation, I hope the CDC will take Tribal 

comments into full consideration, even if it means rethinking decisions that have already been 

made in planning the reorganization. With that said, I am confident that we can together find 

solutions that advance both CDC’s goals and the priorities of Tribal nations.

Given how far along the agency is in this process, there is heightened need for accountability 

measures that demonstrate how Tribal priorities are reflected in the initiative. I urge you to 

establish those accountability measures and clearly communicate to Tribes how they have been 

implemented, with opportunity for a follow-up consultation based on the response.

Thank you again for this opportunity to comment and for your attention to the needs of Cherokee 

Nation and all Indian Country.

Wado,

Cherokee Nation Principal Chief Chuck Hoskin, Jr.
Ewiiaapaayp Tribal Office

Ewiiaapaayp Band of Kumeyaay Indians

4054 Willows Road

Alpine, CA 91901

TEL: (619) 368-4382

FAX: (619) 445-9126

E-mail: ceo@ebki-nsn.gov

VIA EMAIL

tribalsupport@cdc.gov

February 9, 2023

Celeste Philip, MD, MPH

Acting Director, Center for State, Tribal, Local, and Territorial Support Deputy Director for 

Non-Infectious Diseases (DDNID)

Centers for Disease Control and Prevention 

re: CDC/ATSDR Tribal Consultation 

Dear Dr. Philip,

The Ewiiaapaayp Band of Kumeyaay Indians (the “EBKI”) is a federally recognized Tribal 

government in east San Diego County, California. EBKI is pleased to submit recommendations 

to the Center for Disease Control tribal consultation regarding the engagement of CDC with 

Tribes.

Please refer to the U.S. Government Accountability Office (GAO) Report to Congress dated 

March 2022 entitled, “Tribal Epidemiology Centers – HHS Actions Needed to Enhance Data 

Access” (GAO-22-104698). In this report the GAO made five recommendations, including that

“ ... HHS clarify the data it will make available to TECs as required by federal law; and that 

CDC and IHS develop guidance on how TECs should request data, and develop agency 

procedures on responding to such requests.” HHS concurred with these recommendations. 

However, as of this writing the Tribe is not aware of such specific executive actions taken by the 

administration (HHS, CDC, and Indian Health Service (IHS)) to implement the five GAO 

recommendations.

We further recommend the HHS, CDC, and IHS extend the GAO recommendations to all IHS 

Tribal healthcare clinics and consortiums as a necessary measure to extend access and beneficial 

outcomes for Tribes by sharing data and analyses with all Tribal health care entities and not limit 

this improved relationship to the twelve Tribal Epidemiological Centers.

We also recommend the administration support the approval by the 118th Congress of the prior 

bill from the 117th Congress that was H.R. 1397 entitled, “Tribal Health Data Improvement Act 

of 2021.” This bill expands tribal access to public health care data and public health surveillance 
Ewiiaapaayp Band of Kumeyaay Indians 2

programs. It also reauthorizes through FY2025 the National Center for Health Statistics, which is 

part of the Centers for Disease Control and Prevention (CDC), and requires the CDC to take 

certain actions to address the collection and availability of health data for American Indians and 

Alaska Natives.

Specifically, the Department of Health and Human Services must (1) establish a strategy for 

providing data access to Indian tribes and tribal epidemiology centers; and (2) make available all 

requested data related to health care and public health surveillance programs and activities to the 

Indian Health Service, tribes, tribal organizations, and tribal epidemiology centers.

Next, the CDC must make grants to and enter into contracts with tribes, tribal organizations, and 

tribal epidemiology centers for data collection and related activities.

Among other activities, the CDC must (1) develop guidance for state and local health agencies to 

improve birth and death record data for American Indians and Alaska Natives; (2) enter into

cooperative agreements with tribes, tribal organizations, urban Indian organizations, and tribal 

epidemiology centers to analyze and address certain inaccuracies related to records for American 

Indians and Alaska Natives; (3) adopt uniform standards for the collection of health data on race 

and ethnicity; and (4) encourage states to enter into data sharing agreements with tribes and tribal 

epidemiology centers to improve the quality and accuracy of health data.

We further recommend the CDC consult with Tribes to develop effective guidelines for the 

ongoing SARS-COV-2 pandemic, which would be a foundation for establishing an effective plan 

for future public health emergencies.

We recommend CDC guidance developed in consultation with Tribes that establishes an 

affirmative and declarative plan that includes:

• Full vaccination and boosters

• Masking in-doors or in congregate settings

• Physical distancing

• Work at home infected and when possible and to the extent practicable

• Limited travel with enhanced use of videoconferencing and teleconferencing

• Ensure availability of supplemental medications (e.g., Paxlovid)

• Enhanced ventilation and filtration of residential and commercial buildings (e.g., 

ASHREAE), with minimum air exchanges per hour (e.g., MERV 13 to 16), and HEPA 

filtration at 0.3 microns or lesser, and including far ultraviolet systems in commercial, 

health care, and education settings.

For example:

Guidance for Building Operations During COVID-19 Pandemics

https://www.ashrae.org/file%20library/technical%20resources/ashrae%20journal/2020journaldoc

uments/72-74_ieq_schoen.pdf

Ventilation in Buildings

https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation.html#refphf
Ewiiaapaayp Band of Kumeyaay Indians 3

Upper-Room Ultraviolet Germacidal Irradiation (UVGI)

https://www.cdc.gov/coronavirus/2019-ncov/community/ventilation/UVGI.html

Upper-Room Ultraviolet Germicidal Irradiation Guidance for Healthcare Settings

https://www.cdc.gov/niosh/docs/2009-105/pdfs/2009-

105.pdf?id=10.26616/NIOSHPUB2009105

It is a mistake to discount new COVID-19 cases just because death rate remains relatively low, 

and in the context of reduced testing, with virtually no tracing, and with a reduced emphasis on 

non-pharmaceutical interventions. The CDC is betting the U.S. health care system can produce 

vaccines adaptative to virus variants and mutations at as fast a pace as the virus is mutating. This 

is a bet that will not succeed and its consequence threatens the health and general welfare of 

Tribes and their Tribal citizens.

The CDC must appreciate the health risk to Tribes given the high incidence of infection and poor 

health outcomes, including fatalities, among Tribes. 

Nor may the CDC rely upon the excuse than no one saw this coming. The recommendations 

from the “Crimson Contagion” pandemic exercise held in 2019 that forewarned of the impact of 

a coronavirus is0 now public. [https://ia801901.us.archive.org/30/items/crimson-contagion2019/Crimson_Contagion_2019.pdf]. Every mistake this exercise warned against was made, and 

every recommendation it presented was ignored. 

The CDC knows how to defeat a pandemic. We know other public health emergencies will arise. 

We must act to protect those we love and ourselves – or we risk greater setbacks from a virus 

that has demonstrated great adaptative abilities to increase transmissibility and cause long-term 

injury. 

We recommend the CDC consult with Tribes to establish effective COVID-19 measures based 

on sound and accepted epidemiological principles. 

Finally, we wish to take this opportunity to address the CDC consultation requirement now that 

the administration intends to end the public health emergency in May 2023. 

First, the CDC communications and consultation with Tribes about ending the COVID-19 public 

health emergency (PHE) has been missing. Tribes are confused. Many are confused. Tribes do

not understand the situation right now and what it means for Tribes. We need clarity.

First, there is not one national emergency declaration surrounding the COVID-19 pandemic. 

There are five. Each has a different purpose for a different part of the U.S. Federal government. 

These five emergency “buckets” are:

1. FDA

2. Stafford Act (i.e., FEMA)

3. Public Health Emergency
Ewiiaapaayp Band of Kumeyaay Indians 4

4. National Emergency

5. PREP Act

Together, these are responsible for uncatalogued number of flexibilities available throughout the 

pandemic. For example, the emergency use authorization for vaccines occurred under bucket #1. 

Extending Medicaid to more people happened under bucket #3 (although this recently changed; 

see below).

These different mechanisms created a complicated system that needs to be untangled without 

terminating all at once. To help prevent this, the five buckets of emergencies are ending at 

different times. Buckets #3 and #4 are ending in May 2023. All the others are yet to be 

determined. (#5 is fodder for lawyers).

Throughout the pandemic CDC has asserted “we have the tools.” The May termination of 

buckets #3 and #4 means different things for different tools:

Antigen tests. Supply is going be impacted, but not necessarily because of the PHE. It’s 

dependent on Congressional budget. The tests are already commercialized. The U.S. bought a 

stockpile of antigen tests for the USPS program this past winter and still has a stockpile for the 

coming months. It’s not clear when this supply will run out.

The industry (i.e. test makers) are unwilling to produce a surplus of tests because demand is 

unknown. Without a guaranteed purchase (like from the government) or knowledge that more 

waves are coming to drive demand, they are hesitant to manufacture more. It’s not clear whether 

antigen tests, and which ones, will be available on retail shelves after the emergency like they are 

now.

In addition, the PHE requires health insurers to reimburse for up to eight antigen tests, per 

person, per month. After May, insurers will be able to choose whether to reimburse for those 

tests or not. What will be the effect for IHS?

Vaccines. The FDA emergency (#1 above) is not ending. This means COVID-19 vaccines will 

still be available. However, available is different from accessible. Vaccines will be covered by 

the IHS until the stockpile (vaccines which the U.S. government bought from pharma) dries up. 

After the stockpile dries up or we get a Fall 2023 new formula booster, the vaccine will be 

covered by HIS, or by private insurance (through employment) or public insurance (Medicaid, 

Medicare, etc.) for the 92% of Americans who have health coverage. IHS vaccines are free, with 

no co-pay required. And also free for those covered by the Affordable Care Act. Will this 

change?

Paxlovid. This supply apparently has a large stockpile. Once that stockpile is gone, it will be 

privatized. The price will be determined by Pfizer, and the price that individuals pay at the 

pharmacy will depend on health insurance. What does this mean for IHS?

Monoclonal antibodies/Evushield. Apparently, these don’t work against the newest subvariants, 

and pharma doesn’t want to make more because the market keeps evaporating (because the virus 
Ewiiaapaayp Band of Kumeyaay Indians 5

keeps changing). For people for whom Paxlovid doesn’t work or the vaccine doesn’t confer 

protection (e.g., organ transplant patients), it’s not clear what protections there will be. The most 

vulnerable will be less protected than before. What precautions are available for IHS?

National surveillance. Apparently, this will continue to some extent:

• Genomic surveillance: It’s our understanding the wastewater program will remain for 

now.

• Test positivity rates: Will likely go away because CDC can’t compel labs to report.

• Hospitalizations: CDC will still get data, but the frequency will likely slow down. 

• Vaccine uptake: Will likely remain, as CDC is working with states to continue 

monitoring.

• Pharmacy testing: May go away. This turned out to be CDC’s fastest way to evaluate 

vaccine effectiveness. So Tribes may be effected by a delayed system in order to know 

how well our vaccines are working, which is disappointing.

What monitoring of COVID-19 will be available to IHS? Knowing if and when we are in a new 

wave to inform our behaviors, for example, will get more and more challenging.

Healthcare coverage. One of the most impactful tools during the emergency was Medicaid’s 

continuous coverage. During pre-pandemic times, states regularly checked whether people 

enrolled in Medicaid were still eligible. These “checks” were removed during the pandemic. 

When these “checks” resume on April 1, between 5.3 and 14.2 million adults and children will 

lose Medicaid coverage. (Technically, this was under bucket #3, but the Omnibus bill passed in 

December uncoupled Medicaid from the PHE. So this doesn’t have to do with the PHE ending, 

but it’s still a big change we are going to see starting April 1.)

How will Medicaid coverage changes effect IHS and Tribes?

National vs. state. vs. local

Each state has its own authorities and emergency mechanisms. Everything will look different 

depending on the State a Tribe is within (or multiple States). States are responsible for the 

transition from Medicaid continuous coverage back to “checks.” Some states will follow up with 

people to let them know they are missing information so they don’t get dropped; some states will 

update mailing addresses proactively so people don’t lose coverage; some states will do 

nothing. Will HHS/CDC inform Tribes of State Medicaid procedures, and encourage States to 

take no measures that reduce coverage?

Wastewater surveillance is additionally dependent on the state or locality budget, for example. 

This means wastewater monitoring may change based on State funding, regardless of a CDC 

grant. Will CDC inform Tribes of such changes?

Conclusion. Tribes need clear guidance about what happens once the U.S. terminates “buckets”

#3 and #4, and further potential actions. There are still a lot of unanswered questions, and the 

situation is in flux. HHS/CDC/IHS consultation with Tribes is urgent, and clear information and 

guidelines are needed.
Ewiiaapaayp Band of Kumeyaay Indians 6

If you have any questions or concerns at any time, please feel free to contact the Tribe’s Chief 

Executive Officer, Mr. Will Micklin, by telephone at (619) 368-4382, or by email at ceo@ebkinsn.gov. Thank you.

Sincerely,

Robert Pinto Sr

Tribal Chairman

Ewiiaapaayp Band of Kumeyaay Indians
II 

117TH CONGRESS 

1ST SESSION S. 1397 

To amend the Public Health Service Act with respect to the collection and 

availability of health data with respect to Indian Tribes and Tribal 

organizations, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

APRIL 27, 2021 

Ms. SMITH (for herself, Ms. MURKOWSKI, Mr. TESTER, Mr. DAINES, Ms. 

WARREN, and Mr. CRAMER) introduced the following bill; which was read 

twice and referred to the Committee on Indian Affairs 

A BILL 

To amend the Public Health Service Act with respect to 

the collection and availability of health data with respect 

to Indian Tribes and Tribal organizations, and for other 

purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Tribal Health Data 

5 Improvement Act of 2021’’. 


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2 

•S 1397 IS

1 SEC. 2. COLLECTION AND AVAILABILITY OF HEALTH DATA 

2 WITH RESPECT TO INDIAN TRIBES. 

3 (a) DATA COLLECTION.—Section 3101(a)(1) of the 

4 Public Health Service Act (42 U.S.C. 300kk(a)(1)) is 

5 amended— 

6 (1) by striking ‘‘, by not later than 2 years 

7 after the date of enactment of this title,’’; and 

8 (2) in subparagraph (B), by inserting ‘‘Tribal,’’ 

9 after ‘‘State,’’. 

10 (b) DATA REPORTING AND DISSEMINATION.—Sec11 tion 3101(c) of the Public Health Service Act (42 U.S.C. 

12 300kk(c)) is amended— 

13 (1) by amending subparagraph (F) of para14 graph (1) to read as follows: 

15 ‘‘(F) the Indian Health Service, Indian 

16 Tribes, Tribal organizations, and epidemiology 

17 centers;’’; and 

18 (2) in paragraph (3), by inserting ‘‘Indian 

19 Tribes, Tribal organizations, epidemiology centers,’’ 

20 after ‘‘Federal agencies,’’. 

21 (c) PROTECTION AND SHARING OF DATA.—Section 

22 3101(e) of the Public Health Service Act (42 U.S.C. 

23 300kk(e)) is amended— 

24 (1) in paragraph (2)— 

25 (A) by striking ‘‘..’’ and inserting ‘‘.’’; 


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3 

•S 1397 IS

1 (B) by striking ‘‘The Secretary shall’’ and 

2 inserting the following: 

3 ‘‘(A) IN GENERAL.—The Secretary shall’’; 

4 and 

5 (C) by adding at the end the following: 

6 ‘‘(B) EPIDEMIOLOGY CENTERS AND IN7 DIAN TRIBES.—With respect to data access for 

8 epidemiology centers and Indian Tribes, the 

9 Secretary shall establish a data sharing strat10 egy, in consultation with the Secretary’s Tribal 

11 Advisory Committee, for purposes of providing 

12 access to data to the epidemiology centers and 

13 Indian Tribes that protect data privacy and se14 curity and data governance while ensuring that 

15 epidemiology centers and Indian Tribes have 

16 access to data sources necessary to accomplish 

17 their public health responsibilities and plans for 

18 use.’’; and 

19 (2) by adding at the end the following new 

20 paragraph: 

21 ‘‘(3) TRIBAL PUBLIC HEALTH AUTHORITY.— 

22 Beginning not later than 180 days after the date of 

23 the enactment of the Tribal Health Data Improve24 ment Act of 2021, the Secretary shall make avail25 able all requested data collected pursuant to this 


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4 

•S 1397 IS

1 title with respect to health care and public health 

2 surveillance programs and activities, including such 

3 programs and activities that are federally supported 

4 or conducted, to— 

5 ‘‘(A) the Indian Health Service; 

6 ‘‘(B) Indian Tribes and Tribal organiza7 tions; and 

8 ‘‘(C) epidemiology centers.’’. 

9 (d) TECHNICAL UPDATES.—Section 3101 of the 

10 Public Health Service Act (42 U.S.C. 300kk) is amend11 ed— 

12 (1) by striking subsections (g) and (h); and 

13 (2) by redesignating subsection (i) as subsection 

14 (h). 

15 (e) DEFINITIONS.—After executing the amendments 

16 made by subsection (d), section 3101 of the Public Health 

17 Service Act (42 U.S.C. 300kk) is amended by inserting 

18 after subsection (f) the following new subsection: 

19 ‘‘(g) DEFINITIONS.—In this section: 

20 ‘‘(1) The term ‘epidemiology center’ means an 

21 epidemiology center established under section 214 of 

22 the Indian Health Care Improvement Act, including 

23 any epidemiology center serving Indian Tribes re24 gionally or serving urban Indian organizations naVerDate Sep 11 2014 02:59 May 22, 2021 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1397.IS S1397

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5 

•S 1397 IS

1 tionally that is receiving funding from the Indian 

2 Health Service. 

3 ‘‘(2) The terms ‘Indian Tribe’ and ‘Tribal orga4 nization’ have the meanings given to the terms ‘In5 dian tribe’ and ‘tribal organization’, respectively, in 

6 section 4 of the Indian Self-Determination and Edu7 cation Assistance Act.’’. 

8 (f) TECHNICAL CORRECTION.—Section 3101(b) of 

9 the Public Health Service Act (42 U.S.C. 300kk(b)) is 

10 amended by striking ‘‘DATA ANALYSIS.—’’ and all that 

11 follows through ‘‘For each federally’’ and inserting ‘‘DATA

12 ANALYSIS.—For each federally’’. 

13 SEC. 3. IMPROVING HEALTH STATISTICS REPORTING WITH 

14 RESPECT TO INDIAN TRIBES. 

15 (a) TECHNICAL AID TO STATES AND LOCALITIES.— 

16 Section 306(d) of the Public Health Service Act (42 

17 U.S.C. 242k(d)) is amended by inserting ‘‘, Indian Tribes, 

18 Tribal organizations, and epidemiology centers’’ after ‘‘ju19 risdictions’’. 

20 (b) COOPERATIVE HEALTH STATISTICS SYSTEM.— 

21 Section 306(e)(3) of the Public Health Service Act (42 

22 U.S.C. 242k(e)(3)) is amended by inserting ‘‘, Indian 

23 Tribes, Tribal organizations, and epidemiology centers’’ 

24 after ‘‘health agencies’’. 


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6 

•S 1397 IS

1 (c) FEDERAL-STATE-TRIBAL COOPERATION.—Sec2 tion 306(f) of the Public Health Service Act (42 U.S.C. 

3 242k(f)) is amended— 

4 (1) by inserting ‘‘, the Indian Health Service,’’ 

5 after ‘‘Commerce and Labor’’; 

6 (2) by inserting ‘‘, Indian Tribes, Tribal organi7 zations, and epidemiology centers’’ after ‘‘State and 

8 local health departments and agencies’’; and 

9 (3) by striking ‘‘he shall’’ and inserting ‘‘the 

10 Secretary shall’’. 

11 (d) REGISTRATION AREA RECORDS.—Section 

12 306(h)(1) of the Public Health Service Act (42 U.S.C. 

13 242k(h)(1)) is amended— 

14 (1) by striking ‘‘in his discretion’’ and inserting 

15 ‘‘in the discretion of the Secretary’’; and 

16 (2) by striking ‘‘Hispanics, Asian Americans, 

17 and Pacific Islanders’’ and inserting ‘‘American In18 dians and Alaska Natives, Hispanics, Asians, and 

19 Native Hawaiian and other Pacific Islanders’’. 

20 (e) NATIONAL COMMITTEE ON VITAL AND HEALTH

21 STATISTICS.—Section 306(k) of the Public Health Service 

22 Act (42 U.S.C. 242k(k)) is amended— 

23 (1) in paragraph (3), by striking ‘‘, not later 

24 than 60 days after the date of the enactment of the 


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•S 1397 IS

1 Health Insurance Portability and Accountability Act 

2 of 1996,’’ each place it appears; and 

3 (2) in paragraph (7), by striking ‘‘Not later 

4 than 1 year after the date of the enactment of the 

5 Health Insurance Portability and Accountability Act 

6 of 1996, and annually thereafter, the Committee 

7 shall’’ and inserting ‘‘The Committee shall, on a bi8 ennial basis,’’. 

9 (f) GRANTS FOR ASSEMBLY AND ANALYSIS OF DATA

10 ON ETHNIC AND RACIAL POPULATIONS.—Section 

11 306(m)(4) of the Public Health Service Act (42 U.S.C. 

12 242k(m)(4)) is amended— 

13 (1) in subparagraph (A)— 

14 (A) by striking ‘‘Subject to subparagraph 

15 (B), the’’ and inserting ‘‘The’’; and 

16 (B) by striking ‘‘and major Hispanic sub17 population groups and American Indians’’ and 

18 inserting ‘‘, major Hispanic subgroups, and 

19 American Indians and Alaska Natives’’; and 

20 (2) by amending subparagraph (B) to read as 

21 follows: 

22 ‘‘(B) In carrying out subparagraph (A), with respect 

23 to American Indians and Alaska Natives, the Secretary 

24 shall— 


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8 

•S 1397 IS

1 ‘‘(i) in consultation with Indian Tribes, Tribal 

2 organizations, the Tribal Technical Advisory Group 

3 of the Centers for Medicare & Medicaid Services 

4 maintained under section 5006(e) of the American 

5 Recovery and Reinvestment Act of 2009, and the 

6 Tribal Advisory Committee established by the Cen7 ters for Disease Control and Prevention, and in co8 ordination with epidemiology centers, develop guid9 ance for State and local health agencies to improve 

10 the quality and accuracy of data with respect to the 

11 birth and death records of American Indians and 

12 Alaska Natives; 

13 ‘‘(ii) confer with urban Indian organizations to 

14 develop guidance for State and local health agencies 

15 to improve the quality and accuracy of data with re16 spect to the birth and death records of American In17 dians and Alaska Natives; 

18 ‘‘(iii) enter into cooperative agreements with In19 dian Tribes, Tribal organizations, Urban Indian or20 ganizations, and epidemiology centers to analyze and 

21 address misclassification and undersampling of 

22 American Indians and Alaska Natives in data sys23 tems at the Federal, State, and local levels, with re24 spect to— 

25 ‘‘(I) birth and death records; and 


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9 

•S 1397 IS

1 ‘‘(II) Federal, State, and local health care 

2 and public health surveillance systems, includ3 ing with respect to chronic and infectious dis4 eases, unintentional injuries, environmental 

5 health, child and adolescent health, maternal 

6 health and mortality, foodborne and waterborne 

7 illness, reproductive health, and any other 

8 notifiable disease or condition; 

9 ‘‘(iv) adopt, based on local, statewide, Tribal, 

10 and national best practices, uniform standards for 

11 the collection of health data on race and ethnicity; 

12 ‘‘(v) encourage States to enter into data shar13 ing agreements with Indian Tribes and epidemiology 

14 centers to improve the quality and accuracy of public 

15 health data regarding American Indians and Alaska 

16 natives, including by addressing misclassification 

17 and undersampling of American Indians and Alaska 

18 Natives in State and local public health data sys19 tems, including with respect to vital statistics, chron20 ic and infectious diseases, unintentional injuries, en21 vironmental health, child and adolescent health, ma22 ternal health and mortality, foodborne and water23 borne illness, reproductive health, and any other 

24 notifiable disease or condition; 


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10 

•S 1397 IS

1 ‘‘(vi) encourage States to adopt, based on local, 

2 statewide, Tribal, and national best practices, uni3 form standards for the collection of health data on 

4 race and ethnicity; and 

5 ‘‘(vii) 180 days after the date of enactment of 

6 the Tribal Health Data Improvement Act of 2021 

7 and biennially thereafter, issue a report on— 

8 ‘‘(I) which States have data sharing agree9 ments with Indian Tribes, Tribal Organizations, 

10 urban Indian organizations, or epidemiology 

11 centers to improve the quality and accuracy of 

12 health data, listed by data system name; and 

13 ‘‘(II) actions taken by the Director of the 

14 Centers for Disease Control and Prevention to 

15 encourage States to enter into data sharing 

16 agreements with Indian Tribes, Tribal Organi17 zations, urban Indian organizations, and epide18 miology centers to improve the quality and ac19 curacy of health data.’’. 

20 (g) DEFINITIONS.—Section 306 of the Public Health 

21 Service Act (42 U.S.C. 242k) is amended— 

22 (1) by redesignating subsection (n) as sub23 section (o); and 

24 (2) by inserting after subsection (m) the fol25 lowing: 


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•S 1397 IS

1 ‘‘(n) In this section: 

2 ‘‘(1) The term ‘epidemiology center’ means an 

3 epidemiology center established under section 214 of 

4 the Indian Health Care Improvement Act, including 

5 any epidemiology center serving Indian Tribes re6 gionally or serving urban Indian organizations na7 tionally that is receiving funding from the Indian 

8 Health Service. 

9 ‘‘(2) The terms ‘Indian Tribe’ and ‘Tribal orga10 nization’ have the meanings given to the terms ‘In11 dian tribe’ and ‘tribal organization’, respectively, in 

12 section 4 of the Indian Self-Determination and Edu13 cation Assistance Act. 

14 ‘‘(3) The term ‘Urban Indian organization’ has 

15 the meaning given to that term in section 4 of the 

16 Indian Health Care Improvement Act.’’. 

17 (h) AUTHORIZATION OF APPROPRIATIONS.—Section 

18 306(o) of the Public Health Service Act, as redesignated 

19 by subsection (g), is amended to read as follows: 

20 ‘‘(o) To carry out this section, there is authorized to 

21 be appropriated $185,000,000 for each of the fiscal years 

22 2021 through 2025.’’. 

Æ 


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TRIBAL 

EPIDEMIOLOGY 

CENTERS

HHS Actions Needed 

to Enhance Data 

Access

Report to Congressional Addressees

March 2022

GAO-22-104698

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-22-104698, a report to 

congressional addressees

March 2022

TRIBAL EPIDEMIOLOGY CENTERS

HHS Actions Needed To Enhance Data Access

What GAO Found

Among the 12 tribal epidemiology centers (TEC), which are public health entities 

serving American Indian and Alaska Native (AI/AN) communities across the U.S., 

access to epidemiological data varied. Federal law authorizes TECs’ access to 

data from the Department of Health and Human Services (HHS), including data 

from HHS’s Centers for Disease Control and Prevention (CDC) and Indian Health 

Service (IHS), for a variety of public health purposes. However, according to TEC 

officials, access to non-public HHS data, such as CDC data on positive COVID19 tests or IHS data on patient diagnosis codes, varied among TECs. TEC 

officials also described challenges accessing some CDC and IHS data, such as 

the inability to access certain CDC data on infectious diseases and other 

conditions. TECs used available epidemiological data to monitor the spread of 

COVID-19 and to conduct other analyses that support public health decisionmaking in AI/AN communities. However, TEC officials told GAO that their access 

to data influences the analyses they are able to conduct, and that a lack of

access can limit their ability to provide AI/AN communities with meaningful 

information needed for decision-making. 

The presence of CDC and IHS data sharing systems and agreements between 

the agencies and TECs have facilitated TECs’ access to a range of

epidemiological data, including on COVID-19 cases and the health of IHS facility 

patients. However, a number of factors have also hindered TEC access to HHS

data, including

• A lack of policies affirming TECs’ authority to access HHS data. Officials 

from seven of 12 TECs indicated that some CDC and IHS officials with whom

they interacted when requesting data did not recognize that HHS is required

by federal law to provide data in its possession to TECs. According to IHS 

and CDC officials, as of November 2021, HHS had not clarified the specific 

data that TECs are entitled to access under federal law.

• A lack of guidance for TECs on how to request data, and agency 

procedures on how to respond to such requests. CDC and IHS had not 

developed guidance for TECs on how to submit data requests or established 

written agency procedures for reviewing and responding to these requests as 

of November 2021, according to agency officials. CDC and IHS officials told 

GAO that they did not believe that guidance or procedures related to TECs’

data access was needed, because TECs’ requests were infrequent and they 

believed they had successfully responded to their needs. However, officials 

from six TECs told GAO that the process to request and obtain data was 

unclear and inconsistent within HHS. In addition, officials from seven TECs 

reported facing delays receiving CDC or IHS data, with some delays lasting

over 1 year. According to TEC officials, these delays or limitations in 

accessing data made it difficult for them to adequately support tribal and 

community leaders, as they work to understand and address the health 

needs of AI/AN in their communities, including during the COVID-19 

pandemic. View GAO-22-104698. For more information, 

contact Michelle B. Rosenberg at (202) 512-

7114 or RosenbergM@gao.gov.

Why GAO Did This Study

AI/ANs have experienced longstanding problems accessing health 

care services and worse health 

outcomes than the general U.S. 

population, such as a life expectancy 

that is 5.5 years shorter than the U.S. 

average, according to IHS. To provide 

tribes with public health support, 

Congress required the establishment 

of TECs and, in 2010, authorized their 

access to HHS data. The COVID-19 

pandemic highlighted the need to 

understand TECs’ access to 

epidemiological data to help AI/AN 

communities prevent and control 

diseases. 

The CARES Act includes a provision 

for GAO to report on its ongoing 

COVID-19 monitoring and oversight 

efforts. Also, GAO was asked to 

examine TECs’ access to 

epidemiological data. This report (1) 

describes TECs’ access to and use of 

epidemiological data, and (2) examines 

factors that have affected TECs’ 

access to HHS epidemiological data. 

GAO reviewed HHS policies and 

documents and documentation of 

TECs’ data requests. GAO also 

interviewed officials from CDC, IHS,

and all 12 TECs. 

What GAO Recommends

GAO is making five recommendations, 

including that HHS clarify the data it 

will make available to TECs as 

required by federal law; and that CDC 

and IHS develop guidance on how 

TECs should request data, and 

develop agency procedures on 

responding to such requests. HHS 

concurred with these 

recommendations.
Page i GAO-22-104698 Tribal Epidemiology Centers

Letter 1

Background 5

TECs’ Access to Epidemiological Data Varied, and TECs Used 

Available Data for Analyses to Support Tribal Decision-Making 10

While HHS Has Some Systems to Share Data with TECs, Its Lack 

of Policies, Guidance, and Procedures Hinders Access 16

Conclusions 24

Recommendations for Executive Action 25

Agency Comments and Our Evaluation 26

Appendix I Comments from the Department of Health and Human Services 30

Appendix II GAO Contact and Staff Acknowledgments 34

Tables

Table 1: Examples of Analyses Conducted by Tribal Epidemiology 

Centers (TEC) 15

Table 2: Indian Health Service (IHS) and Centers for Disease 

Control and Prevention (CDC) Programs to Support and 

Enhance Tribal Epidemiology Centers’ (TEC) Capacity, 

Fiscal Year 2021 24

Figure

Figure 1: Tribal Epidemiology Centers’ (TEC) Service Areas 9

Contents
Page ii GAO-22-104698 Tribal Epidemiology Centers

Abbreviations

AI/AN American Indian and Alaska Native

CDC Centers for Disease Control and Prevention

COVID-19 Coronavirus Disease 2019

HHS Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act

IHS Indian Health Service

TEC tribal epidemiology center

WONDER Wide-ranging Online Data for Epidemiological Research

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-22-104698 Tribal Epidemiology Centers

441 G St. N.W.

Washington, DC 20548

March 4, 2022

Congressional Addressees

American Indians and Alaska Natives (AI/AN) have experienced longstanding problems accessing needed health care services and have 

poorer health than the general U.S. population. For example, AI/ANs 

have a life expectancy that is 5.5 years shorter than the U.S. average, 

and a Coronavirus Disease 2019 (COVID-19) infection rate 3.5 times 

higher than non-Hispanic whites.1 Legislation enacted in 1992 required 

the establishment of tribal epidemiology centers (TEC) to provide 

epidemiological functions and public health support for tribes, tribal 

organizations, and urban Indian communities.2 Today, 12 TECs, which 

are public health organizations that are funded, in part, by the Centers for 

Disease Control and Prevention (CDC) and the Indian Health Service 

(IHS), serve AI/AN tribal and urban communities across the nation by 

investigating diseases of concern and responding to public health 

emergencies, among other activities. TECs conduct this work to better 

understand health risks for AI/ANs, eliminate health disparities, and 

prevent and control diseases.

Legislation enacted in 2010 directed the Secretary of the Department of 

Health and Human Services (HHS) to grant TECs access to HHS data 

 1See Indian Health Service, Indian Health Disparities Fact Sheet, (Rockville, Md.: October 

2019), accessed November 19, 2021, 

https://www.ihs.gov/newsroom/factsheets/disparities/; and U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, COVID-19 Among 

American Indian and Alaska Native Persons – 23 States, January 31 – July 3, 2020, 

Morbidity and Mortality Weekly Report, vol. 69 no. 34 (Aug. 28, 2020). 

2Indian Health Amendments of 1992, Pub. L. No. 102-573, § 210, 106 Stat. 4526, 4551. 

Letter
Page 2 GAO-22-104698 Tribal Epidemiology Centers

and clarified that TECs are to be treated as public health authorities.3

Specifically, federal law directs the Secretary of HHS to provide TECs 

with HHS data and other protected health information for research and for 

preventing and controlling disease, injury, or disability—which, for the 

purposes of this report, we refer to as epidemiological data.4 HHS 

agencies hold a wide range of epidemiological data. For example, CDC 

maintains data on diseases, such as COVID-19 and influenza, and 

factors that affect health, such as suicide and immunizations. Further, IHS 

maintains data on AI/ANs who receive care through its network of health 

care providers, including federally and tribally operated hospitals and 

clinics.5 Other entities, such as state governments, also maintain 

epidemiological data that may be provided to TECs, in TECs’ capacity as 

public health authorities.

Access to timely, reliable, and identifiable epidemiological data is vital to 

disease surveillance and other epidemiological functions.6 These data are 

central to decision making, as they can help AI/AN communities define 

priorities, develop health improvement strategies, acquire resources, and 

implement effective interventions. TECs rely on the sharing of existing 

epidemiological data accumulated by federal, state, or local governments; 

 3Patient Protection and Affordable Care Act, § 10221, Pub. L. No. 111-148, 124 Stat. 119, 

935 (incorporating S. 1790) (codified at 25 U.S.C. § 1621m(e)). In particular, the law 

provides that TECs are to be considered as public health authorities for the purpose of the 

Health Insurance Portability and Accountability Act (HIPAA). Public health authorities are 

responsible for public health matters as part of their official mandate, and they can include 

federal, state, territorial, or Indian tribal agencies. Under HIPAA, certain entities, such as 

health care providers, health plans, and health care clearinghouses, may grant public 

health authorities access to protected health information for the purposes of preventing 

and controlling disease, among other things. Protected health information includes 

individually identifiable health information on a person’s health condition and care. 45 

C.F.R. §§ 160.103, 164.501, 164.512.

445 C.F.R. § 164.512(b)(1)(i). Epidemiological data may include a variety of health-related 

data on diseases, health events (such as birth defects, injuries, and non-infectious 

diseases), and populations.

5IHS provides health care services to AI/ANs either directly through a system of federally 

operated IHS facilities or indirectly through facilities that are operated by other tribes. As of 

November 2021, IHS, tribes, and tribal organizations operated 45 hospitals and 368 health 

centers as well as a range of other types of health facilitates—of which, 23 hospitals and 

50 health centers were federally operated IHS facilities. 

6Disease surveillance is the process of reporting, collecting, analyzing, and exchanging 

information related to cases of infectious diseases, such as COVID-19 and influenza. 
Page 3 GAO-22-104698 Tribal Epidemiology Centers

however, questions have been raised about TECs’ ability to access HHS 

and state epidemiological data, including CDC’s COVID-19 data.

In 2020, the COVID-19 pandemic highlighted the need to understand 

TECs’ abilities to access federal, state, and local epidemiological data 

that can help AI/ANs make decisions about how to prevent and control 

diseases in their communities. The CARES Act includes a provision for 

GAO to report on its ongoing monitoring and oversight efforts related to 

the COVID-19 pandemic.7 In addition, you asked us to examine factors 

that have affected TECs’ access to epidemiological data, including 

access to COVID-19 data. In this report, we

1. describe TECs’ access to and use of HHS and state epidemiological 

data, and

2. examine factors that have affected TECs’ access to and use of HHS 

epidemiological data.

To describe TECs’ access to and use of HHS and state epidemiological 

data, we reviewed documents and interviewed officials from two HHS 

agencies—CDC and IHS—and all 12 TECs.8 Documents we reviewed 

included notices of funding for HHS programs that support TEC 

operations, reports documenting TECs’ progress towards meeting these 

programs’ objectives, and publicly available analyses published by the 12 

TECs over the past 3 years.9 Further, we reviewed documents related to 

 7Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). 

8Specifically, we interviewed the directors of, or director-appointed designees from, each 

of the 12 TECs: (1) Alaska Native Epidemiology Center; (2) Albuquerque Area Southwest 

Tribal Epidemiology Center; (3) California Tribal Epidemiology Center; (4) Great Lakes 

Inter-Tribal Epidemiology Center; (5) Great Plains Tribal Epidemiology Center; (6) Inter 

Tribal Council of Arizona, Inc. Tribal Epidemiology Center; (7) Navajo Epidemiology 

Center; (8) Northwest Tribal Epidemiology Center; (9) Oklahoma Area Tribal Epidemiology 

Center; (10) Rocky Mountain Tribal Leaders Council Epidemiology Center; (11) United 

South and Eastern Tribes, Inc. Tribal Epidemiology Center; and (12) Urban Indian Health 

Institute. For the purposes of this report, we refer to these individuals as TEC officials. 

In addition, we reviewed documents and spoke with officials from CDC and IHS because 

TEC officials told us they requested access to data held by these two HHS agencies from 

January 2018 through April 2021.

9We reviewed notices of funding for the current funding cycle for HHS programs, including 

CDC’s Tribal Epidemiology Centers Public Health Infrastructure program and IHS’s 

Epidemiology Program for AI/AN Tribes and Urban Communities. We reviewed the most 

recently available progress reports for these programs.
Page 4 GAO-22-104698 Tribal Epidemiology Centers

TECs’ access to CDC, IHS, and state epidemiological data from January 

2018 through November 2021, including agency agreements to share 

data with TECs. We also interviewed officials from CDC, IHS (including 

from IHS headquarters and four IHS area offices that serve tribes in 

different geographic regions across the U.S.), and all 12 TECs; we asked 

officials about TECs’ access to and use of HHS and state epidemiological 

data, as well as how tribes and others use TECs’ analyses.10

To examine factors that affected TECs’ access to and use of HHS 

epidemiological data, we interviewed officials from the 12 TECs, CDC, 

and IHS—including officials from IHS headquarters and the four IHS area 

offices noted above. From these interviews, we identified the most 

frequently mentioned factors that affected TECs’ access to and use of 

HHS epidemiological data. We also interviewed stakeholders selected to 

provide a variety of perspectives on TECs’ access to and use of data.11

To further describe and examine factors affecting TEC access to and use 

of data, we reviewed available documentation showing CDC and IHS 

responses to TECs’ data requests from January 2018 through November 

2021. We also reviewed agency documents including data sharing 

policies and agreements, cooperative agreements, TECs’ progress 

reports, and documents summarizing agency efforts to enhance TECs’ 

access to and use of data. We assessed factors affecting TECs’ access 

to and use of epidemiological data in the context of HHS’s strategic 

objective of improving surveillance, epidemiology, and laboratory services 

by facilitating information exchange. We also assessed these factors in 

the context of IHS’s strategy of assuring data sharing to solidify 

partnerships with TECs.12

We conducted this performance audit from January 2021 to March 2022 

in accordance with generally accepted government auditing standards. 

 10IHS is divided into 12 physical areas of the U.S. Each area has a unique group of tribes 

that an area office works with on a day-to-day basis. We interviewed officials from four 

IHS area offices: Albuquerque, Great Plains, Nashville, and Oklahoma City. We selected 

these offices to obtain a range of perspectives on sharing data with TECs from different 

geographic locations. 

11Specifically, we interviewed representatives from two tribal governments, the National 

Indian Health Board, Council of State and Territorial Epidemiologists, Association of State 

and Territorial Health Officials, and the National Association of County and City Health 

Officials.

12Department of Health and Human Services, Strategic Plan FY 2018-2022 (Washington, 

D.C.: Feb. 28, 2018); and Indian Health Service, Strategic Plan FY 2019-2023 (Rockville, 

Md.: July 9, 2019). 
Page 5 GAO-22-104698 Tribal Epidemiology Centers

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

HHS works to improve the health of the nation. To achieve this goal, HHS 

and its agencies undertake a range of activities, including providing health 

care and implementing public health efforts. For example,

• IHS. IHS provides health care to over 2 million AI/ANs who are 

members or descendants of federally recognized tribes.13 IHS 

provides care through a network of facilities, including federally and 

tribally operated hospitals and health centers. IHS headquarters is 

responsible for setting national health care policy, ensuring the 

delivery of comprehensive health services, and advocating for the 

health needs and concerns of AI/ANs. IHS’s 12 area offices are, 

among other things, responsible for monitoring federally operated IHS 

facilities’ operations and finances, working with the local tribes, and 

providing guidance and technical assistance.

• CDC. CDC is the nation’s lead public health agency. Its role is to 

detect and respond to new and emerging health threats, use science 

and technology to prevent disease, and train the public health 

workforce, among other things. As part of its work, CDC conducts 

disease surveillance by collecting, analyzing, and exchanging 

information related to cases of infectious and chronic diseases that 

can be used to improve public health. It also provides technical 

assistance and guidance to states, territorial, tribal, and local health 

agencies.

HHS maintains a variety of epidemiological data, including monitoring 

systems and other protected health information, that can be used to 

conduct research for the purposes of preventing and controlling disease, 

injury, and disability in populations such as AI/AN communities. 

Epidemiological data maintained by the CDC include data collected 

 13IHS was established within the Public Health Service in 1955. Federal health services to 

maintain and improve the health of AI/ANs are consonant with and required by the federal 

government’s historical and unique legal relationship with, and resulting responsibilities to, 

the American Indian people. 25 U.S.C. § 1601.

Background

Department of Health and 

Human Services
Page 6 GAO-22-104698 Tribal Epidemiology Centers

through surveillance systems on diseases, conditions, and other factors 

that affect health, such as immunizations. These data may include 

information on age, sex, race and ethnicity, and other demographics. A 

variety of sources, such as health care providers, laboratories, funeral 

homes, and state and local health departments, voluntarily submit these 

data to CDC. Epidemiological data maintained by IHS include patient 

registration and health encounter data for individuals receiving care from 

all federally operated IHS facilities and some of its tribally operated 

facilities. These data include information on patient date of birth, 

diagnoses, and treatments.

The 12 TECs have the mission of improving AI/AN health by identifying 

and understanding public health problems and disease risks, 

strengthening public health capacity, and developing solutions for disease 

prevention and control.14 These centers work to fulfill this mission by 

performing seven core epidemiological functions specified in federal law, 

including assisting with identifying health priorities, making 

recommendations for improving health care delivery systems, and 

providing disease surveillance to promote public health.15 (See text box.) 

TECs perform these functions in consultation with and at the request of 

tribes, tribal organizations, and urban Indian organizations. 

Tribal Epidemiology Center (TEC) Core Functions

Federal law identifies seven core functions for TECs to perform in consultation with and 

at the request of Indian tribes, tribal organizations, and urban Indian organizations. 

• Collect data and monitor progress made towards meeting health status objectives. 

• Evaluate delivery, data, and other systems that affect the improvement of Indian 

health.

• Identify highest priority health status objectives and services needed to achieve 

them.

• Make recommendations for targeting needed services.

• Make recommendations to improve health care delivery systems. 

• Provide epidemiologic technical assistance.

• Provide disease surveillance, and assist in promoting public health.

Source: GAO summary of federal law. | GAO-22-104698

 14See Tribal Epidemiology Centers, “About”, accessed on December 2, 2021, 

tribalepicenters.org/about/.

1525 U.S.C. § 1621m(b). 

Tribal Epidemiology 

Centers
Page 7 GAO-22-104698 Tribal Epidemiology Centers

To help facilitate TECs’ access to epidemiological data, federal law 

provides that TECs are to be treated as public health authorities.16 Public 

health authorities are responsible for public health matters as part of their 

mandate, including using surveillance to identify health problems, 

identifying risk factors for health problems, and implementing and 

evaluating interventions to respond to health problems. Public health 

authorities include agencies within the federal government, states, and 

tribes—as well as others who are acting under a contract or grant from 

such an agency. To enable public health authorities to carry out their 

responsibilities, federal law specifies that they may be provided with 

protected health information, which includes individually identifiable 

information on a person’s health condition and care.17 Federal law also 

directs the Secretary of HHS to grant TECs access to protected health 

information in the possession of the Secretary, including data, monitoring 

systems, and delivery systems.18

Each TEC is unique, and TECs vary in terms of their structure, size, IHS 

service area, and populations served.

• Structure. All TECs are housed within various types of broader 

organizations that serve AI/AN tribal and urban communities, 

including organizations that also serve as an Indian health board, 

health organizations that specialize in caring for AI/ANs, area-wide 

tribal councils, and a Tribal Department of Health.19

• Size. TECs vary in size. As of November 2021, the number of staff at 

each TEC ranged from seven to 62, and the number of 

epidemiologists—public health workers that investigate patterns and 

causes of disease and injury—at each TEC ranged from two to 13.

• IHS area. Ten of the 12 TECs’ service areas align with IHS areas. 

Two TECs’ service areas span two or more IHS areas.20

 16Pub. L. No. 111-148, § 10221, 124 Stat. at 935 (incorporating S. 1790) (codified at 25 

U.S.C. § 1621m(e)(1)).

1745 C.F.R. § 164.512(b)(1)(i). 

18Pub. L. No. 111-148, § 10221, 124 Stat. at 935 (incorporating S. 1790) (codified at 25 

U.S.C. § 1621m(e)(2)).

19Area Indian health boards across the U.S. work, in part, to develop health policy and 

programs to promote and protect the health of the communities they serve. 

20The Inter Tribal Council of Arizona, Inc. Tribal Epidemiology Center serves tribes in the 

Phoenix and Tucson IHS areas and the Urban Indian Health Institute serves urban Indians 

nation-wide. 
Page 8 GAO-22-104698 Tribal Epidemiology Centers

• Populations served. Most TECs serve AI/AN communities in more 

than one state. Specifically, nine TECs serve AI/AN populations in two 

or more states, two TECs each serve AI/AN populations in one state, 

and one TEC serves urban Indians across the U.S. (See figure 1 for a 

map of TECs’ service areas.)
Page 9 GAO-22-104698 Tribal Epidemiology Centers

Figure 1: Tribal Epidemiology Centers’ (TEC) Service Areas

Notes: Hawaii is not included in any of the TECs’ service areas.

a

Three TECs serve tribes in Texas: Albuquerque Area Southwest Tribal Epidemiology Center, 

Oklahoma Area Tribal Epidemiology Center, and United South and Eastern Tribes, Inc. Tribal 

Epidemiology Center.
Page 10 GAO-22-104698 Tribal Epidemiology Centers

b

The Urban Indian Health Institute is located in Seattle, Washington and serves urban Indians across 

the U.S.

All TECs had access to a range of epidemiological data that HHS and 

states make publicly available, including national and regional data from 

CDC and IHS on certain diseases and conditions, vital statistics, 

vaccines, and populations. For example, TECs had access to COVID-19 

case, death, and testing data at the state and county levels, which CDC 

makes publicly available through its COVID-19 data tracker. TECs also 

had access to other epidemiological data through CDC’s Wide-ranging 

Online Data for Epidemiological Research (WONDER). This online 

database houses publicly available data on U.S. births, deaths, and 

cancer diagnoses, among other things.

TECs also reported having access to some additional epidemiological 

data, but the specific data to which they had access varied. For example,

• CDC COVID-19 data. As of November 2021, officials from 10 TECs 

told us they had access to CDC COVID-19 data for their service area 

through HHS Protect, HHS’s online repository for COVID-19 data; 

however, the types of data varied.21 Officials from all 10 of these 

TECs told us they had access to CDC’s COVID-19 case surveillance 

 21HHS Protect is HHS’s central repository for COVID-19 data that are collected through 

various HHS agencies, including CDC, and others at the federal, state, and local levels. 

CDC data may not reflect real-time conditions, as states and territories voluntarily submit 

data to CDC, may not submit their data to CDC in real time, and may also submit 

corrections and updates to their data. Further, certain data, including race and ethnicity 

data, maintained in HHS Protect may not be complete because states and territories 

voluntarily submit it.

TECs’ Access to 

Epidemiological Data 

Varied, and TECs 

Used Available Data 

for Analyses to 

Support Tribal 

Decision-Making

TECs’ Access to 

Epidemiological Data Has 

Varied
Page 11 GAO-22-104698 Tribal Epidemiology Centers

data, including positive tests, hospitalizations, and deaths; officials 

from the remaining two TECs chose not to access CDC’s COVID-19 

case data.22 Officials from six TECs told us they also had access to 

COVID-19 vaccination data through HHS Protect.23

• IHS patient registration and health encounter data. Officials from nine 

TECs told us they had access to IHS patient registration and health 

encounter data as of November 2021, such as patient diagnosis and 

procedure codes.24 However, how the data were accessed varied 

across the TECs. Officials from eight of these nine TECs told us that 

IHS provided extracts of these data as of a certain point in time at 

different frequencies, which ranged from quarterly to annually. 

Officials from the remaining TEC told us they had direct, real-time 

access to data through IHS’s electronic health record system for 

certain tribally operated facilities in their service area.25 Further, the 

types of data to which the nine TECs had access varied. Specifically, 

officials from six of the nine TECs told us they had access to patient 

 22An official from one of the two TECs that chose not to access CDC’s COVID-19 case 

data told us that the TEC had not requested access to the data because the TEC had 

access to higher quality data from states in its service area. An official from the other TEC 

told us the TEC had not requested access to the data because the agency had not 

provided the TEC complete information and corresponding security requirements for the 

data. CDC officials told us that all 12 TECs were provided the same information on 

accessing the COVID-19 case data through HHS Protect, including information on data 

security requirements.

23CDC officials told us that, in June 2021, they offered all 12 TECs access to COVID-19 

vaccine data, which includes data on vaccines administered throughout the country, 

including at IHS, tribal, and urban Indian facilities. CDC officials told us that they had 

communicated with TECs on multiple occasions since the data were first offered to TECs, 

providing them with information on how to secure access to COVID-19 vaccine data. 

Further, CDC officials told us this outreach was ongoing, as of November 2021.

24Officials from the remaining three TECs told us that they did not have access to IHS 

patient registration and health encounter data as of November 2021. IHS maintains data 

on patient registrations, including names, addresses, and AI/AN status; and patient 

encounters, such as patient’s diagnostic and procedure codes, provider notes, and 

provider type. These data are submitted by participating facilities operated by IHS, tribes, 

and urban health centers on a regular basis. These facilities submit data through data 

systems, including IHS’s electronic health record system—the Resource and Patient 

Management System. IHS maintains raw data from participating facilities in its National 

Data Warehouse. IHS processes raw data into data tables, which are then copied into 

IHS’s Epidemiological Data Mart. However, some personally identifiable variables, such 

as name and address, are not copied in to the Epidemiological Data Mart. 

25The TEC official told us that the TEC received approval from its local IHS area office to 

access data for tribally operated facilities through IHS’s electronic health records system. 

Officials from this IHS area office confirmed the TEC’s level of access. Further, these 

officials told us that, to gain access to these data, the TEC was required to obtain approval 

from the tribal nation operating the facility. 
Page 12 GAO-22-104698 Tribal Epidemiology Centers

registry data with certain patient identifiers removed—such as name, 

address, and social security number; while officials from the other 

three TECs told us that they had access to data that included some of 

these identifiers.

• Other IHS data. Officials from six TECs told us that they had access 

to other IHS data, which the agency provided in response to some 

TEC requests. For example, officials from one TEC told us that they 

had access to facility-level immunization data, such as the number of

shingles vaccines administered to adults over age 60, for IHS facilities 

in their area. An official from another TEC told us they requested 

specific data points, such as the number of clinics in their area using a 

certain type of COVID-19 test, and they received these data from the 

local IHS area office.

• State data. As of November 2021, officials from all 12 TECs told us 

they had access to epidemiological data directly from at least one 

state health department in their service area. However, the amount 

and type of data to which TECs had access varied by state. For 

example, one TEC told us they had access to three types of data in 

one state—COVID-19 case surveillance data, cancer registry, and 

birth and death records—and access to nine types of data in another 

state, including communicable diseases (such as measles), traumas, 

and hospital discharges.

While TECs had access to some epidemiological data, officials from all 12 

TECs we interviewed described challenges accessing other data from 

CDC, IHS, or states. For example,

• Challenges accessing CDC data. Officials from three TECs told us 

they requested access to non-publicly available data from CDC’s 

National Notifiable Disease Surveillance System, which tracks the 

incidence of infectious diseases, such as influenza and tuberculosis, 

and noninfectious conditions, among other things.26 However, CDC 

officials stated that the agency has not provided access to these data 

as of November 2021 because CDC does not have a system to share 

these data with anyone outside the agency. Our review of selected 

CDC responses to TEC data requests from January 2018 to 

November 2021 identified another challenge. Specifically, CDC 

 26CDC makes some data collected through its National Notifiable Disease Surveillance 

System publicly available. For example, CDC makes weekly and annual tables on the 

number of tuberculosis cases nationally and by state available through CDC WONDER. 
Page 13 GAO-22-104698 Tribal Epidemiology Centers

denied one TEC’s request for individual-level data on sexually 

transmitted diseases, which potentially could be used to identify 

individuals, based on guidelines that prohibit the agency from sharing 

these data with any entity other than IHS.27

• Challenges accessing IHS data. Officials from four TECs told us they 

had requested access to IHS patient registration and health encounter 

data related to substance use diagnoses and treatment. However, as 

of November 2021, TECs typically were not receiving these data 

because, according to IHS officials, IHS redacts these data from 

extracts shared with TECs to comply with federal regulations 

governing substance use disorder patient records.28 Agency officials 

also told us that IHS could provide TECs with some substance use 

disorder data that conform to federal regulations that govern 

substance use disorder patient records, which would likely require 

data to be aggregated at the state or IHS area level. However, IHS 

had not provided these data to TECs as of November 2021. Our 

review of selected IHS responses to TEC data requests identified 

another challenge. IHS officials asked one TEC to submit a request 

for COVID-19 vaccination data in their service area as a member of 

the general public rather than as an entity with public health authority 

status. Specifically, IHS officials asked the TEC to submit a Freedom 

of Information Act request, which is a type of request the general 

public can submit to access certain federal records.29 According to the 

officials, this was part of the normal process for gaining access to IHS 

data.

 27Specifically, CDC cited Council of State and Territorial Epidemiologists and CDC data 

release guidelines for the National Notifiable Disease Surveillance System. These 

guidelines specify that individual-level data on sexually transmitted diseases, which 

potentially could be used to identify individuals, may only be released to the Epidemiology 

Branch of IHS. CDC officials told us that they can make more aggregated data available to 

TECs.

28The one TEC that has direct, real-time access to data through IHS’s electronic health 

record system told us their access includes substance use disorder data. This TEC’s 

access to substance use disorder data is limited to tribally operated facilities in their 

service area that use IHS’s electronic health record system and serve tribes that provided 

approval. Federal law protects the confidentiality of substance use disorder patients by 

restricting the circumstances in which federally assisted programs, including programs 

that are managed by a federal office or an entity receiving any federal funding, can 

disclose information that would identify a person as having a substance use disorder. See 

42 U.S.C. § 290dd-2; 42 CFR Part 2. In 2020, the CARES Act amended federal law to 

permit de-identified records relating to substance use disorder to be disclosed to public 

health authorities. See Pub. L. No. 116-136, § 3221(c), 134 Stat. at 376; 42 U.S.C. § 

290dd-2(b)(2)(D). 

295 U.S.C. § 552.
Page 14 GAO-22-104698 Tribal Epidemiology Centers

• Challenges accessing state data. Officials from three TECs told us 

they had not been able to access any data from at least one or more 

states in each of their service areas because a state’s rules around 

data sharing were restrictive, among other reasons.

Officials from all 12 TECs told us they used available epidemiological 

data from CDC, IHS, or states to conduct a range of analyses to support 

tribal public health decision-making, including for leaders of health 

programs, area health boards, or health care facilities. TEC officials told 

us they analyzed epidemiological data to fulfill their core functions, such 

as identifying health priorities, making recommendations for health 

service needs, and conducting disease surveillance.

Our review of TECs’ reports and publicly available analyses showed that 

TECs have used available epidemiological data to, among other things, 

identify and track the leading causes of mortality and morbidity of AI/ANs 

in their service areas, develop community health profiles outlining the 

health status and needs of AI/ANs in their service areas, and conduct 

surveillance on the spread of COVID-19 in their communities. Table 1 

provides examples illustrating the range of epidemiological analyses 

TECs have conducted.

TECs Used Available 

Epidemiological Data to 

Conduct a Range of 

Analyses to Support Tribal 

Decision-Making
Page 15 GAO-22-104698 Tribal Epidemiology Centers

Table 1: Examples of Analyses Conducted by Tribal Epidemiology Centers (TEC)

Example of TEC 

analyses

Description of analyses

Injury atlas Analyzed state data to describe the leading causes of injury-related death and hospitalizations, and help 

identify effective prevention efforts. 

Special reports for 

tribal health 

departments

Analyzed surveillance data over a 2-year period to identify the top chronic diseases and infectious diseases.

Community health 

profiles

Analyzed epidemiological data from the Centers for Disease Control and Prevention (CDC), the Indian Health 

Service, states, or others to examine the health status of American Indian and Alaska Native (AI/AN) 

communities, monitor progress towards meeting health objectives, and identify and prioritize public health 

needs. These profiles have been completed at the tribal, region, or national level.

Coronavirus Disease 

2019 (COVID-19) 

reports 

Analyzed surveillance data and other information to develop reports summarizing the status of COVID-19 in 

their service area. Reports included a map showing the geographic distribution of the disease, the number of 

confirmed COVID-19 cases across one state, a list of program closures due to disease outbreaks, and a list 

of tribes that declared a state of public health emergency.

Interactive dashboards Analyzed CDC, state, and other data to develop interactive graphics on the incidence of disease and health 

outcomes related to COVID-19, leading causes of death, maternal and child health, and demographics. 

These dashboards can provide data at the service area, state, and county levels. 

Data assessments Examined federal, state, and tribal data on COVID-19 and other priority areas to identify gaps in the 

accessible data, and identified alternative data sources to fill them.

Data registry Maintained data on AI/ANs within TEC service areas, and used these to assess and improve the quality of 

other data, such as state-level cancer registries or death records.

Source: GAO analysis of TEC reports and publicly available analyses. | GAO-22-104698

Officials from all 12 TECs told us that they conducted analyses for and at 

the request of tribes, tribal organizations, urban Indian health programs, 

or IHS. These TEC officials told us that their analyses are used by AI/AN 

communities and their leaders to help make decisions about public health 

interventions, programs, and policies. For example,

• An official from one TEC told us the TEC completed a series of 

community health assessments to examine health risk factors for 

tribes in one state, which tribes used to help identify their most urgent 

health needs and prioritize their public health efforts.

• Another TEC reported examining outcomes and trends among the 

AI/ANs participating in a diabetes program, which could be used to 

inform future programs to improve diabetes care, prevention, and 

outcomes.

TEC officials also told us that their access to data influenced the analyses 

they were able to conduct. They noted that data access, or the lack of 

access, affects their ability to provide tribal and urban health organization 
Page 16 GAO-22-104698 Tribal Epidemiology Centers

leaders with information needed for public health decision making. For 

example, officials from some TECs told us that their inability to access 

IHS data on substance abuse diagnosis and treatment limited their 

ability to assess and assist tribal leaders in responding to the opioid 

epidemic. When data are not available, some TEC officials noted 

difficulties in observing trends in the health of their AI/AN populations and 

providing meaningful information to tribal leaders and others about the 

prevalence, incidence, and burden of disease. Some TEC officials told us 

that their lack of access to data limits their ability to conduct analyses, 

which can make it difficult for tribal leaders, as they work to identify the 

needs of their communities and make informed decisions about how to 

address those needs. In addition, some officials noted that it may also 

limit their tribes’ ability to explain their health needs to others and, 

therefore, may limit opportunities for tribes to receive funding to address 

those needs.

Data sharing systems and agreements have facilitated TECs’ access to 

HHS epidemiological data. Specifically, the presence of data sharing 

systems like HHS Protect—HHS’s central repository for COVID-19 data—

has facilitated TECs’ access to CDC’s COVID-19 data, including case 

surveillance data on the number of positive cases, hospitalizations, and 

deaths, as well as vaccination data. As of November 2021, officials from 

10 TECs reported gaining access to COVID-19 case surveillance data 

through HHS Protect, and officials from six TECs reported gaining access 

While HHS Has 

Some Systems to 

Share Data with 

TECs, Its Lack of 

Policies, Guidance, 

and Procedures 

Hinders Access

Data Sharing Systems and 

Agreements Have 

Facilitated TECs’ Access 

to Data
Page 17 GAO-22-104698 Tribal Epidemiology Centers

to COVID-19 vaccination data through HHS Protect.30 In another 

example, the presence of IHS’s Epidemiology Data Mart has facilitated 

TECs’ access to excerpts of patient registration and health encounter 

data collected from all federally operated and some tribally operated 

facilities in each TEC’s jurisdiction. As of November 2021, 10 TECs have 

established data sharing agreements with IHS to access these data, 

according to our review of the data sharing agreements.31 Other data 

sharing systems have also facilitated TECs’ access to a variety of 

epidemiological data, including CDC’s publicly available WONDER 

system, data.cdc.gov portal, and COVID-19 data tracker.

While the presence of data sharing systems and agreements has 

facilitated TECs’ access to data, TECs have been unable to access data 

in some cases where such systems and agreements have not been 

established or do not meet the needs of the TECs. For example, as 

previously noted, CDC officials told us that they have been unable to 

share detailed surveillance data on nationally notifiable diseases, such as 

influenza and tuberculosis, with TECs because the agency does not have 

a system that enables them to readily share these data.32 Similarly, not all 

TECs had been able to negotiate data sharing agreements with IHS and 

 30CDC officials told us that they have not required TECs to sign a data sharing agreement 

in order to access COVID-19 case surveillance data; however, they have required TECs 

to sign a data sharing agreement in order to access COVID-19 vaccination data. Prior to 

accessing data in HHS Protect, all TECs have been required to sign HHS’s Rules of 

Behavior for the Use of HHS Information and IT Resources Policy, according to CDC 

officials. 

31Two of these TECs had not accessed IHS’s Epidemiology Data Mart data as of 

November 2021. One of these TECs signed its data sharing agreement in September 

2021. According to IHS officials, after the agreement is signed, the TEC must train and 

credential a staff person to work with the data and the agency must compile the 

appropriate data for the TEC; these steps were in process as of November 2021. The 

other TEC signed its agreement in 2013 but TEC officials told us that they have not 

accessed these data because the TEC has direct, real-time access to data through IHS’s 

electronic health record system for certain tribally operated facilities in its service area.

32CDC officials told us that the agency plans to share these data with TECs, but they have 

not established a time frame for initiating or implementing this plan. According to CDC 

officials, the staffing and resource needs of the COVID-19 response have significantly 

limited CDC’s ability to work on expanding access to other data. However, officials also 

noted that CDC is now working to expand the availability of public health data, including 

on nationally notifiable diseases, by making targeted investments in public health data 

infrastructure.
Page 18 GAO-22-104698 Tribal Epidemiology Centers

CDC as of November 2021.33 Although IHS officials told us that the 

agency is open to negotiating the terms of its data sharing agreements, 

officials from two TECs told us that as of November 2021, they had been 

unable to negotiate a data sharing agreement with IHS for the 

Epidemiology Data Mart; therefore, they do not have access to that data. 

In addition, officials from three TECs that had active data sharing 

agreements with IHS told us that their current data sharing agreement did 

not fully meet their needs because IHS had not provided data as 

frequently as they had requested. Similarly, officials from two TECs told 

us that their TECs had not yet accessed any COVID-19 data in HHS 

Protect as of November 2021, including one TEC that told us that it had 

been waiting since April 2020 for CDC to clarify relevant data security 

policies.34

A lack of HHS policies affirming TECs’ authority to access HHS 

epidemiological data, as well as guidance and procedures related to TEC 

requests for such data, have hindered TECs’ access to HHS 

epidemiological data. Officials from seven TECs indicated that some CDC 

and IHS officials with whom they interacted when requesting data did not 

recognize that HHS is required by federal law to provide data in its 

possession to TECs.35 For example, officials from five TECs told us that 

they were asked by CDC and IHS officials to submit requests for data as 

entities without any public health authority standing—for example, as 

researchers or as public citizens through a Freedom of Information Act 

request. Rather than having TECs’ access to data affirmed through HHS 

policies, officials from six TECs told us that their access to HHS data 

depended, in part, on their ability to build strong relationships with CDC 

 33TEC officials we interviewed also reported a range of experiences accessing data from 

states in their service areas. Officials from all 12 TECs told us that they had been able to 

access at least one dataset directly from at least one state in their service area. However, 

officials from three TECs told us that they had been unable to establish data sharing 

agreements with, or obtain access to any data from, at least one state in their service 

area; therefore, these TECs were limited to using only publicly available data from that 

state. 

34The second TEC had not pursued access to COVID-19 data in HHS Protect because of 

concerns about the data’s quality, according to a TEC official we interviewed. CDC 

officials told us that all 12 TECs were provided the same information on accessing 

COVID-19 case data through HHS Protect, including information on data security 

requirements.

3525 U.S.C. § 1621m(e)(1–2); 45 C.F.R. § 164.512(b)(1)(i). 

Lack of Policies, 

Guidance, and Procedures 

Hinders TECs’ Access to 

Data
Page 19 GAO-22-104698 Tribal Epidemiology Centers

and IHS officials.36 Officials from one TEC explained that they must 

request data repeatedly and negotiate access each time.

HHS has a strategic objective to improve surveillance, epidemiology, and 

laboratory services by facilitating information exchange, and IHS has a 

strategic goal of assuring data sharing to solidify partnerships with TECs. 

Yet according to CDC and IHS officials, as of November 2021, HHS had 

not clarified the specific data that TECs are entitled to access under 

federal law.37 Furthermore, as discussed above, we identified one CDC 

policy that agency officials interpreted as prohibiting the sharing of certain 

epidemiological data with TECs, which was cited by CDC officials when 

they denied a TEC’s request for data.

CDC and IHS had also not developed guidance for TECs on how to 

submit data requests or established written agency procedures related to 

responding to these requests as of November 2021, according to agency 

officials. IHS officials from headquarters told us that they use a framework 

for reviewing TECs’ requests for data. However, they had not 

documented or shared this framework with TECs, in part, because the 

review process can vary and requests are adjudicated on a case by case 

basis. Officials from one of the four IHS area offices we interviewed told 

us that it followed an HHS checklist for sharing protected health 

information when reviewing TEC data requests, but officials from the 

other three area offices said that they did not have a policy with respect to 

sharing data with TECs.38 Separately, CDC developed a process for 

TECs to request COVID-19 case surveillance and vaccination data once 

the agency was ready to make these data available to the TECs. 

However, this process is specific to these data sets and does not extend 

to other data maintained by the agency.

CDC and IHS officials reported that they believed they had been 

responsive to each TEC’s needs. Specifically, officials from both agencies 

reported making data available to TECs as permissible by law, 

participating in regular meetings with TEC officials, as well as providing 

 36Similarly, officials from eight TECs also reported a lack of clarity or understanding of the 

role of TECs by at least some state officials, which they say similarly limited their access 

to data. In addition, officials from six TECs told us that some state officials did not 

recognize the public health authority status of TECs.

37See 25 U.S.C. § 1621m(e).

38Officials from two of these IHS area offices told us that they had not shared any data 

with their area’s TEC, and officials from one area office told us that they had only shared 

aggregate de-identified data with the TEC. 
Page 20 GAO-22-104698 Tribal Epidemiology Centers

technical assistance and information. CDC and IHS officials told us that 

they believed that additional guidance for TECs on how to request data 

and agency procedures related to responding to such requests was 

unnecessary, because TEC requests were infrequent and they believed 

they had successfully responded to their needs.

However, officials from six TECs told us that the process to request and 

obtain data from CDC and IHS was unclear and inconsistent within and 

between the agencies. Specifically, TEC officials collectively told us that it 

was unclear what data were available to them, who were the appropriate 

agency contacts to whom to direct their requests, when they could expect 

to receive a response, what type of information to provide that would 

enable a timely response, and what criteria were used to review their 

requests.

A lack of clarity in TECs’ authority to access data, and guidance and 

procedures to request and respond to requests, likely contributed to 

delays TECs have faced obtaining access to CDC and IHS data. 

Specifically, officials from seven TECs told us that they have faced delays 

receiving CDC or IHS responses to their data requests, and officials from 

four of these TECs told us that these delays were significant—over 1 year 

long. For example,

• During the COVID-19 pandemic, TECs experienced delays in 

receiving access to COVID-19 case and vaccination data from CDC. 

Specifically, one TEC requested COVID-19 case surveillance data 

from CDC in May 2020. According to TEC officials, CDC officials told 

them that they could not share the data with the TEC because the 

data included protected health information that the TEC did not have 

authority to receive. Later, CDC officials acknowledged a significant 

miscommunication about this issue and began working to develop a 

method to provide the data to the TEC. In late June, nearly 6 weeks 

after the initial request, CDC provided the TEC with access to the 

requested data. CDC later developed a method for providing the 

remaining TECs with access to COVID-19 case surveillance data for 

their regions and began offering it to them. Further, TECs began 

requesting COVID-19 vaccination data as early as 7 months before it 

was first provided to a TEC. Specifically, one TEC requested these 

data from IHS in January 2021, and another TEC requested the data 

from CDC in April 2021. In June 2021, CDC began outreach to the 

TECs to offer them access to COVID-19 vaccination data, and CDC 

officials told us the agency received the first official request for data (a 

completed data access form) from a TEC in July 2021. In August 
Page 21 GAO-22-104698 Tribal Epidemiology Centers

2021, CDC first provided a TEC with access to CDC COVID-19 

vaccination data, which includes IHS COVID-19 vaccination data.

• One TEC faced a multi-year delay obtaining IHS data. Specifically, a 

TEC official told us that the TEC verbally requested data in August 

2018, and an IHS official told him to delay sending a written request 

for the data until a study using similar data was completed in August 

2019. Our review of the TEC’s correspondence with IHS beginning 

with the TEC’s August 2019 written request showed multiple requests 

for status updates over the next 18 months. IHS and TEC officials 

confirmed that a data use agreement was signed in March 2021. More 

than 1 year and a half after the TEC’s written request and nearly 3 

years after the TEC’s initial verbal request, IHS provided the TEC with 

the data, according to the TEC official.

• An official from one TEC told us that the TEC faced a nearly 8-year 

delay obtaining IHS Epidemiology Data Mart data. Specifically, an 

official from the TEC told us that despite IHS signing a data sharing 

agreement to provide Epidemiology Data Mart data in December 

2012, and ongoing communications with agency officials about 

receiving the data, the TEC did not receive data from IHS until 

September 2020. IHS officials told us that they had not provided data 

during that period because the TEC did not request data until 

December 2019, at which time IHS began working with the TEC to 

train and credential its staff to access the data.

Officials from seven TECs told us that they had stopped making new 

requests for CDC or IHS data—for example, due to their recent 

experiences and the agencies’ delayed responses to other requests. TEC 

officials indicated that the resulting delays or limitations in accessing CDC 

or IHS epidemiological data have made it difficult for them to adequately 

support tribal and community leaders as they work to understand and 

address the health needs of AI/ANs in their communities, including during 

the COVID-19 pandemic.

Officials from 10 TECs told us that their ability to use CDC or IHS data 

was limited due to significant concerns about the data’s quality or 

timeliness. For example, officials from eight of the 10 TECs with access to 

COVID-19 case surveillance data from HHS Protect told us that they were 

unable to use these data because the system included incomplete and 

inaccurate data, such as on patients’ race and ethnicity as well as 

COVID-19 cases. In addition, one additional TEC reported using COVID19 case surveillance data from HHS Protect to assess the completeness 

Data Quality and 

Timeliness Can Affect 

TECs’ Use of Data
Page 22 GAO-22-104698 Tribal Epidemiology Centers

of race and ethnicity data in states’ case reports to CDC.39 In September 

2020, we reported that race and ethnicity information was missing for 

about 64 percent of total COVID-19 cases reported to CDC as of July 31, 

2020, and we recommended that CDC take steps to ensure the complete 

and consistent collection of demographic data.40 CDC has since 

implemented our recommendation, and agency officials told us that the 

completeness of case surveillance data on race and ethnicity had 

improved since our September 2020 report.41 However, CDC officials 

acknowledged that gaps remain and are likely to persist due to a variety 

of reasons, including because the nation’s public health system is 

decentralized and state reporting to CDC is voluntary. In addition, CDC 

officials noted that improving the quality and availability of race and 

ethnicity data requires the entire public health system to undertake 

significant modernization efforts, such as by implementing electronic case 

reporting and electronic laboratory reporting. 

Officials from six TECs reported that IHS Epidemiology Data Mart has 

limitations that prevent TECs from using it for certain analyses. 

Specifically, some TEC officials told us that they would ideally like to use 

these data to conduct active public health surveillance, which requires 

timely, almost real-time access to data. However, TECs do not have realtime access to these data and, as such, cannot use the data for this 

purpose.42 Officials from three TECs told us that their use of these data 

was limited to understanding the regional IHS user population or 

monitoring long-term trends in the health of their communities—for 

example, by examining the prevalence of certain diseases. IHS officials 

told us that their patient data are generally about 30 days old, and they 

provide their most current data to TECs at the time they create their 

Epidemiology Data Mart files. IHS is planning to implement a new 

 39The TEC found that, as of February 2021, race and ethnicity data were missing for 49 

percent of all COVID-19 cases reported to CDC. It also noted that this lack of 

completeness obscures the true burden of disease experienced by AI/AN communities, 

directly affects the ability of public health authorities to address these effects, and limits 

policy makers’ ability to make data-driven decisions for equitable policy and resource 

allocation. See Urban Indian Health Institute, Data Genocide of American Indians and 

Alaska Natives in COVID-19 Data (Seattle, Wash.: Feb. 15, 2021). 

40See GAO, COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted 

Actions, GAO-20-701 (Washington, D.C.: Sept. 21, 2020). 

41For example, CDC officials told us that as of November 15, 2021, 66 percent of COVID19 cases reported to the agency included complete race and ethnicity information. 

42IHS provides Epidemiology Data Mart files to TECs at intervals ranging from quarterly to 

annually.
Page 23 GAO-22-104698 Tribal Epidemiology Centers

centralized electronic health records system in the next 10 years, which 

officials stated may enhance the timeliness of their patient data.

CDC and IHS officials acknowledged that there are limitations with their 

data, and the data likely cannot meet all information needs of TECs to 

fully realize their functions as regional public health authorities. These 

officials told us that TECs would likely need to rely on data from a variety 

of sources, including states, in order to fulfill their responsibilities. While 

officials from five TECs told us that state data was useful to them in 

conducting some epidemiological analyses, officials from 11 of the 12 

TECs told us that they either faced challenges obtaining data from states 

or using available state data due to poor data quality.

TECs’ internal capacity—that is, their resources and abilities—can affect 

their access to and use of epidemiological data. Seeking access to data 

can require a significant investment of resources, according to some TEC 

officials we interviewed. Officials from nine TECs suggested that having 

better access to higher quality data would enable them to use their 

resources more efficiently—thereby expanding their capacity to serve 

their tribes—or to conduct more effective work for their tribes. In addition, 

to enhance their capacity to serve their tribes, officials from five TECs told 

us that they were looking to hire additional staff.

CDC and IHS have programs aimed at supporting and enhancing the 

capacity of all TECs to serve their tribes. Through these programs, the 

agencies award funds and provide technical assistance to TECs. 

Specifically, IHS’s Tribal Epidemiology Center program provides TECs 

with funding to support TECs’ epidemiology and public health functions, 

including by supporting data analysis and disease surveillance.43 In 

addition, CDC’s Tribal Epidemiology Centers Public Health Infrastructure 

program provides funds to all 12 TECs to build data infrastructure, 

increase staff capacity, and establish partnerships. Table 2 summarizes 

IHS and CDC programs to support and enhance TECs’ capacity to serve 

their tribes.

 43Federal funding for this program increased between fiscal years 2019 and 2021 due to 

COVID-19 supplemental funding.

TECs’ Capacity Can Affect 

Their Access to and Use 

of Data
Page 24 GAO-22-104698 Tribal Epidemiology Centers

Table 2: Indian Health Service (IHS) and Centers for Disease Control and Prevention (CDC) Programs to Support and Enhance 

Tribal Epidemiology Centers’ (TEC) Capacity, Fiscal Year 2021

Agency Program name Program goal Total annual program 

funding for TECs 

IHS TEC Strengthen public health capacity, and fund tribal organizations 

in identifying relevant health status indicators and priorities to 

support public health interventions that reduce morbidity and 

mortality in the population using sound epidemiologic principles. 

$10.4 million 

CDC Tribal Epidemiology 

Centers Public Health 

Infrastructure

Expand TECs’ ability to perform their core functions by building 

data infrastructure, increasing staff capacity, and establishing 

partnerships. 

$7.8 million 

Source: GAO summary of IHS and CDC information. | GAO-22-104698

TECs may also receive funding and resources from other federal and 

non-federal programs or sources. For example, aside from the programs 

noted above, officials from six TECs told us they received funding and 

support to enhance their capacity to serve their tribes through other CDC 

programs.44 CDC, IHS, and TEC officials told us that agency officials 

provide technical assistance to TECs and attend periodic meetings to 

address issues that apply to all TECs. To help facilitate the sharing of 

data between states and TECs, CDC funded a program that aimed to 

help TECs establish working relationships with appropriate state officials. 

In addition, in 2021, CDC funded the development of a toolkit to 

document best practices in obtaining and sharing AI/AN health data.45

TECs are uniquely positioned to perform a range of analyses to support 

tribal decision-making and ultimately help reduce health disparities faced 

by AI/AN communities. CDC and IHS provide TECs with a variety of 

resources to fulfill their missions, including funding, technical assistance, 

and data. Although Congress directed HHS to provide TECs with access 

to their data, HHS has not yet developed a policy outlining the data, 

including monitoring systems, delivery systems and other protected 

health information, in its possession that it will make available to TECs, 

pursuant to federal law. In the absence of an HHS policy affirming TEC 

access to data, some TECs have faced a lack of clarity among CDC and 

IHS officials about their authority to access the agencies’ data. CDC and 

 44These programs include CDC’s Good Health and Wellness in Indian Country program, 

which aims to improve AI/AN tribal health, focusing on health promotion and disease 

prevention. 

45This toolkit is available at https://nativedata.npaihb.org/.

Conclusions
Page 25 GAO-22-104698 Tribal Epidemiology Centers

IHS have also not developed guidance for TECs on how to request data, 

or agency procedures on how to respond to such requests. As a result, 

TECs reported facing an unclear and inconsistent process for requesting 

data and receiving agency responses, which likely contributed to delays 

TECs faced in accessing CDC and IHS data. Because TECs provide 

tribes with data to support tribal decision-making, delays or limitations in 

TECs’ access to data may limit the ability of tribes to make informed 

decisions about how to address their communities’ health needs and 

reduce the health disparities faced by their communities.

We are making a total of five recommendations, including one to HHS, 

two to CDC, and two to IHS. Specifically,

The Secretary of HHS should develop a policy clarifying the HHS data 

(including monitoring systems, delivery systems, and other protected 

health information) that are to be made available to TECs as required by 

federal law. (Recommendation 1)

The Director of CDC should develop written guidance for TECs on how to 

request data. Such guidance should include information on data 

potentially available to TECs, how to request data, agency contacts, 

criteria the agency will use to review such requests, and time frames for 

receiving an agency response to data requests. (Recommendation 2)

The Director of CDC should develop and document agency procedures 

on reviewing TEC requests for and making data available to TECs. These 

procedures should include a description of data potentially available to 

TECs, agency contacts, criteria for reviewing TEC data requests, and 

time frames for responding to TEC requests. (Recommendation 3)

The Director of IHS should develop written guidance for TECs on how to 

request data. Such guidance should include information on the data 

available to TECs, how to request data, agency contacts, criteria the 

agency will use to review such requests, and time frames for receiving an 

agency response to data requests. (Recommendation 4)

The Director of IHS should develop and document agency procedures on 

reviewing TEC requests for and making data available to TECs. These 

procedures should include a description of the data available to TECs, 

agency contacts, criteria for reviewing TEC data requests, and time 

frames for responding to TEC requests. (Recommendation 5)

Recommendations for 

Executive Action
Page 26 GAO-22-104698 Tribal Epidemiology Centers

We provided a draft of this report to HHS for review and comment. In its 

comments, which are reprinted in appendix I, HHS concurred with our 

recommendations. HHS also provided technical comments, which we 

incorporated as appropriate.

HHS noted that it will take steps to develop a policy clarifying the HHS 

data that are to be made available to TECs. 

Regarding our recommendations to develop guidance and agency 

procedures related to TECs’ access to and requests for CDC data, HHS 

noted that CDC is committed to ensuring that TECs have access to the

epidemiological data they need to fulfill their public health mission. HHS 

also noted that CDC will strive to balance the goals of the 

recommendations, its responsibilities as a data steward, and obligations 

to protect personally identifiable and other legally protected data. Further, 

HHS noted that the large volume of data CDC receives limits CDC’s 

ability to create a menu of all data sources. Given this, HHS requested a 

minor revision to the wording of these recommendations, which we made. 

To implement these recommendations, CDC plans to identify the data 

that TECs want access to, and it will develop a process for requesting 

data and agency procedures for responding to such requests. 

Regarding our recommendations related to access to and requests for 

IHS data, HHS noted that IHS has a long-standing commitment and 

approach to sharing epidemiological data with TECs that is informed by 

tribal input. HHS noted that formalizing IHS procedures and guidance will 

serve to enhance transparency and may streamline data access for 

TECs. HHS reported that IHS has already assessed existing TEC data 

sharing agreements and reviewed its protocols for responding to TEC 

requests. IHS plans to develop the recommended guidance and 

procedures in order to promote appropriate, timely, and efficient data 

sharing with TECs.

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Health and Human Services, and other

interested parties. In addition, the report will be available at no charge on 

the GAO website at http://www.gao.gov.

Agency Comments

and Our Evaluation
Page 27 GAO-22-104698 Tribal Epidemiology Centers

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or rosenbergm@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix II.

Michelle B. Rosenberg

Director, Health Care
Page 28 GAO-22-104698 Tribal Epidemiology Centers

List of Addressees

The Honorable Patrick Leahy

Chairman

The Honorable Richard Shelby

Vice Chairman

Committee on Appropriations

United States Senate

The Honorable Ron Wyden

Chairman

The Honorable Mike Crapo

Ranking Member

Committee on Finance

United States Senate

The Honorable Patty Murray

Chair

The Honorable Richard Burr

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Gary C. Peters

Chairman

The Honorable Rob Portman

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Rosa L. DeLauro

Chair

The Honorable Kay Granger

Ranking Member

Committee on Appropriations

House of Representatives

The Honorable Frank Pallone, Jr.

Chairman

The Honorable Cathy McMorris Rodgers

Republican Leader

Committee on Energy and Commerce

House of Representatives
Page 29 GAO-22-104698 Tribal Epidemiology Centers

The Honorable Bennie G. Thompson

Chairman

The Honorable John Katko

Ranking Member

Committee on Homeland Security

House of Representatives

The Honorable Carolyn B. Maloney

Chairwoman

The Honorable James Comer

Ranking Member

Committee on Oversight and Reform

House of Representatives

The Honorable Richard E. Neal

Chairman

The Honorable Kevin Brady

Republican Leader

Committee on Ways and Means

House of Representatives

The Honorable Tom O’Halleran

House of Representatives
Appendix I: Comments from the Department of 

Health and Human Services

Page 30 GAO-22-104698 Tribal Epidemiology Centers

Appendix I: Comments from the Department 

of Health and Human Services
Appendix I: Comments from the Department of 

Health and Human Services

Page 31 GAO-22-104698 Tribal Epidemiology Centers
Appendix I: Comments from the Department of 

Health and Human Services

Page 32 GAO-22-104698 Tribal Epidemiology Centers
Appendix I: Comments from the Department of 

Health and Human Services

Page 33 GAO-22-104698 Tribal Epidemiology Centers
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 34 GAO-22-104698 Tribal Epidemiology Centers

Michelle B. Rosenberg, (202) 512-7114 or RosenbergM@gao.gov

In addition to the contact named above, Kristi Peterson (Assistant 

Director), Kristin Ekelund (Analyst-in-Charge), and Patricia Roy made key 

contributions to this report. Also contributing were Todd Anderson, Sonia 

Chakrabarty, Vikki Porter, Lisa Rogers, and Caitlin Scoville.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(104698)
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February 24, 2023

Rochelle Walensky, MD, MPH 

Director, Centers for Disease Control and Prevention 

1600 Clifton Road NE

Atlanta, GA 30329–4027

Re: CDC’s Moving Forward Initiative

Dear Director Walensky: 

On behalf of the National Indian Health Board (NIHB), I write to you regarding the recent Tribal 

consultation on CDC’s Moving Forward initiative. We applaud CDC’s efforts to change not only how 

CDC is organized and how it operates, but also its culture—to orient the agency toward timely action 

and a focus on health equity. While undertaking this change, this is a prime opportunity to position

CDC to better serve Tribal nations, fulfill the federal trust responsibility, and lay critical groundwork 

for meaningfully advancing health equity in Indian Country. 

This reorganization could not come at a more urgent time. The COVID-19 pandemic made it 

impossible to ignore the stark disparities in deaths and other health outcomes experienced by American 

Indians and Alaska Natives (AI/ANs). On August 31, 2022, the Centers for Disease Control and 

Prevention (CDC) released the Provisional Life Expectancy Estimates for 2021, which reported a 

severe drop in life expectancy for AI/ANs–decreasing by 6.6 years from 2019 to 2021. Not only do 

AI/ANs, on average, die younger than all other Americans, but this disparity is worsening at an 

alarming rate. Our peoples’ life expectancy today is the same as it was for the average American in 

1944. Such a crisis of inequity demands a swift and profound response.

To be effective, this response must honor and recognize Tribal sovereignty, the federal trust 

responsibility, and how colonization and U.S. government policies drive the severe health inequities 

we face. As CDC raises health equity to an agency-wide priority, moving forward will require both a 

nuanced understanding of the unique context of Tribal health equity and a commitment to action.

Root causes of AI/AN health inequities. CDC has the opportunity to lead by example and use the 

Moving Forward initiative to address the systemic issues at the root of AI/AN health. Along with the 

commonly discussed “social determinants of health” like housing, economic stability, healthcare, 

transportation, food, etc., the legacies of colonization are powerful drivers of many of the health 

inequities Tribal communities are experiencing.

The systemic issues that give rise to AI/AN health inequities are rooted in the long history of harmful 

federal Indian policies: genocide; uprooting AI/ANsfrom homelands and Tribal community structures;

bans on cultural practices and language; forced relocation to reservations; abusive boarding schools; 
P a g e | 2

and others. Lingering legacies of colonization have become institutionalized in government policies, 

systems, and structures and continue to cause harm.

The Moving Forward initiative and re-organization of the CDC is an unprecedented opportunity

for making the kinds of systemic and cultural changes needed to effectively address these key

drivers of health inequities and set the stage for a more equitable future. 

To address these key drivers and advance health equity, CDC should prioritize these five areas during 

the reorganization:

1. Tribal Sovereignty & the Nation-to-Nation Relationship

2. Federal Trust Responsibility

3. Disrupting Structures of Inequity and Shifting the Balance of Power

4. Visibility of American Indians & Alaska Natives

5. Honoring Indigenous Knowledge & Cultural Lifeways

I. Tribal Sovereignty & the Nation-to-Nation Relationship

Tribal sovereignty. Respecting and upholding Tribal sovereignty must come first and foremost in any 

public health work in Indian Country. As sovereign governments, Tribal nations have inherent 

authority and responsibility to meet their citizens' healthcare and public health needs. 

Respecting Tribal sovereignty, in large part, means honoring self-determination – supporting Tribes to 

make decisions for themselves on the best way to set priorities and design programs tailored to the 

needs of Tribal communities to advance health equity. In addition, Tribal sovereignty opens options 

and potential approaches to health equity that may differ from other communities or populations. For 

example, Tribal sovereignty allows Tribes to use Tribal law as a powerful tool for protecting public 

health and advancing health equity in Tribal communities. Ensuring sufficient flexibility and support 

for Tribes to design their public health priorities and interventions is both more effective in advancing 

health equity and more respectful of Tribal sovereignty.

Nation-to-nation relationship. Like all sovereign nations, Tribes maintain nation-to-nation

relationships with the U.S. government. Therefore, any federal public health programs and health 

equity initiatives must flow through the appropriate diplomatic channels that respect the authority of 

Tribal governments. Because of the central importance of Tribal sovereignty, implementing federal 

public health initiatives in Tribal communities necessitates special attention to the significant nuances 

and complexities that arise at this intersection of jurisdictions. Too often, we see CDC focused on

funding and partnership structures around states and local governments, but not Tribes. CDC must 

entirely rethink these structures to appropriately build in Tribal nations as it works to improve public 

health of the whole country. As we know all too well from the COVID-19 pandemic, public health 

challenges do not end at a particular geographic or jurisdictional border. 

To give a specific example of why recognizing Tribal sovereignty is important, we often see Notices 

of Funding Opportunities (NOFOs) that do not account for the unique position of Tribes as sovereign 

nations. These may include requirements such as a letter from a state chronic disease director or other 
P a g e | 3

state officer, which ignores the nation-to-nation relationship and is never appropriate to ask of a

sovereign Tribe. Listing Tribes as simply eligible for a NOFO does not go far enough.

To address this issue, we ask that the reorganization make sure that all NOFOs from the CDC are 

reviewed before release by an expert in best practices for respecting Tribal sovereignty. In addition, 

CDC should provide training on Tribal sovereignty, the nation-to-nation relationship, and the federal 

trust responsibility to ensure that anyone involved in implementing CDC programs properly 

understands these core concepts, in addition to CDC’s specific role in upholding them. Tribal 

sovereignty must be recognized as a matter of course in the agency’s daily operations.

II. Federal Trust Responsibility

The federal trust responsibility is integral to the unique legal and political relationship the U.S. 

maintains with Tribal governments. This relationship has been established through and confirmed by 

the U.S. Constitution, treaties, federal statutes, executive orders, and judicial decisions. In exchange

for Tribal lands, the United States signed treaties with Tribal nations promising certain rights and

services, including the protection of health and well-being. These treaties are the foundation of the

federal government’s trust responsibility to protect the interests of Indian Tribes and communities. 

Since ensuring good health and well-being for AI/ANs is part of the federal trust responsibility, 

anything that constitutes a barrier to fulfilling the trust responsibility is also a barrier to achieving 

health equity. Conversely, dedication to fulfilling the trust responsibility advances health equity.

CDC’s Moving Forward initiative is a prime opportunity to reexamine the critical role CDC plays in 

fulfilling the federal trust responsibility. A piecemeal, grant-dependent approach to public health is 

inappropriate, as we have clearly seen how ineffective it is at supporting public health in Indian 

Country through the decrease of life expectancy over time. Instead, a cross-agency 10 percent Tribal 

set-aside would be in line with fulfilling the federal trust responsibility and addressing the long history 

of neglect that has led to the current state of health inequities. Funding should not be coming through 

competitive grants to Tribal nations, which only serve to force underserved Tribal nations to compete 

with each other. Grant administration is also a resource intensive burden that is not feasible for many 

Tribal nations. Instead, funding to Tribes should be broad-based and formula driven. 

III. Disrupting Structures of Inequity and Shifting the Balance of Power

The health inequities experienced by AI/ANs are rooted in the history and ongoing legacy of 

colonization – on the structures and policies introduced and maintained by the U.S. government. One 

way colonization led to drastic health inequities was by stripping Tribal nations of their political power 

and self-determination. Because Tribes were systematically excluded from decision-making and

subjected to paternalistic federal policies for several hundred years, government policies, programs, 

and systems have not served the needs of AI/AN people. To achieve health equity, these structures of 

inequity must be dismantled, and power must be returned to Tribal nations – including within the realm 

of public health.
P a g e | 4

Tribal consultation. One of the essential forms of Tribal inclusion in governance is Tribal 

consultation. Because Tribes are sovereign nations, any time a federal government agency 

contemplates a policy change that will impact a Tribe or its citizens, that agency has an obligation and 

responsibility to pursue timely, meaningful, robust Tribal consultation. Meaningful consultation

requires two-way communication and collaboration, not just informing Tribes about decisions that 

have already been made. Consultation should be with government officials with decision-making 

authority, as well as with agency subject-matter experts and designated Tribal liaisons. Follow-up from 

the consultation and application of the Tribal perspectives shared are also necessary for consultation

to be meaningful. 

Tribal empowerment in governance. Tribes also need to be included in government decision-making 

in other ways, like by expanding pathways for AI/ANs to become CDC employees and public health 

professionals, being responsive to the CDC Tribal Advisory Committee, and including Tribes on

agency task forces and committees. For example, the proposed Executive Board to assess and 

recommend agency priorities each year should include permanent representation of an expert on Tribal 

priorities and sovereignty. During this reorganization and on an ongoing basis, CDC needs to prioritize 

integrating support for Tribal nations across all parts of the agency.

IV. Visibility of American Indians & Alaska Natives

For decades, it was the policy of the United States to terminate and assimilate AI/AN people to 

eradicate AI/AN peoples and cultures from existence. While Tribes have been remarkably resilient in 

preserving their communities and cultures despite these persistent challenges, AI/ANs are commonly 

invisible in the larger American cultural context. If AI/ANs continue to be unseen, the inequities will 

continue. Federal agencies like CDC must take active measures to ensure AI/AN people and Tribes are 

visible in two critical arenas: policy creation and data.

Inclusion & visibility in policy creation. Tribes must be included in every step of policy creation. 

Often the impact of policies on Tribes is treated as an afterthought, instead of ensuring Tribes are at 

the table throughout the policy development process. As a result, the policies themselves often leave 

out Tribes entirely and the cycle of invisibility continues. This is an especially significant risk for large 

scale initiatives like Moving Forward – Tribes need to be actively included throughout the process.

Visibility in data. High-quality, meaningful AI/AN health data is essential for identifying disparities, 

setting priorities, designing strategies, and highlighting successes related to health equity. However, 

AI/AN data is missing so often that AI/ANs have come to be known as the “Asterisk Nation” – a 

recognition of how often AI/AN data is withheld and replaced by an asterisk to denote that the sample 

size was too small or the data was statistically unreliable. Racial misclassification, missing data, and 

other quality issues continue to impede the representation of AI/ANs in many data sets. With AI/AN 

people and communities so often missing from the data, this becomes one more form of erasure of 

AI/ANs – our experiences are not represented, our needs are not heard, and our very existence becomes 

invisible. Improving data practices – in a way that supports Tribal sovereignty and is meaningful for 
P a g e | 5

AI/AN – is crucially important as a step to undo the centuries of AI/AN erasure contributing to the 

ongoing health inequities in Tribal communities. 

V. Honoring Indigenous Knowledge & Cultural Lifeways

Colonization and the values introduced through colonization have led to devastating health inequities;

leaning into traditional values and worldviews opens new pathways forward. We can only achieve 

health equity for Indian Country when we approach it through a Native lens.

Connection to community and culture is among the most powerful drivers for good health and 

resilience for AI/AN people. Strengthening connection to community and culture is essential to counter 

the harmful disconnection that resulted from centuries of historical injustices. For example, AI/ANs

currently experience drastic inequities in diabetes rates; this can be traced back to the history of the 

disruption of traditional food systems through the forced removal of Tribes to reservations and the 

subsequent forced reliance on commodity foods. Many Tribal communities have prioritized food 

sovereignty and bringing traditional food systems back to the forefront of daily life, reintroducing 

balanced nutrition and a stronger connection to community and culture. Tribal communities and public 

health programs can share many other examples of how this kind of strengthened connection has led 

to improved health outcomes. CDC programs need to include the flexibility for Tribes to implement

culturally appropriate public health initiatives that will support connection to Indigenous identity and 

community.

Previous government health initiatives have often focused solely on problems and disparities; this can 

leave the inaccurate, harmful impression that the communities experiencing inequities are somehow 

inherently deficient. This undercuts these communities’ self-determination and sets the stage for 

government paternalism. Instead, as CDC reorganizes, the agency should strive for an organizational

culture that is strengths-based and focuses on cultural humility. A strengths-based perspective

recognizes that the answers for achieving health equity for a community lie within that community; 

the strengths, assets, and resilience of individuals and communities are vital to any effective path to 

health equity. The federal government is most effective in working towards health equity when it puts 

its resources behind supporting the leadership of Tribal communities. Tribes know their people, 

communities, social and historical context, needs, and strengths best – Tribes are the experts in 

charting a path to health equity for their people.

VI. Conclusion 

CDC can advance health equity for AI/ANs by ensuring flexibility and Tribal control in public health 

programs for Indian Country; accepting the federal government’s responsibility to ensuring good 

health and well-being for AI/AN people; conducting meaningful Tribal consultation; implementing 

equitable funding structures; and recognizing that the answers for health equity lie within our 

communities. As CDC strengthens the agency’s cross-cutting functions through the Moving Forward 

Initiative, Tribal relations and support should be viewed as a cross-cutting function that is just as 

important as any other. We look forward to continuing this conversation in the months and years 
P a g e | 6

ahead. Please do not hesitate to contact NIHB if we can be of any further assistance with the Moving 

Forward Initiative. 

Yours in Health,

William Smith, Valdez Native Tribe

Chairman

National Indian Health Board
33

Appendix B: List of Participants— February 9, 2023, Tribal Consultation

First Name Last Name Tribal Affiliation / Agency

Cleopatra Adedeji CDC

Rasha Al Rawi CDC

Jemma Alarcon CDC

Noah Aleshire CDC

Shoneen Alexander-Ross Muscogee (Creek) Nation

Katherine Allen-Bridson CDC

Isaac Ampadu CDC

Beverly Anaele CDC

Tranita Anderson CDC

Ty Anderson CDC

Alicia Andrew Native Village of Karluk / Karluk IRA Tribal Council

Jose Aponte CDC

Arielle Arzu CDC

Sharon Attipoe-Dorcoo CDC

Jed Augustine CDC

Margot Bailowitz CDC - CSTLTS

Devin Barich CDC

Connie Barker The Chickasaw Nation

Veronica Beasley CDC

Rhonda Beaver Muscogee (Creek) Nation

Delores Becenti Navajo Nation / Navajo Dept. of Health

James Beck CDC

Mitchel Berger HHS

Holly Billie Navajo/ CDC

Leann Bing ATSDR

Carissa Bishop Access Care Anywhere

Kelly Bishop CDC

April Blowe CDC

Randella Bluehouse Navajo Nation / CDC Contractor

Kailyn Bostic CDC - OTASA

Vickie Bradley Eastern Band of Cherokee Indians

Sharunda Buchanan CDC

Rebecca Bunnell CDC

Tonia Burk CDC - ATSDR

Anna Fox Burnette CDC - OTASA

Sherry Burns Navajo / AMN

Emily Busta CDC

Davina Campbell Oklahoma Choctaw/ CDC

Hallie Carde CDC

Valeria Carlson CDC

Justin Casto CDC

Annmarie Chase CDC
34

Karla Checo CDC

Karen Cobham-Owens CDC

Anne-Marie Coleman CDC

Elizabeth Conrey CDC

Dewayne Crank Navajo Nation

Charles Cuny Oglala Sioux Tribe / Little Wound School

Scott Damon NCEH

Debra Danforth Oneida Nation

Laura Daniel CDC

Teresa Daub CDC

Leslie Ann Dauphin CDC

Adina De Coteau CDC

Tanni Deb CDC

Julie Deerinwater Cherokee Nation

Allayna Dehond CDC

Devin Delrow HHS IEA

Leeann Denham ASTR

Miatta Dennis CDC

Pasha Diallo CDC

Kelly Dickinson CDC

Shani Doss CDC

Tyler Dougherty NIHB

Melanie Duckworth CDC

Brianna Dumas CDC/DNPAO

Lorna Elliott-Egan MDHHS

Jessica Elm Oneida Nation / Stockbridge-Munsee Band of the 

Monhicans

Yvette Falcon Koniag / CDC- OTASA

Angela Falisi HHS - Office of Budget

Alison Feise CDC

Carrie Field National Indian Health Board

Sharon Fields Cherokee Nation

Rebekah Frankson CDC

Herminia Frias Pascua Yaqui Tribe

Katie Fullerton CDC

Kim Gadsden-Knowles CDC

David Gahn Cherokee Nation

Sundak Ganesan CDC DSLR - Supporting Tribal communities 

Anika Garner CDC

Colin Gerber Council of State and Territorial Epidemiologists

Chebreia Gibbs CDC

Candace Girod CDC

George Gover Northwestern Band of the Shoshone Nation

Melissa Gower Cherokee / Chickasaw Nation

Laura Gravesen CDC
35

Donata Green CDC

Brenton Guy CDC/DOP/Drug-Free Communities Branch

Karen Hacker CDC

Miklos Halmos CDC

Kat Hardin CDC/DOP/DFC

Veda Harrell CDC

Zachery Harris CDC

Annie Hatley CDC 

Roberto Henry CDC

Jan Hicks-Thomson CDC

Cynthia Hill CDC

Kimberly Hoch CDC

Katherine Hoffman CDC

Mary Holloway CDC

Meghan Holst CDC

Sara Horak CDC OTASA

John Hough U.S. DHHS CDC National Center for Health Statistics

Robin Ikeda CDC

Laurie Ishak CDC

Chandra Jennings Diversity and Inclusion Recruitment Activity (DIRA)

Billye Jimerson Muscogee (Creek) Nation

Kayla Johnson CDC

Michelle Johnson Jones CDC

Christopher Jones CDC

Erica Jones CDC

Matt Josey CDC-DDID-NCHHSTP-OD

Laurin Kasehagen CDC

Jacob Kerns CDC

Sophia Kiselova-Sammons CDC 

Jill Klosky CDC

Laura Kollar CDC

Jim Kucik CDC

Danielle Lafleur CDC

Tamara Lamia CDC

Karina Lifschitz CDC

Geremy Lloyd CDC

A.C. Locklear Lumbee Tribe / National Indian Health Board

Weston Lowry CDC

Marisa Lubeck CDC

Jennifer Lyke ATSDR

Casey Lyons CDC

Goldie Macdonald CDC

Taressa Marchand Colville Confederated Tribes

Priscilla Markin CDC

John Marr CDC/ATSDR
36

Latisha Marshall CDC

Ashton Martin Sappony / USET SPF

Jay Matthews CDC

Anna-Catherine McCrary CDC

Leslie McCrdd CDC - CSTLTS

Donna McCree CDC

Candice McKee CDC

Eva McLanahan ASPR

Mary McQuilkin Employee of tribal health organization (Nurse 

Practitioner)

Sarah Meehan CDC

Lisa Meissner HHS/OS/IEA

Will Micklin Central Council of Tlingit and Haida Indian Tribes of 

Alaska

Claudia Miron SNS is a federal tribal partner / ASPR/Strategic National 

Stockpile

Cedar Mitchell CDC

Georgia Ann Moore CDC

Mitch Morris CDC

Jill Moses CDC

Ashleigh Murriel CDC

Stephanie Neitzel CDC

Jennifer Nelson CDC

My Nguyen CDC

Kelsey Nies CDC

Melissa Nuthals Oneida Nation

Kevin O'Callaghan CDC

Meghan Oconnell Cherokee / GPTLHB

Joanne Odenkirchen CDC

Ekwutosi Okoroh CDC

Stacey Parker CDC

Sara Patterson CDC

Chandra Pendergraft CDC

Bianca Perri CDC

Geraldine Perry ASRT/CDC

Lori Phillips CDC

Lisa Pivec Cherokee Nation

Sarah Pol CDC

Beth Pollak CDC

Alex Poniatowski CDC

Dr. Nakki Price CDC

Victoria Ramirez CDC

Bryce Redgrave Northern Cheyenne / HIS

Julianna Reece Navajo Nation / CDC Contractor

David Reede San Carlos Apache Tribe / Department of Health and 

Human Services
37

Jovanni Reyes CDC

April Rodgers Viejas Band of Kumeyaay Indians / Yaytaanak Wellness 

Center

Steven Rodgers CDC

Ahniwake Rose Cherokee Nation / National Indian Health Board

Zoe Rothberg CDC

Kameron Runnels Santee Sioux Nation

Charity Sabido-Hodges Cowlitz Indian Tribe

Melinda Salmon CDC

Terisa Sanchez Morongo Band of Mission Indians

Delight Satter Confederated Tribes of Grand Ronde / CDC

Michelle Sauve Mohawk / HHS

Sam Sears National Council of Urban Indian Health

Dean Seneca Seneca / Seneca Scientific Solutions+ 

Shari Shanklin CDC

Katie Sives CDC

Richard Sneed Eastern Band of Cherokee Indians

Neeka Somday Confederated Tribes of the Colville Reservation 

Alisa Spieckerman CDC

Yuri Springer CDC

Sharon Stanphill Cow Creek

Melody Stevens CDC

Pollyanna Stewart State of Alaska/Department of Health

Jon Streater Centers for Disease Control and Prevention

Gregory Sunshine CDC

Marissa Taylor CDC

Jt Theofilos CDC

Sally Thigpen CDC

Lauren Tonti CDC CSTLTS

Tina Tourtillott Menominee / Haskell Indian Nations University

Nate Tyler Makah Tribe / Tribal Councilman Makah Tribe

Monique Vondall-Rieke Koniag / CDC

Nicole Wachter CDC

Rochelle Walensky CDC

Henry Walke CDC 

Bryan Warner Cherokee Nation

Victoria Warren-Mears NPAIHB

Carolina Wasinger Delaware, Cherokee / National Congress of American 

Indians

Alleen Weathers CDC

Angela Webb CDC

Jennifer Webster Oneida Nation

Seh Welch CDC

Isabelle Welsh Keweenaw Bay Indian Community / Michigan Dept 

Health and Human Services
38

Rachel West CDC

Zoe Whidden CSTLTS

Jessica Wiens CDC

Andrea Williams CDC

Stacey Willocks CDC

Brandon Wisneski Oneida Nation

Madeline Woodruff CDC

Sophie Yarosh Tribal Health Associate at MDH / CDC

Debbie Yembra CDC

Rebecca Young CDC

Taylor Yutan CDC

In addition to the participants identified above, one person called in and did not identify

themselves; for protection of their privacy, we have listed only the area code and not the entire

phone number:

1- 949-XXX-XXXX
39

Appendix C: Current CDC/ATSDR Tribal Consultation Policy (dated 2020)


Category: General Administration

Policy #: CDC-GA-2005-16 (Formerly CDC-115)

Date of Issue: 10/18/2005, Updated 01/08/2013, Updated 11/12/2013, Updated 02/28/20201

Proponent: Center for State, Tribal, Local, and Territorial Support (CSTLTS) 

Application: All Locations, Domestic and International

Applicable Staff: CDC Employees

CDC/ATSDR TRIBAL CONSULTATION POLICY

Sections: 1. PURPOSE AND SCOPE

2. BACKGROUND

3. POLICY

4. RESPONSIBILITIES

5. REFERENCES

6. ACRONYMS

7. DEFINITIONS

1. PURPOSE AND SCOPE

This policy provides direction regarding consultation between the Centers for Disease Control 

and Prevention (CDC)2 and Indian Tribes. This policy applies to all CDC employees3 at all

locations, domestic and international, and to all Centers, Institute, and Offices (CIOs), Staff 

Offices, and Business Services Offices, which are hereafter called “CDC Components”4 unless 

otherwise noted. 

CDC and Indian Tribes share the goal of establishing clear policies that further the governmentto-government relationship between the U.S. Federal Government and Indian Tribes. True and 

effective consultation shall result in information exchange, mutual understanding, and informed 

decision-making on behalf of the Tribal governments and the Federal Government. The 

importance of consultation with Indian Tribes was affirmed through Presidential Memoranda in 

1994, 2004 and 2009, and Executive Order (EO) 13175 in 2000.

The goals of this policy include, but are not limited to, assisting in eliminating the health 

disparities faced by Indian Tribes; ensuring that access to critical health and human services 

and public health services is maximized to advance or enhance the social, physical, and 

economic status of Indians; and promoting health equity for all Indian people and communities. 

To achieve these shared goals, it is essential that Indian Tribal governments and CDC engage 

in open, continuous, and meaningful consultation.

1 This update is a non-substantive update limited to copy editing, revising the policy’s format (such as moving or rephrasing content to fit the template), changing nomenclature, and updating website addresses.

2 References to CDC also include the Agency for Toxic Substances and Disease Registry (ATSDR). 

3 For the purposes of this policy, the term “employees” consists of members of the civil service, Commissioned Corps 

officers, and locally employed staff. For more information on these categories, refer to “Employee Categories 

(Updated July 2018),” available at: http://intranet.cdc.gov/ocio/docs/systemstools/EmployeeCategoryHelp_July_2018.pdf. 4 More information on CDC organizational nomenclature is available at: https://sbi.cdc.gov/DOA/pdf/orgnom.pdf.
2 

The U.S. Department of Health and Human Services (HHS) Tribal Consultation Policy requires 

that all operating divisions of the department develop and implement Tribal consultation policies 

that are in compliance with the HHS Tribal Consultation Policy, effective December 14, 2010.

2. BACKGROUND

Founded in 1946, CDC is the leading public health agency in the United States. The CDC 

collaborates with stakeholders and partners to (1) develop expertise, information, and tools to 

promote healthy people and (2) communicate on topics such as health promotion, prevention of 

disease, injury and disability, and preparedness for new and emerging health threats. CDC 

seeks to accomplish its mission by working with partners to monitor health; detect and 

investigate health problems; conduct research to enhance prevention; develop and advocate 

sound public health policies; implement prevention strategies; promote healthy behaviors; foster 

safe and healthful environments; and provide leadership and training. These functions are the 

EDFNERQHRI&'&ƍVPLVVLRQ(DFK&DC Center, Institute, and Office (CIO) undertakes these 

activities to conduct CDC’s specific programs. The steps that are needed to accomplish this 

mission are based on scientific excellence and require well-trained public health practitioners 

and leaders dedicated to high standards of quality and ethical practice.

CDC shares its focus on health protection with its sister agency ATSDR. First organized in 

1985, ATSDR was created by the Comprehensive Environmental Response, Compensation, 

and Liability Act (CERCLA) of 1980, more commonly known as the Superfund law. In 1986, 

Congress passed the Superfund Amendments and Reauthorization Act (SARA). The agency’s 

mission is to serve the public through responsive public health actions to promote healthy and 

safe environments and prevent harmful exposures.

3. POLICY

A. Core Principles

Tribal consultation between CDC and Indian Tribes is built on two core principles, which are 

summarized below. Each of these principles supports the unique circumstances for who is 

engaged, why the engagement is significant, and guidance for how to engage. This relationship 

is derived from the unique political and legal relationship that Indian Tribes have with the 

Federal Government and is not based on race or ethnicity.

Tribal Sovereignty

Since the formation of the Union, the United States has recognized Indian Tribes as sovereign 

nations. As sovereign nations, Indian Tribes exercise inherent sovereign powers over their 

members, territory, and lands. CDC recognizes that each Indian Tribe sets its own priorities and 

goals, including those that establish a safe and healthy environment for its members and 

territory.

Government-to-Government Relationship

A unique government-to-government relationship exists between Indian Tribes and the Federal 

Government. This relationship is grounded in the U.S. Constitution, numerous treaties, statutes, 

Supreme Court decisions, and Executive Orders that establish and define a Federal trust 

relationship with Indian Tribes. This relationship is derived from the political and legal 

relationship that Indian Tribes have with the Federal Government and is not based upon race. 
3 

CDC is committed to continuing to work with Federally recognized Tribal governments on a 

government-to-government basis and strongly supports and respects Tribal sovereignty and 

self-determination in the United States.

This special relationship between the Federal Government and Indian Tribes is affirmed in 

statutes and various Presidential Executive Orders including, but not limited to the following:

x Older Americans Act, P.L. 89-73, as amended

x Indian Self-Determination and Education Assistance Act, P.L. 93-638, as amended

x Native American Programs Act, P.L. 93-644, as amended

x Indian Health Care Improvement Act, P.L. 94-437, as amended

x Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L.104-193

x Presidential Executive Memorandum to the Heads of Executive Departments dated April

29, 1994

x Presidential Executive Order 13175, Consultation and Coordination with Indian Tribal

Governments, November 6, 2000

x Presidential Memorandum, Government-to-Government Relationship with Tribal

Governments, September 23, 2004

x Presidential Memorandum, Tribal Consultation, November 5, 2009

x American Recovery and Reinvestment Act of 2009, P.L. 111-5, 123 Stat. 115 (Feb. 17,

2009)

x Children's Health Insurance Program Reauthorization Act of 2009, P.L. 111-3, 123 Stat.

8 (Feb. 4, 2009)

x Patient Protection and Affordable Care Act of 2010, P.L. 111-148, 124 Stat. 119 (Mar.

23, 2010)

As a Federal Government entity, CDC will comply, to the extent practicable and permitted by 

law, with all provisions in the HHS Tribal Consultation Policy to ensure meaningful consultation 

and timely input from Indian Tribes before actions are taken that will significantly affect Indian 

Tribes.

B. Philosophy

Indian Tribes have an inalienable and inherent right to self-government. Self-government means 

government in which decisions are made by the people who are most directly affected by the 

decisions. As sovereign nations, Indian Tribes exercise inherent sovereign powers over their 

members, territory, and lands. As a Federal organization, CDC recognizes its special 

commitment and unique relationship with Indian Tribes and is committed to fulfilling their critical 

role in promoting the health and safety of Indian Tribes.

C. General Requirements

CDC policy on Tribal consultation will adhere to all provisions in the HHS Tribal Consultation 

Policy. 

CDC will honor the sovereignty of Indian Tribal governments, respect the inherent rights of 

Indian Tribal self-governance, and continue to work on a government-to-government basis. 

Government-to-government consultation will be conducted with elected Indian Tribal Leaders or 

their designated representatives, to the extent practicable and permitted by law, before CDC

takes any action that will significantly affect Indian Tribe(s).
4 

CDC will employ a process to ensure meaningful and timely input by CDC and Indian Tribes in 

the development of policies that have Tribal implications. This Tribal consultation policy does 

not waive any Tribal governmental rights, including treaty rights, sovereign immunities or 

jurisdiction; and nothing in this policy waives the U.S. Federal Government’s deliberative 

process privilege. Nothing in this policy may be interpreted as diminishing or eliminating the 

rights of American Indians or Alaska Natives (AI/ANs) or entities under U.S. Federal law, 

contained in treaties, agreements and other constructive arrangements.

D. Tribal Consultation Process

An effective consultation between CDC and Indian Tribes requires information exchange, 

mutual understanding, full and equitable participation, and building and maintaining trust 

between all parties, which is an indispensable element in establishing an effective consultative 

relationship. CDC will adhere to the consultation process as outlined in Section 8 of the HHS 

Tribal Consultation Policy. Upon identification of an action (i.e., policy; funding/budget 

development; and program services, functions, and activities) significantly affecting Indian 

Tribes, CDC will initiate consultation regarding the event through communication methods as 

outlined in the HHS Tribal Consultation Policy. 

The CDC Tribal consultative process shall consist of direct communications with Indian Tribes 

and Indian organizations as applicable, in various ways as provided in Section 9 on 

Consultation Procedures and Responsibilities of the HHS Tribal Consultation Policy.

E. Consultation Participants and Roles

The government-to-government relationship between the U.S. and Federally recognized Indian 

Tribes dictates that the principal focus for consultation by CDC is with Indian Tribes,

individually or collectively. Consultation parties include:

x Indian Tribes represented by the Tribal President, Tribal Chair, or Tribal Governor,

or an elected or appointed Tribal Leader, or their authorized representative(s)

x CDC Director, ATSDR Administrator, CDC Deputy Director for State, Tribal, Local and

Territorial Support, or their designee(s)

CDC/ATSDR may gather information from Indian organizations in accordance with the Federal 

Advisory Committee Act (FACA), 5 U.S.C. App. 2, or with the “Unfunded Mandates Reform Act 

Exemption” to FACA found in the Unfunded Mandates Reform Act, P.L. 104-4, Section 204. 

The government does not participate in government-to- government consultation with these 

entities; rather the government communicates with these organizations in the interests of Indian 

Tribes and Indian People. CDC may also communicate with Native-serving organizations, 

including urban and rural Indian organizations, in the interests of Indian communities and Indian 

people. Government-to-government consultation at CDC will occur as outlined in the HHS Tribal 

Consultation Policy. 

F. Budget Formulation

HHS conducts annual Department-wide Tribal budget and policy consultation sessions to give 

Indian Tribes the opportunity to present their budget recommendations to the Department to 
5 

ensure Tribal priorities are addressed. CDC will comply with Section 11 on Budget Formulation 

of the HHS Tribal Consultation Policy. 

G. Performance Measures and Accountability

CDC will utilize the HHS and CDC Tribal Consultation Policies to address CDC’s missions and 

performance objectives with respect to: assisting in eliminating the health disparities faced by 

Indian Tribes; ensuring that access to critical health and human services and public health 

services is maximized to advance or enhance the social, physical, and economic status of 

Indians; and helping promote health equity for all Indian people and communities. CDC will 

measure and report results and outcomes of the Tribal consultation performance and will follow 

the goals and objectives of the seated Secretary and Administration according to Section 12 on 

Tribal Consultation Performance and Accountability in the HHS Tribal Consultation Policy. 

H. Evaluation and Reporting

The consultation process and activities conducted according to the policy should result in 

meaningful outcomes for CDC and for the affected Indian Tribes. To effectively evaluate the

results of consultation activity and CDC’s ability to incorporate Indian Tribes’ consultation input, 

CDC will measure the level of satisfaction of Indian Tribes on an annual basis as outlined in 

Sections 12 (Tribal Consultation Performance and Accountability) and Section 13 (Evaluation, 

Recording of Meetings, and Reporting) of the HHS Tribal Consultation Policy. 

I. Conflict Resolution

The intent of this policy is to promote partnerships with Indian Tribes that enhance CDC’s ability 

to address issues, needs and problem resolution. CDC shall consult with Indian Tribes to 

establish a clearly defined conflict resolution process under which Indian Tribes bring forward 

concerns that have a substantial direct effect. However, Indian Tribes and CDC may not always 

agree, and inherent in the government-to-government relationship is the ability for Indian Tribes 

to elevate an issue of importance to a higher or separate decision-making authority.

Nothing in this Policy creates a right of action against the CDC or HHS for failure to comply with 

this Policy.

J. Tribal Waiver

CDC will fully comply with Section 15 of the HHS Tribal Consultation Policy on Tribal waivers 

and process all requests routinely received for waivers under existing program authorities with 

the statutorily set timeframes.

K. Effective Date

This policy is effective on the date of the signature by the CDC Director/ATSDR Administrator.

This policy updates the Tribal Consultation Policy signed on October 18, 2005.
6 

4. RESPONSIBILITIES

A. Center for State, Tribal, Local, and Territorial Support (CSTLTS)

x Designates, through the Deputy Director for State, Tribal, Local and Territorial Support,

the Tribal Support Unit with the responsibility for implementation, coordination, and

agency-wide adherence to CDC/ATSDR and HHS Tribal Consultation Policies

B. CDC/ATSDR Tribal Advisory Committee (TAC)

x Serves as an advisory committee to CDC/ATSDR providing input, guidance, and advice

on policies, guidelines, and programmatic issues affecting the health of Indian Tribe(s)

x Complies with the requirements of the FACA, 5 U.S.C. App. 2, or with the “Unfunded

Mandates Reform Act Exemption” to FACA found in the Unfunded Mandates Reform

Act, P.L. 104-4, Section 204

5. REFERENCES

A. HHS. Department Tribal Consultation Policy, dated December 14, 2010,

https://www.hhs.gov/sites/default/files/iea/tribal/tribalconsultation/hhs-consultationpolicy.pdf.

B. Presidential Memorandum for the Heads of Executive Departments and Agencies,

“Government-to-Government Relationship with Tribal Governments, Presidential

Memorandum,” dated September 23, 2004, https://www.govinfo.gov/content/pkg/WCPD2004-09-27/pdf/WCPD-2004-09-27-Pg2106.pdf.

C. Exec. Order No. 13,175, 65 Fed. Reg. 67,249 (Nov. 9, 2000) – Consultation and

Coordination with Indian Tribal Governments

6. ACRONYMS or ABBREVIATIONS

AIAN – American Indian and Alaska Native 

ATSDR – Agency for Toxic Substances and Disease Registry

CDC – Centers for Disease Control and Prevention 

CERCLA – Comprehensive Environmental Response, Compensation, and Liability Act 

CIO – Centers, Institutes and Offices

EO – Executive Order

HHS – U.S. Department of Health and Human Services

SARA – Superfund Amendments and Reauthorization Act

U.S. – United States 

USC – United States Code

7. DEFINITIONS

Agency – Any authority of the United States that is an “agency” under 44 USC § 3502(1) other 

than those considered to be independent regulatory agencies, as defined in 44 USC § 3502(5)

CDC Components – Organizational entities of CDC that are comprised of CIOs, Staff Offices, 

and Business Services Offices, as outlined in Organizational Nomenclature Used in Delegations 

of Authority
7 

Communication – The exchange of ideas, messages, or information, by speech, signals, 

writing, or other means

Consultation – An enhanced form of communication, which emphasizes trust, respect and 

shared responsibility; is an open and free exchange of information and opinion among parties

that leads to mutual understanding and comprehension; and is integral to a deliberative process

that results in effective collaboration and informed decision making with the ultimate goal of 

reaching consensus on issues

Deliberative Process Privilege – Is a privilege exempting the government from disclosure of

government agency materials containing opinions, recommendations, and other 

communications that are part of the decision-making process within the agency

Executive Order – An order issued by the Government’s executive on the basis of authority

specifically granted to the executive branch (as by the U.S. Constitution or a Congressional Act)

Federally Recognized Tribal governments – Indian Tribes with whom the Federal 

Government maintains an official government-to-government relationship, usually established 

by a Federal treaty, statute, executive order, court order, or a Federal Administrative Action

NOTE: The Bureau of Indian Affairs (BIA) maintains and regularly publishes the list of 

Federally recognized Indian Tribes. 

Indian – Indian means a person who is a member of an Indian tribe as defined in 25

U.S.C. § 5129

NOTE: Throughout this policy, Indian is synonymous with American Indian or Alaska Native.

Indian Organizations – 1) Those Federally recognized Tribally constituted entities that have 

been designated by their governing body to facilitate HHS communications and consultation 

activities, or 2) any regional or national organizations whose board is comprised of Federally 

recognized Indian Tribes and elected/appointed Tribal leaders

NOTE: The government does not participate in government-to-government consultation with 

these entities; rather these organizations represent the interests of Tribes when authorized by 

those Tribes.

Indian Tribe – An Indian or Alaska Native tribe, band, nation, pueblo, village, or 

community that the Secretary of the Interior acknowledges to exist as an Indian tribe

pursuant to the Federally Recognized Indian Tribe List Act of 1994, 

25 U.S.C. § 5129. 

Policies with Tribal Implications – Refers to regulations, statutes, legislation, and other

policy statements or actions that have substantial direct effects on one or more Indian Tribes,

on the relationship between the Federal Government and Indian Tribes, or on the distribution

of power and responsibilities between the Federal Government and Indian Tribes

Self-Government – Government in which the people who are most directly affected by the 

decisions make decisions

Sovereignty – The ultimate source of political power from which all specific political 

powers are derived
8 

Treaty – A legally binding and written agreement that affirms the government-togovernment relationship between two or more nations

Tribal Government – An American Indian or Alaska Native Tribe, Band, Nation, Pueblo, 

Village or Community that the Secretary of the Interior acknowledges to exist as an Indian

Tribe pursuant to the Federally Recognized Indian Tribe List Act of 1994,

25 U.S.C. § 5129

Tribal Officials – Elected or duly appointed officials of Indian Tribes or authorized inter- Tribal

organizations

Tribal Organization – The recognized governing body of any Indian Tribe; any legally 

established organization of Indians which is controlled, sanctioned, or chartered by such 

governing body or which is democratically elected by the adult members of the Indian

community to be served by such organization and which includes the maximum participation of

Indians in all phases of its activities, provided that in any case where a contract is let or grant

made to an organization to perform services benefiting more than one Indian Tribe, the

approval of each such Indian Tribe shall be a prerequisite to the letting or making of such 

contract or grant 

Tribal Self-Governance – The governmental actions of Indian Tribes exercising selfgovernment and self-determination 
40

Appendix D: Dear Tribal Leader Letter for CDC/ATSDR February 9, 2023, Tribal Consultation
December 15, 2022

Dear Tribal Leader:

The Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease 

Registry (ATSDR) announce an upcoming consultation that will convene leaders from tribal nations, CDC, 

and ATSDR:

CDC/ATSDR Tribal Consultation 

February 9, 2023, 4:00–5:00 pm (EST) 

The consultation will occur virtually via Zoom after the commencement of the 25th Biannual CDC/ATSDR 

Tribal Advisory Committee Meeting. To register, please use the registration form to generate a unique 

personalized ID needed to access the meeting. The agenda will be available on the CDC Tribal Health 

website in early January 2023 at www.cdc.gov/tribal. 

This tribal consultation will provide opportunities for leaders from tribal nations, CDC, and ATSDR to 

have a government-to-government discussion to advance CDC/ATSDR support for and collaboration 

with AI/AN tribal nations and to improve the health of AI/AN communities. Tribal nations, CDC, and 

ATSDR share many goals for AI/AN health, including assisting in eliminating the health disparities faced 

by AI/AN tribal nations; ensuring that access to critical health and human services and public health 

services is maximized to advance or enhance the social, physical, and economic status of AI/AN people; 

and promoting health equity for all Indian people and communities. To further advance these goals, 

CDC/ASTDR is conducting tribal consultation to receive input and guidance on strengthening 

relationships during the implementation of the CDC Moving Forward Initiative. 

Your input is very important to us as we work to improve CDC and ATSDR public health capacity, 

programs, and services and to strengthen partnerships with tribes and AI/AN community organizations. 

CDC and ATSDR remain committed to respecting tribal sovereignty while working together to leverage 

capacity, expertise, and resources to achieve the greatest impact on the health issues affecting AI/AN 

communities.

Elected tribal officials are encouraged to submit written tribal testimony by 5:00 pm (EST) on February 

24, 2023, by email to CDC’s Tribal Support mailbox, tribalsupport@cdc.gov, or by mail at the following 

address:
Office of Tribal Affairs and Strategic Alliances

Center for State, Tribal, Local, and Territorial Support

1600 Clifton Road, N.E., Mailstop V18-4 

Atlanta, GA 30329-4027

Telephone: (404) 498-0300 

We look forward to the consultation and hope you will be able to participate.

Sincerely,

Celeste Philip, MD, MPH

Acting Director, Center for State, Tribal, Local, and Territorial Support

Deputy Director for Non-Infectious Diseases (DDNID)

Centers for Disease Control and Prevention
41

Appendix E: Federal Register Notice for CDC/ATSDR December 13,2022, Tribal Consultation