Tribal Consultation on CDC/ATSDR’s Tribal Consultation Policy 

July 2, 2021–September 7, 2021 

The Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease 

Registry (ATSDR) hosted a tribal consultation on CDC/ATSDR’s Tribal Consultation Policy on August 5, 

2021, and accepted written comments until 5:00 pm (EDT) on September 7, 2021. 

Table of Contents 

Tribal Consultation on CDC/ATSDR’s Tribal Consultation Policy .................................................................. 1 

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

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

Consultation Policy ....................................................................................................................................... 2 

1) Better Coordination with Tribes, with the TAC, and Across HHS Agencies..........................................3 

2) Accountability in Reporting and Follow Up .......................................................................................... 4 

3) Use of All Relevant Channels of Communication and Standardizing Communication with Tribes......5 

4) Advanced Notice of Consultations Via Dear Tribal Leader Letters....................................................... 5 

5) Increased Guidance on Consultation Procedures................................................................................. 6 

6) Adequate Preparation Time for Upcoming Tribal Consultations ......................................................... 6 

7) Meeting Mechanism and Increased Flexibility in Meeting Options ..................................................... 7 

8) Increased Proactivity in Providing Technical Assistance ...................................................................... 7 

9) Prioritization of Tribal Public Health Infrastructure and Capacity........................................................ 8 

10) Tribal Funding Flexibility and Transparency ....................................................................................... 8 

Next Steps ..................................................................................................................................................... 9 

Appendix A: Consultation: Written, Oral, and Other..................................................................................11 

Consultation Transcript (Oral Testimony)...............................................................................................11 

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

Written Testimony..................................................................................................................................31 

Appendix B: List of Participants—August 5, 2021, Tribal Consultation......................................................80 

Appendix C: Current CDC/ATSDR Tribal Consultation Policy (dated 2020) ................................................86 

Appendix D: Dear Tribal Leader Letter for CDC/ATSDR August 5, 2021, Tribal Consultation ....................95 

Appendix E: Federal Register Notice for CDC/ATSDR August 5, 2021, Tribal Consultation Policy .............98 

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Introduction 

On August 5, 2021, CDC/ATSDR hosted a virtual government-to-government consultation with tribal 

leaders on ways to improve the CDC/ATSDR Tribal Consultation Policy. There were 179 participants, 

including tribal leaders, CDC/ATSDR senior leaders, and other tribal partners. Comments were accepted 

from July 2, 2021 to September 7, 2021, 5:00 pm (EDT). This consultation was held in response to the 

Presidential Memorandum on Tribal Consultation and Strengthening the Nation-to-Nation Relationships, 

which requires agencies to submit a detailed plan for tribal consultation. CDC/ATSDR is committed to 

working with federally recognized tribal governments on a government-to-government basis. 

CDC/ATSDR strongly supports and respects tribal sovereignty and self-determination for tribal 

governments in the United States and look forward to continuing to work with tribes to improve 

CDC/ATSDR’s tribal consultation process. The current CDC/ATSDR Tribal Consultation Policy is available 

on CDC’s Tribal Health website. 

The Department of Health and Human Services (HHS) Tribal Consultation Policy states that tribes should 

receive at least 30 days’ notice of a consultation and the details about the topic to be discussed. CDC 

issued a Federal Register Notice 34 days before the first consultation session and included the purpose 

and details of the meeting. A Dear Tribal Leader Letter was sent to tribal leaders 30 days before the 

consultation. Additionally, CDC/ATSDR shared information about the virtual consultation session and 

comment period with various tribal partners. 

As the President’s memorandum states, “History demonstrates that we best serve Native American 

people when Tribal governments are empowered to lead their communities, and when federal officials 

speak with and listen to Tribal leaders in formulating federal policy that affects Tribal Nations.” 

CDC/ATSDR sought tribal leader recommendations and feedback on how CDC/ATSDR can improve the 

agency’s policies and practices to better engage with Indian Country through meaningful consultation. 

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

1. How do we strengthen our tribal consultation policy and process to ensure CDC/ATSDR is 

responsive and engaging with Indian Country in a meaningful way? 

2. How do we improve communication and outreach regarding agency policy or program changes 

that impact tribal nations? 

3. Are there specific areas where tribal officials would like more information or feel they are not 

getting adequate outreach to engage in a meaningful way? 

4. How do we improve tribal consultations? Should we have sessions every year? 

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

consultation period. 

CDC received input from 12 federally recognized tribes and 4 tribal partners during the consultation 

period. 

CDC has summarized tribal leaders’ responses to the questions above and provided initial responses to 

the most frequent comments. The agency will use this information to continue to address how the 

agency’s policies and practices around meaningful consultation can be improved. 

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

Tribal Consultation Policy 

This part addresses recommendations made by tribal leaders (or their designees) at the CDC/ATSDR 

Tribal Consultation on August 5, 2021, and during the written comment period ending September 7, 

2021. CDC/ATSDR reviewed all comments and communications received and summarized 

recommendations under the following themes: 1) better coordination with tribes, the CDC/ATSDR Tribal 

Advisory Committee (TAC), and across HHS agencies; 2) accountability in reporting and follow up; 3) 

communication methods; 4) dear tribal leader letters; 5) CDC/ATSDR’s tribal consultation process; 6) 

adequate preparation time; 7) meeting mechanism; 8) technical assistance; 9) prioritization of tribal 

public health infrastructure and capacity; and 10) tribal funding flexibility and transparency. 

1) Better Coordination with Tribes, with the TAC, and Across HHS Agencies 

Tribal leaders recommended that CDC/ATSDR better coordinate consultation activities. Comments were 

received concerning how and when the agency should engage tribal nations, the CDC/ATSDR TAC, and 

other HHS agencies to ensure timely and meaningful engagement is achieved. 

Summary of Recommendations on Better Coordination with Tribes 

Tribal leaders specifically identified a need for better coordination between CDC/ATSDR and tribal 

leaders. They emphasized that tribes should have access to regular engagement with top-level 

CDC/ATSDR leaders to ensure meaningful tribal consultation and that discussions should occur before 

decisions are made that may have significant impact on tribal nations. Tribal leaders requested that 

tribal consultation be planned to provide adequate time for tribal leaders to prepare; they 

recommended that as a new administration is elected and takes office, four years of tribal consultation 

be prescheduled. Tribal leaders also requested that the policy recognize that tribal nations have the 

right to initiate consultation. 

Tribal leaders commented that it is vital for all CDC/ATSDR staff to be educated about meaningful 

consultation and about the reasons for consultation with tribal governments. Their comments 

emphasized the importance of considering tribal sovereignty and consultation rights at both national 

and regional levels to understand regional tribal governments’ interests, needs, culture, and norms. 

Response on Better Coordination with Tribes 

CDC/ATSDR acknowledges tribal leaders’ recommendations for better coordination with tribal nations 

and tribal leaders. 

CDC/ATSDR recognizes the need for tribal leaders to have access to agency leaders and is committed to 

working with agency leaders to ensure they are available. To address this need, CDC/ATSDR will send 

early and frequent communications, invitations, and “save the date” reminders to tribal leaders and will 

ensure that such communications reiterate the government-to-government relationship that 

CDC/ATSDR has with tribal nations. CDC/ATSDR also recognizes the significance of building relationships 

at the staff level in addition to leadership-level relationships and will continue to improve coordination 

and communication between partners. 

Summary of Recommendations on Better Coordination with the TAC 

Tribal leaders specifically recommended better coordination between the CDC/ATSDR TAC and 

CDC/ATSDR. It was recommended that the agency fully utilize the expertise of TAC members. While the 

TAC does not supplant tribal consultation, engaging TAC early in policies, activities, or initiatives that 

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might have significant tribal impact can help ensure that proposed policies, activities, or initiatives are 

tribally informed. Tribal leaders emphasized that the TAC has information that is representative of 

various regions and will allow for tribally informed actions. Tribal leaders recommended that 

CDC/ATSDR engage the TAC to support planning and implementing consultation, and that the agency 

engage the TAC early for transparency in the policy-making process so any proposed policy can be 

tribally informed from the start. Tribal leaders said TAC members are the best conduit through which 

CDC/ATSDR can receive technical assistance that is tribally informed and representative of the various 

regions in the country. In addition, with any consultation, CDC/ATSDR should compile comments and 

recommendations raised, and the TAC should review and consider them. Tribal leaders commented that 

while the TAC is a valuable resource for collecting and collaborating with Indian Country, it is never a 

replacement for tribal consultation. 

Response on Better Coordination with the TAC 

CDC/ATSDR appreciates the recommendations from tribal leaders regarding the CDC/ATSDR TAC. 

CDC/ATSDR recognizes that the TAC does not supplant tribal consultation but agrees that the 

committee’s expertise and regional knowledge could be used to help inform both CDC/ATSDR and tribal 

leaders on policies, issues, or concerns. 

CDC/ATSDR will work with the CDC/ATSDR TAC to support tribal consultation by facilitating and bringing 

issues and concerns to CDC/ATSDR that may rise to the level of tribal consultation. 

Summary of Recommendations on Better Coordination Across HHS Agencies 

Tribal leaders specifically recommended better coordination around tribal consultation across agencies 

within HHS. CDC/ATSDR heard that there needs to be better coordination with other HHS agencies and 

offices, especially with the Indian Health Service (IHS), when there is mutual interest. CDC/ATSDR should 

streamline processes where possible and implement a standardized framework in coordination with 

HHS. Tribal leaders recommended that, where possible, joint HHS consultation should occur, as many 

issues cross multiple agencies. 

Response on Better Coordination Across HHS Agencies 

CDC/ATSDR appreciates the recommendations that HHS agencies increase coordination to support tribal 

consultation when mutual topics of interest are being addressed. CDC/ATSDR recognizes that tribal 

leaders are extremely busy and that collaborative consultation across HHS will help ensure tribal leaders 

are able to convey their recommendations on related matters to multiple HHS agencies at the same 

time. 

Currently, CDC/ATSDR is involved in discussions with HHS to formalize multi-agency tribal consultations 

and to develop an HHS-wide calendar of all tribal-related consultation activities. There are also 

opportunities to work more closely with HHS Regional Offices on annual consultation meetings. These 

activities will help minimize overlap and decrease meetings for tribal leaders. 

2) Accountability in Reporting and Follow Up 

Summary of Recommendations on Accountability in Reporting and Follow Up 

Tribal leaders commented on the need for accountability from all agencies, especially those responsible 

for helping address health disparities in Indian Country. Tribal leaders also recommended that the 

CDC/ATSDR Tribal Consultation Policy explicitly show 1) how tribal leaders’ recommendations and the 

outcomes will be tracked, 2) how recommendations are being used to ensure that true and meaningful 

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consultation is acted upon, and 3) that the agency’s actions are accountable and transparent. 

Information and feedback shared during consultation should be included in the final rulemaking to 

ensure the concerns and questions from tribal leaders are addressed. CDC heard that tribal leaders 

would like an update on the status of previous recommendations and that updates should be provided 

to the TAC, the CDC director and ATSDR administrator, and the HHS Secretary’s Tribal Advisory 

Committee (STAC). 

Response on Accountability in Reporting and Follow Up 

CDC/ATSDR appreciates the recommendations on accountability and acknowledges the need for 

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

continue to prioritize providing updates to the CDC/ATSDR TAC and HHS STAC through regular TAC 

conference calls and quarterly STAC meetings. As CDC/ATSDR works through the recommendations 

from tribal leaders and collaborates with HHS on their Tribal Consultation Policy, CDC/ATSDR will update 

the CDC/ATSDR Tribal Consultation Policy to align with HHS’s policy. 

3) Use of All Relevant Channels of Communication and Standardizing Communication with 

Tribes 

Summary of Recommendations on Use of All Relevant Channels of Communication and Standardizing 

Communication with Tribes 

Tribal leaders specifically recommended that all relevant channels of communication be used to inform 

tribal leaders of upcoming tribal consultation. Tribal leaders expressed the need for CDC/ATSDR to 

maintain an up-to-date list of tribal leaders. They recommended that information be disseminated by as 

many relevant methods of communication as possible (e.g., social media, partner distribution of 

information, Dear Tribal Leader Letters, and both in-person and virtual sessions). Tribal leaders also 

recommended the use of listening sessions and other methods of information gathering prior to policy, 

activity, or initiative development to ensure tribal leaders’ voices are heard. These pre-consultation 

sessions may help inform CDC/ATSDR decisions prior to consultation. Tribal leaders also recommended 

that the CDC/ATSDR point of contact (POC) be listed by name on all correspondence, on the Tribal 

Health website, etc. Tribal leaders recommended that each consultation session be transcribed and 

posted verbatim. Tribal leaders should have time to view consultation documents online and make 

corrections to both verbal and written testimonies. 

Response on Use of All Relevant Channels of Communication and Standardizing Communication with 

Tribes 

CDC/ATSDR acknowledges and understands the importance of standardizing the process for advertising 

and announcing tribal consultation. The agency will work to develop a process that standardizes 

consultation planning and CDC/ATSDR advertising of consultation to tribal leaders and incorporate this 

process into the consultation policy. CDC appreciates tribal leaders’ input on the use of listening sessions 

to support early planning for important policies that impact Indian Country. CDC will take advantage of 

these listening sessions for this purpose in the future. Per tribal leaders’ recommendations, CDC/ATSDR 

will also work to maintain an updated point of contact list to regularly communicate with tribal leaders 

and ensure that national organizations have a designated CDC/ATSDR point of contact to improve 

communication and coordination. 

4) Advanced Notice of Consultations Via Dear Tribal Leader Letters 

Summary of Recommendations on Advanced Notice of Consultations Via Dear Tribal Leader Letters 

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CDC/ATSDR heard from tribal leaders that Dear Tribal Leader Letters (DTLLs) to announce upcoming 

tribal consultation sessions need to be sent to all tribal leaders further in advance via multiple modes of 

transmission. CDC/ATSDR also heard that, following tribal consultation, tribal leaders should be 

informed of tribal leaders’ summarized feedback as well as CDC’s responses to feedback via a DTLL and 

by posting summaries on the CDC Tribal Health website. In addition, tribal leaders said that tribal 

recommendations and the agency’s responses need to be communicated back to tribal leaders in a 

timely manner. 

Response on Advanced Notice of Consultations Via Dear Tribal Leader Letters 

CDC/ATSDR appreciates tribal leaders’ emphasis on the importance of using DTLLs to communicate 

tribal consultation, both before consultations and after them to report on recommendations and followup concerns. CDC/ATSDR sent a DTLL by email on July 6, 2021, to inform tribal leaders about the August 

5, 2021, consultation; however, the letter might not have been received by all tribal leaders. To improve 

this communication channel, CDC/ATSDR will ensure that DTLLs about important meetings be posted on 

the CDC/ATSDR website and advertised through CDC/ATSDR’s and national partners’ communication 

channels. 

5) Increased Guidance on Consultation Procedures 

Summary of Recommendations on Increased Guidance on Consultation Procedures 

Tribal leaders recommended both regional and national listening sessions for tribal leaders for topics 

that might be discussed during tribal consultation sessions. They also recommended that during these 

tribal consultations, CDC/ATSDR review strategies; share background, data, and evidence that will help 

guide decision making; discuss existing and future policy development; and define priorities and goals. 

Tribal leaders recommended that CDC/ATSDR consider ways that information obtained during 

consultations can be analyzed and presented and a timeline to do so. They also recommended that CDC 

share the tribal consultation report with other agencies working with tribal leaders on public health 

issues. 

Furthermore, tribal leaders recommended that information for tribal leaders on how to seek tribal 

consultation be defined clearly and be made easily obtainable on CDC’s Tribal Health webpage. 

Response on Increased Guidance on Consultation Procedures 

CDC/ATSDR will work to provide more awareness and guidance on how tribal leaders may seek 

consultation. During the consultation itself, CDC/ATSDR will furnish more background and details 

concerning the specific topic to provide more guidance for tribal testimony. Additionally, the agency will 

provide a formal report identifying recommendations and the agency’s responses to those 

recommendations within 45 days after each consultation period has closed. CDC/ATSDR also 

acknowledges that certain meeting forums that work for some participants might not work for all. The 

agency will consider this in future consultation planning before determining a meeting mechanism and 

forum. In some instances, consultation may be more appropriate between CDC/ATSDR and an individual 

tribal nation. Once consultation occurs, a summary would be shared with that tribal nation. 

6) Adequate Preparation Time for Upcoming Tribal Consultations 

Summary of Recommendations on Adequate Preparation Time for Upcoming Tribal Consultations 

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Tribal leaders recommended that CDC/ATSDR provide timely notification of upcoming tribal 

consultations. Tribal leaders recommended that tribal consultation be announced with more than 30-

days’ notice to give tribal leaders adequate time for preparation, discussion, and concurrence within 

their tribe. Tribal leaders also noted that adequate preparation time gives them an opportunity to come 

together and generate ideas and solutions at tribal leader meetings internally and nationally and in TACs 

within relevant federal agencies. In addition, tribal leaders would like to be informed earlier in the 

process of any project, program, or policy that may have significant impact on tribal nations. It was 

recommended that CDC/ATSDR use additional ways to engage tribal nations early, including listening 

sessions in preparation for more formal consultation sessions. 

Response on Adequate Preparation Time for Upcoming Tribal Consultations 

CDC understands and acknowledges the importance of providing adequate time to prepare for tribal 

consultation sessions. CDC also acknowledges the importance of the government-to-government 

relationship and having leaders present to receive tribal leaders’ concerns and feedback. To standardize 

and communicate this process, CDC/ATSDR will update its tribal consultation policy to account for the 

time needed to schedule consultation and identify who should participate. CDC/ATSDR recently updated 

the Federal Register Notice (FRN) timeline to specify that FRNs are to be posted for at least 60 days. It is 

anticipated that this extended timeframe will allow for adequate preparation time for tribal leaders. 

CDC/ATSDR also acknowledges that the timeline for preparation may sometimes need to be shorter, 

such as during emergency responses or for deadlines for decisions outside of the agency’s control. 

7) Meeting Mechanism and Increased Flexibility in Meeting Options 

Summary of Recommendations on Meeting Mechanism and Increased Flexibility in Meeting Options 

Tribal leaders specifically recommended that any future tribal consultations be held in person with the 

option for a virtual platform. This will allow all tribal leaders to be engaged in meetings without the need 

to travel and will allow for more robust participation. 

Response on Meeting Mechanism and Increased Flexibility in Meeting Options 

CDC appreciates tribal leaders’ input on the best consultation meeting method and the importance of 

flexibility for meeting locations. CDC/ATSDR will work to ensure flexibility in meeting methods for future 

consultations. 

8) Increased Proactivity in Providing Technical Assistance 

Summary of Recommendations on Increased Proactivity in Providing Technical Assistance 

Tribal leaders recommended that the CDC/ATSDR TAC provide technical assistance to tribal leaders and 

keep tribal leaders informed. Tribal leaders recommended that CDC/ATSDR seek input from tribal 

leaders prior to policy development and said the TAC could help inform CDC/ATSDR based on TAC 

information and input. Tribal leaders also emphasized the importance of resources to address priorities, 

such as direct set-asides in funding and broadband coverage. CDC heard that there needs to be 

communication between tribal leaders and CDC’s Centers, Institute, and Offices (CIOs). Specifically, 

funding opportunities and public health leadership opportunities to strengthen tribal public health 

should be routinely shared with tribal leaders. 

Response on Increased Proactivity in Providing Technical Assistance 

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CDC/ATSDR recognizes the TAC’s important role in serving as subject matter experts and informing tribal 

leaders about CDC/ATSDR’s public health activities. 

CDC/ATSDR appreciates the input on health concern priorities and the importance of resources to 

address the priorities. CDC/ATSDR will look into future listening sessions to gather more details on these 

health priorities and how CDC/ATSDR can support Indian Country with those challenges. To ensure 

meaningful consultation for future sessions, CDC/ATSDR will gather guidance from tribal leaders through 

listening sessions early in the planning process as well as collaborate with national partners to 

communicate these opportunities. 

9) Prioritization of Tribal Public Health Infrastructure and Capacity 

Summary of Recommendations on Prioritization of Tribal Public Health Infrastructure and Capacity 

Tribal leaders specifically recommended that CDC/ATSDR review tribal public health infrastructure and 

funding of systems. Tribal leaders also mentioned that during the pandemic, utilizing and implementing 

tribal-dedicated funding and respecting sovereignty was a true paradigm shift. Allocated funding 

allowed tribes to use their existing infrastructure to help distribute the COVID-19 vaccine in a 

meaningful way that saved lives. This also allowed tribal nations to adapt strategies to their current 

capacity and infrastructure. Tribal leaders asked that this example of tribally allocated funding be 

honored and considered after the COVID-19 pandemic. 

Response on Prioritization of Tribal Public Health Infrastructure and Capacity 

CDC/ATSDR acknowledges the importance of prioritizing public health infrastructure and capacity within 

Indian Country. The agency appreciates tribal leaders’ input on this subject and is prioritizing tribal 

public health infrastructure through multiple CDC/ATSDR activities, such as CDC’s National Center for 

Chronic Disease Prevention and Health Promotion’s (NCCDPHP’s) Healthy Tribes. NCCDPHP partners 

with AI/AN communities to promote health, prevent disease, and strengthen cultural connections to 

improve health and promote wellness. This occurs in four action areas: epidemiology and surveillance, 

environmental approaches, healthcare system interventions, and community programs linked to clinical 

services. In addition, CDC’s Center for State, Tribal, Local, and Territorial Support’s (CSTLTS’s) Tribal 

Public Health Capacity Building and Quality Improvement cooperative agreement works to increase the 

capacity of Indian Country to identify, respond to, and mitigate public health threats, improving the 

health, safety, and well-being of AI/AN communities. While these cooperative agreements do address 

tribal public health infrastructure, CDC/ATSDR acknowledges the importance of increasing opportunities 

and continuing to listen to tribal leaders’ concerns and recommendations concerning tribal public health 

infrastructure. During the 22nd Biannual CDC/ATSDR TAC Meeting, tribal public health infrastructure, 

data, and social determinants of health were discussed to determine ways forward and gather 

information from TAC members on important barriers for tribal nations on these issues. These 

conversations between the agency and tribal leaders will continue as CDC activities and programs 

evolve. 

10) Tribal Funding Flexibility and Transparency 

Summary of Recommendations on Tribal Funding Flexibility and Transparency 

Tribal leaders recommended that CDC provide critical funding and services to AI/AN people in 

furtherance of the government-to-government relationship. CDC should support tribal models of health 

and healing that may not fit Western standards, and funding opportunities should recognize the value 

and applicability of cultural and traditional practices. Tribal leaders also recommended that CDC work 

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closely with tribes to obtain a better understanding of tribal public health needs and allow for tribal 

public health funding flexibility. Tribal leaders encouraged the use of interagency transfers with federal 

agencies like IHS, as well as use of Indian Self Determination Education Assistance Act Self-Governance 

agreements to streamline distribution of funds. Tribal leaders specifically recommended that a 

crosswalk be provided to tribal leaders that shows budget allocations and processes, outlining 

allocations to tribes, states, and other jurisdictions, as well as who has made those budget decisions for 

the previous 3 years and current fiscal year. Tribal leaders requested information on COVID-19 funding. 

Tribal leaders posed specific questions on how much COVID-19 funding has gone from CDC/ATSDR to 

IHS and how much has been distributed to tribes, Tribal Epidemiology Centers (TECs), and other tribal 

evaluation, research, and programming needs. Tribal leaders also requested information about plans for 

the upcoming fiscal year. Tribal leaders recommended a 5 percent set aside for tribal funding and that 

CDC should move away from competitive grant-making practices. Instead, CDC should provide recurring, 

consistent funding to tribes as public health authorities on the same basis as states. Tribal leaders 

recommended information be provided on the $2.25 billion provided to public health agencies, of which 

none was provided to tribal public health. Tribal leaders asked if there is a similar notice of funding 

opportunity for tribes and suggested that $800 million was appropriated for data modernization. Tribal 

leaders said there was a need for consultation so that CDC/ATSDR understands how funding impacts 

public health infrastructure for tribes and TECs. Tribal leaders recommended direct funding for tribal 

public health capacity on a recurring basis and requested information on how funding opportunities 

match with tribal priorities obtained during consultation. Tribal leaders also recommended support for 

technical assistance for health priority issues. 

Response on Tribal Funding Flexibility and Transparency 

CDC/ATSDR appreciates tribal leaders’ concerns about continuing direct investments for tribal 

communities and acknowledges the importance of these funding opportunities. CDC/ATSDR provides 

regular updates on budget, when available, to the CDC/ATSDR TAC during conference calls and biannual 

TAC meetings. To be transparent and provide awareness of funded activities, CDC/ATSDR posts funding 

profiles, information about CDC/ATSDR COVID-19 funding, and other budget resources (e.g., grant 

writing resources) on CDC’s Tribal Health website and through the CDC Grant Funding Profiles site. 

Regarding the request for direct set-asides for tribal nations from each CDC CIO, CDC cannot commit to 

this recommendation. CDC has many budget lines, most diseases are risk-factor-based, and 

Congressional appropriations contain many directives on how the funding must be spent. In many cases, 

CDC does not receive enough funding for a particular public health issue, activity, or program to fund all 

jurisdictions; therefore, many of CDC’s funding opportunities are competitive. Additionally, CDC’s 

funding opportunities must be directly tied to CDC’s underlying statutory authorities and programmatic 

intent. CDC strives to maximize its funding opportunities, to the extent allowable under federal law, as 

much as possible. As permitted by CDC legal authorities and in alignment with programmatic intent, 

direct funding to tribal nations for tribal public health has increased in recent years. CDC now has five 

premier programs that were informed by tribal input, including direct funding to tribes, tribal-only 

eligibility, incorporation of tribal cultural and wellness practices, and provision of funding to tribes and 

tribal-serving organizations to address COVID-19 through a noncompetitive grant (see CDC’s TribalSpecific Cooperative Agreements and Grants). Setting aside 5 percent of every 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 infrastructure across Indian Country. CDC looks forward 

to working with the CDC/ATSDR TAC and tribal leaders and organizations to build on this progress. 

Next Steps 

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

CDC/ATSDR Tribal Consultation Policy. After the comments have been incorporated, CDC/ATSDR will 

conduct an internal review followed by a close review by the CDC/ATSDR TAC, which will act as subject 

matter experts as suggested by tribal leaders during this consultation period. Once the internal review 

and review by the TAC are complete, CDC/ATSDR will send a Dear Tribal Leader Letter with the updated 

consultation policy for additional feedback and approval from tribal leaders. 

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Appendix A: Consultation: Written, Oral, and Other 

CDC/ATSDR’s Tribal Consultation on CDC/ATSDR Tribal Consultation Policy 

August 5, 2021 

Consultation Transcript (Oral Testimony) 

Dr. Nathaniel Smith: Good afternoon, I’m honored to speak with you today. My name is Nate Smith. 

I’m the CDC Deputy Director for Public Health Service and Implementation Science. CDC would like to 

first acknowledge the Muskogee Nation and the Cherokee Nation, whose tribal lands we are on. 

I want to start off by reaffirming our government-to-government relationship. 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. To further 

affirm this commitment, President Biden signed a new Presidential memorandum on January 26 of this 

year that re-commits the Federal Government to respect tribal sovereignty and strengthen the nationto-nation relationship between the United States and tribal nations. This presidential memorandum 

requires CDC/ATSDR to submit a detailed plan for implementation of the executive order. This 

executive order charges agencies to engage in regular meaningful and robust consultation with tribal 

officials when developing federal policies that have implications for tribal governments entities. We’re 

here this afternoon to honor this executive order and engage in consultation about the CDC/ATSDR 

Tribal Consultation Policy and how it can be improved to meet the needs of tribal nations this feedback 

will be used to edit the current CDC/ATSDR Tribal Consultation Policy. Thank you for this opportunity to 

speak with you and hear your guidance, I look forward to hearing your input, as well as any 

recommendations or concerns that you may have regarding the CDC/ATSDR Tribal Consultation Policy. 

I’ll now turn the meeting over to Deputy Principal Chief Bryan Warner, who is also the CDC/ATSDR 

Tribal Advisory Committee co-chair. He’ll provide some opening remarks and then open this meeting in 

prayer. 

Bryan Warner: Thank you, Dr. Smith. Well, good afternoon or good morning, depending on where 

you're joining us from. My name is Bryan Warner. I’m the Deputy Principal Chief of the Cherokee 

Nation, and, like Dr. Smith mentioned, I am, well, I was the co-chair now and the chair as of about an 

hour so, for the CDC/ATSDR Tribal Advisory Committee. It is always my pleasure to welcome you to the 

CDC/ATSDR tribal consultation on the current CDC/ATSDR Tribal Consultation Policy. 

I would like to open this meeting with the prayer. First, I would like to ask if there's anyone that would 

like to volunteer to lead us in prayer. Okay, then, I will stand to task. If you will, bow with me, please. 

Your heavenly Father Lord, we come to you again, Lord, so thankful for this time of fellowship so 

thankful and blessed. To be in your presence, Lord, we just ask that you fill our vessels with the fruit of 

your spirit. Lord, give us an extra measure of wisdom, give us an extra measure of patience, Lord, as we 

go through this task of figuring out a way to better do things and follow your will. Lord we ask for 

guidance, we ask for protection in Jesus’ name, we pray. Amen. 

Okay, well, thank you again for the opportunity to co facilitate this meeting, I will now turn the meeting 

over to Dr. José Montero, director of the Center for State, tribal, Local, and Territorial Support, also 

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known as CSTLTS, to review logistics for the consultation and background on the CDC/ATSDR 

consultation. Let's see, Dr. Montero. 

Dr. José Montero: Thank you very much, Deputy Chief Warner. So, a quick overview of CDC/ATSDR’s 

Tribal Consultation Policy. As Dr. Smith touched on earlier, this consultation is being held to honor 

Executive Order 13 175 and to be consistent with the presidential memorandum on tribal consultation 

and strengthening the nation-to-nation relationships. As I stated previously, CDC/ATSDR is committed 

to working in partnership with tribal nations with the Tribal Advisory Committee, or TAC. 

The TAC, the CDC/ATSDR TAC, advisees us in the planning and coordination of tribal consultation 

sessions and ensures that the CDC/ATSDR activities and policies that impact Indian country are brought 

to the attention of tribal leaders. 

As the presidential memorandum states, history demonstrates that we best serve Native American 

people when tribal governments are empowered to lead their communities and when federal officials 

speak with and listen to tribal leaders in formulating federal policy that affects tribal nations and Alaska 

Native villagers. 

This consultation session, according to the current CDC/ATSDR tribal consultation policy, will be held 

between Indian tribes represented by the tribal president, tribal chair, tribal governor, or an elected or 

appointed tribal leader or their authorized representatives and the CDC/ATSDR administrative 

designees. Those are Dr. Nate Smith and myself. 

We are prepared to listen and hear from tribal leaders of federally recognized tribal nations who have 

joined us for this meeting. The order of feedback will run as follows: first tribal president/chairperson 

governor. Then, we moved into tribal vice presidents, vice chairpersons, or lieutenant governors, then 

elected or appointed tribal officials, and, finally, any designated tribal official. 

For the record, when you begin to speak, please announce your name, title, and tribal nation you are 

representing. For those who would also like to send written remarks, please send us your initial 

comments and recommendations no later than 5 pm Eastern Time on September 7, 2021.You may send 

your comments or emails to our inbox tribalsupport@cdc.gov. Finally, this Zoom meeting is being 

recorded for record keeping purposes only. If you do not wish to be recorded, you can disconnect now. 

I would like now to turn the meeting back to Deputy Principal Chief Bryan Warner, who’ll facilitate the 

discussion. 

Bryan Warner: Thank you, Dr. Montero for that overview and information about the logistics now. I will 

start the discussion portion of the meeting. So, as you see on the slides, CDC/ATSDR is asking for 

specific input on for guiding questions regarding the current CDC/ATSDR Tribal Consultation Policy. 

They are as follows: 

• How do we strengthen our travel consultation policy and process to ensure the 

CDC/ATSDR is responsive in engaging with Indian country in a meaningful way? 

• How do we improve communication and outreach regarding agency policy or program 

changes that impact tribal nations? 

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• Are there specific areas where tribal officials would like more information or feel they are 

not getting adequate outreach to engage in a meaningful way? 

• And finally, how do we improve tribal consultations. Should we have sessions every year? 

We will take comments on each question one, at a time. 

I would like to invite the tribal elected leaders in the audience to share their comments provide 

recommendations on the first question. If you would like to speak, we ask that you raise your hand 

using the feature in Zoom. If you are on the phone, please press star six to unmute, and you can give 

your testimony. We request that you start by sharing your name title and tribal nation you're 

representing. Once you are unmuted, we also invite you to turn your camera on if you would like, so 

that we can see you as you ask your question or give the comments. To assist those joining us over the 

phone, I will read the question aloud on each one. 

So, tribal elected leaders and designated tribal officials, first question again, how do we strengthen our 

Tribal Consultation Policy and process to ensure CDC/ATSDR is responsive and engaging with Indian 

country in a meaningful way? 

I will open up the floor. Looks like we have Dr. Aaron Payment. Mr. Payment, you are, you have the 

floor, sir. Good to see you. 

Dr. Aaron Payment: Can you hear me? 

Bryan Warner: Yes, sir, loud and clear. 

Dr. Aaron Payment: All right, if you don't mind if I could do, I actually have an amalgamation of the 

responses and do my testimony that way. 

Bryan Warner: Dr. Montero? 

Dr. José Montero: We can try to break it down, certainly, you can . . . do you want to comment on all of 

those. If there are specific things based on how the discussion goes, I will recommend you come back 

with each one of the questions later on. 

Dr. Aaron Payment: You'll have to rotate back to me because I’m going to have to go back and segment 

out my responses. I’m sorry. I’m not sure if you heard me. I’m going to have to go and break my 

testimony into separate responses, then, thank you. 

Bryan Warner: Yes, Sir, thank you. 

Dr. José Montero: Kari, process question. Can we accept the whole testimony at once or do we need to 

break it? 

Karen "Kari" Hearod: I think it's fine to accept the whole testimony at once and then we can, in our 

summary, break it down. 

Dr. José Montero: Yes, Dr. Payment, please come back. 

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Dr. Aaron Payment: I'm sorry. I don't mean to be difficult. 

Dr. José Montero: No, we're trying to make this easier, and sending you back to break it down it seems 

as a hassle, so please, you can then come back and tell us, I don't know what the order we have. 

Dr. Aaron Payment: Okay, all right, I appreciate that, especially because I think in a very holistic and 

traditional way, so my testimony will answer all of the questions throughout my testimony, so I 

appreciate that. Thank you. 

Dr. Aaron Payment, Chairperson of the Sault Ste. Marie Tribe of Chippewa Indians, we are the largest 

tribe East of the Mississippi. I'm thankful for the CDC for taking this affirmative step to enhance the 

CDCs Tribal Consultation Policy and I look forward to working with the Agency to create a policy that 

respects and reaffirms tribal sovereignty. 

But first to underscore the critical nature of our collaboration, let me share a few stark statistics. 

American Indian/Alaska Native health outcomes of either remain stagnant or become worse in recent 

years. As tribal communities continue to encounter higher rates of poverty, lower rates of health care 

coverage and less socioeconomic mobility than the general population. As US civil rights Commission 

addresses so effectively in this chapter in Chapter two of the Broken Promises Report tribal 

communities are already at substantial health risks, since the efforts of the Federal Government to 

uphold the trust and treating responsibility for tribal health has been so ineffective. On average, 

American Indian/Alaska natives born today have a life expectancy, that is five and a half years, less than 

the national average with some rural are geographically isolated tribal communities experiencing even 

lower life expectancy. In South Dakota, in 2014, the median age at death for whites was 81 compared 

to 58 for American Indians. This is about a quarter of a century difference for American Indians in life 

expectancy. Further, according to the CDC in 2017 at 800 deaths per 100,000 people American 

Indian/Alaska Natives have the second highest age adjusted mortality rate of any population. In 

addition to the highest uninsured rates, highest infant mortality rates, highest prevalence of diabetes, 

significantly higher suicide, and death rates; um, Hep C and also type two diabetes, chronic liver 

disease, and cirrhosis deaths. Further, while overall cancer rates for whites declined from 1990 to 2009, 

they rose significantly for American Indian/Alaska natives and so I’m going to leave the rest of these 

statistics for my written testimony, and I’ll get right into the responses to the consultation. 

So, strengthening government to government relations, tribal consultation is considered a necessary 

part of the federal treaty and trust responsibility. As President Biden stated in his presidential 

memorandum on consultation “my administration is committed to honoring tribal sovereignty and 

including tribal voices and policy deliberation that affects tribal communities. The Federal Government 

has much to learn from tribal nations and effective communication is fundamental to a constructive 

relationship.” President Biden also called on agencies to engage in regular meaningful and robust 

consultation with tribal officials in the development of federal policies that have tribal implications. We 

are eager to provide the government-to-government relationship between tribal nations and the 

Federal Government. While we recognize that federal agencies regularly conduct consultation, the 

notion that the consultation requirements are achieved by merely scheduling a time and sending 

personnel to hear concerns is neither substantive nor respectful of true government to government 

relationship. 

So, one request is prior to consultation engagement, it must allow for the heads of tribal governments 

to come together, share concerns, generate ideas and solutions, negotiate their roles and 

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responsibilities, and agree on a course of action. Federal agency should provide frequent opportunities 

for agency leaders and tribal leaders to engage in this manner. 

Respect for sovereignty, for tribal nations, should drive and frame every interaction between tribes in 

the federal government. The Agency should ensure that all agency officials and employees are educated 

on tribal sovereignty and the importance of the federal Indian trust responsibility; we call that “Indian 

101.” 

For consultation to be meaningful and robust tribal leaders should have regular engagement with top 

level political leadership, tribal consultation meets the president's criteria only when the top-level 

political leadership is available to tribal leaders before policy decisions are made. CDC should ensure 

that tribal leaders have regular opportunities to meet with the CDC top level political leadership. 

So, in improving accountability, as leaders of sovereign nations we anticipate and will rely upon 

accountability from all the agencies and specifically those that are responsible for helping to address 

the health disparities plaguing our communities. 

We acknowledged that Section G and E of the CDC consultation policy provide for performance 

measures and accountability and evaluation reporting. However, these sections lack any clear 

substance and only point to the corresponding section in the HHS Tribal Consultation Policy. This is not 

go far enough in mandating a thorough review of the tribal consultation and does not provide a 

mechanism for tribal leaders to track how the Agency is using their recommendations. True and 

meaningful consultation requires affirmative efforts from the Agency to demonstrate that our concerns 

are being heard, considered, and adopted. 

So, I would like to request, to facilitate accountabilities, agencies should at minimum issue a dear tribal 

leader letter after tribal consultation that details what was discussed, what tribal leaders requested, 

and follow up actions in response to those suggestions. This communication should invite critique and 

reflectively allow for modification to ensure that the tribes input was understood. 

Other mechanisms should explore and utilize to allow for improved communication and accountability, 

in addition to a follow up letter, for example, having federal agency partner report out in every meeting 

about prior recommendations would lead to an increased accountability and improved transparency 

This in turn would solidify the value and genuine commitment to substance to follow up. 

A report of all consultation activity TAC activity should be provided to the CDC TAC, the CDC director, 

and the HHS Secretary’s Tribal Advisory Committee, and the HHS Secretary. This report should also be 

published on the CDC website and distributed via a dear tribal leader letter. Far too often tribal leaders 

make suggestions but are never heard back from. We are left to wonder whether our time and effort is 

valued and our suggestions received understood and considered. Meaningful consultation is not 

possible without meaningful consideration, communication, implementation, and follow up. It should 

be required that the CDC address why certain suggestions were not implemented as part of the 

consultation. In any follow up mechanism used, the CDC should/must include a way for tribal leaders to 

inquire further of why their request or proposal was not incorporated or to suggest alternative 

approaches that may be mutually beneficial. 

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We also urge the Agency to survey tribal leaders to attend consultations to see if they were effective 

and how they can be improved upon in the future. Assessment of the efficacy of any effort can be a 

valuable tool to build buy-in, respect, ownership, and commitment. 

Tribal leaders have the right to invoke consultation whenever we desire, however many tribal leaders 

do not know of this right, and if they do, there is no clear method for requesting or to initiate formal 

consultation. The CDC consultation policy should prescribe a method for contacting the Agency and any 

timelines for response from the Agency. Providing tribal leaders with prescribed steps on how to 

initiate a tribal consultation and make clear this policy will go a long ways towards facilitating 

accountability. 

Next let's address informed tribal decision making. I understand that some situations call for quick 

decision making, but rapid consultation should be avoided at all costs, except in the most urgent 

situations like the covid19 crisis. Crisis planning does not typically produce good results for Indian 

country, rushing through a consultation exercise does not give tribal leaders enough time to research 

and prepare to discuss the issue at hand. Lack of adequate preparation time often results in 

consultations that feel like they are relegated to a check the box exercise, and not just simply learn 

from Indian country our concerns. Tribal leaders are leaders of sovereign nations and cannot be 

expected to be at the ready for a consultation on the short notice. 

In addition to preparation time, it also takes a lot of time for notices of these meetings to get to tribal 

leaders who are then expected to drop everything to quickly prepare with little or no prep. Tribes 

needed a degree of predictability regarding tribal consultations to operationalize preparation and have 

a mechanism to ensure that we have ample time to prepare. There is currently no prescribed timeline 

in the consultation policy, we believe that a uniform requirement will allow for both the degree of 

predictability and adequate time for tribal leaders to prepare. I urge the Agency to adopt a policy of 

requiring at least 30 days for consultation with limited exceptions for emergency items. The CDC is 

urged to move towards a consultation policy that encourages informed tribal decision making by giving 

tribal leaders ample time to prepare. 

So, communication methods, there are no requirements or standards around how the Agency should 

communicate tribal consultation to tribal leaders. Currently the policy states that the CDC will initiate 

consultation regarding the event through communication methods as outlined in the HHS Tribal 

Consultation Policy. However, section 8A of the HHS department policy on, Tribal consultation merely 

provides a non-exhaustive list of communication methods that the Agency can choose from. We urge 

that the agency to adopt a uniform requirement of sending a dear tribal leader letter to every, for every 

consultation, and mandate that the letter include all pertinent information in advance, so that we can 

be prepared. 

So expanded consultation participation methods, many tribes are small and do not have the resources 

to pay for travel for their leadership to participate in consultations. As we've learned through the 

pandemic it's possible and effective for consultations to be conducted remotely for tribal leaders to be 

engaged in that format. The ability to participate remotely expands the number of tribal leaders who 

may participate, which helps to ensure that the Agency is hearing from a broad cross section of tribal 

leaders from across the country. We request that the agency permanently expand the methods, 

through which tribal leaders could participate in tribal consultation. While the Agency should resume in 

person consultations when it's safe to do so, they must also ensure continue to provide an option for 

tribal leaders to participate remotely and virtually as we're doing today. 

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So tribal technical assistance and I'm just about done, the CDC engages tribal leaders from the start. If 

we engage from the start, it should make for a more fruitful consultation process. The CDC should not 

wait until we have a formulated policy or regulation before asking for feedback from Indian country. 

The CDC tribal advisory committee can be as an essential tool in the consultation process, but not as a 

substitute for consultation. We urge the Agency to begin engaging the TAC early in the policy and 

regulatory making process, so any proposed policy can be tribally informed from the start. 

Tribal advisories or TAC should be used by the Agency when formulating policy because TACs are the 

best conduit through which the CDC can receive technical assistance that is tribally informed and 

representative of the various regions in the country. 

We also urge federal agencies to consider expanding the use of listening sessions during early stages of 

policy development to hear directly from tribal leaders. 

Tribal organizations such as the National Indian Health Board and the National Congress of American 

Indians are routinely consulted by tribal leaders in preparation for TAC meetings and tribal 

consultations and so we're asking to more formally institute that and provide for funding that for that 

continuation. 

Finally, my written testimony is much lengthier and fully articulated pragmatic steps, covering a more 

holistic comprehensive adaptive and reflexive approach to ensure substantive input and participation 

from tribes in the federal outreach that impacts tribal nation and the lives of our respective tribal 

citizens. In my written testimony I include an appendix which details a reflexive conceptual framework 

to give a visual representation of when the process of policy formulation or decision making occurs, 

whether it's conceived by the Federal agencies or requested by tribes, then provide for a preliminary 

draft to be explored through listening sessions, formal consultation, with supplemental guidance from 

tribal advisories, confirmed or refined through reflective review and consent tribes, and finally, as 

drafted as policy or action planning with assessment and evaluation to follow. 

So that was what I have to share with you today. I look forward to submitting my written testimony for 

you and I will wait around for any questions if you have after others testify, thank you. 

Bryan Warner: Thank you, Dr. Payment, much appreciated. So, Captain, do we have anyone else that 

has raised their hand? 

Karen "Kari" Hearod: I am scrolling through. 

Bryan Warner: Okay, we have Verne Boerner. 

Karen "Kari" Hearod: Yes, and, also, Nate Tyler had his hand up a little bit earlier. 

Verne Boerner: And I will defer to Nate Tyler if he had his hand up before me. 

Nate Tyler: Yeah, I’d like to allow Vice Chairwoman Marilyn Scott from the Upper Skagit Indian Tribe to 

go in front of me. 

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Marilyn Scott: Oh, this is Marilyn Scott, can you hear me. 

Bryan Warner: It’s fair. 

Marilyn Scott: Thank you so much for the opportunity to provide comments on the CDC consultation 

policy. My name is Marilyn Scott and I’m Tribal Vice Chair of Upper Skagit Indian Tribe in Washington 

state and I just want to provide some comments on the questions that were presented before the tribes 

to provide comment on and I support all of the comments that Dr. Payment that has already shared with 

the Agency. And wanted to just share some recommendations, in addition to some of the things that 

was already discussed around not having enough notice time and making sure that there's the 

opportunity for tribes to be prepared for consultation, and on what issues and concerns and topics that 

the Agency has that want the tribes to comment and consult on. 

But one of the things I think is so important for us as tribes, with the Agency, is to have the Agency 

consider developing sections within the policy that would establish objectives formalizing the CDC 

policy and seeking consultation and participation of tribes in the development of policies, program, and 

research activity that impact tribes. The agency's responsibility does involve research activities and 

when research is done within tribal communities or if data is being submitted by tribes it's expected 

each tribe has its own policies and program policies that direct how that data and research is handled 

within our tribal community. So, I'm hoping that the Agency will consider establishing specific 

objectives that could be met within the policy. And also, just having a minimum set of requirements 

and expectation, with respect to consultation and participation with the administration within and the 

management policies within CDC. 

I would also like to see that there is an established communication channel with tribes and tribal 

organizations to increase the knowledge and understanding of the CDC programs and funding 

opportunities and priorities. 

Thank you so much, and we will be submitting from the Portland area and the tribes within the Portland 

area written comments for the policy. 

Bryan Warner: Thank you, Ms. Scott. Okay, captain, who did we have next? Is Mr. Tyler? 

Nate Tyler: Okay, Nate Tyler, Makah Tribe, Makah Tribe Council, Portland area representative. So, I 

appreciate the opportunity to provide recommendations on improving the consultation policy through 

the CDC. 

Northwest tribes look forward to working with the CDC closely to improve government-to-government 

relationship and in fulfillment of trust and treaty obligations. As we returned to meet in person, we 

asked that the CDC continues to include a virtual meeting option for travel consultation and TAC 

meetings. We've seen participation increased significantly with the option for us to participate and 

vote virtually. 

We are concerned, however of how the CDC has announced this important tribal consultation on their 

consultation policy. To my knowledge CDC announced this consultation through the Federal Register, 

and not through dear tribal leader letter that was widely distributed amongst the tribes. The current 

Tribal Consultation Policy requires agencies to use all appropriate methods to provide official 

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notification, including mailing, broadcast, email, Federal Register, and other outlets. We recommend 

that any tribal consultation official notification to be complete through a dear tribal leader letter that is 

widely broadcast through the TAC listserv and any other travel listserv CDC maintains. All these letters 

should be posted on the CDC tribal web page, any CDC associated social media streams, and tribal 

partner agency. 

Coordination includes the Indian Health Service and other HHS divisions. 

And on behalf of the Makah Tribe, we're going to also submit our written testimony. And we fully 

support what the Chairman had stated leading off on this consultation; so, appreciate the time, thank 

you. 

Bryan Warner: Thank you. 

Karen "Kari" Hearod: Sir, I believe, next is Mrs. Boerner, or Ms. Boerner. 

Verne Boerner: Sorry, I’m trying to unmute and get my video started. 

Bryan Warner: There you are. 

Verne Boerner: [speaking in indigenous language] Good morning, it is good to be here with you. My 

Inupiat name is Qaanaaq I am enrolled tribal Member with the Native Village of Kiana. I am the 

President and CEO for the Alaska Native Health Board. My English name is Verne Boerner. I am honored 

to join you all here today. I would like to thank you, Dr. Montero and deputy, Deputy Chief Warner for 

hosting today's tribal consultation. I'd also like to extend my thank you to the leadership at CDC and our 

brother and sister tribes across Alaska and the lower 48. 

We are thankful for Executive Order 13175; the Alaska Native Health Board was established in 1968 as 

the unified voice for Alaska native tribes on health. In Alaska we have 229 federally recognized tribes. 

That is 40% of all tribes in the United States. We are dispersed over 660,000 square miles and where 

80% of our communities are off of the road system and depend solely on air and or boat to gain access 

to the communities. Those communities are in effect islands with some of our communities need into 

fly distances equaling those flying from California to Kansas to see a general family practitioner or 

physician. 

Given these extreme conditions, the 229 tribes have taken innovative approaches that truly should and 

must be recognized by the Federal Government as a successful model. The Alaska tribes, those 229, 

have done something quite unique in the United States, they banded together to create the Alaska 

tribal health compact, a single compact negotiated with the Federal Government for healthcare 

services meeting the federal trust responsibility. With that they have been able to create a true system 

of care. That we commonly and proudly refer to as the Alaska tribal health system that system provides 

care the hub and spoke model across the entire state and includes referral patterns, data sharing, and 

resource sharing overall. 

As I share, ANHB has been created to be the voice of, the united voice of the Alaska tribal health 

system, we do not speak on all issues, but we do raise those concerns that tribes have come together 

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and highlighted as their unified positions. We do not supplant tribal sovereignty, we raise it up and we 

celebrate it and we encourage input from the local levels on, to the region's into the state levels. 

With 229 tribes coordination has been the core aspect of being able to develop and create the Alaska 

tribal health system. And some of the recent interactions with regards to how do we strengthen Tribal 

Consultation Policy and process to ensure CDC/ATSDR responsiveness engaging with Indian Country in a 

meaningful way you must look towards those systems that tribes across the nation and across the areas 

have created in order to communicate with the Federal Government. We need to be informed of of the 

meetings that are being brought forward to us, the consultation evens but also included with the 

materials that, that are presented to the TAC. We need that, that transparency with the tribal health 

organizations across the nation. And limiting the TAC to the input to the single individual on the TAC, in 

Alaska’s case, would silence the other remaining 228 tribes in Alaska. And a recent example of the 

challenges that we had faced, due to term expirations, Alaska did not receive the proposed or the, the 

Charter, where CDC was seeking input on any updates or changes to the Charter for the TAC because 

we did not have an active individual. Not because that person wasn't nominated, but because the 

process had not gone through just yet. And therefor for the initial release of that to provide input on a 

fundamental document Alaska did not have that opportunity to do so. 

Individuals do not necessarily, do not have the capacity that particularly in Alaska to help with the 

information dissemination and we depend on statewide organization, such as the Alaska Native Health 

Board, the Alaska native tribal health consortium to help disseminate information and these entities, 

need to be involved with the communication and efforts in order to improve engagement with regards 

to tribal consultation overall. 

So, with regards to communication outreach, we need to ensure that these organizations have a point 

of contact with CDC so that we are able to share those; we agree with the statements that have been 

put forward with regards to issuing dear tribal leader letters and I'm looking at the next questions here. 

I just wanted to highlight and one other area where utilization of the infrastructure and capacity that 

tribes across the nation have built over many decades. In looking at the vaccination efforts for the 

COVID-19 pandemic, utilizing and implementing the sovereign nations or tribal allocations was a true 

paradigm shift and allowing, allowing tribes to utilize their existing structures, their existing 

infrastructure, to help get out the vaccine and a meaningful and lifesaving manner, we advocate that; 

that capacity structure and those communication lines be honored and included, not just in pandemic 

response, but in all areas and aspects of health promotion, disease prevention, surveillance and 

research. 

And with that I'd like to say thank you again. And I do hope that Dr. Montero and Deputy Chief Warner, 

you consider joining us when it is safe to tribal again up in Alaska; Dr. Montero I know that you've been 

up here, but we would definitely like to welcome you back. Thank you. 

Bryan Warner: Thank you, ma'am, and great comments and very well received, but well taken, so thank 

you. And I would love to come up and visit anytime. 

Next up, I believe we have Jennifer Webster. Is that correct, Captain? 

Karen "Kari" Hearod: That's correct, sir. 

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Bryan Warner: Okay, Jennifer, you're up. 

Jennifer Webster: Good afternoon, can you hear me? 

Bryan Warner: Yes, ma'am, okay. 

Jennifer Webster: [speaking in indigenous language] My name is Jennifer Webster. Good afternoon, I'm 

a Council member from Oneida Nation in Wisconsin. We are located just outside of Green Bay with 

about 17,000 members worldwide and about 5000 Members on or near the reservation here. 

Thank you for this opportunity to share our needs with you today. With the new Director of OTASA 

there's an opportunity to bring about positive change and build and strengthen the relationship 

between CDC and tribal nations. With the COVID crisis and the new variant, it's critical that CDC 

engages with tribes, maintains a strong relationship in order to work towards addressing the current 

public health challenge. 

CDC’s track record and working with tribes demonstrates the need for improvement. As quoted in a 

recent 2021 publication from the former director TAC members have raised concerns on how CDC 

engages with tribes and request process improvements, such as the need to provide input earlier in 

project formulation and the need to reach out to tribes for feedback. Tribes need the option of 

consulting on current large projects, new initiatives, and policies because there's been a lack of 

transparency and how decisions get made. 

Tribal leaders have consistently requested that dear tribal leader letters be sent out rather than 

announcements through the Federal Register, and I think everybody's mentioned that already. It 

appears that CDC engages in box checking regarding consultation, in other words the lowest form of 

effort is taken so that the Center can claim that consultation occurred. There also needs, there also 

needs to be, need to build and maintain trust, repair past relationships between CDC and tribal nations. 

So, our specific ask, we request or report on the status of the tracker tribal leaders request and how 

CDC has responded. We would like this to be presented to the TAC and have a report also sent to STAC. 

We request that CDC create a crosswalk table that shows budget allocations and processes; table with 

CDC appropriations and line item; how much has gone to tribes; and if states are expected to work 

with tribes, the distribution, of how much actually went to tribes; how does internal applications align 

with tribal priorities and request through consultation - including details such as when the tribal leaders 

provide consultation on the issues, the programs, and the project; which mechanism formula -

cooperative agreement or contract. Given that tribes have requested the formula funding, 

programming evaluation and research; topic areas of funding, such as COVID, opioids, diabetes, 

childhood adversity - how and who made the decisions and include the three most recent years and the 

upcoming fiscal year. 

For COVID funding, include relevant funding that has gone the IHS, either directly or through an 

agreement with CDC which might otherwise have gone to CDC or other governments; what are the 

plans for tribal spending for the upcoming fiscal year or fiscal year 2020 budget, how much how much 

goes to the tribes, TECs, and other tribal evaluation, research, and programming. 

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We see a major increase in opioid and community violence dollars, we would like to see that at least 5% 

is set aside for times, regardless of if it's an allocation within the legislation. 

Request opportunities consult on recent activities and have dear tribal leaders’ letters go out. 

The CDC Center for State Tribal Local and Territorial Support has awarded funding, $2.25 billion, to 

public health agencies none the tribal public health. So, we're not sure if there was a similar notice of 

funding opportunities for tribes. $800 million was appropriate for data modernization, need for 

consultation, and how this impacts public health infrastructure for tribes and TECs. 

So, with that we'd like to thank you and we will also submit our writing as well to the CDC. Thank you. 

Bryan Warner: Thank you, ma’am, very good. Looks like we have Mr. Daniel Preston. 

Daniel Preston: Okay, let me start my thing here. I thank you; my name is Daniel I’m a Councilmember 

of the Tohono O’odham Legislative Council, and I represent the San Xavier District. And so I guess my 

comments encompass 1-4, not specifically, but you know I echo the same, or we echo the same 

sentiments the comments as Chairman Payment and the rest of the tribal leadership that that had 

spoke. 

We are 35,000 in population, we also have a high prevalence of diabetes and the majority of our 

communities, our rural. And access of services are limited due to access of care, and so we have to work 

within the bounds with what we have. 

And, just to be aware that on Tohono O’odham Nation government has a process and this process 

involves the executive office and the departments to offer comment and recommendations. 

And then goes to the, the legislative committee oversight, the respective oversight then on to the 

Legislative Council to ratify through resolution and is a joint effort. I'm sure there are other tribal 

nations that have their own process but, sufficient time to respond is recommend it from any federal 

agency in regards to tribal consultation. This resolution also requires determine signature after the 

passage of legislative resolution, just as Mr. Payment has mentioned that ample time as needed. I also 

agree that the dear tribal leader letter is a, it is a official outreach to tribal nations and that seems to 

work a little bit. And I understand that it's good that this administration is advocating for that executive 

order. And then also part of our process is the Chairman of Tohono O’odham Nation is the official 

spokesperson of the Tohono O’odham Nation whether he designate somebody but, and again I know all 

tribal nations are very busy, especially during this pandemic time and also yourselves at the federal 

level are very busy, so I think that coordination needs to be better coordinated, so we can be able to 

voice our thoughts our recommendations and our comments, I do have my fellow my colleague 

Councilwoman, Vivian one Sanders on the line; I'm not sure if she would like to add to any of my 

comments that I made here, if that is allowable at this time. 

Vivian Saunders: Not at this time, thank you, very much appreciate Councilman Preston’s comments, 

thank you. 

Daniel Preston: Okay, thank you very much for listening to us and having this virtual meeting. That's it. 

Thank you. 

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Bryan Warner: Thank you, Mr. Preston, much appreciate it. And next we have Dr. Jill Jim. 

Dr. Jill Jim: Ah yes, good afternoon, I'm Dr. Jill Jim. I'm the authorized representative for Navajo Nation; 

I speak on behalf of on President Nez and Vice President Lizer, they're not available to attend today. So, 

I just want to reiterate some of the comments that we provide it to the Department of Health and 

Human Services. 

And regards to the same questions I think one thing that we wanted to just kind of be consistent about 

is just because of the various tribal consultation policies that were asked for to kinda streamline some 

of these expectation across all the agencies under DHHS and so basically to strengthen our tribal 

consultation policies to engage in a meaningful way, that the division meaning the CDC must be 

transparent and accountable. 

There are several parts of the current policy again that require reporting on the outcome of 

consultation and by sometimes we don't always see that happening so would be good for CDC to 

summarize the type of comments they receive and explain how to adopt policy with amended or to 

address these concerns. Um, as well so along these lines, and also [inaudible] to listen to the tribal 

concerns, but they must be incorporated into the final product. 

For in, I think there's some examples that we had for Indian Health Services but I think that the CDC 

similarly this looking at incorporating our recommendations and into any sort of policies that are being 

decided on. And then additionally consultation must not be an afterthought so engaging in a 

meaningful way is often not possible when it's when it's reduced to soliciting input after the fact, so in 

order for there to be true, respect for the government-to-government relationship tribes must be at the 

seat. And to have a seat at the table, this means tribes must be included agency decisions that have 

significant impacts for tribes. So, I just wanted to just express some of those comments that we have 

provided for to the Department of Health and Human Services in regards to that same question, thank 

you very much. 

Bryan Warner: Dr. Jim, Thank you. Okay, before moving on to the next question, Captain, I just want to 

do a little bit looking around and make sure that we've gotten everyone's comments. 

Karen "Kari" Hearod: I see no more raised hands. 

Bryan Warner: Okay, well, I want to thank you for those comments on question one, and I, you know, 

just sitting here listening and thinking back, ample time to prepare a Dear Tribal Leader Letter; you 

know, using other outlets, besides the ones, I think it starts to help summarize, but we will wait for Dr. 

Montero to do that momentarily. 

Now I'd like to open up the floor on comments on the second question, which reads, how do we 

improve communication and outreach regarding agency policy or program changes that impact tribal 

nations? Again, how do we improve communication and outreach regarding agency policy or program 

changes that impact tribal nations? 

And we will open the floor to that question, so, show of hands and we'll get started. 

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Dr. José Montero: Mr. Chairman, quick comment, I know that many of you already answered all four 

questions. When we look at the notes and do our assessment and analysis, we will break it down, so we 

can put it in the right sections. Don’t feel that you have to tell us again, but if you want to add 

something specific that came to your mind after you leave your initial testimony, please feel free to do 

so. All that input is point valuable. Thank you, Sir. 

Bryan Warner: Thank you. Any show of hands? Well, I can kick us off real quick, well, Dr. Jill, it is, I will 

defer to you, ma’am. You have the floor. 

Dr. Jill Jim: Thank you once again to CDC and other leaders on the call. I just wanted to just reemphasize that in regards to just the improving communication and outreach regarding policy or 

program decisions, and one thing that we're recommending is that some type of consultations or 

policies or team does require only a little preparation, but others requires significant amount of time to 

adequately research the issues and prepare to give a formal informed advice. Ideally, we should, this 

should be brought up in the process of the beginning, as soon as the agency begins to consider any 

policy changes or program changes in and long before any proposals are solidified so that way we can 

begin researching the issues at the same time as the federal agency and to be better prepared to 

provide input and effectively engage in the Tribal Consultation Policy or process. So, agencies should 

allow for discussion and feedback through appropriate tribal leaders committees and advisory meetings 

such as this group so, that would just be in regards to having an effective communication process, and 

that would just end my brief comment regarding improving communication. Thank you. 

Bryan Warner: Thank you. All right, Boerner. 

Verne Boerner: Thank you, can you hear me? 

Bryan Warner: Yes, well. 

Verne Boerner: I think the only thing that I would like to add to this in considering what programs have 

a direct impact on tribes and tribal health organizations. I would just like to encourage the agencies to 

keep an open are flexible or broad mind and considering this. We already know that Alaska Natives and 

American Indians suffer some of the highest disparities in the nation, and not all programs have or are 

listed as with tribal set asides. So, the tribes or tribal health board brings an issue to CDC we 

recommend, ah we request, that the agency be responsive to those requests for consultation, when we 

identify that our programs are being directly impacted by a change, a programmatic change. 

Bryan Warner: Thank you. Anyone else? 

Well, I’ll give it a shot. I am Bryan Warner Deputy Chief of the Cherokee Nation. And in regards to 

question two, I believe the CDC should maintain an accurate and updated email list of tribal leaders and 

tribal contacts, for every federally recognized tribes in the nation with various national and regional 

tribal organizations, and tribal epidemiology centers to ensure that information is properly 

disseminated with ample time for tribes prepare and submit written or oral comments. The past year 

and a half has shown us how underserved and unprepared public health infrastructure in Indian country 

is. Any updates from CDC regarding policy changes or consultation are vital to ensure the health and 

well-being of all Native American and Alaska natives and that we as Indian country are following the 

most up to date policies and procedures to keep our Community safe. 

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CDC should share with tribal leaders any public leadership opportunities to strengthen tribal public 

health and share the importance of tribal public health to those national organizations who look to the 

CDC for guidance, such as the NACCHO, ASTHO, and NNPHI. CDC should also work with the TAC to 

address the barriers that the TAC members are experiencing regarding fully utilizing technical assistance 

from their tribes in these discussions. That the complexity of public health issues aren't able to be 

addressed by one technical advisor to cover all 21 CIOs and their process and the TAC member must 

end the process that the TAC member must go through to allow their Technical Assistant representative 

to speak to be simplified by looking at other HHS TACs address the issue. 

We also note that, while the TAC is a valuable resource for collecting and collaborating with Indian 

country it is never a replacement for travel consultation, thank you. 

Any others? Captain, do you see any other hands? 

Karen "Kari" Hearod: I don't see any other hands. I wonder if we should ask if anyone is on their phone 

if they would like to make a comment at star six to unmute. Also, after that I believe Lauri Hayward has 

her hand up now as well. 

Lauri Hayward: Hello, can you hear me? 

Bryan Warner: Yes, ma'am. You’ve got the floor. 

Lauri Hayward: Yes, I was just my name is Lauri Hayward I'm from northeastern California, Pit River 

Nation. I am the Board of Director, Pit River Health Services, chair lady. I just want to echo out that I 

hear your comments regarding TAC. Here in California, we have over you know we have 110 federally 

recognized tribes and then looking at Alaska, and we don't there's not enough TAC members to meet all 

the needs or to represent our areas our regions, because in the other ones there's more. And then 

there's not enough to be able to voice what it is that we want represented at the tables or through 

Consultations. 

So, I just wanted to echo, make that comment and echo that behind the person that had just previously 

spoke. Excuse me but I'm in traffic, and so, for that I also wanted to just tell you all that, thank you for 

these webinars and these times. I know it's been you know the past couple years have been really, a lot 

of work, just to go into all this, so I just wanted to express that. And as far as the broadband, yes, we 

live in a rural area and snow is pretty in the winter and it's very hard to get in and out, over the 

mountain and things like that, but we also you know, could use assistance in Tele health and all those 

other things that require broadband and so forth. So, I just wanted to say thank you, I appreciate you all 

and be safe. 

Bryan Warner: Thank you, anyone on the phone that would like to make a comment on question two, 

please hit star six and you will unmute and we will give you the floor. 

Okay, all right, well, thank you for those comments on question to I will now prepared open up the floor 

for comments on the third question, which reads, “Are there specific areas where tribal officials would 

like more information or feel they're not getting adequate outreach to engage in a meaningful way?” 

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And, and, before we open this up, I will say that on the TAC, we've had a subcommittee that's been 

working quite some time, for I call it a playbook, but it's a resource guide on all the CIOs; and we've also 

had a recent funding profile that was sent to us for FY 2020. So these, hopefully, these are some of the 

things that will help with the outreach, give you an idea who these folks are maybe to forge a 

relationship where we can get some of that meaningful robust consultation moving down the road so 

with that I open the floor to question three. 

Anyone? Reminder, on the phone, star six to unmute, and we will give you your time. 

Nate Tyler: I’d like to add a few more things. Nate Tyler, Makah Tribe, Makah Tribe Council, Washington 

State. As a representative of the Portland area, we, I know we have a number of reps on the on the call 

here. A couple other things I'd like to add, is for the CDC to compile comments and recommendations 

raised here and regional consultations for the TAC to review and consider. Coordinate with the Indian 

Health Service and HHS deviations on issues of mutual concern and anything that does affect us one way 

or another. And to charge and hold responsible all levels of management within CDC and its institutes 

and centers for implementation of this policy. 

And like I stated, Makah tribe will submit written testimony appreciate it. 

Bryan Warner: Thank you, Mr. Tyler, much appreciate it. Any more for question number three? 

Bryan Warner: Okay, well, thank you for those comments on question three. I’ll now open up the floor 

for comments on the fourth question, which reads, “How do we improve tribal consultations? And it's 

kind of a two-parter. Should we have sessions every year? So how do we improve tribal consultations, 

and should we have sessions every year? 

Okay, Ms. Marilyn Scott, you have the floor. 

Marilyn Scott: Yes, thank you so much. I'm sorry, my video is not connecting up. My connection is not 

very well, so sorry I'm not able to put my video up. 

I wanted to just add additional comments with regards to the importance of having a working group 

possibly of the tribal advisory committee that would be responsible for reviewing comments and 

recommendations to the consultation policy and possibly assist the administration in drafting 

consultation policy to present to the tribes through the consultation as part of the consultation 

coordinating with some of the other divisions, because each division has consultation policies, but in 

some cases that works better for tribes if we have collaboration and consultation jointly between 

divisions of the Agency. 

I know that we have our regional consultation with HHS happens annually, but at the same time, some 

of the issues that we tribes need to consult with crosses over between divisions within HHS and, and at 

times it works better, if we have joint consultation sessions, possibly with CDC and Indian Health 

Service as a, as an example at times especially now, with the pandemic sometimes issues that we have 

crossover between the Indian Health Service and CDC so we're trying to address some of the policies for 

the public health and how we're establishing jurisdictions and policies within Indian country within our 

communities, because we serve not only our tribal members and other natives but also other citizens 

that live within the borders of our reservation. So, I think it's important that we have consultation 

between the agencies in some cases like that. And I submit this comment with the recommendation 

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that we also possibly consider having the Agency established better coordination between the tribal 

Advisory Committee and tribal governments, in addition to the consultation. And I thank you again, 

[speaking in indigenous language]. 

Bryan Warner: Thank you, Ms. Scott. Anyone else on question four? Star six to unmute if you're on the 

phone. 

Okay, well, I will. I am Bryan Warner, the Deputy Chief of the Cherokee Nation. I will be brief, but I 

believe the CDC must conduct regular meaningful consultation whenever considering any rule or 

decision making, that will affect Indian country. Consultation should not happen on a strict timeline 

rather it should occur anytime CDC develops policies that have an impact on tribal communities. 

Additionally, CDC must incorporate the information and feedback shared during consultation into the 

final rulemaking to ensure the concerns and questions from tribal leaders are addressed, although. 

And do I have anybody on the phone that would like to unmute? 

For the final question, I will say this has been a very good listening session. I’d like to thank all the 

individuals that have spoken up on behalf of not only their tribe, but the entirety of Indian Country, which 

is very important as we all move together. So, if I have no further comments on the question, I will return 

the floor back to Dr. Montero so that he may use this time to summarize testimony heard during this 

meeting. 

José Montero: Okay, let me see if I was able to unmute myself. 

Bryan Warner: You are good sir. 

Dr. José Montero: Okay, thank you. Thank you, everybody. For those of you on the call, before I on into 

summarize, and I want to highlight, we have many members of CDC’s senior leadership team present. 

There have been many more present at different times of the testimony. As I said earlier, we had Dia 

Taylor, our Chief Operating Officer, we have Les Dauphin, who is our Director for CSELS [inaudible], Dr. 

Karen Remley, who is the Director for the National Center for Developmental Disabilities and Birth Defects, 

we have Dr. Hacker from the National Center for Chronic Diseases. We have Dr. Pat Breysse from the 

National Center for Environmental Health. Those are the ones that I can just see. I may be missing some or 

missed some who made it during the session. So you know that in addition to Dr. Nate Smith and myself, 

there are several other senior leaders here listening to this consultation session. 

So, I am going to follow Chairman Payment’s example. I am not going to go try to summarize what I heard 

question by question but trying to do it in a global systematic way. So, I heard that we need to improve the 

way that we plan and communicate for these sessions, that it has to be a multi-lever approach for the way 

that we invite, make notice, and include the tribal communities on this, that we should have Dear Tribal 

Leader Letters that are part of that communication Process. That as we review and think about our own 

policy, we need to make sure that we have mechanisms for collecting the feedback and providing clear 

reports to the general tribal community to, annual, or whatever the appropriate frequency of Dear Tribal 

Leader Letters is. At the same time that we do that, and include that, with our Tribal Advisory Committee, I 

heard the suggestion to have, within the Tribal Advisory Committee, a subgroup that looks at these issues, 

that looks at the recommendations, and that receives those different reports. 

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Everything has to have proper time. There are different levels of complexity in the different topics that are 

addressed by the consultation process; some of them require way longer time of prep. 

So, the tribal leaders have the time to be briefed on the implications and come to CDC with proper 

recommendations and prepare in a way that they feel confident on that. 

CDC leadership should be present to hear tribal testimony. Actually, that's part of what I highlighted, the 

leadership that we have present today. 

I heard that we should ask the tribes of what topics as well because there may be topics that are impacted 

by things that we didn't anticipate, so it's not just unidirectional from CDC but looking at what the tribes 

have to tell us. There should be a standardized way to follow up on items and recommendations. 

I heard that we should have some interaction and streamlining through HHS policies because there are 

different approaches to consultation policies. At the same time, I heard that we should have, or should 

consider, different OPS, sorry that's a technical term within HHS, different divisions or groups within HHS 

having joined consultation sessions, depending on the topic. 

I hope that I didn't miss any of the big, big, big components. People are quite satisfied with the virtual 

options and hope that after we come back to times of live meetings, we maintain the virtual option that 

has facilitated and increased participation for tribes and tribal members. 

Mr. Chairman, I think that that's what I have in my notes. You know I went to medical school; my 

handwriting is not that good. I cannot read some of my sketchy notes here, so I promise that we will get 

back and get a more clear summary of this after we get the written testimonials. 

Bryan Warner: Thank you, Dr. Montero. I want to thank you and Captain Hearod for being here. And Dr. 

Smith, thank you, sir, for being here and listening, and thank you to all the tribal leaders and tribal 

members across Indian Country. It's very imperative that we do our due diligence. There is talent that has 

been put in each and every one of us, that is specific to us, and thanks be to God for that talent, but it's 

our own diligence will what see that talent through, and of course the many blessings of our Father. 

Again, I want to thank you for giving me this opportunity. I too, as Dr. Montero, I have much chicken 

scratch, so sometimes or I forget or can't read my own writing, so I think it's just a sign of somebody that's 

trying to listen and get everything down. And do the right thing, and that's the option there, that's the only 

option that we have, is do the right thing for Indian Country. And I believe that wholeheartedly, that 

everybody that's here that's commented on the chat or in person has that their heart put in the right spot. 

And I, and I feel a lot of balance with this group between logic and emotion. So, in order to, we've come to 

the end, so I want to close this out, but I offer everybody, I want to start this prayer, and then I’m going to 

go into the Lord's Prayer. So, if you want to join me, in the spirit of being together, we will join in prayer 

now. 

Your heavenly Father, Lord, we thank you for this time this precious time that you give each and every one 

of us lord. Thank you for all the blessings, thank you for the extra measure of mercy and grace that that we 

do not deserve it, yet it's that extra measure that we can give to our brothers and sisters that help us let 

your light shine through us Lord. Lord, I thank you for the day that you put before us. I pray that you help 

us have safe traveling graces as we go home. Put a hedge of protection around our families, Lord, and 

thank you for the prayer that you give each of us our father who art in heaven. Hallowed be thy name thy 

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name. Give us this day our daily bread and forgive us our trespasses as we forgive those who trespass 

against us. And lead us not into temptation but deliver us from evil. For thine is the kingdom and the 

power and the glory forever. Amen. 

I want to again have one more chance to turn this over to Dr. Nathaniel Smith if for any parting comments, 

sir. 

Dr. Nathaniel Smith: Thank you very much. I want to thank all who spoke with wisdom and clarity and also 

thank all those who were listening carefully and work together to help improve the tribal consultation 

process. I heard also clearly the need for accountability in this process, and a continual assessment of the 

effectiveness of the tribal consultation process. So, thanks to all who spoke, all who listened, and those 

who will do the hard work, as we move ahead. This consultation session is now officially adjourned. Thank 

you very much. 

Unknown Speaker: Thank you. 

Dr. José Montero: Thank you, sir. Thank you, everybody, thank you 

************************************************************************************* 

CDC/ATSDR Tribal Testimony Chat Comments: 

Daniel Preston: Just to be aware, the Tohono O’odham Nation government has a process. This process 

involves the Executive Office and the Departments to offer comment and recommendations and then 

goes to the oversight Legislative Committee then onto the Legislative Council to ratify through 

resolution and is a joint effort. I’m sure there are other tribal Nations that have their own process but 

sufficient time to respond is recommended from any federal agency in regards to tribal consultation. 

Thank you. 

Daniel Preston: This resolution also requires the Chairman’s signature after the passage of a legislative 

resolution. Just as Mr. Payment has mentioned that “ample” time is needed. 

Melanie Fourkiller: On behalf of Choctaw Nation -- We agree with the statements made by other Tribes 

regarding proactive and participatory Consultation with Tribal governments, as well as direct 

communication to Tribal Leadership via DTLL on consultation activities. Federal register notices, as is the 

practice with public stakeholders, is not sufficient to engage in Tribal Consultation. Consultation requires 

a mutual dialogue and deliberative process that is not achieved through Federal Register notice and 

comment. Additionally, Tribal Consultation requires honoring the government-to-government 

relationship between the U.S. and Tribal Nations, which means moving away from a competitive grant 

making practice to rather providing recurring, consistent funding to Tribes as Public Health Authorities 

on the same basis as states. The urgency for addressing this has been made very clear during the public 

health emergency - to directly fund Tribal Public Health capacity on a recurring basis. Thank you for the 

listening session. 

Jennifer Webster: Oneida also supports having technical advisors and subject matter experts available 

and easily accessed during meetings. 

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Testimony provided by: 

Aaron Payment, EdD, EdS, Med, MPA - Tribal Chairperson, Sault Ste. Marie Tribe of Chippewa Indians 

Marilyn Scott - Tribal Vice Chairwoman Upper Skagit Indian Tribe; Upper Skagit Indian Tribe 

Nate Tyler - Council Member Makah Tribal Council; Makah Tribe 

Verne Boerner, MPH - President/CEO Alaska Native Health Board; Alaska Native Health Board; Native 

Village of Kiana 

Jennifer Webster - Councilwomen Oneida Nation Legislative Operating Committee; Oneida Nation 

Daniel Preston - Legislator San Xavier District, Tohono O’odham Nation; Tohono O’odham Nation 

Jill Jim, DrPH - Executive Director of the Navajo Department of Health, Authorized Representative, 

Navajo Nation 

Lauri Hayward - Board Chairperson, BOD for Pit River Health Services Inc.; Pit River Tribe 

Melanie Fourkiller - Authorized Representative, Choctaw Nation 

****************************************************************************** 

30 
CDC/ATSDR’s Tribal Consultation on CDC/ATSDR Tribal Consultation Policy 

August 5 – September 7, 2021 

Written Testimony 

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Aaron A. Payment, 

EdD, EdS, MEd, MPA 

Office of the 

Tribal Chairperson 

523 Ashmun Street 

Sault Ste. Marie 

Michigan 

49783 

Phone 

906.635.6050 

Fax 

906-632-6829 

Email 

aaronpayment@saulttribe.net 

FaceBook 

‘Aaron Payment’

Dr. Aaron Payment, Chairperson 

Sault Ste. Marie Tribe of Chippewa Indians 

Testimony for Consultation Between The Tribal Nations and 

Centers for Disease Control and Prevention / Agency for Toxic Substances 

and Disease Registry 

Regarding 

CDC/ATSDR Tribal Consultation Policy and Process 

(Tribalsupport@cdc.gov) 

August 5, 2021 

BiiWaagajiig, n'dizhnikaaz. Kina Baawaa'ting Anishinaabek Omaa go nda Onjikida. My name is Aaron Payment. As the elected Chairperson of the Sault Ste. 

Marie Tribe of Chippewa Indians ("the Tribe"), I am submitting testimony on behalf 

of my Tribal Nation. This Testimony is in response to the Centers for Disease 

Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry 

(ATSDR) request for comment regarding how it can improve its Tribal consultation 

policy and the public health issues impacting Tribal nations. 

Over the course of a Century, sovereign Tribal Nations and the United States signed 

over 350 Treaties requiring the federal government to assume specific, enduring, 

and legally enforceable fiduciary obligations to the Tribes. The terms codified in 

those Treaties – including for provisions of quality and comprehensive health 

resources and services – have been reaffirmed by the United States Constitution, 

Supreme Court decisions, federal legislation and regulations, and even presidential 

executive orders. These federal promises – which exist in perpetuity - collectively 

form the basis for what we now refer to as the federal treaty and trust responsibility. 

During permanent reauthorization of the Indian Health Care Improvement Act, 

Congress declared within the law that, “...it is the policy of this Nation, in fulfillment 

of its special trust responsibilities and legal obligations to Indians . . . to ensure the 

highest possible health status for Indians and urban Indians and to provide all 

resources necessary to effect that policy.

1 

The United States owes a special duty of care to Tribal Nations, which animates and 

shapes every aspect of the federal government’s trust responsibility to Tribes.

Rooted in treaties and authorized by the United States Constitution, the federal 

government’s unique responsibilities to Tribal Nations have been repeatedly reaffirmed by the Supreme Court, legislation, executive orders and regulations.1 In 

1977, the Senate report of the American Indian Policy Review Commission stated 

that, “[t]he purpose behind the trust doctrine is and always has been to ensure the 

survival and welfare of Indian tribes and people.”

This trust responsibility is highlighted recently in the Department of Health and 

Human Services (HHS) Strategic Plan FY 2018–2022: 

Importantly, the Federal Government has a unique legal and political government togovernment relationship with Tribal governments and a special obligation to provide 

services for American Indians and Alaska Natives based on these individuals’
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sault Ste. Marie Tribe of Chippewa Indians Testimony 

CDC/ATSDR Tribal Consultation Policy and Process 

relationship to Tribal governments.1 

The trust responsibility establishes a clear relationship between Tribes and the federal government.2 The 

Constitution's Indian Commerce Clause, Treaty Clause and Supremacy clause, among others, provide the legal 

authority and foundation for distinct health policy and regulatory decision making by the United States when 

carrying out its unique trust responsibility to provide for the health and welfare of AI/ANs. 

The federal government’s work with Tribal nations and tribal people must be informed by this responsibility. 

Tribal Consultation is the primary means through which this relationship is respected and is a necessary 

part of that relationship. Tribal consultation was affirmed by Executive Order in 2000 and through 

Presidential Memoranda in 1994, 2004, 2009, and most recently by President Biden in 2021. 

The Centers for Disease Control and Prevention is one of the federal entities charged the federal trust 

responsibility of addressing the health disparities among AI/AN Tribal Nations and Peoples; however, every 

branch and agency of the federal government is required to honor and uphold the trust obligations for health 

and public health to sovereign Tribal Nations and Peoples. These trust obligations are owed to AI/AN peoples 

and do not have an expiration date. 

AI/AN health outcomes have either remained stagnant or become worse in recent years as Tribal communities 

continue to encounter higher rates of poverty, lower rates of healthcare coverage, and less socioeconomic 

mobility than the general population. As the US Civil Rights Commission addresses so effectively in Chapter 

2 of its 2018 Broken Promises Report, Tribal communities are already at substantial health risk, since the 

efforts of the federal government to uphold its trust responsibility for Tribal health care has been so ineffective.3 

On average, AI/ANs born today have a life expectancy that is 5.5 years less than the national average, with 

some Tribal communities experiencing even lower life expectancy.4 For example, in South Dakota in 2014, 

median age at death for Whites was 81, compared to 58 for American Indians.5 This is nearly a life expectancy 

age disparity of a 1⁄4 of a century. 

According to the CDC, in 2017, at 800.3 deaths per 100,000 people, AI/ANs had the second highest ageadjusted mortality rate of any population.6 In addition, AI/ANs have the highest uninsured rates (25.4%); 

higher rates of infant mortality (1.6 times the rate for Whites)7

; higher prevalence of diabetes (7.3 times the 

rate for Whites); and significantly higher rates of suicide deaths (50% higher). AI/ANs also have the highest 

Hepatitis C mortality rates nationwide, as well as the highest rates of type II diabetes, chronic liver disease and 

cirrhosis deaths. Further, while overall cancer rates for Whites declined from 1990 to 2009, they rose 

significantly for American Indians and Alaska Natives. 

At the core of the federal trust responsibility to Tribal Nations is the fact that the federal government is 

supposed to ensure the health and welfare of Native peoples. The COVID-19 pandemic has given the federal 

government an opportunity to uphold its obligation in a way that is perhaps unparalleled in modern American 

history. However, Tribes are increasingly confronted with systemic barriers that impede their ability to receive 

1 Introduction, “Cross-Agency Collaborations”, https://www.hhs.gov/about/strategic-plan/introduction/index.html 2 See, Worcester v. Georgia, 31 U.S. 515 (1832) (Supreme Court explicitly outlined that the relationship between the federal government 

and the Tribes is a relationship between sovereign nations and that the states are essentially third party actors). 3 U.S. Commission on Civil Rights, Broken Promises: Continuing Federal Funding Shortfall for Native Americans (2018), 

https://www.usccr.gov/pubs/2018/12-20-Broken-Promises.pdf. 4 Id., 65. 5

South Dakota Department of Health. Mortality Overview. Retrieved from https://doh.sd.gov/Statistics/2012Vital/Mortality.pdf 6 Kochanek KD, Murphy SL, Xu JQ, Arias E. Deaths: Final data for 2017. National Vital Statistics Reports; vol 68 

no 9. Hyattsville, MD: National Center for Health Statistics. 2019. 

7 Centers for Disease Control and Prevention. Infant, neonatal, post-neonatal, fetal, and perinatal mortality rates, by 

detailed race and Hispanic origin of mother: United States, selected years 1983–2014. 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

CDC/ATSDR Tribal Consultation Policy and Process 

help from the federal government and this is slowing or even outright denying access to aid. One such barrier 

is the federal Indian health care delivery system is designed to address just a fraction of the needs of a tribe. 

For my tribe, only one third (15,000) of our population reside in our purchase and referred service area. This 

means the remaining two thirds (30,000) go without any Indian Health Care services through our Tribe. This 

is true for most tribes ~ that only a fraction of our population derives health care through Indian Health 

Services. For those who do reside in our service area, the federal government covered less than 50% of our 

identified need. 

As sovereign governments, Tribal Nations have the same inherent responsibilities as state and territorial 

governments to protect and promote the public’s health. Tribes were largely left behind during the nation’s

development of its public health infrastructure and systems continue to be chronically underfunded. As a result, 

many Tribal public health systems remain far behind those of most state, territorial, and even city and county 

public health entities in terms of their capacity. This includes core services, such as disease surveillance and 

reporting; emergency preparedness and response; public health law and policy development; and public health 

service delivery. Additionally, HHS must commit the resources and CDC must continue its meaningful and 

sustainable direct investments into Tribal communities for public health if we are ever to close the gap in the 

disparities of lower health status, and lower life expectancy of AI/AN Peoples compared to the general 

population. 

It is critical that the agency keep these striking health disparities in mind when considering the CDC/ATSDR 

Tribal Consultation Policy and how it can be used as a tool to strengthen the government-to-government 

relationship and help facilitate meaningful progress towards the goal of eliminating AI/AN health disparities. 

CDC/ATSDR TRIBAL CONSULTATION POLICY 

CDC/ATSDR must update their Tribal Consultation policy to increase accountability, acknowledge and honor 

a Tribe’s right to call for Tribal Consultation, and provide opportunities for meaningful engagement in policies 

that impact AI/AN nations during the policy development process. First, Tribal leaders need to know that the 

agency is hearing them and that their recommendations are accepted and implemented to the greatest extent 

possible. To that end, we want to ensure that the agency respects the government-to-government relationship. 

The current consultation policy does not provide a reflexive mechanism for Tribal leaders to verify whether 

the agency considered their feedback, making it difficult to hold the agency accountable for the consultation 

results. We also urge CDC/ATSDR to facilitate accountability with other agencies, particularly when the 

actions of those agencies impact its policies. Meaningful consultation is also tricky when the agency fails to 

give tribal leaders adequate time to prepare, and the agency is not providing support to the organizations on 

which they rely for technical assistance with consultation preparation and participation. Due to the COVID-19 

pandemic, many agencies have recently come to rely on rapid consultations, which Tribal leaders do not find 

helpful as a regular course of action. For meaningful consultation to occur, Tribal leaders must have 

adequate time to prepare. 

The Sault Ste. Marie Tribe of Chippewa Indians looks forward to working with CDC/ATSDR to respect and 

affirm our Tribal sovereignty, and we believe that the steps outlined in this testimony will be beneficial as 

CDC/ATSDR is considering ways to make their consultation policy more responsive to the government-togovernment relationship. 

Strengthening the Government-to-Government Relationship 

Tribal Consultation is considered a necessary part of the federal Indian trust responsibility. As President 

Biden stated in Section 1 of the Presidential Memorandum on Tribal Consultation, “[m]y Administration is

committed to honoring Tribal sovereignty and including Tribal voices in policy deliberation that affects Tribal 

communities. The Federal Government has much to learn from Tribal Nations and effective communication is 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

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fundamental to a constructive relationship.”8 He also called on agencies to engage in “regular, meaningful, 

and robust consultation with Tribal officials in the development of Federal policies that have Tribal 

implications.”9 

Tribal leaders seek to improve the government-to-government relationship between Tribal Nations and the 

federal government. While we recognize that federal agencies regularly conduct consultation, we reject the 

notion that the consultation requirements are achieved by merely scheduling a time and sending personnel to 

hear concerns. Proper consultation and government-to-government engagement exceed that limited scope. The 

engagement must allow the heads of governments to come together, share concerns, generate ideas and 

solutions, negotiate their roles and responsibilities, and agree on a course of action. Consultation policy 

requires recognizing a Tribal Chairperson to speak first among Tribal representatives – yet no parallel construct 

exists for the federal government. That needs to change. Comparable heads of State from the federal 

government must meet with heads of State of Tribal governments. Tribal consultation, as a tool for 

intergovernmental relations, must include the concept of consent to be meaningful, respectful, and ultimately 

successful. 

The Sault Ste. Marie Tribe of Chippewa Indians recommends HHS recognize a cogent and uniform 

definition of "Tribal Consultation" to be used throughout the Department. The absence of such a uniform 

definition creates confusion throughout the CDC/ATSDR and the tribes. Additionally, the uniform definition 

should incorporate the principles of free, prior, and informed consent (FPIC) that is consistent with the United 

Nations Declaration of the Rights of Indigenous Peoples (UNDRIP) which has been affirmed by the 

United States. 

The Tribe also strongly recommends that the Department of Health and Human Services adopt a uniform 

consultation framework throughout the Department, with individual services, bureaus, and offices adding to it 

to reflect their mission areas. Meaningful consultation must include consent to actions that impact Tribal 

resources and people. Moreover, the framework must consist of a dispute resolution mechanism (short of 

achieving consensus) based on international diplomacy standards. If HHS cannot uniformly adopt this 

standard, the CDC/ATSDR should adopt a consultation framework that includes Tribal consent and a dispute 

resolution mechanism (short of achieving consensus) based on international diplomacy standards. 

The CDC/ATSDR and its service to AI/AN people are critical parts of how the United States government 

honors and respectfully implements its trust and treaty obligations to help eliminate the many health disparities 

faced by Tribal nations and ensure access to essential health and public health services. The CDC/ATSDR is 

a direct representative of the United States government, and it provides critical funding and services to AI/AN 

people in furtherance of the trust responsibility. It is imperative that the CDC/ATSDR is mindful of this 

relationship and frames their interactions with Tribal nations. CDC/ATSDR cannot be effective if the 

concerns of Tribal leaders do not inform their policies. 

The "Substantial Direct Effects" That Should Trigger Consultation. 

Any federal action, including legislative, promulgated rulemaking, executive, or administrative policy 

directions, budget formulation, or any other efforts that impact Tribes or may impact how Tribes govern 

their citizens, should be subject to consultation. Quantifying "when" the agency should initiate engagement 

is complicated, but just as federal "notice and comment" has been established for most actions of the federal 

government, so too should the opportunity be afforded for Tribal leaders to weigh in and effectuate outcomes 

that impact their governments and their very lives of their respective citizens. 

8 See “Memorandum on Tribal Consultation and Strengthening Nation-to-Nation Relationships,” https://www.whitehouse.gov/briefingroom/presidential-actions/2021/01/26/memorandum-on-tribal-consultation-and-strengthening-nation-to-nation-relationships/, January 26, 

2021. 9 Id. 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

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The Sault Ste. Marie Tribe of Chippewa Indians also recommends that all agencies recognize Tribal 

governments as having the right to initiate a consultation with the CDC/ATSDR on any significant level 

of government action or generally to set the direction for some new policy initiative not yet contemplated by 

the federal government. Consultation is a much broader thing than what the agency currently practices. 

Consultation should be considered a perpetual activity that is inclusive of every stage of decisionmaking. 

The CDC Tribal Advisory Committee (TAC) can be an essential tool in the consultation process. But note, 

consulting with a TAC is not a substitute for Tribal consultation. TACs should be utilized by CDC/ATSDR 

when they are formulating policies, because TACs are the best conduit through which CDC/ATSDR can 

receive technical assistance that is Tribally informed and representative of the various regions. CDC/ATSDR 

currently has a very active advisory committee that the agency can utilize to inform the different policy areas 

that their programs touch. We urge CDC/ATSDR to begin engaging the TAC early in the policy and regulatory 

making process so any proposed policies can be Tribally informed from the start. Further, the CDC Tribal 

Advisory, as well as, all tribal advisory under HHS, should have a vehicle for reporting up to the HHS Secretary 

Tribal Advisory and for the substance of their work be considered at the White House Counsel level in order 

to ensure cogent Federal Indian Policy. 

We also implore the CDC/ATSDR to consider expanding the usage of listening sessions during these early 

stages of policy development to hear directly from Tribal leaders. During the Clinton Administration, the 

federal government used regular "listening sessions" as an essential communication tool with Tribes. Listening 

sessions are a preemptive step to formulate ideas and proposals for consultation. Listening sessions enhance 

understanding between the federal government and the Tribal governments and identify where strategic issues 

exist. Consultations put forward proposals to which Tribes can respond. And so, in addition to consultation on 

matters as they arise, the Sault Ste. Marie Tribe of Chippewa Indians recommends regular listening sessions 

at the national and regional levels. 

In addition to meeting with Tribal governments on specific issues that arise, the Sault Ste. Marie Tribe of 

Chippewa Indians recommends the CDC/ATSDR meet with Tribal leaders every four years, at the start of each 

Presidential term, for Sectoral and Thematic Priority Listening Sessions. We recommend that, within these 

sessions, the CDC/ATSDR review broad sectoral and thematic strategies; share background, data, evidence, 

or narrative that will help guide decision making; discuss existing and future policy development; and define 

priorities and goals. 

The Tribe also recommends regional bi-annual leadership listening sessions. These meetings would gather 

Regional Directors and Tribal leadership at regional levels and, within the strategic framework established at 

the national level, allow them to: 

1. Define broad mutual goals (identify alignments and areas, not in alignment); 

2. Share background, data, evidence, and narrative that will help guide decision-making; and 

3. Discuss "big picture" ideas (on all sides) reflecting areas of work and the limits of allocation of 

resources. 

The bi-annual leadership meetings would be an opportunity to have an honest discussion of capacity, focusing 

on efficiency and effectiveness throughout the system. We believe the regional bi-annual leadership listening 

sessions will make a significant difference. A method of support could improve the chances of regional meeting 

success. That support system may include training, incentives, newly defined metrics, and opportunities for 

acknowledgment for innovative work. It would also be helpful to have dedicated positions for Tribal experts. 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

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If CDC/ATSDR engages Tribal leaders from the start, it should make for a more fruitful consultation 

process. CDC/ATSDR should not wait until they have formulated a policy or regulation before asking 

for Indian Country's feedback. 

Informed Tribal Decision Making 

We urge CDC/ATSDR to move towards a consultation model that encourages informed Tribal decisionmaking by giving Tribal leaders ample time to prepare so the consultation can be engaging and meaningful for 

both sides. Although some situations call for quick decision-making, the agency should avoid rapid 

consultations in all but the most urgent situations, as was the case throughout the COVID-19 crisis. A 

rushed effort does not produce superior results for Indian Country. We believe that such consultations do not 

give Tribal leaders enough time to research and discuss the issue at hand. The lack of preparation time often 

results in consultations that feel like they exist to allow federal agencies to “check a box” and not learn about

Indian Country’s concerns. Tribal leaders are leaders of sovereign nations; therefore, the agency should not

unilaterally expect them to be ready for a consultation on short notice. While one might argue that a rapid 

consultation meets a minimum technical threshold to be called a “Tribal Consultation,” such meetings are often 

respectful and do not allow for informed and meaningful discussions with Indian Country. 

Further, we urge CDC/ATSDR to adopt a uniform notice requirement that ensures that every federally 

recognized Tribe is able participate in Tribal consultations. It often takes time for notice of these meetings to 

arrive at the desk of Tribal leaders, who the agency then expects to turn their attention towards getting ready 

for the meeting with little time to prepare. Tribal leaders should have some degree of predictability regarding 

Tribal consultations to operationalize preparation and have a mechanism to ensure that they have ample time 

to prepare. We are also concerned that Tribal leaders may not receive the invitation on time and cannot attend 

or have time to prepare. As heads of state of sovereign nations, tribal leaders often have competing priorities. 

It is unrealistic to expect them to be ready on short notice. We urge the agency to adopt a policy requiring 

at least a 30-day notice for consultation, with limited exceptions for emergency items. There is currently 

no prescribed timeline in the policy. We believe that a uniform requirement will allow for a degree of 

predictability and adequate time for Tribal leaders to prepare. Additionally, the agency should establish a fouryear schedule for national and regional listening sessions within the first quarter of each Presidential term. 

Sixty days before any listening session, a Dear Tribal Leader Letter (DTLL) should be issued, as a 

reminder, of the upcoming event. 

There are also no requirements around how the agency should communicate Tribal consultations to Tribal 

leaders. Currently, the policy states that the “CDC will initiate consultation regarding the event through 

communication methods as outlined in the HHS Tribal Consultation Policy.” Section 8(A) of the HHS

Department Policy on Tribal Consultation merely provides an open list of communication methods. A uniform 

means of reaching Tribal leaders is essential. Thus, we urge the agency to adopt a uniform requirement that 

consultation and listening session notices be published concurrently in the following manner: 

1. The agency should publish all notices in a regular section of the Federal Register dedicated to 

Tribal consultation and listening session notices; 

2. Notices should be published on the Indian Health Service (IHS) Tribal consultation and listening 

sessions’ webpage; 

3. Notices should be published on the White House Council on Native American Affairs consultation and 

listening sessions’ webpage; 

4. The agency should publish all notices via DTLL (to be sent electronically and via U.S. post); and 

5. Notices should be published and sent for distribution to the National Congress of American Indians, 

the National Indian Health Board, and other inter-tribal organizations recommended by Tribal 

governments. 

If any of these sites and web pages do not exist, they need to be established and maintained. 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

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The agency must also expand the methods through which Tribal leaders can participate in Tribal 

consultations. As we learned during the COVID-19 pandemic, it is possible for agencies to conduct 

consultations remotely and for Tribal leaders to be engaged in that format. While the agency should resume 

in-person consultations, they must ensure that Tribal leaders can continue to participate remotely. Many Tribes 

are small and do not have the resources to pay for travel for their leadership to participate in consultations. The 

ability to participate remotely expands the number of Tribal leaders who can participate, which helps to ensure 

that the agency is hearing from a broad cross-section of Tribal leaders. 

Improving Accountability 

Tribal leaders require accountability from the agency responsible for providing health care to their citizens as 

leaders of sovereign nations. Tribal leaders need affirmative efforts demonstrating that their concerns 

are being heard, considered, and adopted. 

During consultations, the CDC/ATSDR will receive a large volume of input from tribal leaders. To effectively 

respond the CDC/ATSDR's must: 

1. Accurately record and verify all input; 

2. Perform analysis and identify themes; 

3. Provide a report on the results and how Tribal input has informed the CDC/ATSDR response to tribal 

issues; 

4. Record the position of Tribes regarding the CDC/ATSDR policy recommendations; 

5. Utilize the reports to inform budget formulations, committees work, and other inter-agency work. 

To accurately record input from tribal leaders, each consultation session should be translated to text and 

posted verbatim. No interpretation or distillation should occur at this stage unless as an annotation. The 

agency should sort statements by consultation event date and tribal nation input. To verify input, Tribes should 

have a week to view online and reflexively make corrections (if necessary) to both the verbal (translated 

to text) and submitted written testimonies. 

To identify themes and perform analysis, the agency should establish and publish a protocol for how they 

will interpret the raw data to categorize comments and suggestions. The CDC/ATSDR should adopt a 

methodology similar to what the Council of Energy Resource Tribes uses (CERT's Tribal Input Methodology.) 

Then CDC/ATSDR staff should work to perform a mixed methods approach beginning with qualitative 

analysis and draft categories of like suggestions. This process organically leads to the formation of 

categories that lend themselves to quantitative summaries and categories for 

action planning. Qualitative research software like Nvivo10 may increase efficiency in the process. 

The CDC should publish the consultation analysis with both speech-to-text and the written comments. Within 

two weeks of its publication, Tribal governments should be able to provide comments regarding 

CDC/ATSDR analysis to ensure the original intent of the suggestion is maintained. In situations in which 

the agency needs clarification, the CDC/ATSDR should seeks clarification from those who provided the 

input. 

To report on how tribal input has informed the CDC/ATSDR' response to tribal issues within a month 

of consultation, the CDC should provide a follow-up written analysis explaining how it will use Tribal 

input to address each topic addressed in consultation along with impact analysis on how it expects the 

"consultation informed" policies to perform. 

10 Richards, Lyn. Using NVivo in Qualitative Research. London & Los Angeles, Sage, 1999. ISBN 0-7619-6525-4. 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

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The agency should publish a record of Tribal support and opposition to Indian Health Service policy 

decisions. In situations in which consultation sessions do not end in "consent," the dispute resolution 

mechanism (to be based on international diplomacy standards) should be engaged. To utilize the reports 

and records of support and opposition, they should all be invoked during budget formulation, tribal advisory 

committee work, and play a key role in across agency work performed by the White House Council for Native 

American Affairs for inter-agency project management with goals and objectives, milestones and measurables 

and assessment including at least an annual report during the White House Tribal Leaders Summit. 

Education & Training 

The CDC/ATSDR must educate (initially and continuously) all its vital policy staff members about the 

meaning of consultation and the reason for consultation with Tribal governments. Just like any organizational 

education objectives, understanding the basis and basics of tribal sovereignty and Tribal consultation is critical. 

Without an organized curriculum with rubrics of targeted understanding and ongoing assessment to ensure 

continued learning, this knowledge cannot be otherwise acquired or retained if not utilized regularly. The 

United South and Eastern Tribes (USET) noted that education should be like what the US does with its foreign 

Ambassadors: Ambassadors are fully briefed on the culture, top issues, and history of their nation. In the same 

way, US federal representatives should be "briefed"/given ongoing education regarding the Tribal Nations they 

are working with. The Sault Ste. Marie Tribe recommends national level representatives be regularly and 

consistently educated on Tribal sovereignty, consultation rights, and the reason for consulting with Tribes; at 

the regional level, education must include the region's Tribal governments' interests, needs, cultures, and 

histories. 

Tribal Technical Assistance 

Tribal organizations, such as the National Indian Health Board and the National Congress for American 

Indians, are routinely consulted by Tribal leaders in preparation for TAC meetings and Tribal consultations. 

However, there is little support for this work. We urge the agency to financially support the work of 

National, Regional, and Inter-Tribal organizations, who are vital in ensuring that Tribal leaders have 

access to the subject matter expertise that helps them prepare to offer meaningful feedback to the 

agency. We believe that this technical assistance is vital to full and meaningful consultation. 

Reflexive Tribal Consultation Conceptual Framework 

The above has been distilled into a Reflexive Tribal Consultation Conceptual Framework (see Appendix A) 

to depict the steps for meaningful Consultation with tribes that respects tribal sovereignty, invites integration 

of tribal input at all stages including necessary validity checks on content and is steeped in UNDRIP concept 

of FPIC ~ Free Prior Informed Consent to truly respect tribal sovereignty in shared decision making. This 

proposed method borrows from general American Indian consensus building that creates ownership and buyin of the outcome. Sequential yet cyclical steps are further articulated in Appendix A on page 13. 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

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TRIBAL PUBLIC HEALTH CAPACITY & INFRASTRUCTURE 

The COVID-19 pandemic brought with it a disproportionate impact on AI/AN people and illuminated 

many of the disparities Tribes experience, particularly in the public health arena. These have contributed to 

disproportionately poorer COVID-19-related health outcomes experienced by AI/ANs. It has never been more 

important to increase the resources flowing to Indian Country. Now is the time to adjust the funding and policy 

landscapes to better support Tribal public health infrastructure, the societal realities Tribes experience 

associated with poverty, remoteness, and lack of investment into Tribal public health systems. 

According to the latest data from the CDC, American Indian and Alaska Native (AI/AN) people are 1.7 times 

(70%) more likely to be diagnosed with COVID-1911, 3.4 times (340%) more likely to require hospitalization12 

and 2.4 times (240%) more likely to die from COVID-19-related infection when compared to non-Hispanic 

white people13. However, these disparities in COVID-19-related death rates are not evenly shared across all 

AI/AN age groups. Young AI/ANs are experiencing the largest disparities. Among AI/ANs aged 20-29 years, 

30-39 years, and 40-49 years, the COVID-19-related mortality rates are 10.5, 11.6, and 8.2 times, respectively, 

higher when compared to their white counterparts14. 

AI/ANs continue to face significant chronic health disparities, especially for conditions like diabetes and 

respiratory illnesses, which increase the risk of a poor COVID-19 health outcome, including death. These 

disparities will continue to go unaddressed without a bold and substantive IHS budget. A weak budget would 

leave Indian Country more vulnerable to COVID-19 outbreaks. It is imperative to prioritize Tribal public 

health infrastructure and capacity for Tribes to see meaningful decreases in these disparities. NIHB fully 

supports the Biden Administration’s call for increased health and public health equity. 

Unfortunately, because of high rates of misclassification and under-sampling of AI/AN populations in federal, 

state, and local public health disease surveillance systems, available data likely significantly underrepresents 

the impact of COVID-19 in Indian Country. To be clear, misclassification of AI/ANs on disease surveillance 

systems is not unique to COVID-19, however, the issue has taken a new level of urgency given the 

unprecedented devastation of this pandemic on underserved communities. Multiple states with large AI/AN 

populations including but not limited to Minnesota, Michigan, New York, and California continue to report 

thousands of COVID-19 cases without any information on patient race/ethnicity or categorizing cases as 

“other” on demographic forms. In California, for instance, the state noted they lack race/ethnicity data for 

nearly 30% of reported cases. Multiple studies demonstrate that surveillance systems frequently misclassify 

AI/ANs or omit them from surveillance systems entirely. These issues continue exacerbate health disparities 

including those from COVID-19. 

The CDC must work with state and local health departments, community-based organizations (CBOs), 

Federally Qualified Health Centers (FQHCs), IHS facilities, Tribally-run health facilities, and Tribal 

Epidemiology Centers (TECs) to ensure that complete and accurate data is captured and shared with 

Tribes so they can effectively respond and recover from COVID-19, and other similar public health 

11 Data reported by state and territorial jurisdictions (accessed 03/10/2021). Numbers are ratios of age-adjusted rates standardized to the 

2019 US intercensal population estimate. Calculations use only the 53% of case reports that have race and ethnicity data available; this can 

result in inaccurate estimates of the relative risk among groups. 

12 COVID-NET (https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covid-net/purpose-methods.html, accessed March 1, 2020, 

through February 27, 2021). Numbers are ratios of age-adjusted rates standardized to the 2019 US standard COVID-NET catchment 

population. 

13 NCHS provisional death counts (https://data.cdc.gov/NCHS/Deaths-involving-coronavirus-disease-2019-COVID-19/ks3g-spdg, data 

through March 6, 2021). Numbers are ratios of age-adjusted rates standardized to the 2019 US intercensal population estimate. 14 Arrazola J, Masiello MM, Joshi S, et al. COVID-19 Mortality Among American Indian and Alaska Native Persons — 14 States, January–

June 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1853–1856. DOI: http://dx.doi.org/10.15585/mmwr.mm6949a3 

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Sault Ste. Marie Tribe of Chippewa Indians Testimony 

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emergencies. Timely and accurate data play a vital role in public health decision-making, and would allow for 

better, data-driven Tribal public health policy, which would better protect Tribal members. 

Expand and Strengthen the Government-to-Government / Expand Self-Governance. 

The Tribes and CDC established the CDC TAC in 2005 to improve the government-to-government 

relationship. The TAC serves as an advisory body to CDC on policies, programs, and funding opportunities 

that impact Tribes but does not supplant formal Tribal consultation. Meaningful and robust Tribal consultation 

must continue. Tribal leaders know best how to care for their people; therefore, it benefits the CDC to 

implement and incorporate Tribal leader recommendations into every aspect of the CDC that impacts AI/ANs. 

Tribes and the TAC have repeatedly called upon the federal government to expand self-determination and selfgovernance authority across all of HHS. In the interim, the CDC should work closely with Tribes to obtain a 

complete understanding of the current public health needs and allow for maximum flexibility in the 

administration of funded Tribal public health programs. 

Remove Barriers that Inhibit Adoption of Traditional Practices 

Recognizing Tribal sovereignty means recognizing the sovereign right of Tribal nations to utilize traditional 

practices to provide for the health and public health of their people. Traditional medicine is central to many 

Tribal cultures and is effective at treating and preventing many chronic health issues facing AI/AN people. 

Tribal Nations continue to experience many barriers when implementing or incorporating traditional 

and cultural practices as grant activities because it is not supported by CDC even though such practices 

have been supporting Tribal health and wellness for time immemorial. The CDC could and should support 

Tribal models of health and healing that may not fit well into standard Western approaches by including 

language in their funding opportunity announcements that recognize the value and applicability of cultural and 

traditional practices as viable Tribal grantee activities. 

New CDC-Wide Requirement 

The Consolidated Appropriations Act of 2021 directed each Center, Institute, and Office (CIO) within the CDC 

to create written guidelines to integrate Tribal public health priorities and needs across the entire agency. These 

written guidelines are to be developed in consultation with the CDC TAC and will establish best practices 

around the delivery of Tribal technical assistance, as well as the consideration of cultural and traditional Tribal 

public health practices. Because the CDC is required to work with the TAC to develop these guidelines, the 

Tribes are afforded an unprecedented opportunity to create a new, more inclusive path forward for working 

with CDC. However, consultation with the CDC TAC does not supplant Tribal consultation. NIHB 

requests that the agency engages in meaningful and robust Tribal consultation throughout the 

development process. 

Create Set-Aside Funding for Tribes Throughout the CDC and Invest in Tribal Public Health Systems 

Tribes interact with the CDC on a regular basis and there should be funding dedicated to ensuring that the 

agencies can meet unique Tribal needs. Unfortunately, the status quo often prevents the fulfillment of Tribal 

needs. For example, CDC frequently distributes funding via competitive grants and conducts programming 

aimed at strengthening Tribal public health infrastructure and systems, but these methods of funding do not 

allow for equitable funding across all Tribal public health systems. 

Dedicated funding for Tribes and Tribal organizations is the most effective way to ensure that adequate 

resources are reaching Indian Country, while also furthering the fulfillment of the federal government’s trust

responsibility for health. With Good Health and Wellness in Indian Country (GHWIC) as 

a potential model, CDC should consult with Tribes to design and fund Tribal public health infrastructure and 

capacity development initiative in Indian Country with the flexibility to permit Tribes to tailor programs to 

their unique community priorities. The CDC must commit to these direct Tribal investments that support 

Tribes in addressing public health development and other issues. There should be a minimum of 5% setaside for Tribes across all CDC Centers, Institutes, and Offices (CIOs) to meaningfully begin to build 

equitable Tribal public health systems, compared to states and local health departments. This funding 

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will help integrate Tribal public health needs and priorities across the entire CDC and all CDC programs. For 

those CDC CIOs that do not send funding out as grants, at least 5% of funding resources for internal 

activities should be directed and dedicated to Tribal support. 

Ensure Tribal Access to Data and Support Tribal Data Sovereignty 

Recent federal scientific initiatives throughs the National Institutes of Health (NIH) and the Food and Drug 

Administration (FDA), have sought Tribal leaders’ endorsement of their projects in Indian Country. While 

Tribal advocates support the development of scientific initiatives to prevent and cure diseases, Tribes are 

sovereign nations and are the ultimate stewards and owners of the data collected on their Tribal citizens. 

The CDC must work collaboratively with Tribes to ensure that Tribes have access to their Tribal data. 

Understanding and honoring Tribal data sovereignty must be the cornerstone of all CDC Tribal data collection 

efforts. Doing so will improve overall public health data reporting and provide the most accurate information 

for developing budget and public health priorities, while allowing Tribal leaders and administrators the most 

accurate data in determining resource allocation and program development and evaluation. 

Structural challenges in data reporting only serve to render invisible the disparate impact of COVID-19 in 

Indian Country. For example, TECs continue to face significant barriers in exercising their statutory public 

health authorities by facing major hurdles in accessing federal and state public health surveillance systems, 

including for COVID-19, which often has incomplete or inaccurate race/ethnicity data. In addition, not every 

state, city and county jurisdiction include AI/AN as a distinct demographic on health assessment and 

surveillance forms, often lumping them under “other.” These race/ethnicity data gaps contribute to ongoing 

underestimates that only further obscure the true burden of COVID-19 and other diseases for AI/ANs. 

Furthermore, Tribes often experience significant barriers in accessing the patchwork of state infectious disease 

tracking and reporting systems. This must be corrected to allow the Tribes access to their own data in a timely 

manner. 

While available data demonstrates higher rates of health disparities among AI/ANs in a variety of health 

conditions, estimates of disease prevalence and incidence for AI/ANs are likely to be underestimates due 

to high rates of racial misclassification and undercounting of AI/AN populations in state and federal 

surveillance systems. A comprehensive plan to address the gaps in data collection across these surveillance 

systems is drastically needed to improve the information readily available to Tribal leaders to better inform 

their public health policies and programs. 

Promote and Sustain Environmental Health Improvements in Indian Country 

The health of the environment directly impacts public health in Indian Country. Contaminated drinking water, 

harmful air pollutants, destruction of natural habitats, climate change, extreme weather, and exposure to toxic 

heavy metals are issues that Tribal communities struggle to prevent, often with little or no support from the 

federal government. Twenty-five percent of the nation’s 1,300 Superfund sites are in or near Indian Country, 

even though Indian County is, tragically, only approximately 2.3% of the national land area. Lack of access 

to clean water, pollution, and insufficient sanitation infrastructures impact the physical and mental 

health as well as emotional and spiritual wellness for AI/AN communities and individuals. Without proper 

access to clean water and adequate sanitation infrastructure it is hard – if not impossible – for Tribal citizens 

to be healthy and for Tribes to adhere to CDC recommendations and guidelines for COVID-19 mitigation and 

control, which further propagates COVID-19 infections across Indian Country. The CDC must establish Tribal 

sanitation and clean water infrastructure as a public health priority. 

Prioritize Indian Country in the Ending the HIV Epidemic: A Plan for America 

The rate of HIV infection among AI/ANs in 2016 was 10.2 per 100,000 – the fourth highest among other 

racial/ethnic groups. Furthermore, the frequency of HIV diagnoses among AI/AN persons continues to rise. 

The current national plan does not address the unique prevention and care realities of Indian Country. There 

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must be specific language to discuss American Indians and Alaska Natives as a population that is statistically 

at higher risk for acquiring or passing away from HIV or viral hepatitis. The CDC should continue to engage 

with Tribes through formal consultation to incorporate Tribes in all the federal government’s HIV response 

activities, including how best to capture AI/AN data in an accurate and respectful manner. 

Linkage to care has been proven to be one of the most effective and simple interventions that can be 

undertaken with a person newly diagnosed with HIV or a person that has fallen out of care. However, only a 

handful of providers across the entire I/T/U healthcare system are trained to provide HIV specialty care 

for American Indians and Alaska Natives. Therefore, many AI/ANs are required to rely upon referral 

care to providers outsides the Indian health system, and outside of their own communities – often 

traveling hours to make appointments. These providers, while technically knowledgeable, may not have 

experience or the cultural knowledge to provide comprehensive, competent care to AI/AN people living 

with HIV. The lack of local providers, distance to HIV specialists, and absence of culturally competency 

serve as deterrents for many AI/AN seeking ongoing care and monitoring. HHS and the CDC should, as 

integral components of its national HIV response, direct funding to support Tribal-specific training, 

technical and capacity building assistance, and materials dissemination. 

CONCLUSION 

To fulfill the federal Indian trust responsibility and to address social determinants of health and poor 

health status for AI/ANs the CDC/ATSDR must update their Tribal Consultation policy to increase 

accountability, acknowledge and honor the Tribe’s right to call for Tribal consultation, and provide 

opportunities for meaningful engagement in policies that impact Tribal nations during the policy 

development process. 

Thank you for your attention to the Biden Administration Memo and efforts to address its Tribal consultation 

policy. Rededication to government-to-government relationship presents an opportunity to improve 

the processes that maintain and strengthen these sacred relationships. Given the status of Tribes as preexisting sovereigns and their unique position in the American legal framework, Tribal consultation must be 

robust and meaningful. There must be accountability from CDC/ATSDR. Thank you again for taking this 

first step and giving my tribe the opportunity to comment. We look forward to an ongoing dialogue on how 

to make Tribal consultation more respectful and responsive to the needs of Tribes. 

Respectfully, 

Dr. Aaron A. Payment, Chairperson 

Acknowledgement: 

This policy position paper in for the form of consultation testimony was crafted in collaboration between the Sault Tribe of 

Chippewa Indians, the National Indian Health Board and the National Congress of American Indians for which Dr. Payment 

serves as 1st Vice President. Dr. Payment also serves as a Member of the HHS Secretary Tribal Advisory, NIH Tribal Advisory, 

SAMSHA Tribal Advisory and President of the Midwest Alliance of Sovereign Tribes and the United Tribes of MI. 

12 
 

 

 

 

 

 

 

 

 

Sault Ste. Marie Tribe of Chippewa Indians Testimony 

CDC/ATSDR Tribal Consultation Policy and Process 

APPENDIX A 

REFLEXIVE TRIBAL CONSULTATION CONCEPTUAL FRAMEWORK 

Understandably, the concept of Consultation can represent a “chicken and egg” challenge with the question ~ at what 

point is it appropriate to engage Tribal Consultation? In order to avoid a paternalistic approach of presenting preconceived outcomes, policy initiation should occur as soon as a problem or challenge (issue) arises or when requested 

by tribe(s). This conceptual framework is intended to be reflexive throughout like a feedback loop and to be a guide 

rather than a regimented series of steps. While sequential, steps should allow for reflexively returning to an earlier 

stage if tribal agreement on substance or consensus is not reached. This makes for a more deliberative process, but 

will likely build trust and buy-in by tribal governments. 

Step 1: 

Step 2: 

Step 3: 

Step 4 & 5: 

Step 6 & 7: 

Step 8: 

Once an issue presents itself, either the federal government or tribal representative initiates a request 

to begin Tribal Consultation; 

To flesh out and to gain an exhaustive understanding of the issue, listening sessions should be held. 

Notice should go to tribal leaders but expect administrative representatives and subject experts to 

participate; Some level of agreement should be sought to determine if Consultation is necessary. 

Tribes should play the key role in making this determination; 

Formal notice of Consultation (no less than 30-day notice) with the Tribal Leaders should occur 

with the highest-ranking agency official possible. National and Regional Native Organization 

should be engaged to assist in preparing tribes for a full scope of understanding of the policy issue 

and possible solutions; 

The full unedited or unfiltered results should be posted along a “notice and comment” approach. 

This step should allow for tribes to correct, make revisions, or provide addendums to provide a 

validity check and ensure substantive agreement; 

If substantive disagreement exists, to gain clarity, or if requested by tribes, these steps allow for 

fuller integration of the tribal perspective(s). If needed, this may necessitate cycling back to Step 

1 on the area(s) in need of clarification or consensus. 

Policy or Pareto Optimum is a state so as to make any one individual or preference criterion better 

off without making at least one individual or preference criterion worse off. This is an idealized 

state and may not be reached but true and meaningful Consultation with tribes warrants a process 

that invites and integrates the very individuals for whom a proposed solution is intended to benefit. 

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August 25, 2021 

The Honorable Rochelle Walensky, MD, MPH 

Director 

Centers for Disease Control and Prevention 

Agency for Toxic Substances and Disease Registry 

1600 Clifton Road NE 

Atlanta, GA 30329–4027 

Re: CDC/ATSDR Tribal Consultation Policy 

Dear Dr. Walensky: 

On behalf of the National Indian Health Board (NIHB),1 we are responding to your call for Tribal 

Consultation regarding the Centers for Disease Control and Prevention (CDC)/Agency for Toxic 

Substances and Disease Registry (ATSDR) Tribal consultation policy. We applaud CDC/ATSDR 

for taking this step towards reaffirming and strengthening the Government-to-Government 

relationship that exists between Tribal Nations and the Federal Government. CDC/ATSDR has a 

central role in fulfilling the United States’ federal Indian trust responsibility. Therefore, the agency 

must have a policy that ensures that Tribal Consultation is meaningful, thorough, and consistent 

with the other operating divisions throughout HHS. 

CDC/ATSDR must update their Tribal Consultation policy to increase accountability, 

acknowledge and honor the Tribe's right to call for Tribal Consultation, and provide meaningful 

engagement in policies that impact American Indian and Alaska Native (AI/AN) Nations during 

the policy development process. First, Tribal leaders need to know that the agency is hearing them 

and that their recommendations are accepted and implemented to the greatest extent possible. To 

that end, we want to ensure that the agency respects the government-to-government relationship. 

The current consultation policy does not provide a mechanism for Tribal leaders to verify whether 

the agency considered their feedback, making it difficult to hold the agency accountable for the 

consultation results. We ask that, at minimum, the CDC/ATSDR issue a Dear Tribal Leader 

Letter (DTLL) 30 days after every consultation that outlines what participants discussed, 

enumerates Tribal recommendations and requests, and reports what the federal government 

is doing with that information and input. We also urge CDC/ATSDR to facilitate accountability 

with other agencies, particularly when the actions of those agencies impact its policies. Meaningful 

consultation is similarly compromised when the agency fails to give Tribal leaders adequate time 

1 Established in 1972, the National Indian Health Board (NIHB) is an inter-Tribal organization that advocates on behalf of Tribal 

governments to provide quality health care to all American Indians and Alaska Natives (AI/ANs). A Board of Directors, consisting 

of a representative from each of the twelve Indian Health Service (IHS) Areas, governs NIHB. Each Area Health Board elects a 

representative to sit on the NIHB Board of Directors. In areas with no Area Health Board, Tribal governments choose a 

representative who communicates policy information and concerns of the Tribes in that area with the NIHB. NIHB advocates for 

all tribes, whether they operate their entire health care program through contracts or compacts with IHS under Public Law 93-638, 

the Indian Self-Determination and Education Assistance Act (ISDEAA), or continues to rely on IHS for delivery of some, or most, 

of their health care. 
 

 

 

 

 

 

 

CDC/ATSDR and the Federal Trust Responsibility 

 

 

 

 

 

 

 

 

 

 

National Indian Health Board 

CDC/ATSDR Tribal Consultation Policy and Process 

to prepare. Additionally, the agency is not providing support to the organizations that Tribal 

leaders rely on for technical assistance with consultation preparation and participation.2 Due to the 

COVID-19 pandemic, many agencies have recently come to rely on rapid consultations, which 

Tribal leaders do not find helpful as a regular course of action. For meaningful consultation to 

occur, Tribal leaders must have adequate time to prepare. 

Tribal leaders look forward to working with CDC/ATSDR in ways that respect and affirm their 

Tribal sovereignty. We believe that the steps outlined in this letter will be beneficial as 

CDC/ATSDR is considering ways to make their consultation policy more responsive to the 

government-to-government relationship. 

Beginning with first contact and ending with the decision by the United States to cease Tribal 

treaty making in 1871, the United States and its predecessor European sovereigns and sovereign 

Tribal Nations signed over 350 Treaties requiring the federal government to assume specific, 

enduring, and legally enforceable fiduciary obligations to the Tribes. The terms codified in those 

Treaties – including for provisions of quality and comprehensive health resources and services –

have been reaffirmed by the United States Constitution, Supreme Court decisions, federal 

legislation and regulations, and even presidential executive orders. These federal promises – which 

exist in perpetuity - collectively form the basis for what we now refer to as the federal trust 

responsibility. During permanent reauthorization of the Indian Health Care Improvement Act, 

Congress declared that “...it is the policy of this Nation, in fulfillment of its special trust 

responsibilities and legal obligations to Indians . . . to ensure the highest possible health status for 

Indians and urban Indians and to provide all resources necessary to effect that policy.”3 

This trust responsibility, was highlighted recently in the Department of Health and Human 

Services (HHS) Strategic Plan FY 2018–2022: 

Importantly, the Federal Government has a unique legal and political government to- government 

relationship with Tribal governments and a special obligation to provide services for American 

Indians and Alaska Natives based on these individuals' relationship to Tribal governments.4 

The trust responsibility establishes a clear relationship between Tribes and the federal government. 

This responsibility must inform the federal government’s work with Tribal nations and Tribal 

people. Tribal consultation is the primary means of respecting and being a necessary part of 

that relationship. The executive branch affirmed Tribal Consultation by Executive Order in 2000 

and through Presidential Memoranda in 1994, 2004, 2009, and most recently by President Biden 

in 2021. 

CDC/ATSDR is one of the federal entities charged with addressing health disparities among 

AI/AN Tribal Nations and Peoples. However, every branch and agency of the federal government 

2 See discussion infra “Tribal Technical Assistance” 3 25 U.S.C. § 1602 

4 Introduction, “Cross-Agency Collaborations”, https://www.hhs.gov/about/strategic-plan/introduction/index.html 

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National Indian Health Board 

CDC/ATSDR Tribal Consultation Policy and Process 

must honor and uphold the trust obligations for health and public health to sovereign Tribal Nations 

and Peoples. These trust obligations are owed to AI/AN people and do not have an expiration date. 

AI/AN health outcomes have either remained stagnant or become worse in recent years as Tribal 

communities continue to encounter higher poverty rates, lower rates of healthcare coverage, and 

less socioeconomic mobility than the general population. As the US Civil Rights Commission 

addresses so effectively in Chapter 2 of its 2018 Broken Promises Report, Tribal communities are 

at substantial health risk since the efforts of the federal government to uphold its trust responsibility 

for Tribal health care have been so ineffective.5 On average, AI/ANs born today have a life 

expectancy of 5.5 years less than the national average, with some Tribal communities experiencing 

even lower life expectancy.6 For example, in South Dakota in 2014, whites’ median age at death 

was 81, compared to 58 for American Indians.7 

According to the CDC, in 2019 AI/ANs had the second highest age-adjusted mortality rate of any 

population of 767.3 deaths per 100,000 people.

8 In addition, AI/ANs have the highest uninsured 

rates for adults aged 18-64 (32.9%) and children under the age of 18 (16.7%)9; higher rates of 

infant mortality (2.7 times the rate for whites)10; higher prevalence of diabetes (2.3 times the rate 

for whites)11; and significantly higher rates of suicide deaths (20% higher than non-Hispanic 

white)

12. AI/ANs also have the highest Hepatitis C mortality rates nationwide13, and the highest 

rates of type II diabetes, chronic liver disease, and cirrhosis deaths. 

The core of the federal trust responsibility to Tribal Nations is that the federal government is 

supposed to ensure the health and welfare of AI/AN peoples. The COVID-19 pandemic has given 

the federal government an opportunity to uphold its obligation in a way that is perhaps unparalleled 

in modern American history. However, systemic barriers are increasingly impeding Tribes’ ability 

to receive help from the federal government—slowing or even outright denying access to aid.14 

As sovereign governments, Tribal Nations have the same inherent responsibilities as state and 

territorial governments to protect and promote the public’s health. Tribes were left behind by the 

federal government during the nation’s development of its public health infrastructure and systems 

continue to be chronically underfunded. As a result, the capacity of many Tribal public health 

5 U.S. Commission on Civil Rights, Broken Promises: Continuing Federal Funding Shortfall for Native Americans (2018), 

https://www.usccr.gov/pubs/2018/12-20-Broken-Promises.pdf. 6 Id., 65. 

7South Dakota Department of Health. Mortality Overview. Retrieved from https://doh.sd.gov/Statistics/2012Vital/Mortality.pdf 8 CDC National Center for Health Statistics. Underlying Cause of Death 1999-2019 on CDC WONDER Online Database, 

released 2021. 

9 National Center for Health Statistics. Percentage of angina for adults aged 18 and over, United States, 2019. National Health 

Interview Survey. Generated interactively: Aug 12 2021 from 

https://wwwn.cdc.gov/NHISDataQueryTool/SHS_2019_ADULT3/index.html 

10 CDC 2020. Infant Mortality Statistics from the 2018 Period Linked Birth/Infant Death Data Set. National Vital Statistics 

Reports. Table 2. https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-7-508.pdf 11 CDC 2021. Summary Health Statistics: National Health Interview Survey: 2018. Table A-4a. 

http://www.cdc.gov/nchs/nhis/shs/tables.htm 

12 CDC 2021. National Vital Statistics Report, Vol. 69, No. 13. Table 10. https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr69-13-

508.pdf 

13 CDC 2020. Viral Hepatitis Surveillance — United States, 2018. Table 3.7. 

https://www.cdc.gov/hepatitis/statistics/2018surveillance/pdfs/2018HepSurveillanceRpt.pdf 

14 CDC 2021. National Vital Statistics Report, Vol. 69, No. 13. Table 10. 

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National Indian Health Board 

CDC/ATSDR Tribal Consultation Policy and Process 

systems remains far behind most state, territorial, city, and county public health entities. Many 

Tribal public health systems lack core services, such as disease surveillance and reporting, 

emergency preparedness and response, public health law and policy development, and public 

health service delivery. To address the chronic health disparities and lower life expectancy of 

AI/AN peoples, HHS must commit the resources, and CDC/ATSDR must continue its meaningful 

and sustainable direct investments into Tribal communities for public health. 

The agency must keep these striking health disparities in mind when considering the CDC/ATSDR 

Tribal Consultation Policy. This policy can strengthen the government-to-government relationship 

and help facilitate meaningful progress towards the goal of eliminating AI/AN health disparities. 

Strengthening the Government-to-Government Relationship 

Tribal Consultation is considered a necessary part of the federal trust responsibility. As President 

Biden stated in Section 1 of the Presidential Memorandum on Tribal Consultation, "[m]y 

Administration is committed to honoring Tribal sovereignty and including Tribal voices in policy 

deliberation that affects Tribal communities. The Federal Government has much to learn from 

Tribal Nations, and effective communication is fundamental to a constructive relationship."15 He 

also called on agencies to engage in "regular, meaningful, and robust consultation with Tribal 

officials in the development of Federal policies that have Tribal implications."16 

Tribal leaders seek to improve the government-to-government relationship between Tribal Nations 

and the federal government. While we recognize that federal agencies regularly conduct 

consultation, we reject the notion that the consultation requirements are achieved by merely 

scheduling a time and sending personnel to hear concerns. Proper consultation and governmentto-government engagement exceeds that limited scope. The engagement must allow for the heads 

of governments to come together, share concerns, generate ideas and solutions, negotiate their 

roles and responsibilities, and agree on a course of action. Consultation policy requires recognizing 

a Tribal Chairperson to be first to speak among Tribal representatives – yet no parallel construct 

exists for the federal government. That needs to change. Comparable heads of State from the 

federal government must meet with heads of State from Tribal governments. 

Moreover, we recommend that HHS recognize a uniform definition of “Tribal Consultation” to be

used through the Department. The absence of such a uniform definition creates confusion 

throughout the various HHS departments, such as CDC/ATSDR, and the Tribes. Additionally, 

Tribal consultation as a tool for intergovernmental relations must include the principles of free, 

prior, and informed consent (FPIC) if it is to be meaningful, respectful, and ultimately successful. 

Therefore, the uniform definition should incorporate the principles of FPIC that is consistent with 

the United Nations Declaration of the Rights of Indigenous Peoples (UNDRIP) that was 

affirmed by the United States.17 

15 See “Memorandum on Tribal Consultation and Strengthening Nation-to-Nation Relationships,”

https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/26/memorandum-on-tribal-consultation-andstrengthening-nation-to-nation-relationships/, January 26, 2021. 16 Id. 17 https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html 

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Improving Accountability 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

National Indian Health Board 

CDC/ATSDR Tribal Consultation Policy and Process 

The CDC/ATSDR plays a critical role in how the United States government honors its trust and 

treaty obligations. The government has tasked the agency to help eliminate the many health 

disparities faced by Tribal nations and ensure access to essential health and public health services. 

The CDC/ATSDR is a direct representative of the United States government, and it provides 

critical funding and services to AI/AN people in furtherance of the trust responsibility. The 

CDC/ATSDR must be mindful of this relationship, and the agency should ensure that respect 

for the sovereignty of Tribal Nations frames every interaction. CDC/ATSDR cannot be 

effective if the concerns of Tribal leaders do not inform their policies. 

Tribal leaders require accountability from all agencies tasked with addressing the health disparities 

plaguing Tribal communities. The agency and its Tribal Consultation Policy must assure 

Tribal leaders that any federal action that impacts Tribes or may impact how Tribes govern 

their citizens are subject to consultation. These actions include, but are not limited to program 

development, promulgated rulemaking, executive or administrative policy directions, budget 

formulation, or any other efforts by the agency that has the potential to impact Tribes or Tribal 

citizens. We acknowledge that quantifying "when" the agency should initiate engagement can be 

complicated. However, just as federal "notice and comment" has been established for most federal 

government actions, so too should the opportunity be afforded for Tribal leaders to weigh in and 

effectuate outcomes that impact their governments. 

CDC/ATSDR Tribal Consultation policy should make it clear to Tribal leaders that they 

have a right to ask for consultation whenever they desire. The policy should prescribe a method 

of contacting the agency and any timelines for a response from the agency. Providing Tribal 

leaders with prescribed steps on initiating a Tribal consultation and making that clear in their policy 

will go a long way towards facilitating accountability. 

Tribal leaders require affirmative actions demonstrating that their concerns are being 

heard, considered, and adopted. We acknowledge that Sections 3(G) and 3(E) of the 

CDC/ATSDR Tribal Consultation Policy provides “Performance Measures and Accountability”

and “Evaluation and Reporting” guidance. However, these sections lack any actual substance and 

only point to the corresponding section of the HHS Tribal Consultation Policy. The current policy 

does not go far enough in mandating a thorough review of the consultations with Tribal leaders 

and does not provide a mechanism for Tribal leaders to track how the agency uses their 

recommendations. To facilitate accountability, CDC/ATSDR should, at minimum, issue a DTLL 

after every Tribal consultation that details what participants discussed, what Tribal leaders 

requested, and follow-up actions in response to those suggestions. 

Other mechanisms should be explored and utilized that will allow improved communication and 

accountability in addition to a follow-up letter. For example, having federal agency partners report 

out in every meeting about prior recommendations could increase accountability and improve 

transparency. Similarly, the agency should provide a written report of all consultation and 

CDC/ATSDR Tribal Advisory Committee (TAC) activity to the CDC TAC, CDC/ATSDR 

Director, Secretary of HHS, and the Secretary's Tribal Advisory Committee. This report should 

also be published on the CDC website and distributed via a DTLL. 

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National Indian Health Board 

CDC/ATSDR Tribal Consultation Policy and Process 

Further, the Tribal Consultation Policy should require that CDC/ATSDR address why the 

agency did not implement certain suggestions. In any follow-up mechanism used, the agency 

must include a way for Tribal leaders to inquire further about why their request or proposal was 

not incorporated or to suggest alternative approaches that may be mutually beneficial. Far too 

often, Tribal leaders make suggestions but never hear back. Instead, they are left to wonder if their 

request was received, understood, and considered. This often leads to a decrease in Tribal leader 

participation. Therefore, we urge the agency to survey Tribal leaders who attend the consultation 

to see if they were effective and how the agency can improve future Tribal Consultations. 

Additionally, the agency should track participation to ensure that there is sufficient representation 

and input. Meaningful consultation is not possible without meaningful consideration, 

communication, implementation, and follow-up. 

Informed Tribal Decision Making 

We urge CDC/ATSDR to move towards a consultation model that encourages informed 

Tribal decision-making by giving Tribal leaders ample time to prepare so the consultation 

can be engaging and meaningful for both sides. Although some situations call for quick 

decision-making, the agency must still honor the trust responsibility and consult with Tribes. These 

inherent Tribal rights must stand even during national emergencies. Additionally, rapid 

consultations should only be used in all but the most urgent situations, such as the case throughout 

the COVID-19 crisis. A rushed effort does not produce superior results for Indian Country. We 

believe that such consultations do not give Tribal leaders enough time to research and discuss the 

issue at hand. The lack of preparation time often results in consultations that feel like they exist to 

allow CDC/ATSDR to "check a box" and not learn about Indian Country's concerns. Tribal leaders 

are leaders of sovereign nations; therefore, the agency should not expect them to be ready for a 

consultation on short notice. While one might argue that a rapid consultation meets a minimum 

technical threshold to be called a "Tribal Consultation," such meetings do not allow for informed 

and meaningful discussions with Indian Country. 

Further, we urge CDC/ATSDR to adopt a uniform notice requirement that ensures that 

every federally recognized Tribe can participate in Tribal consultations. It often takes time 

for notice of these meetings to arrive at the desk of Tribal leaders, who the agency then expects to 

turn their attention towards getting ready for the meeting with little time to prepare. Tribal leaders 

should have some degree of predictability regarding Tribal consultations to operationalize 

preparation and have a mechanism to ensure that they have ample time to prepare. We are also 

concerned that Tribal leaders may not receive the invitation on time and cannot attend or have time 

to prepare. Tribal leaders are leaders of sovereign nations and often have competing priorities. It 

is unrealistic to expect them to be ready on short notice. We urge the agency to adopt a policy 

requiring at least a 30-day notice for consultation, with limited exceptions for emergency 

items. There is currently no prescribed timeline in the policy. We believe that a uniform 

requirement will allow for a degree of predictability and adequate time for Tribal leaders to 

prepare. 

On Thursday, August 5, 2021, CDC/ATSDR held a formal Tribal Consultation on the agency’s

Tribal Consultation Policy. To our knowledge, there was no DTLL issued for this consultation 

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National Indian Health Board 

CDC/ATSDR Tribal Consultation Policy and Process 

and notice only appeared in the Federal Register on July 2nd, 2021. This is unacceptable and 

is a failure by the agency to provide adequate, informed, and timely notice to Tribal leaders. 

Unfortunately, this is not the first time the agency has failed to provide proper notice. Currently, 

there are no requirements in the agency’s Tribal Consolation Policy around how the agency should 

communicate Tribal consultations to Tribal leaders. The policy states that the "CDC will initiate 

consultation regarding the event through communication methods as outlined in the HHS Tribal 

Consultation Policy." Section 8(A) of the HHS Department Policy on Tribal Consultation merely 

provides an open list of communication methods. There needs to be a uniform means of reaching 

Tribal leaders. We urge the agency to, at minimum, adopt a uniform requirement to send a 

DTLL for every consultation and mandate that the letter include any pertinent information 

(such as a Federal Register notice). 

The agency must also expand the methods through which Tribal leaders can participate in 

Tribal consultations. As we learned during the COVID-19 pandemic, it is possible for the agency 

to conduct Tribal Consultations remotely and for Tribal leaders to be engaged in that format. 

While the agency should resume in-person consultations, they must continue to ensure that Tribal 

leaders can participate remotely. Many Tribes are small and do not have the resources to pay for 

travel for their leadership to participate in consultations. The ability to participate remotely 

expands the number of Tribal leaders who can participate, which helps to ensure that the agency 

is hearing from a broad cross-section of Tribal leaders. 

We also urge the agency to consider expanding the usage of listening sessions during these 

early stages of policy development to hear directly from Tribal leaders. If CDC/ATSDR 

engages Tribal leaders from the start, it should make for a more fruitful consultation process. The 

agency should not wait until they have formulated a policy or regulation before asking for feedback 

from Indian Country. 

Tribal Technical Assistance 

The CDC/ATSDR Tribal Advisory Committee (TAC) and Tribal technical assistance from 

National, Regional, and Inter-Tribal organizations can be essential tools in the consultation 

process. But note, discussions with a TAC are not a substitute for Tribal consultation. TACs should 

be utilized by CDC/ATSDR when they are formulating policies because TACs are the best conduit 

through which CDC/ATSDR can receive technical assistance that is Tribally informed and 

representative of the various regions. CDC/ATSDR currently has a very active advisory committee 

that the agency can utilize to inform the different policy areas that their programs touch. We urge 

CDC/ATSDR to begin engaging the TAC early in the policy and regulatory making process so 

any proposed policies can be Tribally informed from the start, prior to initiating formal 

consultation. Additionally, we request that the agency support the TAC’s desires for the Tribal 

Public Health Work Group, a vital means for technical assistance and expert guidance for the TAC. 

To have meaningful consultation with the CDC/ATSDR TAC, the agency must prioritize 

completing the CDC/ATSDR TAC charter revision process and prioritize the TAC’s input on all

changes to the charter. We support the TAC’s request that the CDC/ATSDR responds to the 

proposed charter edits by October 15, 2021. We also ask that any revisions or edits 

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National Indian Health Board 

CDC/ATSDR Tribal Consultation Policy and Process 

CDC/ATSDR makes be marked and that the agency provide detailed explanations for any changes 

they rejected. 

We recognize that only the primary TAC delegates can speak during official TAC meetings to 

maintain compliance with the statutory exemption to the Federal Advisory Committee 

Management Final Rule (FACA) found in the Unfunded Mandates Reform Act (UMRA). During 

the meetings, the TAC member must yield their seat to allow authorized representatives, technical 

advisors, or guests to talk. This requirement is contrary to traditional Tribal ways and customs, 

which allow for interactions where everyone involved can contribute equally to the discussion. We 

encourage the CDC/ATSDR to consider how these restrictions impact the quality of conversations. 

We implore the agency to explore meeting formats that conform with the UMRA while allowing 

for the least burden and inconvenience. 

We also have concerns about support for technical assistance for Tribal leaders from Tribal 

organizations. Tribal organizations, such as NIHB, are routinely consulted by Tribal leaders in 

preparation for TAC meetings and Tribal consultations. However, there is little support for this 

work. We urge CDC/ATSDR to support the work of Tribal organizations, who are vital in 

ensuring that Tribal leaders have access to the subject matter expertise that helps them 

prepare to offer meaningful feedback to the agency. We believe that this technical assistance 

is vital to full and meaningful consultation. 

Conclusion 

Thank you for your attention to the Biden Administration Memo and efforts to address its Tribal 

consultation policy. Rededication to government-to-government relationship presents an 

opportunity to improve the processes that maintain and strengthen these sacred relationships. 

Given the status of Tribes as pre-existing sovereigns and their unique position in the American 

legal framework, Tribal consultation must be robust and meaningful. There must be accountability 

from CDC/ATSDR. Thank you again for taking this first step, and we look forward to an ongoing 

dialogue on how to make Tribal consultation more respectful and responsive to the needs of Tribes. 

Sincerely, 

Stacy A. Bohlen 

CEO 

National Indian Health Board 

8 
Oneida 

Oneida 

Business Committee 

Nation =CKJDOOO

r'\

PO Box 365 • Oneida. WI 54155-0365 oncida-nsn.gov ONEIDA 

September 1, 2021 Sent electronically to Tribalsupport@cdc.gov 

Capt. Karen Hearod, MSW, LCSW 

Office of Tribal Affairs and Strategic Alliances 

Center for State, Tribal, Local, and Territorial Supp01i 

Centers for Disease Control 

1600 Clifton Road NE, Mailstop V 18-4 

Atlanta, GA 30329-4027 

RE: CDC/ATSDR Tribal Consultation Session 

Dear Capt. Hearod, 

On behalf of the Oneida Nation (the "Nation"), I submit the ,following comments for the 2021 

CDC/ ATSDR Tribal Consultation. I thank the CDC for providing Councilwoman Jennifer 

Webster an opp01iunity to provide testimony on behalf of the Nation during the virtual consultation 

Below you will find some information about our Nation and our full written testimony. 

ONEIDA NATION BACKGROUND 

The Nation is a Title V Self-Governance Tribe with approximately 17,359 citizens. Our 

reservation was established in 1838 and covers nearly 65,400 acres located within the boundaries 

of Brown and Outagamie Counties in Northeast Wisconsin. About 7,832 enrolled members live 

within the two counties, 57% of which live on Oneida Reservation land. We have 2,130 or 12.3% 

of enrolled members that reside within Southeast Wisconsin. 

The governing body of our Nation is the General Tribal Council who elect and authorize the 

Oneida Business Committee to oversee Tribal operations. The Oneida Business Committee 

consists of a Chairperson, Vice Chairperson, Secretary, Treasurer, and five council members, each 

elected to concmTent three-year terms. 

The purpose of our inherent right to self-governance is to protect the health, safety, and welfare of 

our members while protecting our culture, revitalizing our language, and restoring the environment 

to improve the quality of life for the community. 

We are committed to maintaining our language and culture. The rich traditions, culture and 

language are incorporated into the very fabric of the Nation. For nearly 200 years, we have lived 

A good mind. A good heart. A strong fire. 
in Wisconsin. We have built a community that is proud and dedicated to a good mind, a good 

heart, and a strong fire. 

The Nation is located within the Bemidji Area and we have had a Compact and Funding Agreement 

with the US Department of Health and Human Services since 1997. Our Comprehensive Health 

Division serves over 14,000 patients and supplies a number of services including, but not limited 

to, ambulatory medical services, family health services, mental health, substance abuse, internal 

medicine, laboratory services, nurse services (population based), purchased/referred care, 

respiratory services, telehealth and tele behavioral health services, medicine services, community 

health representatives, public health nursing, long term care services, pharmaceutical services, 

public health, and more. 

FUNDING 

As you know, the IHS and tribal healthcare systems are chronically underfunded. We appreciate 

the recent one-time investments through CARES Act & the American Rescue Plan Act. Now more 

than ever, it is important that tribal nations receive funding as quickly and efficiently as possible 

to adequately respond to the pandemic. With this in mind, the Nation makes the following 

recommendations regarding funding: 

Grants vs. Formula-Based Funding 

The Nation believes that the CDC should move away from grants and competitive funding and 

move to a recmTing formula-based funding. As of this week, there 1,101 funding opp01tunities 

listed on Grants.gov website that are open to tribal governments. No tribe can apply for and 

administer all of these grants. 

The Nation believes Indian Self Determination Education Assistance Act (ISDEAA) SelfGovernance agreements should be used to disburse CDC funding to Tribal Nations. This will 

allow Tribes to develop long-term plans to meet the needs of their communities rather than spend 

valuable time and resources on applying for, administering, and reporting on grants. The CDC 

should develop program formulas in consultation with Tribal Nations and identify all sources of 

funding that Tribal Nations are eligible for to remove the bureaucracy and streamline the process 

for distributing funds to the intended recipient. 

Limit Reporting Requirements & Maximize Flexibility 

CDC should also streamline reporting requirements and maximize funding flexibility for tribes. 

While the Nation is appreciative of new funding opp01tunities provided by Congress and CDC, 

the process to apply for, track and manage funding streams from multiple HHS agencies is 

burdensome. This is especially true during the COVID-19 pandemic, when many tribes have been 

forced to place supp01i staff on furlough or layoff status. 

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A good mind. A good heart. A strong fire. ONEIDA 
� 

ONEIDA 

Even non-competitive funding opportunities, such as Supp011ing Tribal Public Health Capacity in 

Coronavirus Preparedness and Response grant (RFA-OT20-2004), required significant staff time 

to prepare. Fmihe1more, as circumstances and needs changed over the course of the pandemic, we 

had to submit budget modifications and requests for extensions in order to best utilize the funds, 

taking even more staff time away from other duties. Compare this to funding provided through the 

IHS, which allows maximum flexibility. 

Inter-Agency Transfers to IHS 

It is the responsibility of HHS to ensure that federal funds, such as CARES Act and American 

Rescue Plan Act funds, reach tribes quickly and efficiently. For future funding, the Nation 

encourages CDC to streamline the process by negotiating inter-agency transfers with the IHS for 

distribution of funds to tribes through IHS Self Governance funding agreements. 

Agencies like CDC have limited experience working with tribes in comparison to the established 

relationship with the IHS. The IHS has over 26 years of experience working with tribes and has 

long established mechanisms in place to ensure funds get out to the tribes in an effective manner. 

Distributing HHS funds through existing IHS funding agreements is the most efficient way to 

deliver these needed resources to tribes with the least administrative burden. 

TRIBAL CONSULTATION & COMMUNICATION 

With the COVID crisis and new variant, it is critical that CDC engages tribes and maintains a 

strong relationship in order to work toward addressing this significant public health challenge. The 

CDC's track record on working with tribes demonstrates a need for improvement. As quoted in a 

recent journal publication: "TAC members have raised concerns with how CDC engages the tribes, 

and requested process improvements, such as the need to provide input earlier in project 

formulation and the need to reach out to all tribes for feedback." (Clelland article 2021 - former 

Director of Office of Tribal Affairs and Str

ategic Alliances, Center for State, Tribal, Local, and 

Territorial Support) 

Communication Methods 

We request that Dear Tribal Leader Letters be sent out rather than announcements through the 

Federal Register for tribal consultation and funding oppo11unities. We recommend that you reach 

out to IHS staff and HHS IEA Tribal Affairs staff for examples of best practices for sharing Dear 

Tribal Leader Letters and announcements so that they reach a wide audience. We also recommend 

you share your announcements with tribal organizations like NIHB, the Self-Governance 

Communication and Education Tribal Consortium, and others who can spread the word to tribal 

leaders. These federal agencies and tribal organizations have existing email lists that may be 

helpful. In addition, after consultations are held, it is imperative that the CDC send up a follow up 

Dear Tribal Leader Letter to the tribes, tribal organizations, including urban health programs, 

summarizing the findings of the consultation, what responses were received, what responses were 

A good mind. A good heart. A strong fire. 
� 

implemented and not implemented and the justification as to why or why not those suggestions 

were implemented. 

Tribal Consultation 

In order to ensure that the CDC honors tribal sovereignty, government-to-government 

relationships, and fulfills its trust responsibility, we recommend that the CDC: 

• Establish staff-level and leadership-level relationships with Tribes. Relationships between 

Federal and Tribal officials can provide a foundation for effective communication and a 

meaningful understanding of a Tribe's concerns. 

• "Substantial Direct Effects" should trigger consultation. Tribes should have the 

oppmtunity to say whether an action requires consultation and agencies should be aware 

that Tribes may be affected not just by on-reservation actions, but also by funding and 

personnel decisions related to Federal Indian programs and off-reservation actions. 

• "Consultation" must be a two-way dialogue and opportunity for joint decision-making on 

a nation-to-nation level that is more than a procedural or "check the box" exercise. 

Information-Sharing 

The Nation requests the following information: 

• A report on the status of the tracker of tribal leader requests and how CDC has responded.

We would like this to be presented to the TAC and have a report sent to the ST AC.

• We request that CDC create a crosswalk table that shows budget allocations and processes:

o Table with CDC appropriation and line item;

o How much has gone to tribes and if states were expected to work with tribes for

distribution;

o How does internal allocation align with tribal priorities and requests through

consultation, including details such as when did tribal leaders provided consultation

on the issue/project/program;

o Which mechanism (fmmula, co-operative agreement, contract - given that tribes

have requested formula funding);

o Programming, evaluation, and research;

o Topic area of funding such as COVID, opioids, diabetes, childhood adversity;

o How and who made the decisions;

o Include 3 most recent years and upcoming fiscal year.

• What are the plans for tribal spending for upcoming FY?

o For FY 2022 Budget how much will go to tribes, TECs, and other tribal evaluation,

research, and programming?

o Do funding oppmtunities include tribal set asides, patticularly for opioid and

community violence programs?

• Request oppo1tunity to consult on recent activities and have Dear Tribal Leader Letters go

out

• CDC's Center for State, Tribal, Local, and Tenitorial Suppmt (CSTLTS) has awarded

funding $2.25 billion to public health agencies. How much of this funding was provided to

tribal public health agencies?

A good mind. A good heart. A strong fire. ONEIDA 
• $800 million was appropriated for data modernization. Need for consultation and how this

impacts public health infrastructure for tribes and TECs.

CONCLUSION 

Please accept these comments with our sincere request to work together with the Centers for 

Disease Control in the spirit of paiinership and shared interest. I thank you for this opp01iunity to 

provide comments and recommendations and look forward to the CDC's consideration of our 

recommendations. Please contact Candice E. Skenandore, Self-Governance Coordinator, at (920) 

615-9702 or cskena10@oneidanation.org if you have any questions or to discuss the comments.

Sincerely, 

� 

T ehassi tasi Hill, 

Oneida Nation Chai1man 

A good mind. A good heart. A strong fire. ONEIDA 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMITTED VIA: tribalsupport@cdc.gov 

September 7, 2021 

José T. Montero, MD, MHCDS 

Director 

Center for State, Tribal, Local, and Territorial Support 

Centers for Disease Control and Prevention 

RE: NPAIHB Testimony – CDC/ATSDR Tribal Consultation Policy 

Dear Dr. Montero: 

On behalf of the Northwest Portland Area Indian Health Board (NPAIHB), we 

submit testimony on the Centers for Disease Control and Prevention 

(CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) Tribal 

Consultation Policy pursuant to 86 Fed. Reg. 35298 (July 2, 2021). Established 

in 1972, NPAIHB is a tribal organization under the Indian Self-Determination 

and Education Assistance Act (ISDEAA), P.L. 93-638, advocating on behalf of the 

43 federally recognized Indian Tribes in Idaho, Oregon, and Washington on 

specific healthcare issues. NPAIHB operates a variety of important health 

programs on behalf of its member tribes, including the Northwest Tribal 

Epidemiology Center. 

On August 5, 2021, the Office of Tribal Affairs and Strategic Alliances (OTASA) 

within the Center for State, Tribal, Local, and Territorial Support convened for 

the Tribal Consultation to receive input and guidance on improving the current 

CDC/ATSDR Tribal Consultation Policy in partnership with American Indian and 

Alaska Native (AI/AN) Nations, including those represented in the Portland 

Area. On behalf of Northwest Tribes, we share our gratitude to you, Captain 

Hearod, CDC OTASA staff and others who supported this consultation. 

We also appreciate the opportunity to provide our written testimony to the 

CDC/ATSDR on the Tribal Consultation Policy. 

I. NPAIHB’s Recommendations

1. Objectives Section

We recommend that CDC/ATSDR add an objectives section with the following 

language: 

The objectives of the CDC/ATSDR Tribal Consultation Policy are to: 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dr. José T. Montero 

September 7, 2021 

Page 2 

• Honor self-governance and self-determination of Indian Tribes. 

• Ensure consultation with Indian Tribes on proposed, new, and existing policies, 

programs, research activities/projects, and research and funding priorities that 

impact Indian Tribes; 

• Establish a minimum set of requirements and expectations with respect to 

consultation and participation of CDC leadership; 

• Identify critical events for which Tribal consultation and participation will be 

required for the CDC and its Institutes and Centers; 

• Establish improved communication channels with Indian Tribes and Indian 

organizations, and the Tribal Advisory Committee (TAC) to increase knowledge and 

understanding of CDC programs, funding opportunities, and priorities; 

• Ensure compilation of comments and recommendations raised during regional 

consultations for the TAC to review and consider; 

• Coordinate with the Indian Health Service and other HHS divisions on issues of 

mutual concern; and 

• Charge and hold responsible all levels of management within CDC and its Institutes 

and Centers for implementation of this policy. 

2. Tribal Consultation Process (Section 3D) 

CDC only announced this consultation on the CDC/ATSDR Tribal Consultation Policy through the 

Federal Register (FR) and not through a Dear Tribal Leader Letter (DTLL). Most tribes do not 

regularly check the FR so notice is often delayed to Tribal Nations when a DTLL is not circulated. 

The current CDC/ATSDR Tribal Consultation Policy, Section 3(D), states that “CDC will adhere to 

the consultation process as outlined in Section 8 of the HHS Tribal Consultation Policy.” The 

HHS Tribal Consultation Policy, Section 8(A)(1), states that HHS frequently uses a DTLL format to 

notify Indian Tribes of consultation activities and that Divisions work with the Principal Advisor 

for Tribal Affairs, IOS/IEA, for technical assistance on the proper format and protocols. We do 

not know if CDC worked with Tribal Affairs on this consultation. In addition, Section 8(A)(2), 

states that the consultation shall be communicated to affected Tribes “using all appropriate 

methods including, mailing, broadcast e-mail, FR, and other outlets.” It further notes that the 

FR is the most formal type of notice. 

We request that the CDC/ATSDR Tribal Consultation Policy incorporate Section 8 from the 

HHS Tribal Consultation Policy into the CDC/ATSDR Tribal Consultation Policy, and that these 

additional requests be included: 

• Any tribal consultation official notification always include a DTLL, not just the FR, that 

is widely broadcast to the TAC listserv and any other tribal listserv CDC maintains. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dr. José T. Montero 

September 7, 2021 

Page 3

• Any Areas who are not represented on the TAC at the time of notification be included 

in any outreach made via Area officials, Tribal Leaders, Tribal Nation officials, Area 

Health Boards, and Regional and National Tribal Organizations. 

• All copies of DTLLs should be posted on the CDC Tribal webpage, and any CDC 

associated social media streams. 

• CDC/ATSDR will work with Principal Advisor, Tribal Affairs, IOS/IEA, on any 

consultation notice to ensure broad dissemination. 

3. Section 3E – Evaluation and Reporting 

Section 3E of the CDC/ATSDR Tribal Consultation Policy states that CDC will measure the level of 

satisfaction of Indian Tribes on an annual basis as outlined in Sections 12 and 13 of the HHS 

Tribal Consultation Policy. 

We request that CDC/ATSDR: 

• Comply with the requirements of sections 12 and 13 of the HHS Tribal Consultation 

Policy. 

• Include language that requires CDC/ATSDR to provide Tribes with copies of all reports 

and evaluations of consultation activities so that Tribes can provide more informed 

feedback on consultation activities. 

II. Review of Proposed Changes to Policy 

We request that CDC convene a workgroup of the TAC charged with reviewing comments and 

recommendations to the Policy and to prepare a draft CDC consultation policy to be 

presented to the Tribes through consultation. Any revisions to HHS and IHS tribal 

consultation policies should be included in the CDC policy to ensure that all agencies are using 

consistent tribal consultative practices. 

III. Conclusion 

We reiterate to CDC/ATSDR and all Centers, Institutes, and Offices (CIOs) to utilize all pathways 

to announce consultation and ensure widespread awareness of and engagement by Tribal 

Leaders; that these also be timely and consistent to be considerate of Tribal Leader’s schedules

and planning needed to be prepared. We further urge the CDC/ATSDR to implement these 

requests in consistent and ongoing consultation with Tribal Nations. 

We look forward to working with CDC closely to improve the government-to-government 

relationship and in fulfillment of trust and treaty obligations. Please contact Candice Jimenez, 

NPAIHB Health Policy Specialist, if you have any questions at 503-926-4179 or via email at 

cjimenez@npaihb.org. 
 

 

Dr. José T. Montero 

September 7, 2021 

Page 4

Sincerely, 

Nickolaus D. Lewis 

Chair, Northwest Portland Area Indian Health Board 

Councilman, Lummi Indian Business Council 

cc: Rochelle Walensky, Director, CDC/ATSDR, director@cdc.gov 

Captain Karen Hearod, Director, OTASA, CSTLTS, Rqj0@cdc.gov 

Jenna Myer, Deputy Director, OTASA, CSTLTS, kuy2@cdc.gov 
 

 

711 Stewarts Ferry Pike 

Suite 100 

Nashville, TN 37214 

P: (615) 872-7900 

F: (615) 872-7417 

www.usetinc.org 

Transmitted Electronically 

to Tribalsupport@cdc.gov 

September 7, 2021 

Captain Karen Hearod, MSW, LCSW 

Director, Office of Tribal Affairs and Strategic Alliances 

Center for State, Tribal, Local, and Territorial Support 

Centers for Disease Control and Prevention 

160 Clifton Rd. NW, Mailstop V18-4 

Atlanta, GA 30329-4027 

Dear Director Hearod, 

On behalf of the United South and Eastern Tribes Sovereignty Protection Fund (USET SPF), we submit 

these comments in response to the Tribal consultation held on August 5, 2021 by the Centers for Disease 

Control and Prevention (CDC) and the Agency for Toxic Substances and Disease Registry (ATSDR) on 

strengthening its Tribal Consultation Policy. USET SPF is encouraged that CDC/ATSDR is adhering to 

President Biden’s Memorandum issued on January 26, 2021 to reaffirm the Administration’s commitment to

uphold and implement the directives of Executive Order 13175, “Consultation and Coordination with Indian 

Tribal Governments” (E.O. 13175). President Biden’s January 26th Memorandum emphasized the 

Administration’s commitment to respect Tribal Nation sovereignty and self-governance, while 

acknowledging that honoring the federal government’s trust and treaty obligations to Tribal Nations is vital 

due to current crises related to health, the economy, social justice, and climate change. We remain 

concerned with some of CDC/ASTDR’s existing protocols for consultation, communication, and outreach to 

Tribal Nations, including during the COVID-19 pandemic. USET SPF urges CDC/ATSDR to meaningfully 

adopt and implement Tribal guidance received during this consultation in fulfillment of trust and treaty 

obligations, and to generally improve its Tribal consultation practices. 

USET SPF is a non-profit, inter-tribal organization advocating on behalf of thirty-three (33) federally 

recognized Tribal Nations from the Northeastern Woodlands to the Everglades and across the Gulf of 

Mexico.1 USET SPF is dedicated to promoting, protecting, and advancing the inherent sovereign rights and 

authorities of Tribal Nations and in assisting its membership in dealing effectively with public policy issues. 

1 USET SPF member Tribal Nations include: Alabama-Coushatta Tribe of Texas (TX), Aroostook Band of Micmac Indians (ME), 

Catawba Indian Nation (SC), Cayuga Nation (NY), Chickahominy Indian Tribe (VA), Chickahominy Indian Tribe–Eastern Division 

(VA), Chitimacha Tribe of Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians (NC), Houlton 

Band of Maliseet Indians (ME), Jena Band of Choctaw Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee 

Wampanoag Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), Mississippi Band of Choctaw Indians (MS), Mohegan Tribe 

of Indians of Connecticut (CT), Monacan Indian Nation (VA), Nansemond Indian Nation (VA), Narragansett Indian Tribe (RI), 

Oneida Indian Nation (NY), Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian Township (ME), Passamaquoddy 

Tribe at Pleasant Point (ME), Penobscot Indian Nation (ME), Poarch Band of Creek Indians (AL), Rappahannock Tribe (VA), 

Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida (FL), Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), 

Tunica-Biloxi Tribe of Louisiana (LA), Upper Mattaponi Indian Tribe (VA) and the Wampanoag Tribe of Gay Head (Aquinnah) 

(MA). 

Because there is Strength in Unity 
 

 

 

 

 

 

 

 

 

USET SPF welcomes the opportunity to provide recommendations on how CDC/ATSDR can improve its 

consultation and coordination efforts with Tribal Nations. We see the value in the spirit of the January 26th 

Executive Memorandum, which is to recommit and refocus federal agencies to engaging in meaningful 

Tribal consultation. However, these actions alone are not sufficient to address systemic failures in the 

various consultation processes across the federal government. Broadly, the U.S. must work to reform the 

Tribal consultation process—to “build back better,” in a way that truly modernizes our relationship with the

federal government. Tribal Nations continue to experience inconsistencies in consultation policies, the 

violation of consultation policies, and mere notification of federal action as opposed to a solicitation of input. 

Letters are not consultation. Teleconferences are not consultation. Providing the opportunity for Tribal 

Nations to offer guidance and then failing to honor that guidance is not consultation. 

While each executive department and its agencies must reevaluate its protocols and procedures for Tribal 

consultation, communication, and engagement, there must be a broader reconciliation across the federal 

government to provide certainty, consistency, and accountability in this process. The federal government 

must work to standardize and provide a uniform foundation to its Tribal consultation methods to provide 

certainty to Tribal Nations and federal officials alike. It is time for a Tribal Nation-defined consultation 

model, with dual consent as the basis for strong and respectful diplomatic relations between two equally 

sovereign nations. In the short term, we must move beyond the requirement for Tribal consultation via 

Executive Order to a strengthened model achieved via statute. 

In the long term, we must return to the achievement of Tribal Nation consent for federal action as a 

recognition of sovereign equality and as set out by the principles of the United Nations Declaration on the 

Rights of Indigenous Peoples. Our recommendations focus on general principles of how federal 

departments and agencies must improve their coordination and consultation efforts, as well as specific 

issues Tribal Nations have encountered with CDC/ATSDR actions and activities. 

Evolve Consultation to Consent 

The U.S. must move beyond a “check the box” method of consultation and instead work to formalize

diplomatic relations with and seek the consent of Tribal Nations individually. This directive is reflected in 

Article 19 of the U.S.-endorsed United Nations Declaration on the Rights of Indigenous Peoples, which 

states that nations, “shall consult and cooperate in good faith”, with the governmental institutions of our 

Tribal Nations, “in order to obtain [our] free, prior and informed consent before adopting and implementing 

legislative or administrative measures that may affect [us].” 

Due to the COVID-19 pandemic, virtual and teleconference consultations have had to take the place of inperson, face-to-face, consultations. While this is not a preferred method of consultation, it does offer the 

federal government another opportunity to engage, communicate, and consult at a Leader-to-Leader level. 

These methods of consultation provide the federal government with the opportunity to engage and 

communicate directly with every Tribal Nation. 

Standardize and Codify Consultation Requirements 

For far too long, Tribal Nations have experienced inconsistencies in consultation policies, the violation of 

consultation policies, and mere notification of federal action as opposed to a solicitation of input. Letters are 

not consultation. Teleconferences are not consultation. Providing the opportunity for Tribal Nations to offer 

guidance and then failing to honor that guidance is not consultation. Accountability is required to ensure 

Tribal consultation is meaningful and results in corresponding federal efforts to honor Tribal input and 

mitigate any concerns. All federal agencies, including independent federal agencies and the Office of 

Management and Budget, must be statutorily required to adhere to consultation policies with additional 

oversight from the White House and Congress. USET SPF strongly supports the codification of consultation 
 

 

 

 

 

 

 

 

 

 

 

requirements for all federal agencies and departments, including a right of action to seek judicial review of 

consultation when the federal government has failed to engage, communicate, and consult appropriately. 

We further urge the Biden-Harris Administration to use its authority, in consultation with Tribal Nations, to 

create and implement a standard consultation process for use by all agencies. 

Tribal Consultation Should Occur on a Nation-to-Nation, Leader-to-Leader Basis 

Although consultation can pertain to very specific programmatic issues requiring technical and subject 

matter expertise, true consultation should occur at a Leader-to-Leader level. Duly elected or appointed 

Tribal Leaders must be afforded the respect and opportunity to directly voice Tribal Nation concerns to 

those federal officials with actual decision-making authority. We must further have the opportunity to 

include and confer with our respective expert staff during every consultation, just as federal officials do. 

In addition, because the U.S. is engaged in a diplomatic relationship with each federally recognized Tribal 

Nation, greater effort must be made to consult with Tribal Nations on an individual basis. Due to the 

COVID-19 pandemic, virtual and teleconference consultations have had to take the place of in-person, 

face-to-face, consultations. While this is not a preferred method of consultation, it does offer the federal 

government another opportunity to engage, communicate, and consult at a Leader-to-Leader level. These 

methods of consultation provide the federal government with the opportunity to engage and communicate 

directly with every Tribal Nation. 

No Delegation of Federal Consultation Obligations 

The trust relationship exists between the federal government and Tribal Nations exclusively. To this point, 

the federal government must not delegate its consultation obligation to third party entities, which include 

non-profit organizations, industries/corporations, hired consultants and contractors, non-Tribal 

archaeologists and anthropologists, and other units of government. When other entities are party to or 

involved in federal actions, the federal government must exercise appropriate oversight in ensuring Tribal 

interests are not adversely impacted. Tribal Nations, and not any other entity, are the final arbiters of 

whether a federal action impacts our governments, homelands, cultures, public health, or sacred sites. 

Consultation Should be Early and Ongoing, with Advance Notice and Sufficient Response 

Timelines 

One of the guiding principles of E.O. 13175 is to establish regular, meaningful consultation and 

collaboration with Tribal Nations in developing and implementing federal policies. However, this principle 

has been exercised using methods that have not always taken into consideration the direct and in-direct 

implications for Tribal Nations. Under the current consultation framework, federal departments and 

agencies often unilaterally conduct their own internal review of proposed policies and actions, which 

frequently results in a finding of no impact. This fails to recognize and adhere to the federal government’s 

fiduciary trust and treaty obligations to Tribal Nations. Rather, consultation and collaboration must 

recognize Tribal Nations as equal sovereigns. Tribal Nations must always be engaged at the earliest stages 

of federal decision-making process. In addition, our authority to initiate consultation in response to federal 

action (or proposed federal action) must be recognized and honored. 

Deference to Tribal Nations 

E.O. 13175, Section 3 lays out a set of policymaking criteria that have been implemented unevenly over the 

last two decades. In particular, this includes directives to extend “maximum administrative discretion” to

Tribal Nations by encouraging Tribal Nations to develop our own policies and standards to achieve 

objectives as well as consult with us on the necessity of any federal standards. USET SPF urges 

CDC/ATSDR and the Biden Administration to consider how this section can be better operationalized and 

consistently applied throughout the federal government. In addition, the Indian Canons of Construction 

should always be applied during Tribal consultation, the policymaking process, and beyond. That is, any 

ambiguities in law or policy should be interpreted in favor of Tribal Nations. 
 

 

 

 

 

 

Flexibility for Tribal Waivers 

Similarly, E.O. 13175, Section 6 encourages the federal government to facilitate and streamline Tribal 

applications for waivers of statutory and regulatory requirements. With some notable exceptions, this 

section does not appear to be actively implemented across the federal government. CDC/ATSDR 

and the Biden Administration should also revisit this section and examine what further Executive action is 

necessary to ensure its widespread operationalization. 

Transparency in Decision-making 

All too often following Tribal consultation, the federal government renders a decision without further 

explanation as to how that decision was reached. This is particularly true in the case of “check-the-box” 

consultation, where Tribal Nations provide input and that guidance is ignored completely. Not only does this 

run counter to the federal government’s consultation obligations, it undermines our Nation-to-Nation 

relationship. In recognition of and out of respect for our governmental status, as well as in the spirit of 

transparency, each federal agency should be required to publish a summary of all comments received, how 

that guidance influenced the agency’s decision, and why the decision was reached. 

Educate Federal Employees on Tribal Sovereignty and U.S.-Tribal Nation Relations 

It is critically important that all employees of federal departments and agencies receive comprehensive 

training on working with and communicating effectively with Tribal Nations. Federal actions impact Tribal 

Nations and our citizens. Every right-of-way permit, application for land into trust, and environmental and 

cultural review document are reviewed by federal employees. However, many of the same federal 

employees engaging in decision-making that impacts our interests do not fully understand the history of 

U.S.-Tribal Nation relations and the federal trust obligation. This lack of education and understanding 

regarding the fiduciary trust and treaty obligations contributes, at least in part, to federal failures to properly 

consult. USET SPF has long recommended mandatory training on U.S.-Tribal relations and the trust 

obligation for all federal employees. This training should be designed in consultation with Tribal Nations. 

Invest in Diplomacy 

CDC/ATSDR must fully recognize and uphold our Nation-to-Nation diplomatic relationship. This directive 

extends to ensuring both the department and Tribal Nations have access to resources that support 

diplomatic activities. True diplomacy, as evidenced by activities conducted by the U.S Department of State, 

would involve U.S. ambassadors appointed to liaise with each federally recognized Tribal Nation on behalf 

of the federal government, rather than facilitating this relationship through national or regional 

consultations. While we recognize retooling the consultative relationship to allow for a truly diplomatic 

relationship involves many steps, funding for these activities is certainly one of them. We encourage 

CDC/ATSDR to consider how it might include diplomacy in future budget requests. This would include 

funding for the department to build and sustain diplomatic infrastructure, as well as increased funding for 

Tribal Nation participation in these processes. CDC/ATSDR budgets should reflect a broad commitment to 

improvements in our Nation-to-Nation relationship, including its own functions. 

CDC/ATSDR Consultation and Communication with Tribal Nations Should be Consistent and 

Responsive 

As Tribal leaders stated during the August 5th consultation session, CDC/ATSDR consistently fails to 

properly consult with and implement the guidance of Indian Country. For example, it frequently treats the 

two annual meetings of its Tribal Advisory Committee (TAC) as consultations. While TACs can help inform 

and are vital parts of the consultation process, they should only supplement—never supplant—consultation. 

Another example can be found in CDC’s failure to honor Tribal guidance amid the COVID-19 pandemic. 

During the onset of the pandemic, $40 million was allocated to CDC for Tribal Nation public health activities 
 

 

 

 

 

 

under the first COVID-19 relief package. Despite Tribal advocacy, CDC rejected requests to transfer 

funding through IHS—which would have expedited access for Tribal Nations—instead distributing these 

funds through non-competitive grant funding for direct service Tribal Nations and Tribal Nations with a 

ISDEAA Title I or Title V contracts and compacts. This process ultimately led to unacceptable delays in 

funding and resulted in unequitable distribution to all Tribal Nations seeking funding. CDC must actively 

seek to prevent this from happening again. In doing so, CDC must work with IHS and Tribal Nations to 

determine how the agency can ensure all mechanisms for the funds it administers are reflective of the 

federal trust obligation to Tribal Nations. 

As CDC’s existing consultation policy states, “it is essential that Indian Tribal governments and CDC 

engage in open, continuous, and meaningful consultation.” This involves soliciting Tribal input from across 

Indian Country, and then honoring and implementing the guidance that is given during the consultation 

process. CDC must work to ensure its consultation policy better reflects these directives, including through 

mechanisms providing for fulfillment of the policy’s requirements on the part of the agency.

CDC/ATSDR Should Establish Specific Tribal Consultation Protocols for Data Collection and 

Sharing in Indian Country 

The collection, use, and publication of sensitive data on Indian Country’s demographics has long been an

issue affecting Tribal Nations and citizens. Prior to the adoption of enhanced privacy and confidentiality 

protocols, Tribal Nations and citizens were among those communities that were exploited in research 

through deceptive actions and the unscrupulous sharing of data among other research individuals and 

entities. While improved privacy and confidentiality protocols have been adopted since then, there still 

needs to be enhanced protocols developed and adopted that recognizes the sovereignty of Tribal Nations 

to determine how and if their data is collected, used, and shared with federal partners. We recommend that 

CDC/ATSDR consult with Tribal Nations to develop defined protocols regarding data collection, retention, 

and privacy in Indian Country. The objectives identified through these consultations should inform revisions 

to CDC/ATSDR’s Tribal Consultation Policy. Since the beginning of the COVID-19 pandemic Tribal Nations 

have been subject to increased data sharing measures that involve sensitive data on Tribal government 

operations and individual citizens. Tribal Nations should be informed as to how their data is being collected 

and used by CDC/ATSDR as well as empowered to review, authorize, or disallow the sharing of sensitive 

data with CDC/ATSDR’s federal partners.

Similarly, CDC must improve data sharing with Tribal Nations and Tribal Epidemiology Centers (TECs). 

Last year, the CDC refused to provide access to TECs and Tribal Nations seeking vital public health data 

regarding the incidence of COVID-19 among our citizens. While state public health agencies report public 

health data, including data collected from and about Tribal citizens, to the CDC, this is not routinely shared 

with Tribal Nations and TECs. This data is then shared with the CDC through cooperative agreements. 

However, Tribal Nations and Tribal Epidemiology Centers (TECs) continue to experience frequent 

challenges in accessing not just public health data on both the federal and state level, but Tribal data as 

well, which often is not reported back to the Tribal Nation. This includes vital COVID-19 data. This lack of 

access to quality public health data has hindered the ability of Indian Country to respond to the public 

health crisis in our communities due to COVID-19. 

Despite being designated as Public Health Authorities, both Tribal Nations and TECs continue to 

experience frequent challenges in accessing data on both the federal and state level—including vital 

COVID-19 data—on top of the consistent lack of investment in TECs and Tribal public health capacity. 

TECs continue to petition both the CDC and state public health departments for this vital information but 

have only received state data where there are positive Tribal-state relationships and some extremely 

limited COVID-19 testing data from CDC. While CDC was ultimately given a directive to share data with 

TECs, this information was of poor quality and further hindered the work of TECs, including USET. In turn, 
 

 

 

 

 

 

 

COVID-19 response at the Tribal level was without an accurate picture of the reach of the disease into our 

communities. 

CDC must ensure that TECs have access to critical public health data from federal and state governments. 

Both should be statutorily required to share all available public health data with TECs and Tribal Nations. 

This should be made a requirement of state cooperative agreements with CDC. In addition, CDC must take 

steps to improve the quality of public health data shared with TECs and Tribal Nations. This includes 

requiring states to collect race/ethnicity data, as well as working with states and Tribal Nations to correct 

racial misclassification. Now and after the pandemic, CDC must work with TECs and Tribal Nations on an 

ongoing basis to ensure quality public health data, including health data related to the COVID-19 pandemic, 

is provided to TECs and Tribal Nations. 

Conclusion 

An essential aspect of the federal trust responsibility and obligations to Tribal Nations is the duty to consult 

on the development of Federal policies and actions that have Tribal implications. This requirement is borne 

out of the sacred relationship between the federal government and Tribal Nations, as well as numerous 

treaties, court cases, laws, and executive actions. It is a recognition of our inherent sovereignty and selfdetermination. For too long, the United States has failed to fully uphold and implement E.O. 13175 and 

other consultation directives. This has resulted in irreparable damage to Tribal Nation homelands, sacred 

sites, and interests, as well as costly litigation against the federal government. Recent events, including the 

COVID-19 crisis, have underscored the urgent need for radical transformation in the recognition of our 

governmental status and the delivery of federal obligations to our people. 

We can no longer accept the status quo of incremental change that continues to maintain a broken system. 

The federal government must enact policies that uphold our status as sovereign governments, our right to 

self-determination and self-governance, and honor the federal trust obligation in full. This includes evolving 

away from the current broken model of Tribal consultation and into a future in which Tribal Nation consent 

is sought for federal action. We ask that CDC/ATSDR join us in realizing this change and advocate for this 

change among its partners in the Executive Branch. Should you have any questions or require further 

information, please contact Ms. Liz Malerba, USET SPF Director of Policy and Legislative Affairs, at 

LMalerba@usetinc.org or 615-838-5906. 

Sincerely, 

Chief Kirk Francis Kitcki A. Carroll 

President Executive Director 
 

 

 

 

 

 

 

WINNEBAGO TRIBE OF NEBRASKA 

P.O. Box 687 * Winnebago, Nebraska 68071 * PH: 402-878-2272 * Fax: 402-878-2963 

Visit us at: www.winnebagotribe.com 

September 7, 2021 

VIA ELECTRONIC MAIL ONLY 

The Honorable Xavier Becerra 

Secretary 

United States Department of Health and Human Services 

Washington, DC 20201 

RE: Centers for Disease Control and Prevention Tribal Consultation Policy 

Dear Secretary Becerra, 

On behalf of the Winnebago Tribe of Nebraska (the “Tribe”), please find our comments 

on the Centers for Disease Control and Prevention (“CDC”) Tribal Consultation Policy. Thank 

you for holding consultation and the opportunity to provide input on this matter. We especially 

appreciate that Dr. Rochelle Walensky participated in your most recent Secretary’s Tribal 

Advisory Committee meeting – the first CDC Director to do so. 

Through treaties, the supreme law of the land, the United States made promises to the 

Winnebago people and other tribes. We have never forgotten those promises and will continue to 

advocate for our county to keep them. True consultation can achieve real solutions that better the 

lives of American Indian, Native Hawaiian and Alaska Native people. 

I. THE WINNEBAGO TRIBE OF NEBRASKA 

The Winnebagos make our home on a reservation along the banks of the Missouri River 

in Northeastern Nebraska and Northwestern Iowa. We have over 5,000 tribal members and 

numerous tribal enterprises that employ thousands of employees in a five-county area, Nebraska, 

Iowa, and around the world. The Tribe formed Ho-Chunk, Inc., the economic development 

corporation of the Tribe, in 1994. Ho-Chunk, Inc. is now the largest minority-owned company in 

Nebraska and has received numerous awards for its innovative approaches to tribal economic 

development. The Tribe owns two gaming operations in Nebraska and one gaming operation in 

Iowa which provide approximately 40 percent of the Tribal government revenues that are 

integral to support tribal government operations and programs. These enterprises also provide 

hundreds of local jobs to both tribal members and non-members alike and are respected and 

important pillars in our communities. 
 

 

 

 

 

WTN Letter to CDC re: Consultation Policy 

September 7, 2021 

Page 2 of 7 

II. WINNEBAGO COMPREHENSIVE HEALTHCARE SYSTEM 

The Tribe established the Winnebago Comprehensive Healthcare System (“WCHS”) to 

carry out health care services on behalf of the Tribe. WCHS is comprised of two divisions: the 

Winnebago Public Health Department and Twelve Clans Unity Hospital. Prior to the 

establishment of WCHS, the Health Department was operated as a program within the Tribe and 

the hospital was managed by the Indian Health Service (“IHS”). The Health Department was 

originally formed by the Tribe in the late 1970s starting with Public Health Nursing and 

Community Health Representatives. Since then, it has grown to more than sixteen different 

programs to provide the vast array of health services now available to the Winnebago 

community. 

In 2015, the Tribe established a Self-Governance Steering Committee to plan and prepare 

for expanded public health services and eventual assumption of the hospital, formally known as 

the Omaha-Winnebago Hospital. In 2018, the Tribe completed negotiations with the Indian 

Health Service and entered into a Tribal Self-Governance Compact pursuant to Title V of the 

Indian Self-Determination and Education Assistance Act to carry out the health programs for the 

Tribe. On July 1, 2018, the Tribe assumed management of the hospital through WCHS and it 

was renamed Twelve Clans Unity Hospital in honor of the twelve traditional clans of the 

Winnebago Tribe. 

III. TWELVE CLANS UNITY HOSPITAL 

The United States promised the Winnebagos a physician and medical care for our people. 

We never forget that promise and about fifteen years ago, we planned on assuming the Indian 

Health Service hospital. But in 2015, when the federal government’s operation of the hospital 

became life threatening, the Winnebago people suffered loss of life and CMS revoked the 

hospital’s Medicare and Medicaid certification. We worked twice as hard to have our own 

hospital and the Twelve Clans Unity Hospital was born to serve the Winnebago people and 

surrounding tribes. We took the hospital into our own hands and opened our state-of-the-art 

hospital in 2018, the first one of its kind in the Great Plains Region. 

Our hospital serves an estimated 10,000 Native Americans who live on the Winnebago 

Reservation and in the surrounding region. Health care services provided by the hospital and the 

Tribe’s Public Health Department include an ambulatory care clinic, inpatient care, express care 

clinic, pharmacy, radiology, emergency care, medical laboratory, physical therapy, social 

services, dental, optometry, audiology, and behavioral health. Twelve Clans is in the process of 

completing CMS certification and is implementing a strategic planning process to ensure the 

hospital services are designed to meet the needs of the population it serves. 
 

 

 

 

 

 

 

 

 

 

WTN Letter to CDC re: Consultation Policy 

September 7, 2021 

Page 3 of 7 

IV. PANDEMIC 

For the past year and a half, the COVID-19 pandemic wreaked havoc upon our lives and 

threatened our very existence. Our government quickly pivoted to operate remotely to protect our 

tribal members. We shuttered our enterprises to protect our employees. We made decisions to 

best serve the needs of our people and preserve our resources as the economy declined. 

On March 24, 2020, we declared a public health emergency to protect our people and our 

homelands. On that same day, we created the Winnebago Pandemic Task Force to ensure the 

health, safety, and welfare of Tribal members during the public health emergency. The Tribe 

provides critical health resources and operates social services, law enforcement, education and 

numerous other important services to our Tribal citizens and other community members. 

Further, we are responsible for protecting our invaluable workforce who provide these 

services and protections through our Tribal government and Tribal enterprises. We made the 

difficult decision to close our government and gaming operations on March 17, 2020. We 

implemented a curfew on April 15, 2020, and a mandatory face mask policy on April 27, 2020. 

To date, we have experienced 382 positive cases of COVID-19 and seven tragic losses of life. 

However, our swift and diligent actions to protect of tribal members and other employees likely 

saved countless lives. 

On December 16, 2020, the Tribe secured its initial allotment of sixty-five (65) doses of 

Pfizer-BioNTech vaccines from the Indian Health Service. The Tribe sent two healthcare 

professionals to Eagle Butte, South Dakota, to transport the vaccines to Winnebago. Following a 

traditional blessing ceremony, we immediately launched our efforts to vaccinate the Winnebago 

people. The Tribe’s health system has since administered more than 5,055 vaccinations and the 

number continues to increase each week. The Tribe’s vaccination rate is 74 percent for those age 

12 and older for at least one dose. 

This past year, through the Winnebago people’s resolve, we were able to do a lot with 

limited resources. Once, around the globe, we learned how to protect ourselves from the virus 

and with the coming of lifesaving vaccines, we are fortunate to be able to recoup some of our 

economic activity. The leadership of our Tribe was tested, as we have been many times, in our 

history of removal, war, and survival. 

The pandemic laid bare what we need to more adequately provide for the Winnebago 

People. We are committed more than ever to ensuring we have a safe environment, clean water, 

adequate housing, and energy sovereignty for the resilience and self-sufficiency of the 

Winnebago People. The pandemic only strengthened us as we had to make and must make the 

best decisions we can for the future of our people. 

V. LITTLE PRIEST TRIBAL COLLEGE 

Dozens of tribes have prioritized building their own institutions of higher learning over 

the last few decades. These schools are hubs of our communities, families, and tribes, to educate 
 

 

 

 

WTN Letter to CDC re: Consultation Policy 

September 7, 2021 

Page 4 of 7 

tribal members so they can climb to new heights and create more opportunities for themselves, 

their families, and the next generations. Tribal colleges and universities are a natural path for 

those who wish to live in, work in, and serve their tribal communities including corresponding 

federal programming and services that are built-in to tribal governments. 

In 1996, the Tribe opened the doors to the Little Priest Tribal College to fulfill the goal of 

its namesake, Chief Little Priest, to “Be Strong and Educate my Children.” The college prepares 

students to succeed in a multicultural world by emphasizing quality education of the highest 

level, humanistic values, and life skills. 

The school is accredited by the Higher Learning Commission with an enrollment of 113 – 

slightly down from 121 due to the pandemic. On average, 10-12 students graduate each year. The 

college issues the two-year degrees - Associate of Arts (A.A.) and Associate of Science (A.S.). 

Generally, the classes taken at Little Priest represent the first and second years of study at a fouryear institution. The college has agreements with five colleges and universities that allow our 

students to transfer, with no loss of credit, to a four-year school including the University of 

Nebraska-Omaha, Briar Cliff University, and Wayne State College. 

Like the rest of the country, the COVID-19 pandemic forced Little Priest to find creative 

solutions to new problems. The college moved to fully online classes on March 16, 2020. Our 

sports seasons were cancelled. Our students were sent home. We created an internet café offcampus to allow for students without reliable access to internet a place to complete schoolwork 

while the Little Priest campus was closed. 

Little Priest worked closely with the Tribe to address issues brought on by COVID-19. 

For example, the college and tribal health department worked together to use newly vacant 

dorms as quarantine housing for COVID-19 positive members of the community. The Tribe used 

the college’s electronic billboard, located on the busiest stretch of road in the community, to 

display up to date COVID cases, hospital contact information, and now vaccination numbers for 

the community. 

There is no part of society that has been more directly impacted by COVID-19 than 

education – the pandemic has become a pivot point where some are left behind in a stone age and 

others are thrust into the future. COVID-19 has forced us to develop remote learning and rely on 

high-speed internet. It has changed education as we know it and will be a necessity going 

forward. TCUs need resources to keep up in a post COVID-19 world. 

The ultimate goal of the Tribe is to be self-sufficient, and our college plays an important 

part is reaching that goal. Little Priest provides Winnebago tribal members high quality 

education and they can use the skills they have gained to improve their quality of life. Several of 

our tribal leaders have graduated from Little Priest, and Little Priest continues to play a critical 

part building a brighter future for the Winnebago people and educating future leaders. 
 

 

 

 

 

 

 

 

 

 

 

WTN Letter to CDC re: Consultation Policy 

September 7, 2021 

Page 5 of 7 

VI. CDC OWES A TRUST RESPONSIBILITY TO TRIBES 

CDC needs to factor in and consider longstanding treaty and trust obligations in policy 

decisions and interactions with Congress. The United States as a whole made promises to Indian 

tribes and signed legally binding treaties, which the founding fathers understood to be the 

supreme law of the land. These promises and obligations of the United State continue to this day 

and are an obligation of the entire Federal government, not simply one agency or department. 

This includes all 535 Members of Congress and the President and all federal agencies, including 

CDC. 

VII. CDC MUST UPHOLD NATIVE POLITICAL STATUS 

Native Hawaiians, American Indians, Alaska Natives have a political status within the 

United States. Such status has been upheld by the U.S. Supreme Court in decisions such as 

Morton v. Mancari. CDC must strive to strengthen hiring, consultation and outreach policies to 

ensure that native populations are being served. 

CDC staff should have a working knowledge of treaty and trust obligations and how they 

impact their program areas and the President’s Budget. CDC should include and consider Native 

Hawaiians, American Indians, and Alaska Natives in all aspects of programming and research. 

CDC should have high level staff with expertise in Indian law and policy. CDC’s 

institutional structure should have Indian law and policy built into it. 

XIII. CDC HAS AN OBLIGATION TO CONSULT WITH TRIBES 

President Joe Biden made it a priority of the Biden-Harris Administration “to make 

respect for Tribal sovereignty and self-governance, commitment to fulfilling Federal trust and 

treaty responsibilities to Tribal Nations, and regular, meaningful, and robust consultation with 

Tribal Nations cornerstones of Federal Indian policy.” We welcome this opportunity to work 

with CDC to ensure that the United States works toward fulfillment of its constitutional, treaty 

and trust responsibilities to tribes. 

Consultation is a two-way street where we expect proper notice, the courtesy of regular 

communication, either government can initiate consultation, and adequate time to respond. We 

expect consultation to be conducted for any action or decision that potentially impacts or 

involves the Tribe. CDC must have an overarching goal of weaving tribal priorities into its 

fabric, as an institution, and in carrying out its duties. This requires Federal agencies to respect 

tribes as sovereign nations. 

IX. FOOD SOVEREIGNTY 

We believe in and are prioritizing our food sovereignty. We are and need to be 

responsible for exercising and protecting it. CDC must understand the historic, political and 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WTN Letter to CDC re: Consultation Policy 

September 7, 2021 

Page 6 of 7 

legal bonds for tribes to fully realize self-governance and self-determination in the life of our 

own food systems. We are innately connected to food by our culture, tradition, land, sovereignty, 

health, elders and the next generations. It is our very essence. 

X. DATA 

The collection and use of data are underdeveloped for Indian tribes across the board. 

CDC should make collection of data relating to American Indians, Native Hawaiians, and Alaska 

Natives more robust. CDC should include and consider such data in the development of the 

President’s Budget. Treaty and trust obligations to tribes are historical and longstanding and 

consideration of them should be a mandatory part of the fabric, not a discretionary one. 

XI. NATIVES CANNOT BE LEFT BEHIND 

CDC should be working hard to ensure that all federal health research includes American 

Indians, Alaska Natives, and Native Hawaiians. President Biden’s directive to executive 

departments and federal government agencies to develop a comprehensive approach to 

advancing equity for all will help to better serve and uplift all Americans, especially those who 

have been historically underserved, marginalized, and adversely affected by persistent poverty 

and inequality. Few groups have been more historically underserved or marginalized than Indian 

people. This is especially tragic in light of the fact that treaty and trust obligations to tribal 

nations are historical and in perpetuity. CDC leadership should always bear this in mind in 

making policy decisions that touch the lives of Native Americans on a daily basis. 

XII. EQUITY AND PARITY 

The United States Congress and the Administration ensured that tribes are included in 

national relief and recovery packages. The Administration is conducting extensive consultation 

on implementation of these critical programs for our people’s public health and our tribe’s 

economic recovery. CDC needs to strive to ensure inclusion of tribal citizens in all research and 

health equity of tribal citizens across the country. 

There needs to be consistency across CDC so tribal leaders know what to expect. CDC 

needs to provide better opportunities for tribally driven research and funding for data 

sovereignty. CDC must have a dialogue about how urban Indians are portrayed in data. Racial 

equity should include tribes driving the federal research agenda. CDC needs to build strong 

partnerships with tribal colleges and universities. 

With our country’s history of exploitation of human beings and resources, on one side, 

and loss of generational wealth, on the other, federal policies must continue to incrementally 

level the playing fields for tribal health and well-being. The administration’s laser focus on 

addressing these historic disparities would, in turn, strengthen tribal health care and ensure 

healthier outcomes for all Americans. 
 

 

 

 

 

 

 

 

 

WTN Letter to CDC re: Consultation Policy 

September 7, 2021 

Page 7 of 7 

XIII. POLICY CONCERNS 

1. The CDC consultations must be regular (at a minimum on an annual basis), robust and 

transparent. ‘Dear Tribal Leader’ letters are effective and now so are virtual consultations. 

Outreach and timely notice are key to ensure greater participation and true engagement. 

2. The CDC policy ought to strongly align with the overarching consultation policy of the U.S. 

Department of Health and Human Services and President Biden’s executive orders. HHS should 

monitor CDC to ensure that President Biden’s directives for tribal consultation are being carried 

out. 

3. In light of the pandemic, a strong tie between CDC and tribal governments is starkly 

important to reaching all Americans. CDC needs to devote adequate staff to regularly engage 

with tribal nations. 

4. The policy is a living document not to be placed on a shelf. We hope to experience more 

respectful two-way communication and thorough follow up to tribal concerns. 

5. CDC needs to account for the diversity, ruralness and remoteness of tribal nations to ensure 

that the public health needs of and treaty and trust obligations to our communities are met. 

6. CDC needs to conduct outreach and build relationships with tribal colleges and universities in 

line with historically black college and universities and Hispanic serving institutions. 

7. CDC needs to build on a more respectful exchange that tribes are beginning to experience 

with it and CDC must become more accustomed to. 

Thank you for your time and consideration of our comments. Our deepest thanks to you 

especially for taking this nation-to-nation responsibility very seriously. 

Sincerely, 

Victoria Kitcheyan 

Chairwoman 
Confederated Tribes and Bands Established by the 

of the Yakama Nation Treaty of June 9, 1855 

Sept. 7, 2021 

Sent via Email 

Rochelle P. Walensky, M.D., 

Center for Disease Control 

1600 Clifton Rd. 

Atlanta, GA 30329 

Re: Comments on Center for Disease Control and Preventiont

s 

Consultation Policy 

Dear Director Walensky: 

I write on behalf of the Confederated Tribes and Bands of the Yakama Nation (the 

"Yakama Nation") in response to President Biden's Memorandum of January 26, 

2021, Tribal Consultation and Strengthening Nation-to-Nation Relationships. The 

Yakama Nation is a sovereign federally-recognized Native Nation pursuant to the 

Treaty with the Yakamas of June 9, 1855 (the "Treaty").1 The Yakama Nation is 

pleased that the new Administration seeks to prioritize respect for tribal sovereignty 

and self-governance, to fulfill trust and treaty responsibilities, and to provide regular, 

meaningful, and robust consultation with Native Nations. Outside this comment 

letter, the Yakama Nation formally requests consultation with the United States 

Center for Disease Control and Prevention ("CDC") regarding further relationship 

development and the implementation of its consultation polices. This formal 

consultation must take place here, in Toppenish, Washington, at the Yakama Nation's 

governmental headquarters. 

The following will set our overarching recommendations for the CDC to enhance its 

consultation efforts. It is the Yakama Nation's position that the CDC has not always 

treated concerns about impacts to tribal resources with appropriate care. We stl'Dngly 

encourage the CDC to put in place additional requirements to ensure that policies, 

rules, and decisions fully consider and address the concerns of Native Nations. At a 

minimum, these requirements should address what meaningful and robust 

1 Treaty with the Yakamas, U.S.-Yakama Nation, June 9, 1855, 12 Stat. 951. 

Yakama Nation, Post Office Box 151, Toppenish, WA 98948 (509) 865-5121 
y AR.AMA NAT[ON'S COMMENTS TO CDC 

SEPT.7,2021 

consultation means, what actions require true consultation, when consultation should 

occur, and who should be involved in consultation. 

I. NATION-TO-NATION RELATIONSHIPS REQUIRE FREE, PRIOR, AND INFORMED

CONSENT 

The United States endorsed the United Nations' Declaration on the Rights of 

Indigenous Peoples ("UNDRIP") on December 16, 2010. UNDRIP Article 32 directs 

nation-states to consult with Native Nations "in order to obtain their free and 

informed consent prior to the approval of any project affecting their lands or territories 

and other resources, particularly in connection with the development, utilization or 

exploitation of mineral, water or other resources." The Yakama Nation stands firm 

in its position that, given the directives of the Presidential Memorandum and 

Executive Orders discussed, that the free, prior, and informed consent of tribes must 

be required for project or agency decisions that would impact our resources. This 

policy direction would not be pioneering. In fact, the Advisory Council on Historic 

Preservation ("ACHP") developed a plan to support UNDRIP. 2 We therefore 

encourage the CDC to follow the ACHP's lead and incorporate the principles of 

UNDRIP in the CDC's programs. 

To elaborate, the principle of free, prior, and informed consent parallels the CDC's 

objective in promoting and honoring self-determination. Tribes represent "separate 

sovereigns preexisting the Constitution" with the inherent right to self-determination. 

Santa Clara Pueblo v. Martinez, 436 U.S. 49, 56 (1978). The "United States recognizes 

the right of Indian tribes to self-government and supports tribal sovereignty and selfdetermination." Exec. Order No. 13175, 65 Fed. Reg. 67,249 (Nov. 9, 2000). And, 

UNDRIP Article 3 acknowledges that "Indigenous peoples have the right of selfdetermination." Accordingly, self-determination is sewn into the fabric of federal 

caselaw, federal statutes, treaties, UNDRIP, and the CDC's directive to honor tribal 

self-determination. Federal agencies must therefore both educate themselves and 

honor these established principles if it hopes to provide true, meaningful consultation. 

II. CREATE A GENUINE, MEANINGFUL RELATIONSHIP THROUGH RESPECT

The Yakama Nation proposes three actions and policy directives the CDC must take 

if it is honest about this endeavor. First, Federal agencies like the CDC, must enter 

the consultation process not as a mere notification procedure of an Agency action, but 

with the goal of cooperating with the Yakama Nation and genuinely seeking to reach 

2 AD\'ISORY COUNCIL ON HISTORIC PRESERVATION, United Nations Declaration on the Rights of 

Indigenous Peoples (last visited March 15, 2021) https://www.achp.gov/indian-tribes-and-nativehawaiians/united-nations-declaration-rights-indigenous-peoples. 

PAGE20F5 
YAKAMA NATION'S COMMENTS TO CDC 

SEPT. 7, 2021 

common agreement on the matter at issue. This means the CDC must develop clear 

processes for documenting the consultation, ensuring protection of culturally sensitive 

information, complying with Tribal laws or protocols governing consultation, and 

implementing a certification process at the completion of consultation for both parties 

to agree that meaningful consultation had occurred. Simply cataloguing tribal 

concerns does not represent meaningful consultation. Instead, the CDC must 

communicate clearly to the Yakama Nation how its final decision addressed our input, 

and where the CDC is unable to fully address the Yakama Nation's concerns, it must 

clearly explain that reasoning. 

Second, consultations should occur throughout the evolution of the project, providing 

constant and continuous communications between the CDC and the Yakama Nation. 

Meaningful and robust consultation is a dialogue that requires an unbroken mutual 

exchange of information, it must include federal agencies sharing internal reports, 

analyses, deliberations and pre-decisional documents with the Yakama Nation. 

Agencies should ensure that all information, including the potential impact of the 

decision, is provided to the Yakama Nation and is presented in a manner and form 

that is understandable to our communities and is culturally appropriate. 

Additionally, every department within the CDC must be aware of these 

responsibilities to meaningfully engage and share information with the Yakama 

Nation in their decision-making. 

Third, the consultation and relationship goals that the CDC seeks can only be 

achieved thorough a genuine understanding of the culture and history of the Yakama 

Nation; an understanding that is only achieved by consulting the Yakama Nation here 

at our governmental headquarters in Toppenish, Washington. Meaningful 

consultation has not always occurred between the CDC and the Yakama Nation. 

Federal Agencies, like the CDC, believe "meaningful and robust" tribal consultation 

may occur through general, nation-wide phone calls to discuss policies that will impact 

tribal rights or interests. These general calls provide a few tribal leaders the ability 

to speak on an issue for perhaps two-to-three-minute increments. These alleged 

"consultations" are perceived as an insult, and stand in stark contrast to what a 

meaningful, t·obust nation-to-nation relationship represents. 

The Yakama Nation therefore requests that the Department provide true, meaningful 

consultations to Native Nations and their leadership, to listen to our concerns, and to 

consciously develop policy around those concerns. For the Yakama Nation, a 

meaningful consultation must take place here, in Toppenish, when the Yakama 

Nation is represented by a full quorum of elected Tribal Council Members present and 

sitting in a regular or special session of Tribal Council. To honor the nation-to-nation 

relationship, the CDC must likewise send an official representative with decisionmaking authority over the activity or policy being discussed, rather than a mere agent 

PAGE3OF5 
YAKAMA NATION'S COMMENTS TO CDC 

SEPT. 7, 2021 

of such official. This needed, mutual and equal conversation between sovereign 

representatives would represent our robust nation-to-nation relationship. 

Ill. FURTHER DIALOGUE AND INQUIRY 

The Yakama Nation is interested in how the CDC will weigh agency decisions that 

may impact the environment or tribal interests, including cultural and spiritual 

interests, against President Biden's Executive Order on Protecting Public Health and 

the Environment and Restoring Science to the Climate Crisis, E.O. 13990, 86 Fed. Reg. 

7037 (Jan. 20, 2021). The Yakama Nation would like to understand how the CDC 

intends to address existing regulations, orders, policies, and agency actions that stand 

inconsistent with the Administt·ation's efforts to combat climate change. What steps 

will the CDC and its sub-agencies take to ensure that decisions that are currently in 

process, particularly those involving greenhouse gas emissions and fossil fuel 

infrastructure, will incorporate climate change objectives? 

The Administration's commitment to climate change is reiterated in Taclding the 

Climate Crisis at Home and Abroad, E.O. 14008, 86 Fed. Reg. 7619 (Jan. 27, 2021), 

"[i]t is the policy of my Administration to organize and deploy the full capacity of its 

agencies to combat the climate crisis to implement a Government-wide approach that 

reduces climate pollution in every sector of the economy." The Yakama Nation would 

like to discuss how the CDC intends to carry out these directives. Executive Order 

14008 directs agencies to approach climate change in a way that protects public 

health, conserves land, waters, and biodiversity, and delivers environmental justice. 

The Y akama Nation would like to discuss with the CDC about opportunities to 

preserve tribal resources and the environment while fulfilling this mission. Given the 

short timeframe, the Yakama Nation has not had an opportunity to identify specific 

regulations and policies that are inconsistent with these directives. However, the 

Yakama Nation anticipates robust and continuing dialogue with the CDC about these 

issues in order to help identify specific problems and to find solutions. 

In addition, the Administration's plan for Advancing Racial Equity and Support for 

Underserved Comnrnnities through the Federal Government, E.O. 13985, 86 Fed. Reg. 

7009 (Jan. 20, 2021), calls for all agencies to ensure correction of historical inequities 

affecting people of color, marginalized communities, and those affected by poverty. 

The Yakama Nation would like to discuss how the CDC intends to amend, remove, or 

identify its policies and regulations that impair racial equity or have historically 

ignored tribal sovereignty. The CDC also holds a history of approving projects and 

taking actions that prove detrimental to the interests of the Yakama Nation and other 

Native Nations. There exists, however, a history of collaboration and we hope to build 

upon that collaboration. This collaboration should, among other things like 

meaningful consultation, open itself and recognize the value of tribes' Traditional 

PAGE40F5 
Y AKAMA NATION'S COMMENTS TO CDC 

SEPT. 7, 2021 

Knowledge. We therefore encourage the CDC to similarly revisit its policies in light 

of the recent Executive Orders to determine how Traditional Knowledge could be 

better integrated into its actions. 

IV. CONCLUSION AND INVITATION

The Yakama Nation remains optimistic for our continued relationship. We hope that 

the CDC is genuine in its calls for a meaningful and robust relationship. To that end, 

we invite the CDC to meet with us, ask questions, listen, and authentically learn 

about us and our concerns. We therefore await your visit to the Yakama Reservation 

to discuss our inquiries and develop our mutual, equal relationship further. 

If you have any questions or concerns regarding our Letter, please contact Mr. Ethan 

Jones, Lead Attorney for the Yakama Nation Office of Legal Counsel, at (509) 834-

8005 or via email at Ethan@yakamanation-olc.org. 

Respectfully, 

Delano Saluskin, Chairman 

Yakama Nation Tribal Council 

PAGE 5 OF 5 
 

 

Appendix B: List of Participants—August 5, 2021, Tribal Consultation 

First Name Last Name Tribal Nation/Agency 

Jessie Adair Stillaguamish Tribe of Indians 

Cleopatra Adedeji Centers for Disease Control and Prevention (CDC) 

Walter Alarcon CDC 

Benjamin Alford Indian Health Service (IHS) 

Alicia Andrew Karluk Ira Tribal Council 

Julie Armstrong CDC 

Vijay Aspaas IHS 

Maria Ayala-Perales CDC 

Connie Barker The Chickasaw Nation 

Nicole Barron CDC 

Elizabeth Bell CDC 

Herlynn Benoit CDC 

Eva Bighorse Arizona Department of Economic Security (AzDES)/ 

Division of Developmental Disabilities 

Kelly Bishop CDC 

Lydia Blasini-Alcivar CDC 

Verne Boerner Alaska Native Health Board 

Denise Boggs CDC 

Anthony Boone CDC 

Kailyn Bostic CDC 

Christopher Braden CDC 

Vickie Bradley Eastern Band of Cherokee Indians, Public Health and Human Services 

Breanna Branche CDC 

Pat Breysse CDC & Agency for Toxic Substances and Disease Registry (ATSDR) 

Gia Brooks Chemehuevi Indian Tribe 

Rebecca Bunnell CDC 

Alisa Burley Snoqualmie Indian Tribe 

Bridget Canniff Northwest Portland Area Indian Health Board 

Hallie Carde CDC 

Yulia Carroll CDC 

David Caruso CDC 

Thelma Cela Seminole Tribe of Florida 

Zeshan Chisty CDC 

Jason Chou CDC 

Bryan Christensen CDC 

Meghan Clancy CDC 

Carmen Clelland Health Resources and Services Administration (HRSA) 

Karen Cobham-Owens CDC 

Fredrick Dahlgren CDC 

Les Dauphin CDC 

Winn Davis Alaska Native Health Board 

Mark Davis CDC 

80
 

Adina de Coteau CDC 

Sonya Diggs Choctaw Nation of Oklahoma 

Sonal Doshi CDC 

Deborah Dotson Delaware Nation 

Tyler Dougherty National Indian Health Board 

Audrey Dowling CDC 

Christopher Earl CDC 

Rachel Edwards Nez Perce Tribe 

Jessica Elm CDC 

Marcelina Flores CDC 

Stephanie Foster CDC 

Melanie Fourkiller Choctaw Nation of Oklahoma 

Rebekah Frankson CDC 

Alean Frawley CDC 

Herminia Frias Pascua Yaqui Tribe 

Dan Garcia CDC 

Athena Gemella ATSDR 

CheBreia Gibbs CDC 

Sheryl Goodson Chickasaw Nation 

Melissa Gower Chickasaw Nation 

Brittany Grear CDC 

Nathan Griffin CDC 

Dawn Griffin CDC 

Karen Hacker CDC 

Rebecca Hall CDC 

S. Kayleigh Hall CDC 

Todd Hallmark Choctaw Nation of Oklahoma, Choctaw Nation Health Services Authority 

Katy Halverson Coquille Tribe 

Summer Hammons Tulalip Tribes 

Veda Harrell CDC 

Jennifer Hartnett CDC 

Lakesha Hawkins Choctaw Nation of Oklahoma 

Lauri Hayward Pit River Tribe, Pit River Health Service 

Karen "Kari" Hearod CDC 

Noelle Henderson ATSDR 

Diane Henry Tulalip Tribes 

Jan Hicks-Thomson CDC 

Ryan Hill CDC 

Kim Hoch CDC 

Brian Howard United South & Eastern Tribes (USET) Sovereignty Protection Fund 

Joy Hsu CDC 

Brandy Humphreys Confederated Tribes of Grand Ronde 

Robin Ikeda CDC 

Ikovwa Irune CDC 

81
 

Georgia Jackson Native Village of Tazlina 

Constance James IHS 

Calla Jamison CDC 

Dara Jefferson Native Center for Behavioral Health 

Jill Jim The Navajo Nation, Navajo Department of Health 

Candice Jimenez Northwest Portland Area Indian Health Board 

Dolores Jimerson Quiletute Tribe of The Quileute Reservation, Quileute Health Center 

Patsy Jimmy IHS 

Hope Johnson IHS 

Chris Jones CDC 

Sherry Jones CDC 

Karrie Joseph National Indian Health Board 

Cassandra Josey CDC 

Rhonda Kaetzel ATSDR 

Samantha Kessler CDC 

Martha Ketcher Cherokee Nation 

Kyle Key The Chickasaw Nation 

Laura Kollar CDC 

Rebecca Kone CDC 

Alfred Koroma CDC 

Rachel Kossover-Smith CDC 

Trinidad Krystall Riverside San Bernardino County Indian Health Clinic, Inc. 

Jim Kucik CDC 

Rhea Lansang Tran CDC 

Fergus Laughridge Ft. McDermitt Paiute Shoshone Tribe, Fort McDermitt Wellness Center 

Doreen Fogg-Leavitt Inupiat Community of the Arctic Slope 

Santee Lewis Navajo Nation Washington Office 

Philip Ling Chickaloon Village Traditional Council Health Department 

Steve Literati CDC 

Myron Lizer The Navajo Nation 

A.C. Locklear National Indian Health Board 

Julia Lothrop HHS 

Katherine Luce CDC 

Liz Malerba USET Sovereignty Protection Fund 

Cynthia Marshall CDC 

Nina Martin National Indian Health Board 

Marisol Martinez CDC 

Grace Marx CDC 

Suzanne Mason Pit River Nation, Pit River Health Services 

Monica Mayer Mandan, Hidatsa, and Arikara Nation 

Victoria McBee CDC 

Trevor McCoy CDC 

Donna McCree CDC 

Robert McDonald CDC 

82
 

Abdeljalil Mekkaoui Department of Homeland Security 

Marilyn Metzler CDC 

Jenna Meyer CDC 

Jessica Miller CDC 

Maria Mirabelli CDC 

Miranda Mitchell ATSDR 

Jose Montero CDC 

Meredith Moore CDC 

Georgia Moore CDC 

Javier Morales IHS 

Michele Morris The Navajo Nation, Navajo Department of Health—Executive Office 

Darcy Morrow Sault Ste. Marie Tribe of Chippewa Indians 

Emily Mosites CDC 

Daniel Moya New Mexico Department of Homeland Security and Emergency 

Management (DHSEM) 

Karen Mumford CDC 

Jean Nahomni Mani Great Plains Tribal Leaders Health Board 

Debi Nalwood IHS 

Nellie Neal CDC 

Romni Neiman CDC 

Maria Ness American Indian Health Commission of WA State 

Travis Noland Cherokee Nation 

Darla Obi Nisqually Tribe 

Joanne Odenkirchen CDC 

Keydra Oladapo CDC 

Patrick Papillion ATSDR 

Stacey Parker CDC 

Aaron Payment Sault Ste. Marie Tribe 

Chandra Pendergraft CDC/CSTLTS 

Gene Perry Cherokee Nation 

Neela Persad CDC 

Melinda Peter Council of Athabascan Tribal Governments 

Gunnar Peters Menominee Indian Tribe 

Lori Phillips CDC 

Lisa Pivec Cherokee Nation 

Lindsay Prescod CDC 

Daniel Preston Tohono O’odham Nation, Tohono O’odham Legislative Council 

Lauren Ramsey CDC 

Jeff Reczek CDC 

Alicia Red Hat EPA 

David Reede San Carlos Apache Tribe Department of Health and Human Services 

Karen Remley CDC 

Jim Roberts Alaska Native Tribal Health Consortium 

Joel Rosette Chippewa Cree Tribe, Rocky Boy Health Center 

83
Alyssa Rowell New York State Department of Health (NYSDOH)/Office of Health 

Emergency Preparedness (OHEP) 

Jessica Rudolfo White Mountain Apache Tribe 

Andrew Ruiz CDC 

Vallee Sain Santa Clara Pueblo 

Teresa Sanchez Morongo Band of Mission Indians 

Aishwarya Sasidharen CDC 

Delight Satter CDC 

Vivian Saunders Tohono O’odham Nation 

Laura Sawney Cherokee Nation 

Laura Schieve CDC 

Marilyn Scott Upper Skagit Indian Tribe 

Natasha Seaforth Tribal Organizations: Sac & Fox Nation, Choctaw Nation, 

Squaxin Island, Jamestown S'Klallam 

Sam Sears National Council of Urban Indian Health 

Ryan Seelau National Congress of American Indians (NCAI) 

Dana Shelton CDC 

Arlene Sherman CDC 

Joann Wu Shortt CDC 

Caitrin Shuy Hobbs, Straus, Dean and Walker, LLP 

Julia (Gia) Simon CDC 

Candice Skenandore Oneida Nation 

Nathaniel Smith CDC 

Tyler Smith Big Fire Law and Policy Group 

Richard Sneed Eastern Band of Cherokee Indians 

Sharon Stanphill Cow Creek Band of Umpqua Tribe of Indians 

Sunny Stevenson National Council of Urban Indian Health 

Jon Streater CDC 

Dia Taylor CDC 

Andrew Terranella CDC 

Candy Thomas Osage Nation 

Phoebe Thorpe CDC 

Thomas Tortez Torres Martinez Desert Cahuilla 

Stephanie Tran CDC 

Alston Turtle Ute Mountain Ute Tribe 

Nate Tyler Makah Tribe 

Mitchell UNKNOWN HHS 

Jen UNKNOWN Native Village of Tazlina 

Alberta Unok Alaska Native Health Board 

Christine Vanover CDC 

Malia Villegas Native Village of Afognak 

Susan Wacaster CDC 

Nicole Wachter CDC 

Lisa Wade Chickaloon Native Village, Chickaloon Village Traditional Council 

Bryan Warner Cherokee Nation 

84
Nicholas Warren American Association for Cancer Research 

Elizabeth Watanabe Snoqualmie Indian Tribe 

Michael Weahkee IHS 

Alleen Weathers CDC 

Daniel Weber CDC 

Jennifer Webster Oneida Nation 

Seh Welch CDC 

Rachel West CDC 

David Wharton Choctaw Nation of Oklahoma Health Services 

Erin Whitehouse CDC 

Selwyn Whiteskunk Ute Mountain Ute Tribe 

Brandon Wisneski Oneida Nation 

Sharon Wong CDC 

Jeremy Woodruff IHS 

Jams (Patrick) Young ATSDR 

Andrea Zekis CDC 

Elizabeth Zurick CDC 

In addition to the participants identified above, several people called in and did not identify 

themselves; for protection of their privacy, we have listed only the area codes and not the entire 

phone number: 

1-301-xxx-xxxx 

1-404-xxx-xxxx 

1-404-xxx-xxxx 

1-404-xxx-xxxx 

1-404-xxx-xxxx 

1-404-xxx-xxxx 

1-404-xxx-xxxx 

1-503-xxx-xxxx 

1-580-xxx-xxxx 

1-678-xxx-xxxx 

1-712-xxx-xxxx 

1-775-xxx-xxxx 

1-906-xxx-xxxx 

85
Appendix C: Current CDC/ATSDR Tribal Consultation Policy (dated 2020) 

86
 

 

 

 

 

 

 

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. 

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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 

backbone of CDC′s mission. Each CDC 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. 

2 
 

 

 

 

 

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: 

• Older Americans Act, P.L. 89-73, as amended 

• Indian Self-Determination and Education Assistance Act, P.L. 93-638, as amended 

• Native American Programs Act, P.L. 93-644, as amended 

• Indian Health Care Improvement Act, P.L. 94-437, as amended 

• Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L.104-193 

• Presidential Executive Memorandum to the Heads of Executive Departments dated April 

29, 1994 

• Presidential Executive Order 13175, Consultation and Coordination with Indian Tribal 

Governments, November 6, 2000 

• Presidential Memorandum, Government-to-Government Relationship with Tribal 

Governments, September 23, 2004 

• Presidential Memorandum, Tribal Consultation, November 5, 2009 

• American Recovery and Reinvestment Act of 2009, P.L. 111-5, 123 Stat. 115 (Feb. 17, 

2009) 

• Children's Health Insurance Program Reauthorization Act of 2009, P.L. 111-3, 123 Stat. 

8 (Feb. 4, 2009) 

• 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). 

3 
 

 

 

 

 

 

 

 

 

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: 

• Indian Tribes represented by the Tribal President, Tribal Chair, or Tribal Governor, 

or an elected or appointed Tribal Leader, or their authorized representative(s) 

• 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 

4 
 

 

 

 

 

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. 

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4. RESPONSIBILITIES 

A. Center for State, Tribal, Local, and Territorial Support (CSTLTS) 

• 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) 

• 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) 

• 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 

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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 

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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 

8 
Appendix D: Dear Tribal Leader Letter for CDC/ATSDR August 5, 2021 , Tribal Consultation 

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July 6, 2021 

Dear Tribal Leader: 

The Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR) 

is seeking your recommendations and feedback on how we can improve the agency’s policies and practices to 

better engage with Indian Country through meaningful consultation. To gather this feedback, CDC/ATSDR is 

hosting a tribal consultation session on Thursday, August 5, from 3:15–4:45 pm (EDT). You can register to attend 

this consultation session here: 

https://cdc.zoomgov.com/meeting/register/vJIsfu-gqDgsGD1rTre7HPjbXyIF3v5jSp4 

The consultation will be held on the implementation of Executive Order 13175 of November 6, 2000, consistent 

with the Presidential Memorandum of January 26, 2021 on Tribal Consultation and Strengthening the Nation-toNation Relationships. The Presidential Memorandum requires CDC/ATSDR to submit a detailed plan for 

implementing Executive Order 13175, which charges agencies to engage in regular, meaningful, and robust 

consultation with tribal officials in the development of federal policies that have implications for tribal 

governments and entities. CDC/ATSDR is committed to working with federally recognized tribal governments on 

a government-to-government basis and strongly supports and respects tribal sovereignty and self-determination 

for tribal governments in the United States. The current CDC/ATSDR tribal consultation policy is available at: 

https://www.cdc.gov/tribal/consultation-support/tribal-consultation/policy.html. 

CDC/ATSDR is also committed to working in partnership with tribal nations and the Tribal Advisory Committee 

(TAC) that advises CDC/ATSDR in the planning and coordination of tribal consultation sessions and ensures that 

CDC/ATSDR activities or policies that impact Indian Country are brought to the attention of all tribal leaders. As 

the President’s memorandum states, “History demonstrates that we best serve Native American people when 

tribal governments are empowered to lead their communities, and when federal officials speak with and listen 

to tribal leaders in formulating federal policy that affects tribal nations.” 

Specific questions on which we invite your feedback are listed below. 

1. How do we strengthen our tribal consultation policy and process to ensure CDC/ATSDR is responsive and 

engaging with Indian Country in a meaningful way? 

2. How do we improve communication and outreach regarding agency policy or program changes that 

impact tribal nations? 

3. Are there specific areas where tribal officials would like more information or feel they are not getting 

adequate outreach to engage in a meaningful way? 

4. How do we improve tribal consultations? Should we have sessions every year? 

These topics will be open for discussion at the consultation session on August 5, 2021. For those who would also 

like to send in written remarks, please send us your initial comments and recommendations no later than 5:00 

pm (EDT) on September 7, 2021, to tribalsupport@cdc.gov. This initial feedback will help guide us in next steps 

for further consultation. 
 

Sincerely, 

José T. Montero, MD, MHCDS 

Designated Federal Official, CDC/ATSDR Tribal Advisory Committee 

Director, Center for State, Tribal, Local, and Territorial Support 
Appendix E: Federal Register Notice for CDC/ATSDR August 5, 2021, Tribal Consultation Policy 

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