Department of Health and Human Services 

Centers for Disease Control and Prevention 

Agency for Toxic Substances and Disease Registry
 

Tribal Consultation Advisory Committee (TCAC) Meeting 

January 27, 2010 

Orientation Session Summary 

Table of Contents Page 

January 27, 2010 

Acronyms 4 

Organizational Improvement Process 5 

Office of Communications 9 

Overview and Importance of CDC Tribal Consultation Policy 15 

Knowledge to Action Science Clips 19 

Office of State and Local Support 20 

Office of Public Health Preparedness and Response 24 

Office of Surveillance, Epidemiology, and Laboratory Services 35 

Explanation of Epi Aids & Examples from Indian Country 36 

Wrap-Up and Closing 39 

Participant Roster 40 
 

 

 

 

 

 

 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Acronyms 

ADP Associate Director for Program 

ADS Associate Director for Science 

AHRC Atlanta Human Resources Center 

AI / AN American Indian / Alaskan Native 

ATSDR Agency for Toxic Substances and Disease Registry 

BRFSS Behavioral Risk Factor Surveillance System 

BSC Board of Scientific Counselors 

CAMICC CDC / ATSDR Minority Initiatives Coordinating Committee 

CDC Centers for Disease Control and Prevention 

COTPER Coordinating Office Office for Terrorism Preparedness and Emergency Response 

CRI Cities Readiness Initiative 

CVD Cardiovascular Disease 

DEO Division of Emergency Operations 

DoD Department of Defense 

DOJ Department of Justice 

DSAT Division of Select Agents and Toxins 

DSLR Division of State and Local Readiness 

DSNS Divison of Strategic National Stockpile 

EC Enterprise Communications 

EIS Epidemic Intelligence Service 

EPA Environmental Protection Agency 

HHS Health and Human Services 

ICS Incident Command System 

IH S Indian Health Services 

IOM Institute of Medicine 

LRN Laboratory Response Network 

MASO Management and Analysis Services Office 

MCH Maternal and Child Health 

MISO Management Information Sercices Office 

NACCHO National Association of County and City Health Officials 

NCCDPHP National Center for Chronic Disease Prevention and Health Promotion 

NCEH National Center for Environmental Health 

NCHM National Center for Health Marketing 

NCHHSTP National Center for HIV / AIDS, Viral Hepatitis, STD, and TB Prevention 

NCID National Center for Infectious Diseases 

NCIRD National Center for Immunization and Respiratory Diseases 

NCIPC National Center for Injury Prevention and Control 

NCPDCID National Center for Preparedness, Detection, and Control of Infectious Diseases 

NIHB National Indian Health Board 

NIMS National Incident Management System 

NIOSH National Institute of Occupational Safety and Health 

OCOO Office of the Chief Operating Officer 

OD Office of the Director 

OMHD Office of Minority Health and Health Disparities 

2 
 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

OPHPR Office of Public Health Preparedness and Response 

OPM Office of Personnel Management 

OSELS Office of Surveillance, Epidemiology, and Laboratory Services 

OSLS Office of State and Local Support 

OTA Office of Tribal Affairs 

OWCD Office of Workforce and Career Development 

PHEMCE Public Health Emergency Medical Countermeasures Enterprise 

PHEP Public Health Emergency Preparedness 

PHER Public Health Emergency Response 

PIHS Phoenix Indian Health Service 

PHS Public Health Service 

PIMC Phoenix Indian Medical Center 

SLTT State, Local, Tribal, and Territorial 

SME Subject Matter Experts 

SNS Strategic National Stockpile 

SSAG Stockpile Service Advance Group 

TCAC Tribal Consultation Advisory Committee 

TCPW Tribal Consultation Policy Workgroup 

TCE Trichloroethylene 

US United States 

USDA US Department of Agriculture 

VBAC Vaginal Birth After Caesarean 

WHO World Health Organization 

3 
 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Department of Health and Human Services 

Centers for Disease Control and Prevention 

Agency for Toxic Substances and Disease Registry 

Tribal Consultation Advisory Committee (TCAC) Meeting 

January 27, 2010 

Orientation Session Summary
 

Organizational Improvement Process 

Louis Salinas, BA, MPA, Chief of Staff 

Office of the Director 

Centers for Disease Control and Prevention 

Mr. Salinas thanked TCAC for inviting him to present, and offered greetings from Dr. Frieden. 

He then reported on CDC’s organizational improvement process. Dr. Frieden came on board as 

CDC’s new Director June 29, 2009 and was very eager to initiate some actions to help improve 

the agency. The guiding principle that Dr. Frieden used for the organizational improvement was 

that, “All successful organizations continuously assess demands, opportunities and challenges 

and make appropriate adjustments...to increase effectiveness. Although change is never easy, 

CDC needs to adapt. Our goal is to solidify CDC’s role as a respected leader . . .” His objective 

was to take CDC back to the premier position he believes CDC should be in not only for the 

nation, but also for the world. The goals of the organizational improvement effort are to: 

1) position CDC to strengthen surveillance, epidemiology, and laboratory sciences; strengthen 

the agency’s ability to support state and local public health; and to strengthen the agency’s 

response to H1N1; and 2) provide public health leadership in global health; health policies, 

especially health reform; and better address the leading causes of death and disability. 

In terms of the organizational objectives, Dr. Frieden wanted to strengthen the response to 

H1N1 and other public health emergencies; establish systems that better identify and address 

the leading causes of death and disability; strengthen management and CDC-wide cohesion; 

place responsibility and accountability in the hands of Center Directors and technical leadership; 

advance coordination among reinvigorated leadership; rebuild common scientific culture and 

values for action; and accelerate recruitment of key staff and institution-wide staff strengthening. 

4 
 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

As follows are the organizational charts before and after the organizational improvement 

process: 

5

Prior to the Organizational 

Improvement Process 

7

Dr. Frieden felt that the extra layer of the six Coordinating Centers and the National Institute for 

Occupational Safety and Health (NIOSH) in the former structure was impeding programs’ 

access to the Director and wanted to change that. Phase I of the organizational improvement 

process (June 2009 through September 2009) used information from data gathered from an 

Organizational Issues report, speaking to leaders throughout CDC, CDC employee blogs, and 

discussions with partners. Phase II (September 2009 through December 2009), the 

implementation phase, aligned functions and work streams to organizational units. Continuing 

organizational efforts are to align administrative codes to new organizational units, ensure that 

office design plans are approved through an internal CDC review or Office of Personnel 

Management (OPM) / external review, align budgets to new organizational units, et cetera. 

Administrative, personnel, and budgetary documentation and alignments will continue and are 

being handled by units throughout CDC, such as the Management and Analysis Services Office 

(MASO), Management Information Services Office (MISO), and Atlanta Human Resources 

Center (AHRC), with overall coordination from Office of the Chief Operating Officer (OCOO). All 

of the senior leadership positions were posted and competed for, and selections for many of the 

positions have already been made. Several are depending approval at the departmental level 

and will be announced shortly. Certain activities are now located in the following areas: 

 Office of State and Local Support (Tribal Public Health Liaison Activities) 

 Office of Public Health Preparedness and Response (Strategic National Stockpile) 

Associate Director for Program (ADP) (Office of Minority Health & Health Disparities) 

 ADP / Office of Surveillance, Epidemiology, and Laboratory Services (Training opportunities: 

http://www.cdc.gov/omhd/training.htm) 

Mr. Salinas highlighted the following quote from White House Executive Order 13175: 

“History has shown that failure to include the voices of tribal officials in formulating policy 

affecting their communities has all too often led to undesirable and, at times, devastating 

and tragic results. By contrast, meaningful dialogue between federal officials and tribal 

officials has greatly improved federal policy toward Indian tribes. Consultation is a critical 

ingredient of a sound and productive federal-tribal relationship.” 

5 
 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

In terms of ensuring that there is meaningful dialogue between federal officials and tribal 

officials, CDC strives to continue discussions to help facilitate continued dialogue to help lead 

the discussion of programs addressing issues and leveraging resources, which is very important 

in a climate of having to do more with less. Mr. Salinas pointed out that CDC colleagues would 

be speaking to tribal leaders throughout the day, as well as the following day during the 

Consultation Session, with respect to identifying and addressing health issues and will entertain 

and initiate action to address all of the issues identified to ensure continued collaboration. 

Discussion Points 

	 Mr. Finkbonner raised the issue of input from tribal leadership into the CDC organization 

improvement process that arose during the TCAC meeting, and was expected to be 

presented upon the next day during the Consultation Session. With a consultation process, 

tribal leadership would have been notified and permitted to offer input into the changes prior 

to its full implementation. The Office of State and Local Support (OSLS), where a majority of 

the tribal issues will be fielded, some tribal leaders are going to have heartburn that they are 

being couched in terms of “Local” versus include the term “Tribal” in the name itself. Dr. 

Bryan and CAPT Snesrud already do a great job in terms of addressing tribal issues, and 

they and any others in liaison position should help to teach the overall organization how to 

work with tribes. 

	 Mr. Salinas responded that Dr. Frieden came to CDC from New York. Mr. Salinas was Dr. 

Frieden’s Program Consultant / Project Officer when he was the Director of the Tuberculosis 

Control Program in New York in the early 1990s. New York was then suffering from an 

epidemic of tuberculosis and multi-drug resistant tuberculosis, and had few resources with 

which to work. Congress reacted and allocated funding to New York to deal with this issue. 

Federal funds have limitations and working within the bureaucracy it is difficult to spend 

great deals of money, so he suggested that the best approach would be to divide up the 

problem into: diagnosis, lab, treatment, and prevention. Dr. Frieden instead insisted that 

they were going to tackle the problem all at once—move the whole glacier all at once—and 

he did it. When Dr. Frieden came to CDC, one of the first things he discussed with Mr. 

Salinas was how to deal with certain issues, including tribal issues. By coincidence, Mr. 

Salinas ran into CAPT Snesrud in the hallway that day and he explained to her that Dr. 

Frieden was very interested in this issue and that he would arrange a meeting for her to 

present information and make some recommendations to Dr. Frieden. CDC considers state, 

local, and tribal entities to be their partners because the agency cannot do anything without 

them. Having come to CDC from a local health department, and being very much aware of 

the quality of technical assistance and how important that is to an organization and to 

relationships between organizations, Dr. Frieden wanted to do something to make 

improvements for these relationships. He expressed disappointed in the quality of technical 

assistance that CDC provides organizations, which varies tremendously. With that in mind, 

Dr. Frieden wanted to create an office to deal specifically with this issue and to enhance 

CDC’s relationship with its partners. Related to that, he expressed a desired to increase the 

number of staff actually assigned to organizations because the number of field staff 

assigned over the years has been limited. Mr. Salinas stressed that they all utilize whatever 

communication mechanisms available in order to get the message across. With Dr. Frieden, 

it is about action not “lip service.” 

6 
 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

	 Mr. Franklin responded that Mr. Salinas had offered very encouraging words in speaking so 

highly of Dr. Frieden and his goals for CDC. He thought the first demonstration of that was 

how fast Dr. Frieden was moving with the departmental changes. This certainly illustrates 

that he is a person of action. While Mr. Franklin could see the wisdom of the decision to 

move tribal issues to OSLS, tribal members have grown tired of being lumped into groupings 

in which states are receiving top billing. There is no mention in the name of OSLS of tribes 

at all. The definition of local government seemed to include tribal and territorial 

governments. When tribes hear the term “local government” they think of something totally 

different, such as county governments that hate tribes, and city governments that do not 

want them and fail to recognize that tribes are much more important than they are. Based 

on the name of the new office, it appeared that CDC was also not recognizing that. Mr. 

Franklin expressed his hope that CDC would entertain the notion of renaming this the Office 

of Tribal, State, and Local Support. 

	 Dr. Bryan indicated that there was some precedent across HHS and within CDC now to use 

the acronym SLTT for State, Local, Tribal, and Territorial. He thought it was a reasonable 

message for CDC to entertain from tribal colleagues that the name should include “tribal.” 

Often there is a footnote that state and local includes tribes and territories as well. How 

	 Mr. Antone relayed concerns about problems with state distribution of funds through 

cooperative agreements of CDC funds. The way that states have of doing accounting and 

running their contracts makes tribes look bad. President Obama has recognized 

government-to-government relationships. Mr. Antone wondered whether any thought had 

been given to this. In 2005, CDC was contemplating an Indian Office that was separate and 

distinct that would have a direct line of communication with tribes. He wondered whether 

there had been any discussions regarding this. 

	 Mr. Salinas replied that they had not had any discussions about this to his knowledge. 

	 While Dr. Bryan said he could not confirm whether there had been direct discussions at Dr. 

Frieden’s level at this point, they have put forth written strategies / recommendations for the 

establishment of a unit directed toward tribal affairs, suggested a name for that unit, Office 

of Tribal Public Health Support. This in the works and he thought it had been considered as 

they moved forward in terms of the current plans for OSLS. 

	 Dr. Williams drew their attention to the document that his office prepared for Joe Henderson 

and his group as part of the organizational design activities. There was a section that dealt 

specifically with forming a tribal affairs unit, a potential name, et cetera. 

	 Mr. Trudell expressed concern that tribes would once again be “lost in the shuffle.” He 

acknowledged the hard work of Dr. Bryan, CAPT Snesrud, and others associated with CDC 

to bring the problems in Indian Country to the forefront. They have taken people on field 

trips to various areas to see the issues and problems first hand. Some tribal members have 

to travel 100 miles to get people to IHS facilities. Some reservations have clinics in their 

districts, but these are typically understaffed, underfunded, and unable to meet the needs of 

their districts. The transportation of people from 100 miles out does not lend to a healthy 

community. His own population of about 4,000 members spread throughout 50 states is 

highly mobile. Approximately 25% of those members live within the boundaries of the 

reservation. They provide service to all tribally enrolled people. They have a 638 facility, 

7 
 

 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

which means they are contract for services. Prior to that and prior to the installation of a 

bridge across the Missouri River, folks travel 90 miles to Wagner one way, which was their 

health facility. There is a lack of adequate funding to provide even minimal services. A 

problem across the countries for all tribes is that if their people are referred our for further 

assessment and / or treatment of their health problems, is that services are often denied 

because of a priority system within the IHS. Aberdeen Area participates in TCAC to 

determine how they can enable more service without people accumulating considerable 

debt and receiving threatening letters from collection agencies. He thought they were 

making a lot of progress by having CDC visit reservations to see some of the issues 

themselves. Aberdeen Area is number one in terms of problems in many health categories. 

It was not clear to him, with the reorganization, how OSLS would operate. Not seeing 

“tribes” or “tribal governments” specifically included in the name of the office, he wondered 

whether they had slipped backwards. President Obama has also visited some reservations 

and has made a commitment to Indian Country, but it seems that this may be lost in the 

shuffle of various departments that come under HHS. 

	 CAPT Snesrud requested that TCAC members save testimony-related comments for the 

Consultation Session the next day so that they could get through all of the presentations. 

Office of Communications 

Donna Garland, BA, Acting Director 

Office of Communications 

Centers for Disease Control and Prevention 

Ms. Garland explained that CDC’s mission is to prevent and control disease, injury, and 

disability. This mission is at the core of what CDC does both domestically and internationally. 

HHS organization is a Cabinet level organization, and the Public Health Service (PHS) is the 

uniformed Corps that most people think of as part of HHS. CDC actually contains two boxes 

within the HHS organizational chart: CDC and the Agency for Toxic Substances and Disease 

Registry (ATSDR). CDC reports directly to the Secretary of HHS, but CDC also encompasses 

ATSDR. ATSDR was formed through a Congressional act and was ultimately co-located with 

CDC in Atlanta, so the Director of CDC serves as the Director of CDC and the Administrator of 

ATSDR. ATSDR partners most often with the Environmental Protection Agency (EPA), which is 

why the title of the Director is Administrator, because the Administrator of EPA and of ATSDR 

are on par with each other. Dr. Frieden holds two official titles within the federal government 

rubric: 

US Department of Health and Human 

Services Public Health Service 

Agency for Healthcare 

Research and Qual ty 

(AHRQ) 

Centers for D sease 

Control and Prevention 

(CDC) 

Agency for Toxic 

Substances and Disease 

Registry (ATSDR) 

Food and Drug 

Administration 

(FDA) 

Health Resources and 

Services Administration 

(HRSA) 

Indian Health Serv ce 

(IHS) 

Nat onal Institutes 

of Hea th 

(NIH) 

Substance Abuse and 

Mental Health Services 

Adm n stration (SAMHSA) 

8 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

The interim CDC structure is as follows, including photographs of the staff serving in leadership 

roles: 

One of the challenges is that many of these leadership staff members are acting; that is, they 

are either temporary in the position or are awaiting final approval from the Secretary to take on 

their permanent positions. 

The scope, breadth, and depth of the agency is impressive though it is still not enough to do all 

of the work that needs to be done. CDC, as the federal agency charged with protecting the 

health of people in the United States (US), is staffed with world class scientists and world class 

staff. All of these staff members believe in and carry out the mission of promoting health and 

quality of life through disease prevention and control and, today especially, being prepared. 

CDC has a very diverse workforce, yet continues to strive to do better in order to reflect the 

communities in which the agency works. The make-up of CDC’s staff continues to change. 

More than 1/3 of CDC’s employees are members of a racial / ethnic minority groups, women 

account for over 60% of CDC’s workforce, disabled employees account for 5% of the agency’s 

workforce, 25% of CDC’s staff is African American, and just under .05% of the agency’s staff 

are American Indian. While the agency stands proud with the diversity it has, they continue to 

work hard to make the organization as diverse and strong as it can be. 

Being centrally located in Georgia, CDC has had and continues to have a profound impact on 

Atlanta’s and Georgia’s economy. The agency’s total budget was $10.1 billion for fiscal year 

2009. CDC ranks among the top 20 employers in Georgia. Based upon an economic impact 

study, CDC would be 246th on the Fortune 500 list, and would be the 12th largest business in 

Georgia if budget was revenue. CDC creates 28,000 jobs in Georgia. A KPMG study in 2002 

reported that CDC pumped more than $400 million into Georgia’s economy in direct purchases, 

a number that has undoubtedly grown tremendously over the past two years. The majority of 

CDC employees work out of the Atlanta, Georgia headquarters; however, the agency has a 

major presence in 16 locations in the US and its territories and provides considerable public 

health resources as reflected in the following maps: 

9 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010

CDC’s Domestic CDC National Presence Public Health Resources 

Seattle Spokane 

San 

Francisco Ft Collins 

Denver 

Hyattsville 

Washington 

DC Area 

Pittsburgh 

Morgantown 

Chicago 

Cincinnati

Research 

Triangle Funding Amount ($) 

Atlanta 

Anchorage San Juan Miami 

= CDC staff serving by State

People are often surprised to find out that CDC funds operations globally throughout the world. 

CDC has global disease protection centers in which it is developing hubs of operation around 

the world for early advanced warning of diseases that might affect the US population. 

International activities and support are depicted in the following map: 

Current CDC International Activities 

and Support 

CDC Funded Sites 

Global Disease
 Detection Centers
 

DoD
 Collaborations
 

WHO Cooperative

Agreement
 

CDC Influenza
 International Assignees
 

CDC Global AIDS
 Program

CDC collaborates strongly with the Department of Defense (DoD) globally and in the US. DoD 

staff are co-located with CDC staff in Atlanta who sit with the Office of Public Health 

Preparedness and Response (OPHPR), and who work very closely with how CDC is preparing 

to defend the nation against diseases as well as their mission to defend against other threats. 

CDC has a significant presence in the World Health Organization’s (WHO) office, and share 

staff back and forth. A number of CDC staff are secunded to WHO. CDC also works 

throughout the world in HIV / AIDS activities. CDC is responding to the Haiti earthquake 

disaster. Sadly, CDC still has a staff member who is unaccounted for there who was working in 

Haiti on HIV / AIDS activities. They had more than 40 locally employed staff who lived and 

worked in Haiti prior to the earthquake, and have deployed 25 to 30 additional staff members to 

engage in response work, including epidemiologists, sanitarians, public affairs person, et cetera. 

10 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

The President Obama clearly recognizes of the role of public health in terms of safety (water, 

air, food, homes, work); detection and treatment of health problems in all Americans; prevention 

and control of infectious diseases (immunizations, AIDS); preventable illness and death 

(smoking, poor nutrition, physical inactivity, safeguard pregnancy); and tracking and monitoring 

rates of illness and death in communities [From THE WHITE HOUSE, May, 15 2009]. CDC is 

pleased that public health is on President Obama’s agenda. President Obama and his staff 

were deeply engaged in the pandemic H1N1 response. 

As noted, key CDC strategic directions include strengthening surveillance and epidemiology and 

the ability to support health departments; and providing provide leadership in health policies, 

community prevention, and global health. CDC is chartered as a domestic public health 

agency, but in the real world, diseases do not say, “I can’t jump on an airplane and go to the US 

because CDC does not work there.” CDC must also focus on thinking and acting globally to 

affect the health of all people. 

In terms of how Dr. Frieden is helping CDC think differently, among his earliest messages were 

prioritization of the work that CDC does, as reflected in the following illustration: 

Prioritization 

Large burden 

Implementation 

Plan 

(mapping, allies) 

Feasibility 

(cost, politics) 

Amenability 

(proven interventions) 

Ambitious but 

realistic goals 

Evaluation 

Honest 

Transparent 

Expected 

Results 

Achieved 

Results 

While everyone knows that more funds are need, more money is not coming. Therefore, they 

have to be better about how they focus what they do. The above process chart offers a process 

by which to think about how to address the burden. The Community Guide is a place in which 

CDC collects and publishes proven interventions. Consideration must also be given to 

determining the feasibility of the work that the agency does. If something can be prevented and 

afforded, thought must be focused on ambitious, realistic goals. Dr. Frieden is very ambitious 

and, as mentioned earlier, wants to move the entire iceberg—not just icebergets or ice cubes. 

Planning, mapping, and implementing are also crucial. Throughout the entire prioritization / 

implementation process, there should be an evaluation process that is honest and transparent 

in terms of assessing expected versus achieved results. 

11 
 

’ 

 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Another way in which Dr. Frieden is helping CDC to think differently about its work is to focus on 

how much impact CDC efforts have. He uses the following example to illustrate his thoughts 

about this: 

Largest 

Impact 

Smallest 

Impact 

Factors that Affect Health 

Examples 

Socioeconomic Factors 

Changing the Context 

to make individuals default 

decisions healthy 

Long-lasting 

Protective Interventions 

Clinical 

Interventions 

Condoms, eat healthy, 

be physically active 

Rx for high blood 

pressure, high 

cholesterol 

Poverty, education,

housing 

Immunizations, dental, 

eye care, cessation 

treatment, colonoscopy 

Fluoridation, 0g trans 

fat, iodization, smoke 

free laws, tobacco tax 

Counseling 

& 

Education 

Historically, CDC has spent a lot of time and effort focusing on the top of the pyramid counseling 

and educating people, giving them guidelines to promulgate. However, as shown in the 

illustration, those efforts often have the smallest impact because they focus on small effect 

areas. Dr. Frieden is challenging CDC to focus the efforts toward the bottom of the pyramid that 

have potentially major impact. The message is not to throw out the items at the top of the 

pyramid because they are still important, but is instead to be realistic about how much impact 

such efforts have in the greater sphere of the work. 

There are urgent realities. The 21st Century brings with it new challenges, as well as new 

opportunities. These 21st Century threats begin with the basics of health and include the 

problems people face everyday such as health disparities, tobacco use, poor nutrition / lack of 

physical fitness, overweight and obesity, drug and excessive alcohol use, poor mental health, 

chronic diseases (e.g., cardiovascular disease, cancer, diabetes, lung disease, kidney disease, 

and other chronic conditions), non-intentional and intentional injuries, premature birth, birth 

defects, disabilities, and unsafe environments. Many of these threats are preventable, but are 

still increasing in communities across the US. More and more people are not able to enjoy the 

best possible quality of health as a result. Dr. Frieden has challenged them to change the 

mindset that some ailments are simply part of living, and instead think about a different reality in 

which hypertension, for example, is not a part of the way we are supposed to live and that there 

is a choice to do things differently. CDC has a major leadership role to play in combating these 

threats by supporting the research and programs necessary to ensure that people and CDC’s 

partners have access to the best possible health protection information and tools they need; and 

to make decisions about health. Business as usual is not enough. They must do more and do it 

faster, smarter, and better in order to make an impact. In the midst of thinking about chronic 

conditions and illnesses that can be prevented, they must also be prepared, able, and willing to 

respond to critical urgent matters of the day. CDC has engaged in numerous exercises and real 

response efforts in order to respond to the world’s challenges. Ms. Garland said that she is 

proud to work at a CDC that is willing and able to stand up and serve when emergencies occur, 

in addition to addressing day-to-day challenges. 

12 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Discussion Points 

	 Mr. Antone requested information about CDC’s social determinants of health efforts. 

	 Ms. Garland responded that she did not know a lot about it, given that she had be immersed 

in the organization improvement efforts throughout the last few months. There is a very 

strong work group that is addressing social determinants of health. They have taken an 

academic approach to begin with, but are working to figure out how social determinants of 

health can proliferate throughout the organization. She stressed that just because she was 

not aware of activities did not mean they were not in progress. 

	 Mr. Antone wondered whether due to the reorganization of CDC, addressing social 

determinants of health had come to a halt. 

	 Ms. Garland responded that she would not say that it had come to a halt, given that there 

are numerous program folks who are still working on this, but do not know yet exactly where 

they fit in the organization. 

	 CAPT Snesrud asked Mr. Antone whether he was referring to the meeting the National 

Center for HIV / AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) hosted in 

December 2009. 

	 Mr. Antone responded that Dr. Fenton was going to sort out all of the suggestions that were 

generated during that meeting and perhaps include them as a requirement in grant 

applications, and then monitor this. The theme of that meeting was important in terms of the 

Native American community and raise the standard of living. Women, being the carriers of 

the unborn, need to be healthy because that contributes to everything a person is. He 

thought this was an important concept to embrace. 

	 CAPT Snesrud indicated that Dr. Fenton and Dr. Dean from NCHHSTP would be in 

attendance at the Tribal Consultation meeting the next day, and she planned to make sure 

that Mr. Antone was afforded the opportunity to have some dialogue with them. 

	 In terms of communication, Mr. Antone requested that Ms. Garland shed some light on how 

American Indian / Native Alaskan issues (AI / AN) issues that come forth are transmitted to 

Dr. Frieden. 

	 Ms. Garland replied that in terms of CDC’s communications work CDC and the 

organizational improvement effort, they have been challenged over the last few months with 

merging two prior communication groups into a single Office of Communication and making 

that smaller: Enterprise Communications (EC) and the National Center for Health Marketing 

(NCHM). One component of the communication effort under Dr. Frieden is his deliberate 

effort at tactically sending messages to tribal nations and others. Some of the work included 

in her work plans is from the last TCAC meeting regarding the implementation of specific 

communications activities with tribes. She also has e-communications as part of the new 

office, so she is interested in determining how that can help them better connect with tribes 

to have a two-way process. 

13 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

	 Mr. Antone also wondered specifically how information from OSLS, TCAC recommendations 

for example, would be submitted to Dr. Frieden. 

	 Dr. Bryan responded that this is a question in front of them currently in terms of logistics and 

process as they plan through the transition with Karen White, Kristin Brusuelas, and others 

engaged in a leadership role in terms of channeling messages to the Office of the Director 

(OD). He suggested asking the question again of Karen White when she presented later in 

the day. 

	 CAPT Snesrud pointed out that Ms. Garland’s office had been and would continue to be a 

critical link in how they connect the breadth and depth of CDC in a format that tribal leaders 

could readily access. 

Overview and Importance of CDC Tribal Consultation Policy 

CAPT Mike Snesrud, Senior Tribal Liaison for Policy Evaluation 

Centers for Disease Control and Prevention (CDC) /
 

Agency for Toxic Substances and Disease Registry (ATSDR)
 

In light of where they are currently, CAPT Snesrud said she thought it was important to take a 

look back historically at the journey that CDC had taken, in particular, in the development of the 

CDC Tribal Consultation Policy which has been the driving force that has enabled a lot of the 

synergy that has been going on throughout the agency to be responsive to public health issues 

affecting AI/ANs. . CDC’s Tribal Consultation Policy Initiative reflects CDC’s commitment to 

take its place in assuming a role in implementation of the federal trust responsibility. The 

statement that CDC made early on was that it’s policy would be evolving, dynamic, and able to 

be changed as the dialogue and consultations with Tribes ocurr. As HHS is evaluating their 

consultation process and tribes are sharing their opinions, CDC is critically assessing this in 

relation to CDC’s policy. 

The Tribal Consultation Policy Initiative occurred from 1999 to 2005. A CDC Tribal Consultation 

Policy Workgroup (TCPW) was re-established in 1999 that was comprised of natives and nonnatives who were very interested in and committed to furthering the work that the agency as a 

whole was doing with Indian Country. In March 2000 and February 2001, under Dr. William’s 

leadership, CDC hosted the first tribal meetings. Some of the dialogue and testimony from the 

transcripts then continued to be reflected in current dialogue and testimony, so while we have 

come a long way, Tribes and CDC need to consider what can be added to current interactions 

based on the work that was done then. When CDC was directed by HHS to develop a plan and 

an agency-specific tribal consultation policy, the TCWG developed a comprehensive plan to 

obtain input from tribal leaders on tribal public health needs and CDC’s proposed approach to 

tribal consultation. The plan was published with HHS in January 2001. 

The Tribal Consultation Initiative included 12 CDC national and regional tribal consultation 

sessions hosted by area Tribal health boards held during the Summer and Fall of 2002. The 

sessions facilitated dialogue and garnered input from tribal leaders and AI/AN stakeholders 

across the country. During 2003 there were also HHS regional tribal consultation sessions, 9 

out of 10 which CDC Senior Tribal Liaisions and other leadership staff participated in. The CDC 

Tribal Consultation Plan was presented at the National Indian Health Board (NIHB) Consumers 

14 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Conference in 2003. CDC continued to participate in HHS regional consultation sessions in 

2004 to consult and obtain additional tribal recommendations. The draft policy was presented at 

the NIHB Consumers Conference in 2004. A revised draft of the Tribal Consultation Policy was 

published for tribal comment during early 2005. During July through August 2005, based on 

tribal recommendations, CDC and ATSDR Consultation Policies were combined into one 

policy. ATSDR had originally developed their consultation policy in 1994. Released in October 

2005, CDC / ATSDR became the first of 11 HHS operating divisions to establish a tribal 

consultation policy in compliance with the revised HHS Tribal Consultation Policy released in 

January 2005. 

The Federal Trust Relationship is unique and is expressed through recognizing and honoring of 

tribal sovereignty, commitment to government-to-government relationships, upholding and 

supporting of the federal trust responsibility, and commitment and implementation of tribal 

consultation. The purpose of the CDC Tribal Consultation Policy is that it establishes agency 

policy on consultation with AI / AN governments and elected leaders; provides guidance to 

agency staff on working effectively with AI / AN customers; enhances tribal access to agency 

programs; complies with and supports HHS policy; and is dynamic, responsive to change, and 

modifiable. 

Procedural guidance offers information pertaining to understanding about when and with whom 

to consult; engaging tribal representatives as meeting co-chairs and following their guidance on 

protocol; involving state health department representatives; documenting consultation activities 

accurately and completely; and providing timely feedback to tribal consultation participants and 

the communities they represent. Activities that warrant consultation include the following: 

 Formulation of new program announcements primarily intended to benefit AI / AN 

populations 

 Notices of proposed rule making that have tribal implications 

 Establishment of new public health programs targeting AI / AN 

 Development of policies or guidelines that have tribal implications or will primarily or 

substantially affect AI / AN populations 

 EPI-AID deployments involving AI reservations or trust lands, AN villages, or urban AI / AN 

populations 

 Research proposals involving AI / AN persons or communities 

 Development of training and educational opportunities for AI / AN health professionals, or 

future health professionals 

 Negotiations with state and local health officials on matters affecting AI / AN populations 

within, or adjacent to, their public health jurisdictions 

Key activities include CDC biannual tribal consultation sessions; Tribal Consultation Advisory 

Committee (TCAC); HHS national and regional tribal consultation sessions; and agency budget 

formulation and resource allocations for tribal programs. 

15 
 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

16 
 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

The purpose of TCAC is to provide a complementary venue wherein tribal representatives and 

agency staff will exchange information about public health issues in Indian Country, identify 

urgent public health needs in AI / AN communities, and discuss collaborative approaches to 

addressing these issues and needs. TCAC is a FACA-exempt advisory committee to the CDC / 

ATSDR Director. TCAC supports, and not supplants, any other government-to-government 

consultation activities; assists in the planning and coordination of biannual tribal consultation 

sessions; provides an established, recurring venue wherein tribal leaders will advise the agency 

regarding the government-to-government consultation process; and helps to ensure that 

activities or policies that impact Indian country are brought to the attention of all tribal leaders. 

Responsibilities for CDC through the proposed Office of State and Local Support (OSLS) are to 

monitor and ensure agency-wide adherence to CDC and HHS tribal consultation policies; and 

serve as the administrative base for two Senior Tribal Liaisons, “OD / CDC staff designated by 

the CDC Director who are knowledgeable about the agency’s programs and budgets, have 

ready access to senior program leadership, and are empowered to speak on behalf of the 

agency for AI/AN programs, services, issues, and concerns.” OSLS reporting and inventory 

functions include management of agency assets devoted to AI / AN; collaboration across 

national centers and offices in regard to tribal programs / services; monitoring agency 

performance measures; reviewing and clearing AI / AN-related documents and publications; and 

CDC response to departmental information requests and required annual reports. 

OMHD / OCPHP / OD points of contact include the following: 

 CAPT Mike Snesrud, RN, Senior Tribal Liaison for Policy and Evaluation (pws8@cdc.gov, 

404-498-2343) 

 CAPT Ralph T. Bryan, MD, Senior Tribal Liaison for Science and Public Health 

(rrb2@cdc.gov, 505-248-4226) 

OTA / NCEH / ATSDR points of contact include: 

 Annabelle Allison, Tribal Liaison, Office of Tribal Affairs, (hhd4@cdc.gov, 770-488-3991) 

CDC / ATSDR Minority Initiatives Coordinating Committee (CAMICC) representatives’ 

responsibilities include monitoring Center / Office (C/O) compliance with the procedures outlined 

in the Tribal Consultation Policy; advising C/O directors regarding tribal consultation procedures; 

maintaining timely information flow to and from OD / CDC on AI / AN issues; participating in 

TCAC meetings on behalf of their respective CC / CO; and supporting agency-wide consultation 

efforts; assist OSLS, the Senior Tribal Liaisons and NCEH / ATSDR OTA in the coordination of 

activities that target AI / AN tribes, communities, and organizations. CAMICC responsibilities 

are to ensure that Center / Office leadership is well-informed about AI / AN health issues; and 

provide the information needed to compile CDC’s Annual Report to HHS on Tribal Consultation 

activities and budget allocations. Tribal Consultation Policy and Center responsibilities include 

consultation at the center level to promote the principle that each center bears responsibility for 

addressing AI / AN public health needs within the context of their respective missions; and 

effective implementation of these components to ensure consistency across the agency and 

help to enhance collaboration among centers / offices around tribal issues. 

17 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Current CDC AI / AN programs include tribal grants and cooperative agreements; CDC-funded 

state and academic programs; technical assistance and outbreak investigations; community 

outreach / health assessment; training and publications; direct assistance, field assignees; and 

designated staff. With regard to intra-agency consistency and sustainability, the CDC TCP 

provides CDC staff and leadership with uniform guidance for working effectively with its tribal 

partners and constituents. The policy identifies when CDC programs should involve tribal 

leaders, outlines specific responsibilities for agency components regarding program activities, 

and also formally defines the roles of leadership positions within the CDC dedicated exclusively 

to guiding CDC operations in, and relationships with, AI / AN communities (Senior Tribal 

Liaisons). A strong consultation policy is the foundation for effective government-to-government 

relationships. The procedural guidance provided by this policy provides is helping to ensure 

that more tribes and tribal organizations benefit from CDC expertise and resources by 

eliminating barriers and enhancing tribal access to CDC programs. 

In order to enhance tribal access to CDC and ATSDR programs to benchmark steps toward 

effective tribal consultation, annual performance measurement will include assessment of 

resources allocated to serve AI / ANs; and inventory of new programs and policies affecting AI / 

AN communities. Enhanced tribal access to CDC programs and resources creates impact. 

CDC’s commitment to meaningful consultation with AI / AN tribes and increased awareness 

among tribal stakeholders of CDC as a partner has helped to bring more CDC resources to 

Indian country. Guidance has begun to enhance both intra- and extra-agency operations to 

improve CDC tribal relationships and strengthen the public health impact of CDC programs in 

Indian Country. Internal operations and communication related to AI / AN health programs have 

been established and have become more efficient and effective. The Tribal Consultation Policy, 

as official policy, is helping to ensure sustained application of these uniform guidelines beyond 

the tenure of current staff / leadership. The following table reflects the type and number of tribal 

cooperative agreements from 2004 to 2009: 

Tribal Cooperative Agreements 

Categories of 

Awardees 

FY 2004 

(48 / 58) 

FY 2005 

(51 / 66) 

FY 2006 

(50 / 69) 

FY 2007 

(48 / 68) 

FY 2008 

(51/ 76) 

FY 2009 

(56/78) 

Tribal 

Governments 14 21 20 20 25 33 

Health 

Boards 8 9 8 7 6 12 

AN 

Corporations 

6 7 9 9 6 19 

Urban 

Programs 

3 6 6 6 5 6 

Tribal Orgs 11 8 7 6 9 8 

Total Dollars 

Awarded 

$25,694,984 $22,523.405 $22,029,344 $21,948,174 $22,839,514 $23,854,212 

* 

18 
 

 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Knowledge to Action Science Clips 

John Iskander MD MPH 

Office of the Associate Director for Science 

Centers for Disease Control and Prevention 

Agency for Toxic Substances and Disease Registry 

Dr. Iskander reported that the vision of the Office of the Associate Director for Science (ADS) is 

that “Excellent public health science is available and regularly used to solve important real world 

problems” and that its mission is to “Ensure the quality and integrity of CDC science and 

encourage the use of the best science to solve public health problems.” The Acting Associate 

Director for Science is CAPT Peter Briss and the Deputy Associate Director for Science is Tanja 

Popovic. 

One of the collaborations that the ADS office has been working on with the CDC Library and a 

variety of subject matter experts within CDC is a project called Science Clips, a weekly public 

health literature compilation service intended to serve as “scientific situational awareness.” 

Science Clips have an emphasis on applied public health and prevention science that has the 

capacity to improve health now. Dr. Bryan came up with a very innovative idea, which was to 

develop a supplement issue in conjunction with the Consultation Session focusing on AI / AN 

public health issues, with his leadership and a variety of other subject matter experts and the 

outstanding work of the CDC Library—one of the hidden treasures of the agency: 

 Subject matter experts representing multiple CDC centers including NCCDPHP, National 

Center for Immunization and Respiratory Diseases (NCIRD), National Center for 

Preparedness, Detection, and Control of Infectious Diseases (NCPDCID), and Office of 

Workforce and Career Development (OWCD) include Ralph Bryan, Lemyra DeBruyn, Nancy 

Kuchar, Dave Espey, Tom Hennessy, Howie Goldberg, Amy Groom, and Myra Tucker. 

 CDC library staff include: Jocelyn Rankin, Director; Gail Bang, Team Lead; Rebecca 

Satterthwaite; and Deidre Thomas. 

This is available to everyone who is on the All CDC distribution list, and an electronic version 

was provided to TCAC members the previous day. In addition, hard copy versions were 

expected to be provided during the Consultation Session the next day. Dr. Iskander said he 

was struck by the fact that these encompass the breadth of public health, including diabetes, 

chronic disease prevention, injury prevention, violence prevention, H1N1, broader infectious 

disease issues, et cetera. They are truly emblematic of the challenges and prevention 

opportunities currently facing the community. Whenever possible, there is a link to the 

publications. They will use HAN for distribution and PubMed to allow as much access as 

possible. 

Future Directions for Science Clips include internet posting, access and alerting for SLTT staff 

more broadly, and additional supplements and enhanced editorial content. Feedback may be 

sent to scienceclips@cdc.gov or the CDC Public Health Library and Information Center may be 

contacted via telephone at (404) 639-1717. 

19 
 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Office of State and Local Support 

Karen White, Acting Deputy Director 

Office of State and Local Support 

Centers for Disease Control and Prevention 

Agency for Toxic Substances and Disease Registry 

Ms. White indicated that the mission statement of the Office of State and Local Support (OSLS) 

is, “To achieve a healthier United States through a public health system comprising the Centers 

for Disease Control / Agency for Toxic Substances and Disease Registry, state, territorial, and 

local health departments and tribal governments. Their vision statement is, “To improve the 

health of America.” This is a system to improve the health of America that includes CDC and 

state, county, local, tribal, and territorial entities. This is about America as a country, as well as 

a country of people. The organizational improvement process focused on functions versus form 

and structure. Functions of this office are to: 

 Promote shared leadership of public health policy and practice with public health agencies 

through increased collaboration and communication 

 Develop and oversee a cross-agency process of performance and accountability that 

monitors the achievements and advance of the national public health system 

 Provide guidance, strategic direction, and oversight for investment of CDC resources and 

assets in public health agencies 

 Expand and develop the capacity at public health agencies in support of public health 

practice 

 Support the development and implementation of public health information technology and 

management that assures the rapid collection, analysis and dissemination of data to assist 

in establishing program goals, objectives, priorities 

 Provide guidance, strategic direction and support for the recruitment, development, and 

management of the nation’s public health workforce 

The OSLS organizational structure is as follows: 

Office of State and Local 

Support Offi th D 

P ic Heal S Publ H P P 

A tab ty 

G ntal 

Re 

Part & S 

Al 

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and T at 

S da d 

A ed ion P bli H La 

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CDC F eld S 

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Cap De pm 

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A ss, 

An 

C ni 

20 
 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

OSLS is horizontal in scope, strategic in action, and supportive in purpose. It is not vertical, 

tactical, or punitive. It is crosscutting and is not engaged in any single program or responsible 

for any categorical program or single action of work. OSLS is looking at systems, practice, 

performance, and accountability as a whole of public help. They engage the vertical side of 

things in a way to achieve a good horizontal approach. They are the nexus of where the vertical 

and horizontal meet. The value of this office pertains to how it exploits and expands its point at 

the nexus and leveraging. Bringing tribal health concerns and tribal partners and relationships 

to the forefront is a strategic issue versus just dictating this. They can demand that tribes be 

included in grants, but that will not make any difference. These issues and discussions must be 

strategically placed in order for people to think about how they work with tribes, and how they 

engage the help of native people into the way they think about public health and chronic 

disease. This office is also meant to be supportive in purpose. That is in the name, and will not 

change, and is in the intent of what they do. 

With regard to next steps, the tribes are a separate unit within the Branch of Government 

Relations. This is a blessing and a curse. The blessing is that it is there and it stands alone 

and stands out. Everybody will have to work together on this. The challenge is that there is 

nothing there other than Dr. Bryan and CAPT Snesrud. While they have strong backs, they 

cannot carry this all on their own. Plus they have a lot of years to make up for at CDC in terms 

of the way that they have managed this and organized it. She gave Dr. Bryan and CAPT 

Snesrud a week following this meeting to “hit the ground running” in terms of establishing this 

office and this team. Throughout February, they planned to bring in the bigger picture and 

issues. She expected Dr. Bryan and CAPT Snesrud to reach out to TCAC members with regard 

to the way they should be thinking about this. Beginning March 1, 2010 they will strategically 

think about how to set up this team in OSLS and how the team relates to other teams in 

Government Relations and across the other areas of OSLS. CAPT Snesrud told her the 

previous day that it would feel good to be part of a larger team and to have the support of others 

around her who want to do the right thing to more fully engage Tribes and work to make this 

happened in multiple ways. Ms. White expressed her hope that by the next TCAC meeting in 

the summer, they would really be able to see a difference in the way that this office is working 

with tribes and the way that this team is structured to work and relate to tribes. As she said 

earlier, she saw this as a relay to take what has been established so far within the Office of 

Minority Health and Health Disparities (OMHD), pick up the baton and take it the next part of the 

journey. 

Ms. White shared her contact information, which is 404-639-7804 and kew1@cdc.gov. She 

stressed that she sincerely wanted people to feel free to call her or leave her a message. In 

conclusion, she thanked TCAC members for the privilege to talk with them. In her 25 years with 

CDC, while she has worked with individual tribal members and individual tribes, this is the first 

time that she has been able to speak with a larger group of tribal members. 

Discussion Points 

	 Mr. Antone requested that Ms. White elaborate on funding through states and that this may 

not be working very well. 

	 Ms. White acknowledged that there have been times when states have not funded tribes at 

a level that they should have to resolve a challenge or a problem. States have been CDC’s 

21 
 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

primary portal for distributing funding, but they do not focus well or spend some of their 

funds well at the local level regardless of whether it is a large city, small city, or county. 

They assess whether states are posing barriers to getting funding out, and how the funds 

that states do have can be leveraged. They have conducted some assessments in states 

where the senior management officials are, though they have not been able to change a lot 

of what Congress intends for CDC, but they have been able to reflect better on the way 

states work with the funds that CDC provides to them and to try to influence and inform the 

expansion of states’ thinking. Everyone in public health has worked in public health a 

thousand years it seems. There is almost never a new person in public health. The 

challenge is to help these individuals think differently such that they give thought to other 

means of distributing funding (e.g., providing funding in a separate stream, engaging tribes 

directly, working directly with the county instead of flatly giving everybody $10,000). Some 

states have been very responsive to that and have admitted that they did not previously 

consider thinking different. This also has to be changed at CDC in terms of getting folks to 

think more deliberately about the way they allocate funding. 

	 Mr. Antone expressed his hope that tribes would not be imbedded with locals in terms of 

disseminating funds and information. 

	 Ms. White replied that that intention of OSLS is to work with all four units as equals: states, 

territories, tribes, and locals. The state does not have any more dominance in terms of 

decisions. That mindset is part of how they are working with CDC. When they talk to CDC 

about some of the decisions being made and point out some of the issues, such as why 

certain mechanisms are being used for funding, or why information is being disseminated in 

a particular way through states versus directly to tribes, locals, and territories. Often this is 

reflexive and people do not know why things are done in a certain manner. Dr. Bryan and 

CAPT Snesrud have been great about providing contact information, et cetera. That is an 

intended change in the way that CDC will work. 

	 Mr. Finkbonner said he was glad to hear that they were taking into consideration the way 

that resource utilization is being used at the state and local levels. He suggested assessing 

resources in general, not just funding. H1N1 is just one of the resources that CDC allocates 

to the states, and is a prime example of how public health works once resources leave CDC 

and is given to the states to provide to tribes. Some states are very good at this, while 

others are not. Some states have the best intentions, but the resources do not always make 

it to the places where they are most needed in an efficient manner. He offered to provided 

specific examples in order to contribute to the information needed by OSLS. 

	 Ms. White said it would be helpful to receive further information. She stressed that she was 

not CDC bashing or headquarters bashing. There is a challenge in recognizing that not all 

states do the right thing. People at CDC always begin with the right intention to do the right 

thing, and it takes a little while before they realize that this does not always translate down. 

This is not out of malice or neglect, but simply out of habit a lot of times. When CDC has 

pointed those issues out and has been able to provide evidence, the states typically realize 

that this is wrong and they are able to respond about the way they should have done 

something or explain why they did something the way they did. Sometimes the policy or 

resource distribution is not changed, but if it is explained, people are much more 

comfortable with the way that it went and then can figure out how to change it in the future. 

22 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

	 With regard to data sharing, Ms. Begay noted that CDC provides funding to the state and 

IHS. For several years tribes have been requesting access to data. This is another area 

she hoped that OSLS could assist tribes in gaining access to data that would help them 

improve their emergency preparedness, planning, implementation, and evaluation of public 

health activities in Indian Country. Data is a crucial area for which tribes have been 

advocating. 

	 Ms. White said that while she could not make any commitments from the state perspective 

in terms of what data they collect, what they share, and how they share it with CDC. 

However, as part of information technology and management, OSLS is interested in 

engaging the tribes and others with respect to improving data collection / access. Data is at 

the heart of everything CDC does. If everybody does not have the right data or access to 

the right data, nothing can happen. Everyone must realize that data is at the heart of 

everything they do and share as much of it and be as transparent with it as possible. As 

they discuss the work that will occur in the next several months with regard to the tribes and 

developing strategies, data should be at the top of the list. 

	 Ms. Begay suggested that since CDC gives funding to the states, it should be a requirement 

of the contractual agreement and part of OSLS’s oversight to ensure that states are required 

to work closely with tribes to provide them with data. 

	 Ms. White replied that this office will be able to do this. Because they do not work vertically, 

they will not be able to write the grants or cooperative agreements, but they can influence 

what goes into these to ensure that they include language directing states to work with tribes 

and to share data with them. They can also recommend working more directly with tribes on 

this issue. In a meeting she attended earlier in the morning, the question was raised 

regarding how CDC could ensure that this occurs, and she suggested including it in 

cooperative agreements. 

	 Dr. Kraus stressed that tweaking the name of this new office to include the word “Tribe” or 

“Tribal” is essential. There is not a level of understanding that tribes actually exist and that 

tribes should be on a peer level. This is not on a lot of public health people’s horizons, even 

with states that directly surround major tribes or series of tribes. She has found this to be 

true even with some CDC staff. If someone has not started out in a tribal area, none of their 

other experiences will prepare them for the multitude of issues. It is very educational to 

have the word “Tribal” so that people will think about it. The people who approach the office 

need to know that tribes are a major partner. 

	 Ms. White agreed and said that this was a reflexive response in terms of the office. They do 

have to think about this. As they have worked through some issues over the last several 

months that have arisen with respect to this office is that this is the dress rehearsal. They 

are trying to figure out what they can do, what they have done right, what they have done 

wrong, and then make corrections to that. Clearly, the name is going to require further 

discussion and they will address this issue. They also plan to do some work out of this 

office with regard to changing culture and changing thinking, which reflects this point, in 

terms of making sure that tribes are visible not only in the name of the office, but also in the 

work and the way CDC considers work. Culture change is an effort that will come out of this 

office in terms of what it means for this office to give state, local, tribal, and territorial 

support. This is about listening, incorporating what is heard into the way the work is done, 

23 
 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

and demonstrating that through the product. They have to change the way people think 

about this. This is not something they can edict. Instead they want to acknowledge that the 

culture at CDC in terms of working with different partners has to improve. This has to 

similarly improve on the outside. This is not just CDC’s problem. Part of the reason that this 

office was developed was because the relationship between CDC and states, locals, tribes, 

territories, and other partners and strategic alliances were broken. CDC acknowledged this 

right up front. Dr. Frieden being a local health officer was the first one to say that. However, 

there is no relationship that is broken on one side. It has to be broken on both sides. 

Without these conversations up front, everything else is lost. She requested that they 

engage with Dr. Bryan and CAPT Snesrud to share more ideas about how to make this 

better at CDC and in the states that surround the tribes and have not been responsive. 

	 Mr. Valdo emphasized that it would mean a lot to tribes to be included in the office name. It 

is in the mission, and while he appreciated that, tribes need to be elevated if it will not ruffle 

any feathers. 

	 Ms. White replied that it would cause no heartache for anyone, because several people at 

CDC have pointed this out. It should not ruffle any feathers, but if it does, who cares? That 

is the best way of getting some things done. She assured them that she would take this 

back as an issue. 

	 Mr. Gilbert pointed out that all tribes do not fit the same mold from state to state or 

reservation to reservation. This is definitely true for Alaska where they have to deal with 

state, county, and borough governments. He extended an invitation to Ms. White to visit 

Alaska in order to better understand how their processes work in terms of tribal health 

programs’ and tribal governments’ relations to Alaska local governments. 

	 Ms. White thanked Mr. Gilbert and said she would really like to do that for a couple of 

reasons, one of which is that it would be great to work closer and to get to know the tribes 

from where they work, and she has been dying to travel to Alaska to talk about public health 

but nobody has asked her. As the federal government, they have to be invited, and she 

considered this an invitation and will look into it. 

Office of Public Health Preparedness and Response 

Lynn Austin, PhD 

Deputy Director for Operations 

Office of Public Health Preparedness and Response 

Centers for Disease Control and Prevention 

Dr. Austin thanked TCAC for offering her the opportunity to speak with them. She is fairly new 

to OPHPR, which was formerly known as the Coordinating Office for Terrorism Preparedness 

and Emergency Response (COTPER). Little changed about the organizational structure, 

though there were some minor changes. The organizational structure is reflected in the 

following chart: 

24 
 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Office of Public Health Preparedness and Response 

OPHPR has four major divisions, though COTPER had five. One of COTPER’s divisions was 

the Division of Business Services, which they did not really consider a programmatic division, so 

that has been moved into an office within the Office of the Director. OPHPR is operating 

currently with two Deputy Directors, Dr. Austin and Dr. Stephanie Zaza, who is the Deputy 

Director for Strategy. Dr. Austin reviewed each box in the organizational chart. She explained 

that the offices in the wings support the four major divisions in the middle: Division of 

Emergency Operations (DEO), Division of State and Local Readiness (DSLR), Division of 

Select Agents and Toxins (DSAT), and Division of Strategic National Stockpile (DSNS). 

The vision remains largely the same, “OPHPR helps the nation prepare for and respond to 

urgent public health threats by providing strategic direction, coordination, and support for all of 

CDC’s terrorism preparedness and emergency response activities.” OPHPR’s mission is, “We 

safeguard health and save lives by providing a flexible and robust platform for public health 

emergency response.” Ever since Dr. Austin has been there, they have been in a public health 

response, which is unheard of and unprecedented in their history since they began as 

COTPER. H1N1 began within two weeks after she arrived at OPHPR and is not over, and now 

they are in the throes of the Haiti response. There is an extraordinary amount of work 

underway. She has been at CDC for over 20 years and 33 years with the government, and she 

has never seen an organization so dedicated and work so hard and such long hours. 

OPHPR focuses on an all-hazards approach to maximize available resources, so terrorism and 

emergency response dollars are to focus on four primary areas: biological and chemical 

attacks; nuclear / radiological events; trauma / explosion injury-related types of events; and 

natural / environmental events such as in Haiti. OPHPR has the capability through the public 

health system of working with communities and individuals to prevent, protect against, quickly 

respond to, and recover from health emergencies, particularly those in which scale, timing, or 

unpredictability threatens to overwhelm routine capabilities. OPHPR has a Joint Information 

Center that is really a central part of distributing information and response to a terrorist or public 

health emergency event, and is trying to unite communities to be protected from infectious, 

occupational, environmental, and terrorist threats. That includes Tribal Nations. 

25 
 

 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

OPHPR’s focus is to provide a strategic direction on preparedness to CDC, as well as training 

and education. There were bits and pieces being done, but this was not done in a very 

cohesive, organized manner. Through an appropriated line item, OPHPR now has funds to 

allocate across CDC. There is a large terrorism preparedness budget, but OPHPR itself keeps 

only about 10% for in-house operations. Most of the rest of the funds are allocated through 

public health partnership grants, the stockpile, and across CDC. The subject matter expertise 

for the four primary areas of focus (e.g., biological / chemical; nuclear / radiological; trauma / 

explosion; and natural / environmental) is outside of OPHPR in the National Center for 

Environmental Health (NCEH) or National Center for Infectious Diseases (NCID). OPHPR is 

the facilitator as well as coordinator of the funding and projects and priorities that go out to those 

organizations. OPHPR CDC is committed to publicly reporting the progress that states and 

other awardees have made in public health preparedness and to develop appropriate, specific, 

measurable, and validated performance measures. OPHPR is committed to presenting an 

increasingly clear picture of public health preparedness in the US. The first report was 

published in February 2008 on state preparedness activities funded through the Public Health 

Emergency Preparedness Cooperative Agreement. The second report was published in 

January 2009 on Terrorism Preparedness and Emergency Response funded activities across 

CDC, and the third report is scheduled to be published in 2010 on progress in state 

preparedness. 

OPHPR is very focused on ensuring that populations are well-represented. To that end, they 

have a Board of Scientific Counselors (BSC) that gives advice and direction to OPHPR and sets 

part of the strategic focus and direction for OPHPR’s programs and priorities. Dr. Austin 

reported that BSC member Bonnie Hillsberg has been representing American Indian / Alaska 

Native tribes. Dr. Hillsberg is a Senior Program Manager at the National Indian Health Board 

(NIHB). NIHB advocates on behalf of all Tribal Governments and American Indians / Alaskan 

Natives in their efforts to provide quality health care. Her role is to increase public health 

capacity in all of Indian Country, which includes injury prevention, diabetes, obesity, cancer, 

chronic disease, elder care, HIV / AIDS, tobacco, substance abuse, suicide prevention 

and other health issues that affect Native American and Alaskan Native communities. 

With respect to OPHPR’s operational focus, over $700 million is set aside to fund cooperative 

agreements for state and local preparedness efforts. These cooperative agreements include 

language requiring state and local entities to work with AI / AN. The funding also supports a 

large amount (over $500 million) in the Strategic National Stockpile (SNS) of critical medical 

assets, which is to protect state and local communities. The federal government supports and 

coordinates having the stockpile, but its sole purpose is to protect the citizens of this country 

and other assets when called upon to do so. OPHPR also manages CDC’s emergency 

response operations through the CDC Emergency Operations Center; and manages the 

regulation of the possession, use, and transfer of select agents to protect public health and 

safety. These funds are managed by OPHPR DSLR, which provides guidance and funds 

(~$688.9 million in FY09) to 62 state, local, and territorial public health departments to 

strengthen preparedness, including for pandemic influenza. DSLR also provides technical 

assistance and consultation through Project Officers and CDC Subject Matter Experts (SMEs); 

and develops performance metrics and gathers performance data on exercises and real events 

through public health department reporting. 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

DSLR has developed and implemented a Public Health Emergency Preparedness (PHEP) 

evaluation framework and related capacity and capability performance measures. Currently, 

PHEP awardees are collecting and reporting data on seven performance measures in 

laboratory preparedness, incident management, and crisis and emergency risk communications. 

Work is underway to develop performance measures in other areas. All states have public 

health emergency preparedness and pandemic influenza response plans in place. All states 

have staff to evaluate urgent disease reports 24/7/365. More than 160 Laboratory Response 

Network (LRN) laboratories can test for biological agents, with nearly 90% of the US population 

living within 100 miles of an LRN lab. All states trained staff in their roles and responsibilities 

during an emergency using the Incident Command System (ICS). All states have a crisis and 

emergency risk communication plan. 

The Strategic National Stockpile is managed by OPHPR’s DSNS, which manages and 

maintains the national repository of critical medical assets including antibiotics, antiviral drugs, 

antitoxins, other life-support medications, and supplies. DSNS also procures, stores, and 

delivers these assets to the site of a public health emergency and can deploy a Stockpile 

Service Advance Group (SSAG) to assist state and local officials during a public health 

emergency. In addition, DSNS provides technical assistance to state and local public health 

departments to move medical assets from warehouses to points of dispensing. All states have 

plans in place for receiving and distributing Strategic National Stockpile assets and are 

exercising those plans. The supply of smallpox vaccine has increased from 15.4 million doses 

available in 2001, to more than 300 million full doses currently—enough to vaccinate every 

American, if necessary. Treatment countermeasures stockpiled in regard to pandemic influenza 

(e.g., antiviral drugs, respirators, and surgical masks) continue to increase. The CHEMPACK 

Program forward places life-saving medical assets in states for use in the event of a chemical 

incident. The Cities Readiness Initiative (CRI) helps major US metropolitan areas increase their 

capacity to dispense antibiotics within 48 hours of a public health emergency 

CDC’s Emergency Operations Center is managed by OPHPR’s DEO, which functions as CDC’s 

command center for coordinating emergency responses to domestic and international public 

health threats. The center is staffed 24/7/365 to provide worldwide situational awareness and 

coordinate CDC’s preparedness, assessment, response, recovery, and evaluation for public 

health emergencies. The EOC serves as point of contact for state agencies reporting potential 

public health threats to CDC. The EOC increased its level of response 44 times to respond to 

public health emergencies between September 2001 and April 2009 and a couple of times since 

then. More than 1,300 people were deployed during the recent pandemic H1N1 influenza virus 

outbreak. In addition, the EOC conducted agency-wide exercises to test response plans for 

hurricanes, detonation of radiological dispersal devices, and an outbreak of pandemic influenza; 

and implemented the National Incident Management System (NIMS) in 2005 to better 

coordinate and manage emergency responses by all federal, state, and local agencies. 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

The following is snapshot of the kinds of responses for which the EOC has been activated and 

engaged: 

Over 200 people are already engaged in the Haiti response, including a number of people who 

were on the ground in Haiti at the time the earthquake occurred. These individuals are 

receiving a mere $3.00 per day incidental allowance, though they are sleeping on the ground, 

have no means by which to bathe, and are eating military meals ready to eat (MREs). Yet these 

people are highly dedicated and volunteer to go, which is amazing. 

The Select Agent Program, which is managed by OPHPR’s DSAT regulates all entities that 

possess, use, or transfer biological agents or toxins that could pose a severe threat to public 

health and safety. The program is designed to ensure compliance with the select agent 

regulations by providing guidance to registered entities and conducting evaluations and 

inspections. In addition, this program collaborates with the US Department of Agriculture 

(USDA) and the Department of Justice (DOJ) to protect public health by ensuring laboratory 

biosafety and security among facilities working with select agents. The program currently 

regulates 51 select agents and 336 entities are registered that possess, use, or transfer select 

agents. The program received a 100% quality rating score from the HHS IT Investment Review 

Board for the National Select Agent Registry; successfully merged 1.4 million records from the 

DSAT and USDA’s Animal and Plant Health Inspection Service (APHIS) databases; provided 

training and guidance to the regulated community to assist entities in complying with the 

requirements for notification of thefts, losses, or releases of select agents; and completed the 

biennial review of the select agent list and posted it in the Federal Register for public comment. 

28 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Strategic National Stockpile 

Steven A. Adams, MPH, Deputy Director 

Division of Strategic National Stockpile

Office for Public Health Preparedness and Response 

Centers for Disease Control and Prevention 

Mr. Adams reported that the DSNS mission is “to deliver critical medical assets to the site of a 

national emergency.” Wrapped up in that simplistic mission are a number of complexities that 

fill the SNS staff’s days. DSNS works within the HHS Public Health Emergency Medical 

Countermeasures Enterprise (PHEMCE) requirements process to assure that they have the 

most appropriate countermeasures. They create pathways to move the materiel to the area of 

need in the timeframe that is clinically relevant. Given that initial medical responses are local, 

DSNS assures integration with local planning. DSNS also provides technical assistance to 

assure that state / local partners who receive SNS assets are ready to effectively use them; and 

maintains materiel in a manner that assures viability. 

The program was created in 1999 and currently has a $3.5 billion portfolio of antibiotics, medical 

supplies, antidotes, antitoxins, antiviral, vaccines, and other pharmaceuticals that are housed in 

a network of strategically located repositories. Commercial partnerships are utilized for storage, 

maintenance, and rapid transport and federal partnerships are used for purchasing and security. 

The SNS contains an evolving formulary. DSNS supplements and re-supplies state and local 

medical materiel response; provides extensive training and technical assistance to local 

officials; and is integrated into a much broader national public health preparedness effort. 

DSNS efforts support the inclusion of tribal governments and communities in state and local 

public health preparedness. Mr. Adams stressed that they were doing their best to learn from 

this process and from TCAC members. They do not have it right yet, but are dedicated to doing 

whatever they can from where they sit to encourage a reach in both directions, from tribal 

communities to state and local governments and vice verse, to ensure integration so that at the 

time of a response, the linkages are already made, planning is already done, and ideally the 

exercising and lessons have been learned together. 

DSNS did a satellite broadcast on January 28, 2009. This broadcast was focused on partnering 

with tribal governments and communities during mass antibiotic dispensing. Partners in this 

effort included CDC’s Senior Tribal Liaison, Executive Director Northwest Portland Indian 

Health Board (Lummi Tribe); Border Health Manager & Tribal Liaison New York State DOH; 

Tribal Emergency Management Director, and Poarch Band of Creek Indians. The broadcast 

was designed to assist state and local SNS planners in reaching out to and partnering with 

American Indian and Alaska Native governments. An archived version remains available at: 

http://www2a.cdc.gov/phtn/tribal/ and is also available on CD-ROM. Continuing education credit 

is available for viewing this broadcast, and the archived version continues to be accessed. 

A brochure was developed to help prepare tribal nations to receive SNS assets. The division 

partnered with the IHS and the Phoenix Indian Health Service (PIHS). The brochure 

encourages tribes to work with state and local partners and the IHS to plan how to request, 

receive, and distribute SNS supplies; and suggests emergency response exercises. A copy of 

the brochure was provided in TCAC members’ information packets. 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

DSNS has also engaged in additional tribal-specific efforts. February 10, 2009, DSNS 

participated in Tribal Consultation Advisory Committee Engagement Meeting in Albuquerque, 

New Mexico. The division participated in the Tribal Pan Flu Planning and Awareness 

Conference convened March 24-25, 2009 in Camp Verde, Arizona. In addition, DSNS 

collaborated on the development of a resource guide titled “American Indian / Alaska Native 

Tribal Government - 2009 H1N1 Influenza Planning and Response.” 

Again, DSNS is trying to take any opportunity possible to help champion the idea of integration. 

They began 10 years ago working primarily at the state level, and then working with the states 

and locals to get them to work together, and are no encouraging a more inclusive approach in 

which state, local, and tribal entities are working together. While this is not as much of an issue 

in some states, it is clearly a national issue and priority for DSNS. The division continues to 

look for opportunities where its Program Services Consultants, the SNS staff who are assigned 

to each of the 50 states, can provide on-going technical assistance for countermeasure 

dispensing. They are actively seeking opportunities to push the concept of integration of all. 

DSNS has participated in several meetings to voice its encouragement for this process, and 

stress the criticality of integrating all of those who would have a role in carrying out the response 

in the front end planning. An old adage of emergency response is that you don’t want to make 

friends on the day of the disaster. Networks should be created beforehand, and the capabilities 

and limitations of all parties having a role in a response should be known in advance. This is 

true within DSNS, CDC, and in the broader context of integration of organizations and response. 

A number of technical assistance resources for countermeasure dispensing are available and 

can be acquired by contacting state and local or SNS field representatives. These tools include 

the following: 

 Formal guidance Version 10.02: Receiving, Distributing and Dispensing SNS Assets 

 State and local exercise support and evaluations 

 Classroom instruction 

 Satellite educational broadcasts 

 Listserv of about 4,000 people who have a role in stockpiling medical countermeasures 

Further information is available at the following sites: 

 http://emergency.cdc.gov/bioterrorism 

 http://emergency.cdc.gov/stockpile/ 

Division of State and Local Readiness 

Christine Kosmos, BSN, MS 

Director, Division of State and Local Readiness 

Office of Public Health Preparedness and Response 

Centers for Disease Control and Prevention 

Ms. Kosmos reported that the DSLR administers two major sources of funding for state and 

local preparedness and response: Public Health Emergency Preparedness (PHEP) cooperative 

agreement; and Public Health Emergency Response (PHER) grant, which was added to 

DSLR’s portfolio for H1N1 response. In addition, DSLR provides funding and coordinates 

technical assistance; tracks progress and evaluates performance; and collaborates with 

awardees on development and reporting of performance measures. One of the things that 

30 
 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

DSLR wants to do better and has learned from the H1N1 response is that the majority of the 

work is done at the local, county, and tribal levels and that they need to work deeper within 

these organizations to better prepare the nation. 

The PHEP cooperative agreement supports all-hazards preparedness in state, local, and 

territorial public health departments. Nearly $7 billion in funding was awarded as of FY 2009 to 

62 awardees, including 50 states, 4 localities, and 8 territories and freely associated states. 

Tribal organizations were funded through states. DSLR is developing a new program 

announcement for the PHEP cooperative agreement that will reflect a capabilities-based 

approach that merges public health and emergency management capabilities. The new 

program announcement will be for a five-year program period that is anticipated to begin in 

2011. A new strategic PHEP framework will be instituted to ensure that program objectives are 

aligned with preparedness goals, functional objectives, the existing measurement framework, 

the National Health Security Strategy, and the Revised Target Capabilities List. 

Discussion Points 

	 It was noted that Dr. Hillsberg is no longer on the BSC, and that she had been replaced by 

someone else. 

	 Dr. Austin responded that the BSC is comprised of approved members who have to go to 

HHS for approval, so when members are swapped, OPHPR must submit a new package. 

	 Mr. Franklin inquired as to how DSLR is tracking whether states are contacting tribes, and if 

so, what they are doing about California. 

	 Ms. Kosmos replied that Mr. Franklin raised a very important point. CDC has had a long 

and strong relationship with the organizations that they fund, but those are 63 agencies. 

They must figure out a better plan for working beyond the state to reach the local, county, 

and tribal organizations to ensure that the funds are getting down where they need to be 

and that it results in increasing preparedness. 

	 Mr. Franklin said that he did not think they should be working “down” to get to tribes. They 

should be working across. This speaks to why tribal leaders are so concerned with the 

name of the Office of State and Local Support, because Tribes are not included and funds 

are being gotten “down” to them. Indian people die because states do not want to work with 

tribes and this is being overlooked. 

	 Ms. Kosmos apologized for misspeaking by using the term “down to tribes.” One thing that 

has come out in the in-progress reviews is that as an organization, CDC does not have a 

good platform for working with anyone beyond the 62 awardees. It has been recognized as 

a major gap, and certainly a gap within DSLR, that CDC does not have strong relationship 

with the people the states work with. However, this is where “the rubber meets the road.” 

Trying to get information from local, county, and tribal entities about what is working, what is 

not, and how much funding is getting to those levels is very difficult. One thing she has put 

on DSLR’s agenda is to develop a better platform for finding out this information. There 

must be more visibility about how things are getting implemented and what the successes 

and challenges are at levels other than the state. Although they do not yet know the 

solution, the can look to some of their work with National Association of County and City 

Health Officials (NACCHO) as a model. They found that states were reporting one thing, but 

31 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

local organizations were having a very different experience. Thus, they developed the 

Sentinel Network, which is a network of 122 local health departments. This will be able to 

give them ground truth about what is occurring at other than a state level. Building upon 

that lesson learned and seeing how they can apply it on a broader level is something CDC 

must do as an organization, and within DSLR. As recently as a couple of weeks before this 

meeting, DSLR was hearing that H1N1 funding did not reach local levels. Hearing this at 

the back end of a response is obviously a major problem. In order for states to apply for 

more funds for H1N1 response, they must tell DSLR how much of the funds they were 

supposed to distribute very specifically to local, county, and tribal organizations. This was a 

directive in the guidance for dissemination of the funding. However, this was very slow to 

occur. They plan to develop better systems for tracking and accountability. For the fourth 

round of funding, states are having a very difficult time explaining how the funds received 

thus far have been allocated. Some states do better than others, but generally states do not 

have a good way of tracking the funds that they awarded; therefore, they are having 

difficulty accounting for this to CDC. There is clearly a lot of work to do. DSLR and CDC as 

an agency have learned that they need to trust and verify. They need good ground truth 

and situational awareness, and it must come from various points of view. They own this and 

will chip away at it. The situation did not get this way overnight, so it will take time to correct. 

	 Mr. Franklin pointed out that tribes are the most regulated people in the world, and that he 

could think of a million ways to regulate states and would be happy to help develop a 

system for accountability. 

	 An audience member noted that some tribes experience difficulties because their lands 

overlap two states, and the two states may argue over who is supposed to be accountable 

to the tribe. It comes down to who is going to divide funds, how much population is living 

where, and it is not a county. 

	 Ms. Kosmos replied that funding tribal nations is very difficult to sort out because of issues 

such as this. The funding mechanism was set up to try to push states to be more 

collaborative with local, county, and tribal entities. This has obviously not worked well in 

every case, but they do not necessarily need to “throw the baby out with the bathwater.” 

Funding individual nations would likely collapse DSLR because they would never have the 

bandwidth to do something like that. It is more a matter of logistics. Perhaps there is 

something between A and B that would be a better fix, such as legislation or inclusion in 

cooperative agreements. 

	 Dr. Bryan added that DSLR had done a remarkable job at taking some of their advice and 

putting it on the ground. The language in the guidance is very clear about inclusion of tribes 

with the state awardees, up to and including requiring letters from the local tribal 

organizations and tribal governments of concurrence with the applications as they come in, 

and the strong language in regard to the expectations. Many of the issues are personpower issues in terms of tracking accountability. Another problems is process at the statetribal levels when funds are sitting in states and tribes are trying to access them. The 

mechanisms by which that happens have experienced many problems. There is no 

consistency in the way that states manage and distribute funds. Sometimes this is done 

through contracts based on deliverables, sometimes mini-grants are used, and sometimes 

population-based formula grants are utilized. A suggestion was made to COTPER in 2008 

for CDC to develop best practices, standardization, or ideas if nothing else to try to 

systematize the process by which states distribute funds to tribes. 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

	 Ms. Kosmos agreed 100%. In addition to some of the other lessons DSLR learned with the 

H1N1 response, which counted on state, local, county, and tribal organizations to stand up a 

response, having a cooperative agreement that relies on CDC getting money to states and 

states then parsing out money through contracts is an extraordinarily slow process that does 

not lend itself to an emergency response framework. In addition, in the midst of a response 

one of the things needed most is staff. However, when the funds cannot be distributed in a 

rapid manner to local, county, and tribal groups, they cannot hire the staff necessary to 

address the response. They must understand these two grants for what they are: 

cooperative agreements. The PHEP is basically a planning grant, which is different from the 

PHER grant. DSLR plans to consider whether there are better ways to fund state, county, 

local, and tribal organizations for emergency response. They have learned the lesson that 

perhaps a cooperative agreement or grant is not the best way to disseminate money rapidly. 

Many states do not have good mechanisms for contracting on an emergency basis. 

	 Ms. Hughes pointed out that tribal leaders have been making statements for years regarding 

why the systems and process in place would not work for Indian Country. Now 

preparedness discussions will be in terms of an event that can be analyzed to determine 

what could be done to make systems / processes more feasible for handling an event. In 

the early H1N1 discussions, tribes state repeatedly that those without excellent working 

relationships with states would not have access. This has now been demonstrated and 

changes must be made. 

	 Mr. Franklin agreed that not only did they demonstrate lack of access in many areas, but 

also Arizona demonstrated what could happen when tribes did have access. There are now 

models of what works and what does not. 

	 Ms. Hughes added that she is from Wisconsin where tribes have an excellent relationship 

with the states. They had total access in a timely manner. The day before she left to travel 

to this meeting, she received a report from the county, city, local, and tribal governments 

that analyzed what was effective with the preparedness approach to H1N1. This should be 

done on a national level in order to implement best practices that can help tribes where such 

relationships do not exist. 

	 Ms. Kosmos responded that DSLR is mandating an after action review, which will be 

required from each of the 62 awardees. Those working with state governments were 

encouraged to get to the table in order to inform these awardees. DSLR plans to analyze 

these to improve future efforts. 

	 Mr. Finkbonner added that he works in the Northwest primarily in three states (e.g., 

Washington, Oregon, and Idaho). Washington has great relationships with its tribes; 

however, they experienced considerable problems with both the SNS and H1N1 distribution 

systems (two different systems). The problems were great enough that tribal leadership 

engaged in conference calls and meetings with the secretary of health to discuss these 

issues as they were unfolding in order to address them in real time. This illustrates that 

even if there are good relationships in place, the system can still fall apart. There are many 

models, and what it really boiled down to was relationships at the local levels. These are 

often strained with tribes because this is where resource battles occur. When the sharing of 

resources is pushed to the local level, tribes typically lose because it is distributed to locals 

rather than tribes. What he wanted to resonate with Ms. Kosmos more than anything 

33 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

regarded how to make direct allocations to tribes without other intervening jurisdictions. 

Public health is public health and preferences should not be made based on who someone 

likes or does not like. 

	 Ms. Kosmos said she thought that everyone who lived through this understand that there 

were many challenges to the H1N1 response in the areas of vaccine distribution; allocation 

of funds to state, local, and tribal levels; et cetera. Despite all of that, components of the 

response worked well. It is doubly challenging when local, county, and tribal groups do not 

have a trusting relationship with their state because it adds to the complexity of the 

response and to the feelings of inequity. She requested further input with respect to how to 

address the challenge of direct funding, direct allocation, et cetera to tribes given that there 

are so many tribes. It is not clear how to make this work without collapsing the system due 

to the logistical issues associated with exponentially increasing the challenges. The 62 

cooperative agreements are challenging enough. Multiplying that by several times is 

untenable. 

	 Mr. Franklin suggested funding directly through IHS or Area Health Boards. California’s 

Area Health Board would have had no problem getting information to all of the tribes in the 

state. 

	 Ms. Hughes suggested including language in cooperative agreements to require states to 

fund tribes directly rather than passing it through counties. 

	 Dr. Bryan suggested that pieces of this may work with IHS, pieces that work with states, et 

cetera. He does have concerns regarding some of the logistical issues with IHS. 

	 Ms. Manuel pointed out that it will be different in area because of the number of tribes that 

are in each state and county. Her reservation is primarily in Pima County, and they work 

well with the county, but she would prefer direct funding from CDC. When they receive a 

grant, it can take a year before it gets into the tribal system. She agreed that IHS could be a 

good mechanism, and her reservation has a good relationship with IHS. 

	 Mr. Trudell agreed that IHS has a system in place that could be utilized for funding 

distribution. The diabetes funds have been distributed to areas through IHS since the 

inception of this funding. Thus, there is already a model for working through IHS. 

	 Mr. Curley said it was not clear to him that distributing funds through IHS was the best 

solution, given that there have been some problems there as well. He suggested that 

consideration be given to allocating a specific base amount to each state for tribes, and then 

permit the tribes within each state determine how they want it to be allocated. This would be 

local self-determination. It is ridiculous what tribes have to go through to make programs 

work. The requirement for tribes to put together PODs only to find out when implemented 

that this work was not really that important, especially for small tribes. For smaller tribes this 

was a waste of time and manpower. 

	 Ms. Kosmos indicated that she would connect with Dr. Bryan with respect to further actions 

and how to move forward. She thanked everyone for their input, stressing how helpful it 

was to hear validation of what DSLR thought was occurring. This verified for them the 

importance of obtaining better ground truth from local, county, and tribal organizations to 

help DSLR develop better policies. 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

	 CAPT Snesrud reported that on one of the conference calls, there was a suggestion of 

forming a subcommittee constituted of TCAC members and other interested PHEP tribal 

folk. This would enable Dr. Bryan to have a particular linkage if Ms. Kosmos was involved 

and engaged in this subcommittee. With respect to Program Consultants and Project 

Officers, there seems to be a circular fashion in and out, not because it is not a good place 

to work, but because of the overwhelming work that must be done. That said, the tribes met 

someone two or three years ago and have been waiting to connect. It is likely that TCAC 

will form a subcommittee that will look to DSLR for assistance in designating staff to work 

with the TCAC. 

Office of Surveillance, Epidemiology, and Laboratory Services 

RADM (Ret) Stephen B. Thacker, MD, MSc, Acting Director 

Office of Surveillance, Epidemiology, and Laboratory Services (OSELS) 

Centers for Disease Control and Prevention 

Dr. Thacker shared the organizational chart of the new Office of Surveillance, Epidemiology, 

and Laboratory Services (OSELS): 

He reported that one of Dr. Frieden’s priorities is to enhance surveillance and epidemiology at 

CDC. Dr. Frieden is very data-driven and he was an Epidemic Intelligence Service (EIS) 

Officer. OSELS has a science focus for cross-cutting support of CDC programmatic activities. 

The Office of the Director is very small, with just a few people. The genomics program recently 

moved into OSELS. The Biosurveillance Coordination Unit, Behavioral Risk Factor Surveillance 

System (BRFSS), and CLIA have moved there as well. OSELS currently has approximately 

1,200 to 1,300 people. Of those, 300 are fellows and EIS is one of the fellowship programs. 

The key about the OSELS program different from the infectious and chronic disease programs 

is that OSELS is there to support programmatic activities and to enhance cross-cutting 

activities. For example, if they want to enhance surveillance activities throughout the states, 

OSELS has laboratory, informatics, surveillance, et cetera activities and the fellows to 

implement these activities in the same organization. The idea is to enhance the capacity of 

programs in state, local, and tribal organizations so that they can do their jobs more effectively. 

35 
 

 

Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Not all of the OSELS positions are populated. Most of the OD boxes have acting leaders such 

as himself. Their job is to implement the other of Dr. Frieden’s priorities to support state, local, 

and tribal activities; enhance surveillance and epidemiology; use policy more effectively; 

translate science into practice; and enhance global health activities. HHS and the Hill have 

approved this organizational chart, which is now in MASO at CDC awaiting approval. 

Essentially this is an approved activity. 

Explanation of Epi Aids & Examples from Indian Country 

Douglas Hamilton, MD, PhD, Director 

Epidemic Intelligence Service (EIS)Program 

Centers for Disease Control and Prevention 

Dr. Hamilton indicated that he is currently serving as the Director of the Epidemic Intelligence 

Service program at CDC in Atlanta. This focus of his presentation was sustainable public health 

training programs. The EIS program has been in operation for 55 years. In very simplistic 

terms, the EIS program is a two-year post doctoral fellowship in applied epidemiology that is 

targeted toward health professionals. In many ways, this program is modeled on a traditional 

medical residency program. The EIS program was established in 1951 with 23 recruits. In 

1954, the first female officer and first Asian officer were admitted. In 1956 the first Hispanic 

officer was admitted, in 1965 the first African American / Black officer was admitted, and in 1968 

the first Native American officer was admitted. Approximately 20% to 35% of recent graduates 

represent ethnic minorities. The EIS Class of 2009 had a total class size of 82 (69 US, 12 

international); 27 men (33%) and 55 (67%) women, a major shift; and 21 of 70 (30%) were 

minorities (US / US Permanent Residents). Professional backgrounds included 41 (50%) 

physicians (63% with advanced degrees); 25 (30%) doctoral-level scientists; 6 (7%) MD / PhD; 

7 (9%) veterinarians; and 3 (4%) RN / MPH. This is about the mix that has been included 

during the last couple of years. 

A watershed moment for the EIS program occurred in 1955 with the Cutter vaccine incident. 

During the early 1950s, a formalin inactivated vaccine for poliomyelitis was developed by Dr. 

Jonas Salk and tested in over 200,000 children. On April 12, 1955 (the 10th anniversary of the 

death of Franklin Roosevelt) the availability of the new vaccine was announced. Vaccination of 

children began the next day. Dr. Langmuir set up a plan for surveillance for polio, largely in 

anticipation of vaccine failures. On April 25, 1955 a report of a baby in Chicago, inoculated 9 

days earlier, developing polio was reported to CDC. An EIS officer arrived to investigate the 

next morning. The next day, an EIS officer in Napa California called to report a second case. 

By the end of the day, six cases had been identified. Dr. Langmuir traveled to Washington 

where he lobbied for and received permission to set up an emergency national surveillance for 

polio. At this time, the future of the polio vaccination campaign was in question as people 

argued that the vaccinations should be stopped. By May 6, 1955, vaccine produced by the 

Cutter company was implicated as the responsible exposure. Vaccine distribution was 

temporarily suspended until the factory could be checked and appropriate safety measures 

instituted. During this incident CDC, through the use of the EIS officers, demonstrated its ability 

to rapidly respond to a public health emergency. 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

The content of the EIS training falls into two broad areas: applied epidemiology and emergency 

response. The methods of instruction are very similar to formal residency training. There is a 

small amount of didactic material pertaining to applied epidemiology and emergency response. 

Methods of training include structured courses, including case studies; exercises / simulations; 

required activities on-the-job; mentoring; and experiential learning. 

The EIS mission is to develop skills in applied epidemiology, quantitative work, research design, 

epidemiologic judgment, and health communications. Domestic and international service 

includes responding to requests for epidemiologic assistance, prevention, disease and injury 

control, health promotion, and capacity-building. Much of the work of EIS officers is done in 

experiential learning. An EIS officer’s assignment may be to a state or local health department 

whether they will be engaged in broad, front-line public health experience; and surveillance, 

investigation, and intervention. Or his or her assignment may be to CDC headquarters where 

specialized, disease- or problem-specific experience will be gained (e.g., vaccine preventable 

disease, STD, injury, ectopic pregnancy); and the EIS officer will be involved in surveillance, 

investigation, and policy development. 

One of the mechanisms the EIS Program uses is the epidemiological assistance (EPI-AIDs) 

mechanism. This includes providing needed service to states and other local health authorities; 

allowing for rapid response to public health emergencies; providing supervised training 

opportunities for EIS officers; and fulfilling regulatory responsibility for cruise ships. The 

reasons for requesting an EPI-AID include the need for technical expertise, the need for 

additional resources, problems that involve multiple states, and facilitated access to CDC 

laboratory support. It is important to understand that CDC has no regulatory control. If Ebola 

breaks out in New York City, CDC cannot work on it unless New York City extends an invitation 

to CDC to do so. The one exception is the regulatory control over cruise ships with a foreign 

ports of call. The criteria for an EPI-AID are that it must be requested by appropriate official, 

have public health importance, require a timely response, require epidemiologic methods, and 

contribute to EISO development. There also must be unavailability of other sources of support, 

it cannot be part of a planned or on-going activity. The following represent EPI-AIDS for 1999 

versus 2009: 

EPI-AIDs in Fiscal Years 

1999 and 2009 

1999 2009 

106 91 Total EPI AIDs Issued 

82/4 

(77%/4%) 

80/8 

(88%/9%) 

In United States/ 

Multi State 

2 (2%) 0 (0%) In Puerto Rico 

1 (1%) 0 (0%) In U.S. Trust Territory 

21 (20%) 11 (12%) International 

EPI-AIDs by Subject Area 

Fiscal Year 1999 vs. 2009 

1999 

(n=106) 

2009 

(n=91) Subject Area 

82 (77%) 57 (63%) Infectious Disease 

9 (8%) 18 (21%) Emergency Response 

8 (8%) 3 (3%) Maternal & Child Health 

3 (3%) 9 (10%) Environmental Problem 

2 (2%) 2 (2%) Injury 

2 (2%) 2 (2%) Other 

Infectious disease EPI-AIDS clearly represent the bulk of requests for assistance to which the 

EIS program responds, and assistance in this category was provided by various centers (e.g., 

NCID, NCHSTP, and NIP). Emergency response includes response to natural disasters (e.g., 

earthquakes in Bolivia, Hurricane in Dominican Republic, and flooding in North Carolina), as 

well as manmade disasters (e.g., lice infestation among Kosovo refugees or nutritional status 

37 
 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

among refugees in Nepal). Over the years, CDC has begun to respond to more and more 

requests that do not involve the traditional infectious disease or emergency problems. Maternal 

and Child Health (MCH) this year has included evaluation of anemia in different populations 

(Alaskan Native, West Bank), evaluation of increase in uterine rupture following vaginal birth 

after caesarean (VBAC), and an increase in molar pregnancies in a closed population. 

Environmental problems this year have included trichloroethylene (TCE) exposure, and heatrelated mortality in the Midwest. The National Center for Injury Prevention and Control (NCIPC) 

was asked to look at a rise in pedestrian motor vehicle accident deaths in Atlanta, and at an 

increase in suicides among medical residents. Specific examples of EPI-AIDs in Indian country 

include investigation of dental carries in Alaskan Native children (2009-007); an outbreak of 

pertussis (2007-059); three different investigators on different reservations of Rocky Mountain 

Spotted Fever (2005-033, 2004-061, 2003-075); an outbreak of molar pregnancies and adverse 

outcomes (1999-029); and adverse health effects from forest fires (2000-009). 

The following map reflects the types of problems with which EIS Officers deal: 

What Types of Problems do EIS 

Officers Deal With? 

Lead screening 

TB in immigrants 

Malaria Norwalk Virus from oysters 

Hanta Virus Cyclosporiasis 

E. coli 

Copper in drinking water

Cryptosporidiosis 

Legionnaires' Disease 

WTC Bombing 

Hurricane Hugo 

West Nile Virus Forest 

Fires 

Hurricane 

Katrina 

Norovirus 

Monkey Pox 

Discussion Points 

	 Ms. Hughes inquired as to how one gains entry into the EIS class. 

	 Dr. Hamilton responded that the application process is done on-line through a CDC website 

link. In 2009, the program received more applications than ever for approximately 80 spots. 

There were 430 complete applications. An initial screen is done of the applications, and the 

program is able to interview about half of those. There is a first cut based just on the paper 

application, which is really the most difficult because there is no opportunity to look at a 

person and talk to them. Those who make the cut are interviewed in the Fall, and a 

selection is made for the class in December. Typically when selecting a class, the program 

is looking for a couple of things. Clearly, they want the best qualified people they can get, 

but also they are looking for people whose interests mirror the needs of the agency. 

	 Ms. Hughes requested further information regarding who can make an EPI-AID request. 

	 Dr. Hamilton responded that some EIS officers are placed at IHS for their two-year 

assignments. 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

	 Dr. Bryan added that they are assigned to the Albuquerque Division of Epidemiology and 

Disease Prevention within IHS where he is. This is the component of IHS that provides the 

core funding for the Tribal Epidemiology Centers. The EIS officer in Albuquerque has the 

first right of refusal for EPI-AIDs across Indian Country. The nuance is that IHS can invite 

an EPI-AID if it centers around an IHS facility. Even then and invitation would not go out 

and CDC would not come in if there were not an invitation ensuing from the tribe involved. 

That would either come from the principal tribal leader or his or her representative on the 

appropriate tribal council, or for example the Director of the Division of Health. 

	 Dr. Klaus said that she was familiar with a few of the EPI-AID investigations, which have 

largely been infectious disease-oriented and a few months in duration. She was not sure for 

anything not infectious disease-related when the Tribal Epidemiology Center might make a 

request for an EPI-AID. She wondered what the longest period of time would be that an 

EPI-AID would last. 

	 Dr. Hamilton replied that this pertained to the element of timeliness that he mentioned 

earlier. EPI-AIDs do not have to be just for infectious diseases. The issue needs to be a 

public health problem for which an immediate answer is needed. They are not for on-going 

research. For example, a couple of years ago the State of North Carolina wanted to change 

their laws about asthma admissions to emergency departments. Asthma has been around 

forever, but the problem was that they needed to have data within a one-month period 

regarding the impact of asthma admissions on emergency departments. They needed to 

use those data for the legislation. The state health department requested assistance to 

collect this information. The first molar pregnancy was noted three years before the problem 

was recognized as being higher than what would be expected in that population. What can 

happen is that a problem may be identified and an EPI-AID takes place to respond, but in 

the course of the investigation, other questions may be identified that lead to further 

research. However, further research is not part of the EPI-AID. 

Wrap-Up and Closing 

Ms. Hughes, CAPT Snesrud, and Dr. Bryan offered instructions regarding transportation and 

entry to the CDC Roybal Campus for the Tribal Consultation Session to be convened on 

January 28, 2010, and regarding travel home at the close of the session. 

With no further questions raised or business posed, the Orientation Session was officially 

adjourned and the closed Tribal Leaders Caucus began. 

39 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Attendant Roster 

Tribal Consultation Advisory Committee (TCAC) Members 

Chester Antone, Tucson, TCAC Chair (Tohono O’odham Nation, Councilman) 

Roselyn Begay, Navajo Nation (Division of Health, Program Evaluation Manager) 

Joe Finkbonner, Portland (Northwest Portland Area Indian Health Board, Executive Director) 

Reno Franklin, California (California Rural Indian Health Board, Chairman) 

Kathy Hughes, Bemidji, TCAC Co-Chair (Oneida Business Committee) 

Cynthia Manuel, NIHB (Tohono O’odham Nation, Councilwoman) 

Michael Peercy, Tribal Self-Governance Advisory Committee, Choctaw Nation of Oklahoma, 

Epidemiologist 

J.T. Petherick, Oklahoma (Cherokee Nation, Health Legislative Officer) 

Alicia Reft, Alaska (Karluk Ira Tribal Council)
 

Dee Sabattus, Nashville (United South and Eastern Tribes, Inc., Interim THPS Director) 

Lester Secatero, Albuquerque (Albuquerque Area Indian Health Board, Chairman) 

Roger Trudell, Aberdeen (Santee Sioux Tribe of Nebraska, Chairman) 

Derek Valdo, NCAI (from Pueblo of Acoma, National Congress of American Indians)
 

Other Elected Tribal Leaders 

Cathy Abramson, Sault Tribe of Chippewa Indians, Board Member 

Candida Hunter, Hualapai, Councilwoman 

Joyce Jones, Karluk IRA Tribal Council, Vice-President 

Andy Joseph, Jr., Colville Tribes, Northwest Portland Area Indian Health Board Chair, HHS 

Chair Tribe Council, NIHB 

Buford L. Rolin, Poarch Band of Creek Indians, Tribal Chairman 

Other Tribal Organizations / Tribal Health Boards / Tribal Health Professionals 

Stacy Bohlen, NIHB, Executive Director 

Michael Bristow (Osage Tribe of Oklahoma) 

Jessica Burger, NIHB, Deputy Director 

Bridget Canniff, Northwest Portland Area Indian Health Board, Tribal Epi Center Consortium, 

Project Director 

Kristal Chichlowska, Colville Confederated Tribes, California Tribal Epidemiology Center, 

Director 

Alan Crawford (former AI CDC employee) 

Feliciano Cruz, Pascua Yaqui Tribe, Public Health Emergency Preparedness Coordinator 

Larry Curley, Indian Health Board of Nevada, Executive Director 

Elaine Dado, Northwest Portland Area Indian Health Board 

Maria Garcia, Pascua Yaqui Tribe, Program Manager Alternative Medicine 

Tim Gilbert, Alaska Native Tribal Health Consortium, Senior Director, Community Health 

Kristin Hill, Great Lakes Inter-Tribal Epidemiology Center, Director 

Lyle Ignace, Coeur D’Alene, Indian Health Service, Medical Officer 

Luke Johnson, Fort Mojave Indian Tribe, Public Health Emergency Preparedness Coordinator 

Angela Kaslow, CRIHB, Director, Family and Community Health Services 

Deborah Klaus, Navajo Division of Health, Director / Senior Epidemiologist, Navajo Epi Center 

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Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Steven Matles, Indian Health Board of Nevada, Deputy Director 

Jackie McCormick, Northwest Portland Area Indian Health Board 

Ruth Ojanen, Board Member, Norton Sound Health Corporation 

Michael Peercy, Choctaw Nation of Oklahoma, Epidemiologist 

Geoffrey Roth, National Council of Urban Indian Health, Executive Director 

Paul Saufkie, Hopi Tribe, Public Health Emergency Preparedness Coordinator 

Audrey Solimon, NIHB, Senior Advisor, Public Health Programs 

Berda Willson, Norton Sound Health Corporation, Board Secretary 

Centers for Disease Control and Prevention 

Steve Adams, Deputy Director, Division of Strategic National Stockpile, OPHPR / CDC 

Larry Alonzo, Commander, US Public Health Service 

Annabelle Allison, Environmental Health Specialist, NCEH / ATSDR 

Lynda Anderson, DACH / NCCDPHP / CDC 

Lynn Austin, Deputy Director for Operations, OPHPR / CDC 

Mick Ballesteros, Associate Director for Science, National Center for Injury Prevention and 

Control 

Holly Billie, Senior Injury Prevention Specialist, National Center for Injury Prevention and 

Control 

Nell Brownstein, AREB/DHDSP/NCCDPHP/CDC 

Kristen Brusuelas, Chief of Government Relations, State and Local Services 

Ralph Bryan, Senior Tribal Liaison for Science and Public Health 

Pyone Cho, Epidemiologist, NCCDPHP 

Christine Kosmos, Director, Division of State and Local Readiness 

Alex Crosby, Epidemiologist, Division of Violence Prevention, NCIPC 

Linda Crossett, DASH/NCCDPHP/CDC 

Larry Cseh, ATSDR, Environmental Health Scientist 

Sean Cucchi, Associate Director for Policy, NCCDPHP 

Rob Curlee, Deputy Director, Financial Management Office 

Lori de Ravello, IH S / Division of Epidemiology & Disease Prevention, Public Health Advisor 

Roseanne Farris, NCCDPHP / DNPAO, Branch Chief 

Michael Franklin, Senior Public Health Analyst, Financial Management Office 

Donna Garland, Acting Director, Office of Communications / CDC 

Larry Gilbertson, Public Health Advisor, NCCDPHP 

Doug Hamilton, Epidemiologist, EIS Chief, OSELS / CDC 

Christine Kosmos, Director, Division of State and Local Readiness 

Dianne May, PSB/OSH/NCCDPHP/CDC 

Marcus Plescia, Director, DCPC/NCCDPHP/CDC 

Louis Salinas, Chief of Staff, OD/ CDC 

Dawn Satterfield, Native Diabetes Wellness Program 

Mike Snesrud, Senior Tribal Liaison for Policy and Evaluation 

Stephen Thacker, Acting Deputy Director, Office of Surveillance, Epidemiology, and Laboratory 

Services 

Myra Tucker, Tribal Liaison 

Karen White, Acting Deputy Director, Office of State and Local Support 

Lorraine Whitehair, Division of Nutrition, Physical Activity, and Obesity / NCCDPHP 

Craig Wilkins, AI / AN Team 

Walter Williams, Office of Minority Health and Health Disparities 

41 
Tribal Consultation Advisory Committee (TCAC) Orientation Session January 27, 2010 

Other Guests 

Stacey Ecoffey, Principal Advisory for Tribal Affairs, Intergovernmental Affairs, HHS 

Brenda Granillo, Director, Arizona Center for Public Health Preparedness 

Ronald Demaray, IH S, Acting Director, Office of Direct Service and Contracting with Tribes 

42