CDC/ATSDR Tribal Advisory Committee Meeting

8/12/2014

Grand Traverse, Michigan

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and does not necessarily represent Centers for Disease Control and Prevention views or 

policy.”
AUG 12 

Opening Blessing

(Not Recorded)

Welcome and Introductions

Director Cathy Abramson: At this time, I’d like to introduce Dr. Arias, who is the 

Principal Deputy Director for CDC and Prevention/ Agency for Toxic Substances 

and Disease Registry.

Dr. Ileana Arias: Good morning everyone. Thank you so much for joining us and 

welcome to the summer meeting of the TAC, the Tribal Advisory Committee. I’m 

incredibly excited to be here and joining you for this meeting. I’m very, very 

interested in dialoging with you throughout the day on ways that we continue to 

strengthen the relationship that I think we have developed and to continue to 

explore ways that we can help you and that you can help us essentially 

accomplish our mission. As you know, we work 24/7 to make sure that we save 

lives and protect the health of Americans and people throughout the world. Our 

goal is really to accomplish population health improvements and we cannot do 

that if we don’t touch every community in this country in order to be able to do 

that. We have accomplished a lot. We have made significant impacts on 

population health in this country but if you look closely, that’s not something that 

is true of everyone. Some communities are more likely to exhibit that kind of 

improvement; other communities are not. And our commitment is to make sure 

that we understand, number one, what are the needs of those communities that 

have not come as far as others and more importantly what needs to be done in 

order to make sure that they do benefit to the same extent that every other 

community in this country does as a result of the work that we and others do. I’d 

like to thank you for your time joining us and helping us to figure out how it is that 

we can do a better job of accomplishing that. I also want to thank our staff at the 

Office of Tribal, Local and Territorial Support and it’s Tribal Support Unit for the 

work they’ve done in putting this meeting together and for the work that they’ve 

done to date in making sure that the relationship we’ve developed has continued 

to grow and strengthen and that it will continue to do so. In the past, we’ve 

talked about a number of topics that are of concern to us and a concern to you 

and your communities like motor vehicles, tobacco, sexually transmitted 

diseases, and others. We’ll be talking about others that we haven’t addressed to 

date and looking forward to your feedback on what it is that we can do in order to 

make sure that we empower you to be effective in your quests so that we can 

then also be effective in making sure that our agenda is complete. One of the 

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things that we can always do is make sure that we provide the information that 

you need to make the choices that you need to make in order to improve the 

health of your communities. We also then make sure that we generate and 

create the tools that will help you do that. But none of those tools and none of 

the information is helpful if it actually cannot be put into the hands of people who 

can actually make a difference, and that’s not us. So what we’re really interested 

in doing is what’s the information that you need, what are the tools that you need, 

and then what is it that we can do so that you can actually put those in the hands 

of people who need to make action in order to make sure that there is some 

benefit from that information and from those tools. So, again, I thank you for your 

time, for your partnership and your commitment to helping us make sure that 

again every resident of this country is as healthy as they possibly can be.

Director Cathy Abramson: Thank you very much and now at this time I would like 

to introduce Dr. Judith Monroe. She’s the Director of the Office of State, Tribal, 

Local and Territorial Support, and she’s Deputy Director at CDC. Dr. Monroe.

Dr. Judy Monroe: Thank you. So good morning everyone. It’s great to see so 

many of you out this nice rainy morning, but I think it’s so relaxing here so I just 

want to thank Cathy Abramson, Director Abramson and the Bemidji Tribes for 

hosting us. It’s really wonderful to be here, and I understand it will not be raining 

tomorrow, correct?. But no it’s really wonderful here, so thank you. I’d also like to 

welcome two of our new TAC members. We have school board member, 

Beverly Coho from Ramah Chapter of Navajo Nation, and we have tribal council 

member Delia Carlyle from Ak-Chin Indian Community. Good morning. So 

welcome. Welcome. We are really excited because we have 15 members on the 

TAC now. And I think we only have one seat left to fill so we’re quite excited 

about that. So this really promises to provide us here at CDC some really 

valuable insight from all the tribes across the country, so very excited about that. 

And we - I do want to thank all of you for your public service and for what you’re 

doing for public health for American Indian / Alaska Native Communities. I know 

it takes a lot to travel and to just make the meetings and so we want to give our 

sincere thanks for all of you for your wisdom and your advice as we move along. 

You know CDC does support tribal sovereignty and self-determination for tribal 

governments and we will always keep that foremost in our work. As Dr. Arias

said, it’s important that we continue to strengthen our relationship and 

partnership with the tribes so that we can help improve native public health. And 

so we look forward to meaningful discussions over the next couple of days. 

Again, welcome to everyone in attendance.

Director Cathy Abramson: At this time I would like to introduce Captain April 

Shaw. She is the U.S. Public Service Acting Director for Tribal Support Unit.

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CAPT April Shaw: Good morning. Yes, I’m Captain April Shaw. I’m Acting 

Director for Tribal Support Unit and I also wanted to extend a warm welcome to 

the TAC members, to other tribal leaders and tribal elders as well as our other 

guests. I’m looking forward to spending the next few days with you and enjoying 

this beautiful area. Even though it’s rainy it’s still so beautiful out there, so I’m 

looking forward to that. I need to provide a few logistic kinds of information for 

you just to let you know and make you more comfortable on the surroundings. 

So I wanted to let you know there is water available in the room. There are two 

tables on either end of the room with water. Also, there’s a Starbucks across the 

lobby for those that like coffee – I see some of you have already made your way 

over there – coffee or hot tea. As well as there are restaurants located 

throughout the hotel, and in your binders under tab 15, there is a listing of all the 

different restaurants that are in the hotel. For those of you that are going to use a

federal government credit card, please stop by the registration table for some 

important instructions about using your government credit card at different 

locations in the hotel. There’s a little bit of a – kind of a trick to it - so please make 

sure you stop by and ask for instructions about that. Also, I wanted to make you 

aware that there is a special interest session that’s going to be held following the 

conclusion of the meeting today, and it’s going to be presented by CDC’s Office 

of Smoking and Health and I know I sent out a sort of an inquiry to find out how 

many TAC members were interested in attending and I think many of you did 

show interest. So it will be held in this same room from 5 to 6pm this evening, so 

please consider attending. Also, if you brought handouts that you would like to 

share – if you’re a presenter or just information that you want to make available 

to others – we have a resource table located in that back corner over there, so 

please leave your information there so that others can help themselves to that. 

Another important handout that can be found in the front of your binders is called 

“A Guidance for Public Attendees”, and it outlines the protocol that should be 

respected over the course of the next two days. So I’d like to especially highlight 

a few of the guidelines for everyone. During today’s meeting and tomorrow’s 

formal consultation session and formal tribal testimony, only TAC members, CDC 

senior leader, and if space permits, other elected tribal leaders or their authorized 

representatives, may be seated at the table. And members of the public may not 

speak during meeting proceedings. Out of respect for the proceedings of this 

meeting, we would like to ask that attendees not enter or leave the room during 

the opening and closing blessing or during formal tribal testimony. And also, the 

disclaimer always has to be said - please make sure your cell phones and 

laptops and other electronic devices are silenced or turned off during the 

meeting. So please look over this handout for other important information about 

attending this kind of a meeting. And just as a reminder for all TAC members, 

authorized representatives and CDC leadership – please remember to state your 

name before beginning to speak because the sessions are being recorded for the 

purpose of transcribing the minutes.. So now that all the logistics are out of the 

way, I just wanted to let you know that my staff here, the Tribal Support Unit, are 

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really looking forward to serving you and making you feel very, very comfortable 

during this meeting. If there is anything that we can do to make your stay more 

comfortable, if there are any issues that you encounter, please let us know and 

we will do everything we can to make this a really great meeting for you. So 

we’re looking forward to spending time with you. Thank you very much.

Director Cathy Abramson: At this time we’ll go around the table first introductions 

and then we are going to go around outside and everybody can stand up and 

introduce themselves. 

Chairman Robert Flying Hawk: Good morning. My name is Robert Flying Hawk. 

I’m the Chairman for the Yankton Sioux Tribe in South Dakota. Good morning.

Lt. Governor Jefferson Keel: Good morning. My name is Jefferson Keel. I’m Lt. 

Governor of the Chickasaw Nation.

Council Member Patty Quisno: Good morning. I am Patty Quisno, Council 

Member from the Fort Belknap Tribe in North Central Montana.

Council Member Andy Joseph, Jr.: (Speaks in Native language.) A good 

morning. My name is Badger. This is my first meeting. I’m glad we’re doing 

introductions. I know a few people in the room and I’m glad to be here. I’m 

Council Member from the Confederated Tribes of the Colville Indian Reservation 

and also chair the Northwest Portland Area Indian Health Board and sit on the

National Indian Health Board.

School Board Member Beverly Coho: Good morning. My name is Beverly Coho. 

I’m a member of the Ramah Band of Navajos. I’m Elected School Board 

Member who runs a health center. Also, I’m a member of the Albuquerque Area 

Indian Health Board. Thank you.

Council Member Leslie Sampson: Good morning. My name is Leslie Sampson. 

I’m an Alaska Delegate and this is my second meeting.

Ramona Antone-Nez: (Speaks in Native language.) I’m Ramona Antone-Nez and 

I’m an authorized representative for Navajo area. I would like to also send my 

greetings from Vice President Rex Lee Jim who is not able to attend today.

Secretary Shawn Gavin: Good morning everyone. I’m Shawna Gavin, General 

Council Secretary from the Umatilla Tribe, and I’m also the Treasurer on the 

Northwest Portland Area Indian Health Board.

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Chairman Herman Honanie: (Speaks in Native language.) Herman Honanie. 

Chairman Hopi Tribe in northeastern Arizona. I’m a member of the Hopi Tribe 

and a member of the Tobacco clan and I’m very happy to be here this morning.

(Speaks in Native language.) Thank you.

....Audience members stood up and introduced themselves.

Tribal Advisory Committee (TAC) Business

Director Cathy Abramson: Thank y’all for being here and thank you for coming. 

At this time, Romana Fetherolf will be doing the roll call. 

Romana Fetherolf: Good morning. Alaska area. Albuquerque area. The Bemidji 

Area. Billings area. Great Plains area. Nashville area. Navajo area. Oklahoma 

area. Phoenix area. Portland area. Tucson area. At-Large Hopi Tribe. AtLarge Kickapoo Tribe in Kansas. At-Large Confederated Tribes of the Colville 

Reservation. At-Large Noorvik Native Community. Thank you. 

Director Cathy Abramson: Okay, so we obviously have folks here... so that 

means we need to have more meetings here. As tribal reps we work with the 

CDC/ATSDR staff to exchange information about public health issues in Indian 

Country, and identify urgent public health needs and discuss collaborative 

approaches to address these issues and needs. So in addition to assisting in the 

planning and coordination of tribal consultation sessions, we advise them 

regarding the government-to-government consultation process and help ensure 

that CDC activities or policies that impact Indian Country are brought to the 

attention of all tribal leaders. So I’ve been on this committee—I’m not quite sure 

how long but a number of years where I’ve seen a real good change and it’s 

strengthened a lot and I really believe it has a lot to do with...under the 

leadership of Dr. Monroe. Dr. Monroe has been making a great effort to come 

out to Indian Country and get to know us, and that’s good but we’re not all 

cousins across the Indian nation, and we all have various issues/ different issues 

and she’s getting to know us for who we are and in our areas of different needs. 

Some are very similar while others aren’t. So I appreciate that and I’m very glad 

she’s here. Actually, I’m glad you’re all here. So that’s what we do and it’s up to 

- I have talked to some tribal members, tribal - various tribes and their concerns 

and I think what needs to be done more on tribes’ part is their people need to 

contact their committee members and give them information that we can bring 

here because they need to help us out by giving the information to us so that we 

can bring it here so that we have it recorded and that the staff from CDC can see 

what they can do in helping us either resolve an issue or how they can work with 

the tribes or they either can or they can’t, but will give an answer. So that’s what 

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we need to do. And there are monthly phone calls that TAC members...we really 

need to become more active and get on thos phone calls as much as possible, 

and I think that’s the way it’s gonna be for a lot of committees that we do just

have to get on the phone calls. So very important because of budget-wise. 

We’re not always going to be able to travel. I think we meet quarterly - twice a 

year? Twice a year. 

CAPT April Shaw: Hello. Also, I wanted to make sure that the time and date of 

those monthly calls is the best time and date. Since the participation has been a 

little bit lower, we wanted to make sure that it was still a convenient time. So if 

there are conflicts that arise you know every month that you can see that this is 

not a good date and time, please let us know and we’re happy to change that. 

Director Cathy Abramson: For the advisors unfortunately, it’s not paid for. So got 

to be creative there. But they’re very, very helpful. And at this time, I would 

really like to give Lisa Abramson great kudos for helping arrange this, helping out

plan this and getting things going. She worked a lot for putting this together with 

the staff and CDC. .(blank for several minutes 32:25 – 34:49)...of how grants are 

written so that tribes qualify for these grants because a lot of times they’re not 

written in such a way where tribes can apply. So there’s many different issues. 

Liz Carr is here from HHS and she wanted to get up and say a few words. I 

warned her I was gonna pick on her.

Elizabeth Carr: Good morning, again, everybody. On behalf of the newly 

appointed Secretary Burwell, I would like to welcome you to Traverse City and 

the CDC TAC meeting. Like Cathy said, a lot of issues are brought up at the 

STAC and CDC is one of those things that continues to come up, and we always 

have great senior leadership from Dr. Monroe there to listen and bring back the 

concerns to the agency. So we really appreciate her support. Recently we had

the STAC visit the CDC and I think it was a really great turnout and a really great 

experience. I think we learned a lot. I don’t think we expected to learn that much 

and we really appreciated the tours as well. We had great senior leadership 

support there as well. The senior leaders from each of the- what are they calledthe centers were there giving us updates on the work that they do that is in 

relation to Indian Country so I think it was a really great experience. They are 

doing a lot of work behind the scenes that we’re just not aware of and so that’s 

my update for today. If you guys have any questions about the STAC 

specifically, I’m here all week, so thank you.

CAPT April Shaw: Good morning. In keeping with what I said, I’ll announce my 

name, April Shaw, for the recording purposes. So good morning again. Over the

next few minutes, I would like to discuss the Issues and Recommendations 

document. This is something that was sent out to the TAC members a little while 

back and hopefully you’ve had a chance to review it. The discussion this 

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morning is that I wanted to let you know the process that the Tribal Support Unit 

went through to create the document and to get your feedback. Since this is the 

first time that the CDC Tribal Support Unit has produced this, we want to make 

sure that we meet your needs and expectations so your feedback is really 

important to us, as well as to check about some timelines and see whether these 

timelines seem reasonable. So to provide a little background, it was felt by TAC 

members that oftentimes questions and issues would be raised at the different 

meetings and they felt that they were not getting the feedback, the responses 

back from CDC. So in an attempt to be more responsive, CDC created this 

process. So at the winter TAC meeting, we took all the issues, questions and 

recommendations that the TAC members submitted and we brought those back 

to CDC and then gave them to the different centers, institutes and offices to filter 

down to the subject matter experts that could speak to this topic. So, for 

example, if a question might have come in about diabetes, then it might have 

likely gone to the National Center for Chronic Disease Prevention Health 

Promotion. That would be an example. So then we took the responses provided 

by all the subject matter experts and we consolidated it into the one document 

which is called the Issues and Recommendations document, and then we have 

sent it to you for your review, as I mentioned. So going forward we wanted to 

solicit your comments at this time about the process; not specifically about what 

the content is; however, if when you look over the document, you do have further 

questions or comments, we’re happy to take those back and reach out again to 

the subject matter experts for further clarification or more information. But at this 

time just to get your feedback on was the document easy to go through, to read, 

was the format okay for you, and did you have an opportunity to review it before 

the TAC meeting, did you have sufficient time. Just some feedback around those 

kinds of things and then also just what your input is as far as when we should

sort of have a cut off for the issues and questions to be included within each of 

the different editions. So at this time I’d like to open it up to you to give comment 

back on some of those questions or ask any questions that you might have. 

Also, it’s located behind tab 9, the Issues and Recommendations document. If 

you haven’t found that yet, that’s where it’s located.And just as a side note, if 

there is a question that you remember that you asked and you don’t see it 

appearing in this edition of the document, it may be that we’re still researching it 

and the answer, the response will be in the next Issues and Recommendations 

document if we’re still researching.

Ramona Antone-Nez: Ah yes, I have two comments. 

CAPT April Shaw: And please remember to state your name before you respond. 

Thank you.

Ramona Antone-Nez: Ramona Antone-Nez, Navajo Nation. Captain Shaw, 

thank you for your introduction on this document. I do want to say thank you to 

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the OSTLTS staffing for seeing this. I see this as an improvement to address the 

issues that are brought up and the recommendations that are made. What, how 

important the monthly calls are, this was introduced to the TAC members via 

email approximately 2-3 weeks ago for us to have the opportunity to make review 

to the document, and also during the call itself we had that opportunity. So just 

wanted to make that comment that this is an improvement from the 

recommendations that were made. So I just want to acknowledge that and 

acknowledge Dr. Monroe for making this critical improvement because I think 

what will happen is we’ll start to see additional changes. 

CAPT April Shaw: Thank you very much and did you have any comment about 

the format at all? Did you find it easy to read through?

Ramona Antone-Nez: Thank you. My comment is that it’s thorough and it seems 

like the note taking is very well done. I don’t have any recommendations at this 

time in terms of the formatting as the—not bad for the first round. Thanks.

Chairman Herman Honanie: Good morning. Herman Honanie, Chairman Hopi 

Tribe. I just really wanted to say something similar to what she said because I 

missed out on the first call because I just didn’t have the time. And so my 

question to you is there’s gonna be oftentimes that I’m not directly available to 

get on those calls so I was wondering if my chief of staff, someone within my 

office could be able to sit in on my behalf to take the necessary information and 

maybe provide feedback if and when we do have a review ahead of time with 

such issues that are presented prior to the calls.

CAPT April Shaw: Would that be your authorized representative or somebody in 

addition?

Chairman Herman Honanie: Well, at this point I’m just thinking of someone within

my staff because it would just depend on my authorized individual’s availability 

as well, and come to think of it, I need to think a little bit more about that point on 

the authorized representative who could speak on my behalf. 

CAPT April Shaw: I think someone is scribbling a note back there to tell me the 

answer, so hold on one minute.

Chairman Herman Honanie: Okay. The other thing in general is we’re always 

interested in funding to the various programs within CDC so maybe that’s just my 

general question or statement that there are so many things happening in this 

country and with the federal government and we always seem to come up 

against the point whether when we do ask for additional funding for respective 

programs, it seems very, very far and in the distant future that we ever get an 

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increase in funding. So I’m just wondering the point of negotiating on grants or 

especially contracts. What is the future of funding at this point in time?

CAPT April Shaw: I know that in my updates I’m going to go over some funding 

opportunities that have just gone out and I’m gonna go into them in some detail. 

And I think Dr. Monroe may be addressing that in her talk tomorrow as well, but I 

know that CDC does strive to improve the language around writing the proposals 

in order to make it possible for tribes and tribal serving organizations to apply as 

often as possible. Did you want to comment? 

Dr. Judy Monroe: Yeah, I think - we’re gonna go over some detail of direct 

funding. We do have more direct funding available for tribes but it sounds like 

your question was a more general—a larger question about funding in general 

and that, of course, has to do with CDC’s budget at large.

Dr. Ileana Arias: So with this funding in general, I think, you know, none of us can 

say what’s gonna happen in the future. All I can say is we have been 

significantly effective in the last couple of years in terms of making a case for 

public health generally and then for specific things that we have identified as 

priorities for all of us such as the prescription drug overdose issue, the smoking 

issue, and several of those. So we continue to get significant support from 

Congress and the administration for that work that we want to do and it’s looking 

good. It’s not—given the overall financial situation, it’s not like there’s gonna be 

significant amounts of new money coming in but we are seeing significant 

growth; growth that we had not expected we would have seen, given how difficult 

things were. So that speaks to the—I think the success of the work that has 

been done at CDC but also the success of the work that has been done by our 

partners with the money that CDC has provided in order to address the issue. 

So I think that if we continue to strive to making sure that effective programs are 

implemented in ways that actually are going to have the impact that everybody 

wants to have we’ll continue to get that backing and continue to get that support 

on budget issues.

Lt. Governor Jefferson Keel: Could I say something? When we talk about 

funding in general, realizing that we’re talking about the national budget issue, 

but coming back to the report and looking at what tribes are doing in local 

communities and how they’re utilizing funds that’s already available, there are 

some things that are not being reported (I’m trying to get it out) in a way that 

CDC understands really what’s taking place in the community. And I think 

sometimes that’s just a matter of the report format, and I’m not saying it needs to 

be changed or modified, I’m just saying there are activities that are taking place 

within local communities that CDC may or may not be able to assist with or fund 

in the future. But, you know, when we talk about the budget overall, we’re talking 

about continuing resolutions, CR’s in the next few months, so we may not see 

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any type of change or increase until you know the spring, which is typical. So I 

think it may be when we talk about assisting tribes more directly, maybe we go 

back to the block grant funding that goes to the states and how they’re utilizing 

those and how tribes are able to access some of those funds that are 

supposedly, they’re supposed to get to the tribal communities anyway but they’re 

not. So we need to talk about some of those issues.

Dr. Ileana Arias: That’s an excellent point and it’s a combination of the two. One 

is the overall budget and then as Judy was saying, can we identify new ways or 

different ways of making sure that there’s some direct funding to the tribes in that 

general issue whether it’s finding out what’s already being done or what the 

mechanisms that are available that can be tailored so that it does reach you 

know tribal communities.

Dr. Judy Monroe: With that, too, more comment as well. At CDC, we are looking 

at more accountability—when funding does go to the states, we don’t always see 

then who gets funding beyond that and we are looking at mechanisms. I think 

there’s some new—PGO is gonna have some new tools to be able to do that.

CAPT April Shaw: And to answer Chairman Honanie’s question, so your 

authorized representative is the person that could sit in the meetings for you. So 

just for everyone’s information, we meet there Monday at 2:00 p.m. eastern 

standard time currently. And we do have a template that we can send out to 

everyone so that you can list the information for your authorized representative, 

so we can provide that from our office and you can assign someone as well as if 

you need someone to sit in for that meeting just for that temporary meeting, send 

us an email ahead of time and let us know that that person will be taking notes 

for you so that they can bring the information back to you. So I wanted to ask if 

there was anyone else that had any comments about this Issues and 

Recommendations document, again, about did you have enough time to review it 

before our meeting and also we were going to propose possibly 30 days as the 

cutoff. So, for example, at the conclusion of this meeting, 30 days from that point 

would be the cutoff where you could still submit any questions or issues for it to 

come out in the next document. So then after that, then that would just be for a 

document in the future. So you can always submit questions and such to us but 

just to come out in the next document we were proposing that the cutoff maybe 

be 30 days after this meeting, or we’re looking for your feedback on that.

Council Member Andy Joseph, Jr.: (Speaks in Native language.) My mame is 

Badger, Andy Joseph, Jr., from the Colville Tribe and my tribe has a reservation 

that’s 1.5 million acres. That’s the south half of the reservation. North half goes 

clear up into Canada and it doubles in size. You know our people are scattered 

amongst the whole range of land bigger than some states. You know, on 

funding, I’m not going to...I think funding should be sent directly to tribes and not 

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be passed through the state. I’ll use the H1N1. When that first came out, it went 

through the state and hit the counties and the people that were supposed to be 

served first were the young ladies that were pregnant. My daughter was carrying 

at that time. She had to go across to a different county. If you look at the Robert 

Wood Johnson report, you know the two - two of the poorest counties in the 

United States health-wise are on the Colville Indian Reservation. And to me, I 

think the people in the county were so afraid of the sickness that they served 

their own people first. One of our schools that are on our reservation was served 

by a county across the river, and to me that’s just totally not right. Our children 

should’ve been first. Right now we’re being devastated by fires and you know

IHS is so poorly funded some of our programs that were 638 that we contract 

out, like our public health nurses, they had to dig in their own pocket to get 

supplies to you know I guess fight infection, try to keep the disease from 

spreading. You know to me, it shouldn’t be that way if we were directly funded, 

and I would say to use the IHS system on how they spread out the funding. The 

Portland area where we’re from we don’t have hospitals, and to me that’s 

something that costs you know some of our people’s lives not to respond as they 

should. So there’s a different rating score system that IHS gives to areas that 

don’t have hospitals, and to me I think it would be a better way to look at how to 

spread the money out. These public health nurses, they need to be able to have 

access to the tools you know that they were trained in. Thank you.

School Board Member Beverly Coho: Speaking to the issue here, my name is 

Beverly Coho from the Albuquerque area. I find that any feedback in creating a 

sincere dialogue is very meaningful and considering that I’m new, I haven’t read 

the document but my first impression is that it is certainly useful. I can use it to 

orient myself as a new member; also to share with my fellow colleagues, and 

also to find some way to formulate some meaningful input to my roles and 

responsibility here. Your question on process is that it appears to serve the 

purpose of meaningful communication, then ultimately finding some answers. 

Thank you.

Director Cathy Abramson: Okay, before we go any further, can we vote on 

theform that they’ve used and see who requests a motion and support to see if 

you like - if you approve of the format that is being used. 

Ramona Antone-Nez: I do want to make a recommendation before the motion. I 

had taken a better look in terms of the formatting. The recommendation that I 

have is there’s major categories under which the questions or issue is brought 

up. One example, the first one is funding and as we look through the document, 

the next one is CDC organization, etc. My recommendation is right up front 

there, right underneath the italicized to perhaps start a table of contents, if you 

will. This is a 20-page document to start with and just to capture what the 

highlights are perhaps funding is page 1 through 5 and then the next CDC 

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organization is page 7, etc., just so that if you are interested in one particular 

topic, we could just get to that page and start from there. Perhaps even under 

the main heading of the start of the page you could go into the questions. Well, 

some of these questions are long, but I’d like to just make that first 

recommendation in terms of the highlights to start with, as a starting point. 

Thank you.

CAPT April Shaw: Okay, so thank you for your comment. So just to make sure, 

to clarify, so your recommendation is that we take the headings and we put them 

sort of in the table of contents in the very beginning of the document and refer to 

the page number or page numbers where that particular larger heading would be 

found. Do you want that to be alphabetized as well? Would that be helpful, do 

you think? Because I noticed it isn’t.

Ramona Antone-Nez: This is Ramona from Navajo Nation. I’m not really sure 

about alphabetizing or even how you’re gonna prioritize in terms of whether one 

issue or another. But that sounds like a good idea, too. Thank you.

CAPT April Shaw: Thank you very much. One last call for comments. Yes?

Lt. Governor Jefferson Keel: Let me just make sure I understand what we’re 

talking about. I’m just clarifying that you’re wanting to categorize, put these 

things in a table of contents by category, not necessarily by priority. Okay.

Council Member Andy Joseph, Jr.: (Speaks in Native language.) I like the idea of 

having, going through, having those categories. To me, I guess I’m not sure how 

much time we would have to respond to any of these issues. I know as a tribal 

leader, we have all the different departments just as a congress, then there’s 

senator or even the President of the United States, and they have special staff 

that are able to advise them and keep them up on the issues. I might be in a law 

and justice meeting one day or road safety or it could be a you know just a

government, who’s running for Congress kind of day or whatever. Being a tribal 

leader we have all these different responsibilities so to me I would hope that we 

would have the amount of time to respond on these issues. It would give us time 

to seek our advisors that are experts in the area, whatever topic it is. That way, 

when I come back here or if I’m on one of those conference calls, I’ll be able to 

weigh in a little better. Thank you. 

Director Cathy Abramson: This went out three weeks before so people could get

time to respond.

Council Member Andy Joseph, Jr.: (Speaks in Native language.) Just trying to 

follow the rules and say who I am. Anyway, I guess maybe once I get used to 

being an advisor for this committee, I do think that it sometimes it takes time for 

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our staff to study these issues and think them out thoroughly so that we can 

make sure that we’re giving the right input. That’s all.

CAPT April Shaw: Thank you for your comment. April Shaw. Just to clarify a little 

bit, when you receive the Issues and Recommendations document back, like you 

did just now, we were asking for you to review the process in general, to see 

whether the timeframes worked for you. But as far as the content of our 

responses to your questions or issues, those can always be clarified in the future. 

So, for example, if there’s something that your staff helps to review and would 

like more information on, you’re welcome to always ask for more clarification and 

we will send those back to the subject matter experts at CDC/ATSDR. So really 

we were just looking for did you have enough time to sort of review it before you 

came to the meeting to see if there was something that you wanted to discuss at 

the meeting. But we’re always welcoming any other comments. So I think 

Director Abramson is going to take a vote now.

Director Cathy Abramson: Is there a motion, does somebody want to entertain a 

motion to accept this format along with a table of contents. Okay. Beverly? 

School Board Member Beverly Coho: I like to make a motion that we accept this 

format on feedback leaving room for improvement, and then to include the 

comment that was made, recommendation to establish a table of contents. My 

name is Beverly Coho.

Lt. Governor Jefferson Keel: My name is Jefferson Keel. I second the motion.

Director Cathy Abramson: Second by Jefferson Keel. All those in favor, signify 

by saying “I”. Those opposed? Any abstentions? Great. It’s not on our agenda 

but we do need to vote on the minutes from the last meeting. So what would you 

like to do at this time? Is there a motion—does anybody want to entertain a 

motion to approve the minutes? 

Lt. Governor Jefferson Keel: This is Jefferson Keel. I move we accept the 

minutes.

Director Cathy Abramson: Motion by Jefferson Keel to accept the minutes.

Secretary Shawn Gavin: This is Shawna Gavin. I second.

Director Cathy Abramson: Second by Shawna Gavin. All those in favor, signify 

by saying “I”. Those opposed? Any abstentions? One abstention by Andy 

Joseph. Motion carried. 

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CAPT April Shaw: April Shaw. At this time I would like to take nominations for a 

chair that will serve on our Tribal Advisory Committee that will be from this 

meeting for one year time to the following meeting next summer. I do know that I 

spoke with Chairman Antone and he is interested in being the chair again if 

someone would like to nominate him. So I just put that out to you that he is 

interested. We would also like to entertain nominations for a co-chair because as 

we see, Director Abramson was very kind to step up and to do this for us today, 

but I think we are in need of a co-chair and so we would like to entertain for both, 

nominations for chair and co-chair at this time.

Chairman Herman Honanie: Herman Honanie. I would like to nominate Chester 

Antone to continue to be the chair.

CAPT April Shaw: Thank you. Any other nominations for chair? 

Ramona Antone-Nez: Ramona Antone-Nez, Navajo Nation. I just want some 

clarification. The clarification I would like to ask is, is this the same as a co-chair 

and a vice chair? Is that the same roles and responsibilities and would there be 

any influences in terms of chairing a different Tribal Advisory Committee such as 

the TAC? Thank you.

CAPT April Shaw: Could you just clarify the very last thing you said about—

Ramona Antone-Nez: Would there be an impact to chairing other advisory 

committees?

CAPT April Shaw: Liz Carr, can I ask for your input on that?

Ramona Antone-Nez: Would chairing or co-chairing impact different other Tribal 

Advisory Committees? 

Liz Carr: Sorry, are you asking in regards to being nominated and accepted to 

other Tribal Advisory Committees throughout the department? Is that your 

question? Or is it influencing the discussion at the Tribal Advisory Committee 

meetings?

Ramona Antone-Nez: So my question is if a person is chairing or co-chairing this 

particular advisory here, will that impact a different advisory committee?

Liz Carr: No, it should not.

Ramona Antone-Nez: Thank you for the clarification. The other clarification I 

have is a chair for this TAC. Is that equal to or the same as a co-chair or are 

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they different, because you’re looking for two nominees, one chair and a cochair. Is that equal? Thank you.

Liz Carr: So the way we do it at the STAC which is the Secretary’s Tribal 

Advisory Committee is it’s a chair and a vice chair. The title co-chair is a little bit 

misleading. We do it as a chair and a vice chair so when the chair is unavailable, 

the vice chair will chair the meeting. But otherwise it’s a chair and a vice chair. 

Does that clarify your question? Great.

CAPT April Shaw: So I stand corrected. I’m calling for nominations for a chair 

and a vice chair. Thank you for the clarification.

CAPT April Shaw: So far I have the current chairman, Chester Antone as the 

nomination. Would anyone like to nominate someone as a vice chair?

Director Cathy Abramson: I would like to nominate Lt. Governor Jefferson Keel. 

 

CAPT April Shaw: So Lt. Governor Jefferson Keel, would you like to accept the 

nomination?

Lt. Governor Jefferson Keel: Thank you. Thank you, Cathy. I will accept. I hope 

Chester is here next time.

CAPT April Shaw: So at this time I would like to see a show of hands for all in 

favor of Chester Antone as the next – the following year’s chairman of the CDC 

Tribal Advisory Committee. All in favor say “I”. And all opposed? And uh...Then 

I’d also like to...All in favor of – sorry, this is the first time I’ve done this – all in 

favor of Lt. Governor Jefferson Keel as the vice chair, say “I” if in favor. Anyone 

opposed. So congratulations to Chairman Chester Antone. And also Lt. 

Governor Jefferson Keel as our Vice Chair. 

Lt. Governor Jefferson Keel: I think it’s effective after this meeting. 

END. (BREAK)

CDC’s Tribal Support Unit Update

Director Cathy Abramson: They’re yaking so much...I know (laughter). Okay, 

we’re going to get started. I hate to break up all the fun and laughter, but we have 

to. Actually I was prompted – I was having a good time, too. At this time we will 

have Captain Shaw do a Tribal Support Unit update. And before I go any further, 

I just wanted to explain, I know there’s some people that might have a little 

confusion about the meeting. The first part of the meeting is - we conduct our 

business, the Tribal Advisory Committee conducts business with the staff and 

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then tomorrow we will have our tribal consultation and that’s when other people 

will have an opportunity to get up and bring some issues, and that’s on your 

agenda. And if you don’t have an agenda, there should be some on the 

registration table. So, ok.

CAPT April Shaw: Good morning again. April Shaw. I just wanted to sort of put 

a disclaimer out there that if you have questions that you want more information 

about as I’m going through my update, I’m in an acting role and I’ve been in the 

role for about two months, and so if I don’t have the answer, I am happy to take 

the question back and get the information for you. So I probably won’t be able to 

answer everything but I will do my very best and anyway, we’ll go from there. 

So, I wanted to provide some Tribal Support updates and this is some of the 

members that support all the actions and the different activities with our Tribal 

Support Unit. So I wanted to point out that some of the people are here with us 

now under the Tribal Support Unit staff. Miatta Dennis is sitting behind me here. 

She’s a public health analyst, and you may have spoken to Miatta before, 

arranging your travel or helping with the logistics for this meeting. She’s usually 

on the monthly TAC calls as well. And April Taylor isn’t here because she’s 

getting married the end of this week, so she’s gonna be having a big event in her 

life. But she helped a lot with also coordinating the meeting and she’s always on 

the monthly calls and she’s great at supporting all the different kinds of activities. 

We also have three new additions to our Tribal Support Unit and one of them is 

here, Romana Fetherolf is back over here taking notes feverishly and she’s the 

one that did the roll call as well. We also have Deon Peoples and Alleen 

Weathers who are back in Atlanta supporting us as we’re here. They are called 

PHAPs, and it’s the Public Health Associate Program that is for—and Dr. Monroe 

will go into this a little bit more tomorrow, I believe, in her talk, but they’re 

individuals that have graduated recently and want experience in the public health 

area and so they come to a two-year program so we’re really happy to have them 

join our program. This is more of the staff that support our activities and 

communications and data management. And so I just wanted to give a big thank 

you to all of the staff that helped to put this meeting together and that support all 

the different kinds of activities that we do all the time, whether it’s a TAC call or 

whether it’s to send out information or to send out the minutes. So I would just 

like to show my appreciation and thank our staff.

So to go on with some recent and current activities, as we already discussed, the 

first Issues and Recommendations document was completed and was sent out to 

you. And again, we were happy to get your feedback. Going forward we’re 

going to be writing the SOP or Standard Operating Procedure, but we’re always -

we can always update that SOP as well. But we’re looking forward to the issues 

and recommendations that come out of this meeting to put together some more 

information and get you some more responses. Two additional TAC members 

were recruited, as we already mentioned, and so I wanted to formally welcome 

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from Albuquerque Area, School Board Member Beverly Coho. Thank you so 

much for being able to be here. From the Phoenix Area, Tribal Council Member 

Delia Carlyle was not able to make the meeting. Hopefully, she’ll be on our next 

monthly call and you’ll be able to meet her in that way. The coordinated 

Secretary’s Tribal Advisory Committee visit, you heard a little bit about it from Liz 

Carr. I wanted to share a little bit more about the experience. I learned a lot as 

well. Even though I work at CDC, you know, we don’t all know what we do every 

day in our different activities. So basically, as Liz described, we began with a 

meeting that was with the CDC senior leadership, which I think Dr. Monroe is 

going to go into that in a little more detail tomorrow, where they had an 

opportunity to sit down with the STAC members. And from there, we visited the 

Emergency Operations Center which provides up-to-date status on global 

situations such as Ebola and other kinds of emergencies. From there, we toured 

the TB lab, where I learned some startling results like there are 9,500 cases of 

TB in the United States; one-third of the world’s population is infected with TB; 

and there are 8 million cases globally per year. I was really surprised to learn 

those facts. But we toured the TB labs and we saw the equipment and the 

different kinds of conditions that are required to work with that agent, so it was a 

very interesting lab tour. From there, we showed the STAC our - one of our great 

buildings called the Chamblee Environment Health Lab which received the LEED 

award which is Leadership in Energy and Environmental Design. It was 

interesting because the plants that surround the building are watered by a tank 

underground that holds 30,000 gallons of water and that water comes from the 

air. Basically, everyone’s heard that humidity is high in Atlanta. Well, the air 

handlers that filter out the air collect the condensation and it goes into a 30 gallon 

tank underneath and waters those plants, so it sustains it, so it was pretty 

interesting. And we finished up with a smoking lab tour, where we saw things 

like 20 commercial cigarettes being smoked by a machine that collects the tar 

and nicotine for analyzation later on, and discussions around things like the Ecigarettes and the smokeless tobacco. So all in all, I thought it was a pretty 

informative tour.

The National Indian Health Board Tribal Public Health Workgroup met in 

February of 2014, as well as yesterday, and the NIHB received a five-year 

umbrella cooperative agreement to coordinate tribal public health workgroup to 

provide subject matter expertise and advice to the Tribal Advisory Committee 

and the CDC. In July, Dr. Bauer, who is going to be presenting in just a bit, the 

Director for the National Center for Chronic Disease Prevention and Health 

Promotion, and one of her staff and myself from OSTLTS Tribal Support Unit 

visited the Wind River Reservation. This was coordinated by Robert Foley with 

NIHB. Thank you, Robert. He’s in the audience. And it was a really great 

opportunity to visit two tribes, both the Northern Arapaho and the Eastern 

Sheshoni that live on one reservation, the Wind River Reservation. So we visited 

programs such as the CHR program and WIC, the Tribal Fitness Program, 

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Diabetes Program, the White Buffalo Recovery Center Program, which deals with 

addiction problems and substance abuse. And we participated in a horse culture 

activity which was really interesting, which is basically around using the activity, 

the horses and nature to sort of come to an understanding of what’s important 

and just being able to share fears, and it was around positive mental health and it 

was a really interesting and – it was a good activity. But the highlights of my trip 

were the first and last event where the tribal health director for the Northern 

Arapaho Tribe set up a sweat for us. So we got to do a sweat lodge for four 

hours which was pretty intense and pretty amazing, so we participated in that. 

And then the last event was we visited with a tribal elder that I believe she said 

she was 92 years old, who manages the Growing Resilience Community Garden 

Program and she’s still working in her 90’s. An amazing woman. So that was 

really great, too. 

We are in the process of hiring a new CDC Associate Director for the Tribal 

Support Unit and the selection will hopefully be made before September, so you 

will see a constant face at these meetings instead of, you know, us that are doing 

our best to do the acting role, there will be somebody there to provide some good 

strong leadership. And I wanted to let you know that if you hadn’t heard, that in 

FY 2014, the National Center for Chronic Disease Prevention Health Promotion 

announced three new FOA’s. Awards will be made by September 30th. Just a 

few highlights. The first one, a Comprehensive Approach to Good Health and 

Wellness in Indian Country aims to prevent heart disease, diabetes, stroke and 

associated risk factors in American Indian tribes and Alaska Native villages 

through a holistic approach to population health and wellness. So funds will

support approximately 12 American Indian tribes and Alaska Native villages 

directly, and approximately 12 tribal organizations, one in each of the 12 IHS 

administrative areas to provide leadership, technical assistance, training and 

resources to American Indian tribes and Alaska Native villages within their IHS 

administrative areas. The second funding opportunity was partnerships to 

improve community health, and this is to improve health and reduce the burden 

of chronic disease through evidence and practice base strategies to create or 

strengthen healthy environments that make it easier for people to choose and 

make healthy choices and to take charge of their health. And of the estimated 30 

to 40 cooperative agreements that will be awarded, 5 to 10 will fund tribes and 

tribal organizations. And then the third funding opportunity, Racial and Ethnic 

Approaches to Community Health, or REACH, focuses on racial and ethnic 

communities experiencing health disparities. And the object of this project will 

support policy system and environmental improvements in those communities to 

improve health and reduce health disparities. So I wanted to make you aware of 

those. Again, they’ll be - hopefully funding will be awarded by September 30th of 

2014. 

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Also, CDC and IHS and SAMHSA, or Substance Abuse and Mental Health 

Services Administration, are hosting coordination calls or participating in 

coordination calls. One occurred just this past week and the calls are looking to 

coordinate and to share information and to increase communication and 

awareness on different tribal issues. The current topic of focus on this last call 

was tribal specific data to look at what’s available out there and where the gaps 

exist and how to improve upon the system. So we are collaborating together on 

these calls. And the Tribal Support Unit is looking to improve the design for the 

website to make it more user-friendly by using topic boxes, so in the future, you 

will see more pictures and fewer words along on the screen so that the topic box 

will, for example, have policies, reports and publications or another topic box 

might have funding opportunities, announcements, or training and career 

development opportunities. So it should be easier for you to go and find what 

you need within these topic boxes. And lastly, I wanted to provide you with an 

update of some different resources that you might be interested in. Some of you 

may have seen the Knowing Tribal Health and Knowing State Public Health 

Primers that came out of ASTHO. You can find them at this website but they’re 

also behind tab 10 in your binders, so there’s a copy of those in there as well. 

And basically they’re tips for creating successful partnerships between state 

health agencies and tribes and tribal organizations. So one is the Knowing Tribal 

Health and the other is Knowing State Public Health. Another good resource, 

Guide to Assessing Key OSTLTS Resources and Services. Actually, I take that 

back. I think this is the one that’s actually in tab 10. The first one I listed is just 

the link is available, but the Guide to Assessing Key OSTLTS Resources and 

Services is in tab 10. And in that document, you’ll find the different kinds of 

programs that OSTLTS offers for public assistance. So for example, there is 

information in there about public health law and different kinds of trainings, so 

take a look through there and see if there’s some information that might be 

helpful for you. And then also the National Center for Health Statistics released 

an updated document on racial and ethnic disparities in July, so there is a link 

there for that as well, and there’s American Indian/Alaska Native information 

that’s included in this. That concludes my update. Thank you.

Metabolic Syndrome Discussion

Director Cathy Abramson: Thank you, Captain Shaw. Okay, at this time, we are 

going to have a presentation by Dr. Ursula Bauer on (Metallic syndrome 

discussion...what is it?) Oh, Metabolic. (I told you I’m no scientist.) She’s the 

Director of the National Center for Chronic Disease Prevention and Health 

Promotion.

Dr. Ursula Bauer: Good morning everyone. Thank you for the opportunity to 

speak with you today at the summer TAC meeting, this happens to be my first 

time in Michigan and it’s nice to meet with you all. You had requested a 

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discussion on Metabolic Syndrome and so that’s what I look forward to 

delivering. And I hope that you’ll ask questions. I wasn’t sure exactly what about 

Metabolic Syndrome you were interested in hearing about so hopefully we can 

have the discussion and if I’m not able to answer your questions, I’ll certainly be 

able to get you the information that you may need. So how common is Metabolic 

Syndrome. I’ll just give you a quick run through of what we know in terms of the 

American Indian/Alaska Native population which is very little, and then I’ll talk 

about some of the reasons why that is - our knowledge is imperfect around 

Metabolic Syndrome. I think that the point of this slide is that the key variabilities 

in terms of the prevalence of Metabolic Syndrome, this is a study that was done 

primarily of Alaska populations and the Navajo population, and you can see that 

depending on the region in Alaska there was quite a bit of variability in the 

prevalence and then in the southwestern U.S., in Navajo specifically, the 

prevalence was really quite high. And this compares to a prevalence of the U.S. 

non-Hispanic white population of men around 25% and women around 22%, so 

comparable to the western Alaska population, but we do see much higher 

prevalence, especially in the Navajo population. 

So you might be asking what is Metabolic Syndrome, and it has a number of 

names including Syndrome X was an early favorite, Cardio Metabolic Syndrome. 

It’s a cluster of risk factors that include obesity, insulin resistance, dyslipidemia or 

high cholesterol, and then raised blood pressure. And there has been thinking 

that maybe these are biologically related, that there’s an underlying casual 

mechanism. It’s not really clear and there’s actually a fair good of debate about 

the utility of the whole concept of Metabolic Syndrome. But it has served the 

purpose of reminding us that risk factors for heart disease do cluster in 

individuals and if you find one risk factor like high blood pressure or obesity, it’s a 

pretty good idea to look for other risk factors so that we can make sure that we’re 

addressing all of these issues. It was - Metabolic Syndrome as a concept - was 

primarily developed in order to better predict heart disease outcomes in the 

future, so we can identify people at highest risk and can continue to prevent 

those, but it hasn’t really worked well as an effective predictor of future events

which is one of the reasons that we at CDC don’t really focus on the concept of 

Metabolic Syndrome that much. This is a pretty complicated schematic that I’m 

not going to dwell on. It just gets at that cardio metabolic risk and the role of 

insulin resistance - it certainly plays a key underlying negative role in generating 

that cardiovascular risk associated with an increase in risk, and associated with 

the increase in blood pressure. Perhaps the results of obesity complicated by 

smoking and physical inactivity and so on. One of the weaknesses of Metabolic 

Syndrome is that it focuses on those four risk factors; obesity, insulin resistance, 

high cholesterol, blood pressure, but doesn’t address what we know are very 

strong risk factors for heart disease including family history - probably the most 

important; smoking and age, sex and so on. So it’s not as comprehensive a 

picture as we might like. To make matters worse there are a number of different, 

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competing definitions of Metabolic Syndrome. The World Health Organization 

was the first to propose a definition back in the late 1990’s, and now that 

definition is not the most favorite. There are two sort of competing definitions 

which align fairly well but not exactly. So when we’re comparing the prevalence 

of Metabolic Syndrome across different populations in different time periods, we 

really need to be sure that we’re using the same definition. Otherwise, the 

prevalence rates are not comparable. 

So a few things to think about in terms of Metabolic Syndrome. As I mentioned, 

it was developed as a construct really to focus on predicting cardiovascular risk; 

less so diabetes risk because diabetes is actually built into the definition of 

Metabolic Syndrome. Eighty percent of the people with diabetes will go on to die 

of cardiovascular disease, so that’s a major risk factor for heart disease that 

we’re very well aware of. As I mentioned, it does help us to focus on this 

clustering of risk factors but not—we at CDC and in my center really focus on 

pre-diabetes in terms of the intervention that we can deliver to try to improve 

health, and not everybody with Metabolic Syndrome has pre-diabetes and not 

everyone with pre-diabetes has Metabolic Syndrome. So it hasn’t been a 

construct of a lot of utility for us. I do want to talk about how Metabolic Syndrome 

is treated because I think this is probably the key issue that the TAC is 

concerned with. Whether we’re talking about Metabolic Syndrome or prediabetes or obesity, blood pressure, insulin resistance and so on, we do want to 

know what are the interventions that we can put in place to help our people stay 

healthy or improve their health. And across that canopy of diseases and 

conditions, the interventions are remarkably similar in terms of improving diet, 

increasing physical activity, of course, quitting smoking if the individual smokes; 

creating these permanent lifestyle changes that will help prevent a range of 

chronic diseases. Sometimes, as you know, those lifestyle changes are not 

sufficient or they’re very hard to implement and in that case medications can be 

used to treat the individual condition, the blood pressure, the high cholesterol and 

so on. 

I want to talk for my last few minutes about prevention of type II diabetes. At 

CDC, we’re much more focused on the 89 million Americans who have prediabetes and trying to get them into proven programs that are delivered by the

community to prevent those diseases, to prevent the progression to type II 

diabetes. We know that some 15 to 30 percent of people with prediabetes will 

progress to type II diabetes within five years and we know that we can maybe 

prevent that progression in most people with a simple 16 weeks with a total of a 

year of intervention, intensive initially, less intensive later on, delivered over a 

year that can be delivered by lay members in the community. Patients are 

referred by the clinicians and then there’s reimbursement through health 

insurance and receiving Medicaid. And bringing all of those pieces together has 

been something that we’ve been working on at CDC for the last several years 

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and are making substantial progress in terms of getting the programs in place in 

communities and getting those third party payers on board so that we have a 

resource mechanism for the delivery. As I mentioned, in terms of Metabolic 

Syndrome, that diagnosis, if you will, of prediabetes is one of the components. It 

depends on the definition that you’re using, but that is one way that we can 

identify people with prediabetes, and we’re zeroing in on the impaired glucose 

and ascertaining that through a number of different tests. The National Diabetes 

Prevention Program has four components that we are aggressively working on 

now trying to increase that workforce across the country to deliver the program, 

assuring the payers that we are delivering that program with integrity and have 

the data to support the outcomes that the payers are looking for and that’s the 

Recognition Program. So there’s a process to go through for organizations that 

want to become deliverers of the program. And then we are trying to build 

uptake both of the diagnosing pre-diabetes in the clinical setting and referring 

people to that lifestyle intervention. And in this way we hope to build the 

foundation of programs across the country and begin to make a dent in this huge 

phenomenon – some have called it - which I know many of you are experiencing 

with your people with the epidemic of diabetes and that huge burden of prediabetes. And that concludes my presentationfor Metabolic Syndrome. I’ll be 

happy to start answering any questions.

Lt. Governor Jefferson Keel: I have a question. It has to do with pre-diabetes. 

When you say pre-diabetes, what does that really mean?

Dr. Ursula Bauer: Prediabetes refers to the insulin resistance, and that’s 

diagnosed in one of three ways with three different tests and one of which is 

sufficient. So a fasting glucose test and the result is between 100 and 125 mg 

per deciliter. That would indicate impaired glucose, fasting glucose. If it’s higher 

than 125, that’s going to be diabetes as opposed to prediabetes. If it’s lower than 

100 it’s not yet prediabetes. So it’s in that middle range, 100 to 125, that leads to 

the diagnosis. A glucose tolerance test is another way and then the values are 

between 140 and 199 mg per deciliter. That’s the glucose challenge test that 

occurs in the clinic. So that’s another way to diagnose, and then hemoglobin 

A1C is the third, which would have a value of 5.7 to 6.4 on the hemoglobin A1C 

level. And we know that we have certainly dramatically improved our 

management of treatment of diabetes that we’re seeing much better outcomes 

there and certainly the Special Diabetes Program for Indians has been a very 

good success. But we also know that we can prevent that - in many cases, 

prevent that diabetes from ever even happening if we can identify the individual 

with prediabetes and get them into that lifestyle intervention.

Lt. Governor Jefferson Keel: So once a person is diagnosed as diabetes, let’s 

say whatever one of those tests show that they are diagnosed as a diabetic, can 

that ever be changed?

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Dr. Ursula Bauer: So very good question. I would say in theory, yes, you could 

have a diagnosis of diabetes and you could dramatically transform your lifestyle 

losing quite a bit of weight, completely changing your diet, dramatically improving 

your physical activity and you could no longer have diabetes. And we certainly 

know that the rare cases where that has in fact occurred. Most people are not 

able to make that huge transformation that is required and they will have 

diabetes for the rest of their life. The diabetes can be managed very well and 

we’ve gotten even better at doing that, but the prediabetes, that’s the warning 

sign. That’s where we can say, it’s looking like you’re going down this road and 

you can stop that now without that major transformation that would be required. 

The weight loss in prediabetes is actually quite modest just 5 to 7 percent of body 

weight and the changes in nutrition and physical activity. 

Chariman Herman Honanie: Herman Honanie. I have a dumb question. How 

are tribes or agencies across the nation dealing with this prediabetes diagnosis, 

or whatever you want to call it? I mean, how is that done and who’s been 

successful at doing that?

Dr. Ursula Bauer: Very, very good question and one that we really struggle with. 

So we have the intervention and we have a number of organizations like the 

YUSA that have 3,000 brick and mortar venues across the country where they 

are trying to deliver this intervention. It has been very hard to get all of the 

planets aligned, if you will, to get the brick and mortar establishments and the 

trained workforce to deliver the interventions, get the clinicians to diagnose the 

prediabetes and get the health insurance to pay the community they deliver the 

interventions, if you will. So we have a number of successes in communities 

across the country and we are working hard to expand this nationwide and we do 

have some success stories working with some tribes although I’m not gonna be 

able to call those details to my mind. But really delivering this to the extent that’s 

needed to reach those 89 million individuals has been a major challenge for us. 

The Special Diabetes Program for Indians does include that diagnosis of 

prediabetes as one of the things that they’re striving for there but it’s been hard to 

get clinicians across the country to incorporate that diagnosis and then do the 

referral and then have places to refer to. We do recognize that sort of the brick 

and mortar delivery where people have to come to a location to receive an 

intervention is very challenging and we have a number of studies underway, 

some of which are completed and have been very positive to look at virtual 

dissemination of the intervention, so whether that’s through cable television, 

whether that’s through telephone, whether that’s through some kind of internet 

intervention, we are able, it looks like, to deliver the program virtually so that 

people don’t have to travel and show up. So we’re looking at how we can expand 

that kind of access as well.

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Chairman Herman Honanie: I ask that question because just the other day, a 

couple of days ago, my son - my oldest son and I were – I don’t know - we were 

in the truck driving someplace and he was just telling me, you know, dad, he said 

I think I’m going to be a diabetic, I know that I’ve been eating a lot of sugars and 

sweets and stuff like that. I said to him, you know, you ought to check your 

sugar, make a habit of it and see where you’re at. So at what point do I know 

that I have diabetes? I didn’t have an answer and I said I think anything over 150 

is gonna be a sign that you’re gonna be - you’re diabetic, and even maybe higher 

than that. But my point is that it doesn’t seem like I hear too much talk about prediabetes as well as an effort to really identify individuals on the reservation where 

I’m from. We hear the term constantly but I now ask what are we doing about it, 

and if we are doing anything, how successful have we been? I have to say I 

don’t think that we’ve really made such progress because I’m not hearing from 

the CHR’s and the IHS community medical staff that we are making a big impact 

on the prediabetes population or anything like that so that’s the reason why I’m 

asking.

Dr. Ursula Bauer: I would agree with you that we are not making a big impact on 

the pre-diabetes population at this time, and our strategy, with very little funding, 

has been to try to build that infrastructure that’s going to deliver the intervention. 

To your point, we have a lot more work to do to raise awareness about the 

condition. There seems to be a fair bit of awareness, especially in some 

American Indian/Alaska Native communities that “I’m destined to become 

diabetic.” There’s an expectation that “that’s what happens when I get older,” 

and so it will be critical for us and for tribal health services and for tribal 

communities to convey that this is actually within our control. We don’t have to 

just as we age every year. It’s not that we increase our risk of getting diabetes 

every year. That is something that we can take charge of with some modest 

changes. So getting that awareness out will be critical and we certainly look 

forward to partnering with you to figure out how to do that.

Ramona Antone-Nez: Thank you, Dr. Bauer and members of the TAC. Ramona 

Antone-Nez. Two things that I want to bring up. One is when you stated that 

80% of the population that has diabetes will die of heart disease—if I heard you 

right. So the outcome of that is the mortality rate of the affects of diabetes, so 

we’re looking at that spectrum. The other one is - the other point that I want to 

bring up is about the recognition program. You talked about the payers and you 

brought up data, that importance to have information. When you speak about 

data, is that a coordinated effort and does this model here have a database or 

dataset nationally or is that more regionally? I’m interested in about how the data 

is collected and stored and then recalled for public health reports for our local 

communities.

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Dr. Ursula Bauer: Thank you for your question. So the purpose of the data with 

regard to the recognition program is to demonstrate that the organization that is 

implementing the intervention is delivering it to the community members is doing 

that delivery in a way that is actually going to achieve the outcomes so that we 

are preventing the progression of type II diabetes. So what we ask of the 

individual program that is keeping recognition is that you report the number of 

people that you enroll in the program. We report whether those people 

participated in and completed the 16-week intensive intervention and then the 

monthly interventions thereafter to bringing to the close of the year. And then 

there’s a baseline weight measurement and then there’s a weight reported at 

each of the 16-week meetings and at the monthly sessions thereafter. And what 

those data then demonstrate is did the participants lose 5 to 7 percent of their 

body weight, was their blood pressure reduced. There are questions regarding 

diet and physical activity. Participants of part of the intervention are asked to

keep track of their physical activity because we want to see, as part of the data 

that are reported, that people are actually accumulating minutes of physical 

activity and so on. So all of those data then demonstrate whether the 

intervention that’s implemented according to design and then whether it achieves 

the health outcomes that we’re all looking for. Once that’s demonstrated and it 

takes a couple of weeks to do that, then the program is recognized. And then 

payers and clinicians are willing to refer patients there and pay for that service. 

We have a pending recognition status so that organizations that are going 

through that recognition process can accept referrals and be paid for their work 

with the expectation that they will get recognition when they’ve completed the 

recognition program.

Ramona Antone-Nez: Thank you, Dr. Bauer. So this program, this recognition, 

are you aware of this happening in Indian country or Alaska Native communities 

right now considering the public health system that we currently have? Thank 

you.

Dr. Ursula Bauer: So I will follow up on that and get back to you with an answer 

to that question.

Ramona Antone-Nez: One more question to that is, is this available online to get 

a better understanding about this particular program? I’m curious - my curiosity 

is how well can such a recognition program benefit Indian Country in terms of on 

the healthcare or the providers where they see the benefit to increase knowledge 

or increase the awareness on prediabetes? We want to get it at the primary and 

then work through secondary prevention and then, of course, the third part of it. 

So I’m just really curious about that. Is that available online to get a better 

understanding about how this program and this system works? Thank you.

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Dr. Ursula Bauer: Sure. We can follow up and provide the link to the page on the 

CDC website that explains the recognition program. There’s a lot of information 

there on the CDC website about that. I do want to clarify that when a physician 

or a clinical setting administers this program, it becomes very expensive and it’s 

not cost effective to do. That’s why the lay provider, if you will, delivering the 

program in the community is the way we think will really grow the program and 

the challenge is to develop that workforce and to get insurers more comfortable 

with paying those non-traditional providers, if you will. And we think that by 

delivering results, we’ll increase the comfort level of both the clinician and the 

payer, hence the recognition program and the need to really focus on the 

intervention.

Lt. Governor Jefferson Keel: This is Jefferson Keel. What you just talked about 

was one of the topics I was gonna discuss and that is the expense. When you 

talk about trying to get this program—even testing, the general population, when 

a person goes to the clinic for any type of illness, particularly the direct service 

things in the Indian Health Service, most of the time they’re not tested for these 

unless there’s a specific reason for them to be tested, because of the expense, 

the lab work and all those things—unless they have some type of insurance. 

Some of those tribes across the country that are, I guess, more...have the ability 

to do some of these testings and extensive work then are more prepared. But 

then the other part of that is working with the other agencies to develop 

partnerships in terms of how we get these programs established in the 

communities. For instance, if you look at Medicaid, Medicaid doesn’t pay for 

some of these tests. Medicare won’t pay for some of these tests unless it’s 

specifically asked for by the attending physician or primary care physician. So 

it’s very difficult to assume that every patient that goes to a clinic is going to be 

tested or is going to have the benefit of some of these services. Some of the 

smaller clinics across the Indian Country simply don’t have the staff or the 

facilities or the ability to do all this testing. Although it’s wonderful to see and it is 

exciting that we’re engaged in this, I think that the greater role for us is to look at 

how we develop these partnerships within HHS.

Dr. Ursula Bauer: I’ll just make a couple of comments. One is that we would not 

recommend that everyone gets tested or that everyone receive the intervention. 

So if someone comes into a clinic and let’s say they’re older, they’re in their 40’s, 

certainly in their 50’s, they’re overweight or obese, they have high blood 

pressure, that’s probably the time to start looking for pre-diabetes. If there’s no 

pre-diabetes, we would not recommend the intervention but if there is, that’s 

when we would hope that there’s both a referral mechanism and someone could 

receive that individual in their community. You’re absolutely right that a big key 

to scaling this program is to get Medicaid and Medicare onboard. We have two 

studies underway with CMS to demonstrate the efficacy - demonstrate the cost 

effectiveness of the intervention for those populations. Those are three-year 

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studies. I think we’re about halfway through those and once they are convinced 

that yes this is improving health outcomes, improving quality of care and 

reducing costs, then we expect them to make a decision about actually covering 

the program.

Lt. Governor Jefferson Keel: Thank you. Just one last follow up and it has to do 

with you’re talking about identifying those risk factors. I was thinking more along 

the youth. When you look at obesity in Indian country, that it’s prevalent in many 

of our communities, many of those young people have those traits and so even 

those – even the ability to test many of those young people is limited.

Dr. Ursula Bauer: Thank you very much for that remark and that’s critical. The 

emerging epidemic of type II diabetes in youth is a real tragedy and figuring out 

how to prevent that, how to diagnose that and get that managed is really critical. 

Thank you.

Council Member Andy Joseph, Jr.: (Speaks in Native language.) On our 

reservation our tribe received a special diabetes for Indians grant. One of our 

first years in testing, we tested our K to 8th grades and in nine different schools 

on our reservation. One of them is a private school, all the rest are public, and I 

think it was like 38% are already at prediabetic stage. So, I think there needs to 

be more work at the school level for these children to start doing things. And 

there’s also you know the kids aren’t out moving around like they normally were. 

You’ll see them at the house playing these different games all the time on TV. 

To me, I think CDC needs to figure out a way to get into those games to get kids 

more active. 

Ramona Antone-Nez: Thank you very much Dr. Bauer and members of the TAC. 

I have...I want to go back to what Captain Shaw was talking about earlier when 

you talked about the coordination meeting between SAMHSA, CDC and IHS. I 

do not fully know what that coordination calls are, when they take place, who’s on 

the call, etc. In light of this presentation, I would like to recommend that a 

discussion be brought forward to that coordination call in terms of how do we 

address prediabetes in tribal communities because, of course, in the areas we 

have IHS serving as many of our - as a primary provider, perhaps not always and 

then how does that—I mean maybe not primary but in the area where it’s still 

federal facilities still remain and serve, and then it also would go into a 

coordination perhaps of how does this work in the 638 healthcare systems, the 

ones we had 638’d from the federal agencies, because really one way to address 

any of these chronic illnesses and this being one to prevent, that coordination 

effort really needs to take place. So I would like to make that recommendation 

and perhaps one of the ways is to get Dr. Bauer on the call after some sort of an 

agenda is formulated or something to that affect. Thank you.

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CAPT April Shaw: Thank you for your comment. The calls that are currently 

taking place are with SAMHSA so I think they’re more about substance abuse 

and mental health, but that doesn’t mean that there can’t be coordination calls 

started with IHS and CDC and anybody else that would be the appropriate 

person for issues around diabetes.

Ramona Antone-Nez: Thank you for that. This is Ramona Antone-Nez. I do 

want to say that in Indian Country exists the co-morbidities. It’s not just about 

substance abuse when we’re talking about SAMHSA. We’ve got to look at the 

whole picture in terms of many of our people who have prediabetes are 

diagnosed with—in this case type II—may be using substances such as alcohol, 

and then we get into the whole part about the process of progression to kidney 

dysfunctions and then we get into dialysis. So I understand that perhaps 

SAMHSA is just looking at it perhaps in one way for these coordination calls, but 

I would keep in mind and recommend that the co-morbidities do exist and we 

have to look at the person as a whole, as a community as a whole, not just one 

linear part of it, and that’s where I would see the coordination—and would stand 

by that recommendation that that call start to talk and build upon an agenda 

where it’s not just focused linearly. Thank you.

CAPT April Shaw: And depression is certainly—yes, it’s found with diabetes. I’m 

actually a certified diabetes educator and so I really understand that and have 

worked in Indian Country with diabetes programs, so I really appreciate that 

comment and I mean, we can certainly propose that, you know, for the calls. 

Thank you.

Dr. Ursula Bauer: If I could comment as well, Ramona, I think you really made a 

critical point. The longer I work in chronic disease prevention and health 

promotion, the more I recognize that although we can do a lot to make the 

environment and the community more supportive of healthy choices and healthy 

behaviors, there is a motivational component to chronic disease prevention and 

health promotion. An individual does need to have self-efficacy to believe in their 

ability to take a positive step and they have to believe that there’s a reason to do 

that. And mental health and behavioral health and substance abuse all get in the 

way of that self-efficacy and that belief in self and that hope for the future which 

can be so detrimental to chronic disease and to taking action. So absolutely see 

the comorbidity, the overlap, the inability to make real progress in some sense in 

chronic disease prevention and health promotion without also addressing the 

mental and behavioral issues. Those all piece together. Thank you.

Traditional Foods Discussion

Director Cathy Abramson: If there’s no other questions, we’ll go on with Dr. 

Bauer to talk about Traditional Foods discussion.

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Dr. Ursula Bauer: Thank you very much, and I don’t have slides for this 

presentation but it - was a good segue from Council Member Andy Joseph’s 

comment about how do you get the kids more active and the discussion that we 

had about how do we improve people’s ability to make healthy choices. And our 

Traditional Foods Program was one way that we tried to figure out how to do that 

and you’ll notice that I’m speaking about that program in the past tense because 

it is a program that is wrapping up at the end of this year which is September. It 

will be completed. I had mentioned at the February TAC session that we were 

not putting out a new funding opportunity announcement for that program, and 

there were two reasons for that decision. One was that the program in the past 

had been a $1.7 million program with $1 million coming from the Indian Health 

Service, and this year the Indian Health Service did not provide us with that $1 

million, so we would’ve gone forward with a $700,000 program which would have 

been a much smaller program. The second reason is that we were putting out a 

new funding opportunity announcement specifically for tribes that April mentioned 

was released in May. All of those applications came in in July and we’re 

reviewing them now. And that is a $14 million program and includes some 

component of the Traditional Foods Program. So we’re very much looking 

forward to launching that new program and building on the lessons that we 

learned from the Traditional Foods Program. What we did learn from that 

program and from the 17 tribes in Alaska Native villages that implemented that 

program is something I think everybody knows around this table, right, that food 

is such a core component of culture and such a social activity that brings people 

together. And organizing around food, especially around traditional food, is really 

a way to think about health in the community, to bring the community together to 

build awareness about the relationship between social and emotional realm as 

healthy food and nourishing the body, and taking charge of our health through 

healthful nutrition, as well as a way of reconnecting or staying connected to our 

culture and our traditions and our history in the case of the Traditional Foods 

Program. 

What this program tried to do is on an individual basis resurrect the traditional 

diet that nourished the people; bring those back or reemphasize them, and also 

the traditional ways of physical activity. Many of our traditional ways of eating 

involved a lot of physical activity, whether it was fishing or hunting or gathering or 

gardening and growing our food, soit’s a fair bit of physical activity involved. So 

we really tried to incorporate the healthful nutrition, the traditional food, and the 

physical activity, the traditional forms of activity and really build a culture of health 

around that. We have a lot of success with this program but I think you can 

appreciate, from your own experience, how difficult it is to grow that kind of a 

promising program so that it is pervasive across the entire community and across 

all of Indian country, and we’re hoping that we’ll be able to scale some of those 

approaches with the new cooperative agreement. We’re hopeful because we’ll 

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have a lot more money with the new cooperative agreement, and we’ve 

structured that in a different way where we’re including some leadership, some 

facilitation, convening and sharing of best practices through the tribal 

organizations component that I think will be very helpful in really disseminating 

some of the best practices that we know are going on within each tribe and 

village. So let me take a minute to describe the new scope of work and let me 

know what the timeframe is for announcing those awards. As April mentioned in 

her overview, we looked at the 12 IHS administrative areas and we looked at our 

$14 million and we committed to funding one or up to two tribes directly in each 

of those 12 areas and up to two tribal organizations in each of those 12 areas to 

implement a program of work around nutrition, physical activity and avoiding 

commercial tobacco use, as well as a program of work strengthening the 

healthcare system. And this is where some awareness around prediabetes could 

be incorporated into that program of work. The tribes that are funded directly 

would implement activities in each of those four areas and the tribal 

organizations funded in each area would convene the tribes in that area, would 

provide tools and leadership and potentially small grants to ignite activities in one 

or more of these areas. Critically that tribal organization will be bringing tribes 

together to create opportunities to share best practices perhaps to build a little 

peer pressure across the tribes in the area to establish mentorship of 

relationships if that were helpful across tribes and to provide sort of that 

backbone to keep people focused on the activities, the lessons learned and how 

we push those out so that they’re more widely put into use. We hope to invest 

some dollars in evaluation so that we can demonstrate the impact of the program 

and armed with those impacts, grow that program quite substantially over time so 

that we are reaching all tribes and villages and really investing dollars on that 

order of magnitude larger scale in an effort to relieve the burden out there. Let 

me stop here and see if there are questions on that funding opportunity or on the 

Traditional Foods Program. 

Council Member Andy Joseph, Jr.: (Speaks in Native language.) My name is 

Badger. Anyway, I’m really glad to hear about this program. To me, it’s really 

important. One of my elders told me that there’s a cure for every sickness and 

there’s an answer for every question but it’s up to you to go out and find out what 

that is. As I’ve grown up around the traditional foods and the medicines, and the 

thing about it is at home there’s not very many of the elders left that really know 

all of the different foods that are out there. And you’re right, it does take a lot of 

physical strength to get some of these foods and our people follow the foods 

throughout the seasons. And you look at Washington State, the east side of the 

mountains from the Cascades clear into the buffalo country and Montana our 

people used to travel, so if it wasn’t on horseback, it was on foot. And we would 

go clear down—part of my family is from up in Canada and they’d travel clear 

down to the Oregon Siletz Falls area to catch salmon or they’d go up to Kettle 

Falls and go up in the mountains. Right now, it’s berry picking season and 

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salmon fishing season, so there’d be different towns throughout those areas and 

to me, some of our people don’t really understand how to prepare the foods the 

way they used to do so that they’ll keep throughout the years. And nowadays 

they have freezers. Back in our old days we never had a freezer. You had to dry 

and keep your foods a certain way. We never used the grease to you know cook 

our vegetables and anything like that. It was all natural. And to me, I would hope 

that there would be more resources for tribes to look at how many of these 

teachers might be left, the elders that could be given some kind of a stipend that 

wouldn’t affect—a lot of times they can’t really do a lot without affecting their 

retirement or whatever they’re trying to make a living on. And to me, that bit of 

culture is gonna leave us really rapidly if we don’t do something right away to 

obtain the knowledge that’s out there. Like I said, I was fortunate to be raised 

around it. My daughter knows how to prepare just about any of them. But there 

aren’t very many on my reservation that knows, but she knows. 

Ramona Antone-Nez: Dr. Bauer and members of the tribe, this is Ramona 

Antone-Nez. In the Traditional Foods Program, it sounds like it’s gonna be 

ending in September. Would you remind us about whether there were tribal 

communities involved? I mean who were the awardees and what were some of 

the lessons learned from their tenured funding opportunity. Thank you.

Dr. Ursula Bauer: Thank you. There were 17 awards in the most recent five-year 

cooperative agreement, and there were fewer awards—I want to say ten—in the 

previous cooperative agreement that was about three years. And a lot of the 

learning from the first cooperative agreement were incorporated into a second 

one. I think that there were a lot of learnings that actually—we just heard similar 

to what Council Member Andy Joseph, was saying. The need to really 

rediscover this knowledge or make sure that we obtain the knowledge from 

elders before it’s gone. So, for example, one of the grantees, Cherokee of 

Oklahoma, actually had to go to their relatives back in North Carolina to get some 

of their traditional seeds so that they could grow their traditional foods in 

Oklahoma. That had been something that was lost with the relocation. One of 

the grantees in Alaska realized that hunting and dressing an animal is becoming 

a lost art, not just in Indian Country but across the country. And so in that 

program, one of the activities was to actually bring a deer into the third grade 

classroom so that as part of the school curriculum, the children would learn how 

to dress a deer and they would take that deer from the whole dressing to the 

preparation of the meat, to the preparation of the food, to the storage of the food. 

And similar activities with salmon which is a real food key there. So we do need 

to teach these skills if they’re not going to be lost and we need to do that in kind 

of a proactive way, and we might not think about dressing a deer as something 

that fits into the school curriculum, but in fact, we need to do that if we want that 

knowledge to survive. In some areas, tribes have lost their traditional hunting 

and gathering rights, or maybe those rights are on the books but they’re not well32 “This document represents meeting minutes/discussion, etc. of the meeting/session, etc. 

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enforced or not well taken advantage of. So some of the activity is to work with 

the bureaucracy to try to make sure that we assert those rights and then we take 

advantage of those rights. So there was a wealth of experience and learning and 

really very different depending on the grantees and depending on their own 

context, and I’d be happy to send you a list of the 17.

Ramona Antone-Nez: Thank you, Dr. Bauer. This is Ramona. Real quick, I’m 

curious about the effectiveness of these programs. I do agree that it’s important 

that knowledge and skill of traditional foods be revived and continue. In terms of 

incidence and prevalence rates, were we able to see through the programs that 

there was an improvement, or in this case a decrease, in the overall...one health 

disparity to an increase in wellness in terms of were there evidence or promising 

practices to show that there’s a decrease in weight; therefore, increase our 

prevention to prediabetes? And we could talk about the chronics in terms of the 

risk factors for cancer, etc. But I’m just curious about how can we continue to 

capture the data that’s needed to support these types of programs so that 

federally, we can continue to have them funded. Thank you.

Dr. Ursula Bauer: That is an excellent question and that is a contributing factor to 

why the program is not continuing. We can certainly demonstrate outcomes like 

increases in the amount of acreage that was farmed, pounds of vegetables that 

were harvested, numbers of people who took part in activities or who grew their 

own garden and so on, amount of foods...traditional foods that were consumed 

as part of the program. But those numbers actually are quite small and frankly 

the dollar investment was quite small. With 1.7 million, we don’t expect to 

change the world. But it could be seen to me and to us as we looked at this 

program and thought about the huge burden of diseases out there and how we 

address it that this was the full answer. We saw that it needed to be incorporated 

into a fuller mix of activities, and frankly one of the activities that was missing is 

looking at the competing foods. So eating traditional foods sometimes is not 

going to undo or prevent the damage from eating the non-traditional foods most 

of the time. And the access to sugar-sweetened beverages and to the snacks 

and junk foods across Indian Country or across the U.S., across the world is 

unbelievably pervasive. And the foods taste good and they’re cheap relatively 

speaking, so we have to look at the much larger culture within which a traditional 

foods program sits. And as we grow that connection to tradition and that 

connection to culture and that connection to healthy food, we have to be severing 

those ties to the prevailing food environment, if you will. So we see the future of 

the traditional foods approach as existing within a more comprehensive approach 

and for exactly the reason that was part of your question, how do we get the 

outcomes, how do we reach large numbers of people and how do we achieve 

health.

Council Member Andy Joseph, Jr.: You know, part of the problem, I would say, is 

access to our foods because a lot of our tribes were pushed onto reservations 

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where—we have to travel off the reservation to go get certain roots that we 

gather during the springtime, and you know to me, I think if we had more 

access—I could use my sister as an example. About seven years ago, she was 

diagnosed with stage four cancer and ever since she found out she had cancer 

and been going through all her treatments and everything, she spends most of 

her time gathering the traditional foods and eating those versus what’s out there 

in the store. And she’s I guess kind of like a miracle person because she’s still 

alive. She’s out picking berries right now and climbing around in the mountains, 

and that’s a lot of work. Like a toothpick, just skin and bones but she’s surviving. 

If more of our people would follow her example, I would say they’d probably be 

healthy like she is. I had a great, great grandmother who I clean her grave all the 

time. She lived to be 118 years old and you know that’s the kind of health you 

know I want to see come back to our people. Right now, you know, I’ve outlived 

the average Native American in my tribe by two years. So to me I think it’s 

something really important that the CDC should continue on looking at these 

ways to get that funding going because there is a big opportunity. I always say 

that that’s my garden out there is in all the Umatilla territory that our tribes ran in 

and we need to have access to those areas so we can keep gathering our foods.

Director Cathy Abramson: Cathy Abramson. I think you guys all know that I’ve 

been a big supporter of the Traditional Foods Program and I continue, and I’m 

upset that decision was made awhile back that that was gonna discontinue. By 

the way, I did run them down last week. They were in the Bemidji area. All the 

grantees came and did their presentations on their best practices. It’s very sad 

to see that go. I, like Andy, believe that if all our traditions—I mean every time 

we go somewhere for any type of—anything—our tribal leaders are saying bring 

back our culture and tradition. I would believe that there already is data out there 

on today’s beverages and things like that, and there’s no studies or research or 

data done on traditional foods. Again, I don’t know how you do research or 

whatever. I do know this, and I said before I’m not a scientist, I guess, with us 

and our ancestors we’ve been scientists long ago. Our ancestors knew the 

medicines and just the way we lived. And we talked about it’s not just about 

nutrition; it’s not going and gathering food. I went picking blueberries. That’s 

what you do at a certain time of the year. But out there when you’re pickin them, 

there’s St. Johns’ Wort all over the place. St. Johns’ Wort is for depression. So 

out there, there’s medicines for cancer. So there’s all of these things, so you’re 

out there feeling really good, you’re getting exercise, you’re bending around, 

you’re using your hands, you’re picking berries, you’re not smoking cigarettes 

because most of the time it’s dry; you can’t, you know, you’re using your hands 

and you’re picking your berries because you’ve gotta pick berries so you can get 

out of there so you can go swimming. Okay, so we had to fill our cans, so when 

we went as a family, so you had family time and then you had, again, more 

exercise and it was fun. We didn’t drink pop or anything. We had water and 

good clean waters that we take for granted. So there’s all of those things that 

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come into play and sometimes I think we don’t get the big picture about what it is 

we’re trying to talk about here. So, it’s unfortunate. I would like to ask this the 

new awards come out and I would like to see a regular update from those 

individuals that oversee the programs, come to CDC and let us know about their 

programs, especially the Traditional Foods because to me, I’d like to use that 14 

million and just improve the Traditional Foods program. You think of what we 

could do.

Chairman Herman Honanie: Herman Honanie. I’ll try not to be too long. What I 

got out of this this morning and then just listening to everybody and some of the 

points that Ms. Nez here raised, we’ve got diabetes and pre-diabetes and 

everything else. It just reminds me of a group of individuals who have gotten 

together at home and who have started this several years ago about bringing 

back all the traditional practices and farming and planting and then food 

preparation and other things like raising chickens at home again, raising bees 

and producing honey. All of these kind of things. As kids, we used to go up to 

the rocks and you know get stung by the bees and everything else but to get the 

honey and bring it home was an adventure and all of these kind of things and so 

it just kind of reinforces what they’re doing is really, really good but I hope that it 

continues to grow. And when I look around and hear all of us talking about what 

we used to do, what we don’t have here, and you mentioned folks up in Alaska 

having to teach these kind of things, it just reminds me, too, that we started 

herding sheep – I was raised herding sheep and when my dad was around. You 

know, he would start with the sheep all the time for ceremonies and so forth and 

I’d be right there with him and so I learned how to do all of that. Then we 

switched over to cattle and we did the same thing. And then now, it’s really a 

dying art. It’s a dying practice, a tradition. Hardly anyone at home ever does 

herd sheep anymore so thus, hardly anybody knows how to butcher a sheep. 

And...but some of us will still do that for ceremonies and things like that. But I 

think the point I’m trying to make is that we just really have to step into that circle 

and continue ordering those efforts to do what had been done prior. And at least 

in my case, I’d like to think that many of the things that we have done and 

learned, our people have done in years past, are still doable. They’re really 

doable with the economics, having jobs full-time and all of these kind of things is 

impacted as well, our livelihood and the way we practice our lives and tradition 

and so, like you mentioned, you just go to the grocery store and get everything 

you need. And then there’s seasons involved and everything else. So it’s a 

hard, hard way of life to do and cling to all of these traditions but you know it’s not 

so bad when one is raised teaching and learning those practices. I remember 

when I was maybe about, I don’t know, ten years old and we were planting and 

my grandfather came up to me and told me a couple of things about continuing 

the practice of farming. That’s what we subsisted on, that’s what got us here. 

And you (speaks in Native language)which is my Hopi name. He says,(speaks in 

Native language)[Hopi Name], you have to continue this. You have to keep 

practicing that so it won’t go away so that you can live, so that you can feed your 

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family and your grandkids and so on and so forth and teach your grandkids, your 

sons, and everyone else. So I think we just have to realize that we’re the ones 

responsible for a lot of the decline. We need to bring it back. We need to 

support it and we need to teach it and teach everyone around us how important it 

is and then hopefully it does impact our health in the most positive way. And I 

think it’s really enough responsibility on our part. Ms. Nez talked about the 

consequences of a lot of things that we haven’t done. We’ve missed the boat, so 

to speak, to prevent diabetes and everything else. A lot of things are happening 

throughout our reservations; substance abuse, alcohol, all of this kind of thing 

and that’s why we’re such a sick society. If we can do away with alcohol for 

starters, I think we could be on the road to being able to reduce substance 

abuse. I really think that and I really go out of my way—I have never been a 

substance abuser, I don’t drink alcohol. So as a tribal leader, every opportunity I 

get, every time I’m out at a race or a gathering, I tell the kids, I tell the people, 

let’s do away with alcohol, let’s revolt against alcohol and substance abuse. I try 

to do that every time. I know some of my people don’t like hearing it, don’t like 

me saying that, but that’s what I try to advocate and I think part of that is our 

tradition, is not to indulge in that. Thank you.

Director Cathy Abramson: Okay. Thank you very much. At this time we’re going 

to hear wrap up from Romana Fetherolf before we go to lunch.

Romana Fetherolf: Good afternoon. I’m Romana Fetherolf and I will be giving 

the update or the highlights. During the TAC business portion of the meeting, 

Director Cathy Abramson had brought up that tribal members should contact 

their committee members and give them information that can be brought to the 

TAC meeting table. We discussed monthly phone calls, and Captain Shaw 

wanted to make sure that the current time and date for TAC calls worked for 

everyone. It’s currently every other Monday at 2:00 p.m. Eastern Standard Time. 

If this does not work for you, just let Tribal Support know. The Issues and 

Recommendations document was discussed and Ms. Antone-Nez suggested 

adding a table of contents to the document. The document was voted on and 

approved. The minutes were also voted on and approved. The topic of funding 

was brought up as well as the topic of directly funding tribes versus sending 

money to the state. And then TAC members voted to have Councilman Chester 

Antone remain as chairperson and Lt. Governor Jefferson Keel voted in as vicechair...starting tomorrow. We also had a presentation from Dr. Bauer on 

Metabolic Syndrome and Traditional Foods which brought up a lot of discussion 

from TAC members. Dr. Bauer and Tribal Support will work together to provide a 

link to the online information on the pre-diabetes recognition program so TAC 

members can see the information. And Ms. Antone-Nez had brought up a 

coordination meeting between the CDC, IHS, SAMHSA, and whoever else might 

be interested on how do we address pre-diabetes in tribal communities. There 

was also a suggestion from Director Abramson to get updates on what’s the 

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progress with the grantees for these new grant awards being given out. So if I’ve 

forgotten anything, there was a lot of good discussion this morning, so if I’ve 

forgotten anything, please come see me during the break and I can add it to the 

minutes. Thank you.

Director Cathy Abramson: Thank you. I think Ramona said quite a bit that you 

might have not put down because I was commenting up here how she’s a really 

good committee member. You might want to add. So we’re all ready for lunch. 

Okay, we’re going to give you till 1:10 for lunch. We’re starting at 1:10. Okay. 

Thank you. Enjoy.

END. (LUNCH BREAK)

Smoking and Tobacco Use Panel

Director Cathy Abramson: ....Tobacco Use Panel. We have Brian King, Ph.D. 

He’s Senior Scientific Advisor in the Office on Smoking and Health from CDC -

shortened it. And Derek Bailey, Chairman Grand Traverse Band of Ottawa and 

Chippewa Indians and Director of the National Native Network for Cancer and 

Tobacco Prevention and Control Program. Welcome.

Dr. Brian King: Okay, well, thank you for having me. I’m grateful to be here. The 

last time I was at TAC was in 2012 and it was a very pleasant experience and got 

a lot of good follow up after that. So I’m really happy to be here today to talk to 

you about tobacco use and particularly the issue of E-cigarettes. It’s a very 

emerging topic and so there’s been a request to keep the slides to a minimum 

which I can appreciate and commend, at the same time. So I’ll talk for about 5 to 

10 minutes and then hopefully, we can open up the rest of the time for some 

really fruitful discussion about this emerging topic and can answer questions, and 

I’ll give some more information on what the status of these products are and what 

are the interventions that we’re using to address these products. So before I 

delve into the E-cigarettes, I’m just going to briefly talk about tobacco use in 

general, and of course, when I’m talking about this, this is commercial tobacco 

products so it’s the non-sacred commercial products. And we’ll start with the 

50th anniversary Surgeon General’s Report, which some of you may be aware of 

was released in January. This was the 50th anniversary report of the first 

Surgeon General’s Report which was released in 1965 and that pictures our 

current acting Surgeon General, Boris Lushniak. And some of you may recall in 

the media where he claimed “enough is enough.” And it was really a profound 

statement that addresses a lot of what we’re doing in tobacco control and that 

we’ve been working on this issue for several decades and we have proven 

interventions that we know work, and it’s more of just implementing those proven 

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interventions to get us to the end game intervention which is reducing tobacco 

use.

So in terms of background, these are two figures from that Surgeon General’s 

Report. It outlines all of the diseases that we know are attributable to tobacco 

use and particularly smoking, as well as secondhand smoke exposure. So, all of 

the new items that were newly added in the 50th anniversary Surgeon General’s 

Report are noted in the back. So the primary take home message is that really 

smoking damages nearly every part of your body, and the damage from smoking 

is not just limited to the user. We know that there’s no safe level of secondhand 

smoke exposure. Even brief exposure has been known to have adverse health 

affects. And in terms of the death attributable to smoking, we know that in the 

United States about 480,000 deaths per year are estimated to be caused by 

active smokers, and it’s about 50,000 for secondhand smoke. There’s really a 

large burden of both disease and death and that’s why we’ve shown in our 

Surgeon General’s Report and elsewhere that tobacco use is the leading cause 

of preventable disease and death in this country. 

So there’s a lot of disparities, particularly with regard to cigarette smoking. 

Cigarette smoking and combustible tobacco use in general make up the greatest 

burden of death and disease from tobacco use and cigarette smoking is the most 

common type of tobacco use. Currently, there’s about 18% of the U.S. 

population, adult population, who smoke and it’s disparity by different groups, 

and this figure that I’ve included is by race/ethnicity. You can see there’s this 

large area here on race/ethnicity. American Indians/Alaska Natives have higher 

rates of cigarette smoking, and the reason that you see that, the top line 

represents American Indian/ Alaska Natives in this figure and you can see that it 

jumps around a little bit and that’s primarily the sample size but for the most part, 

it’s been fairly stable at a comparable rate over time. And as you can see, that for 

most race/ethnicity, we haven’t seen a lot of changes over time and plus 

underscoring the importance of these efforts to reduce tobacco use.

So in recent years, we’ve seen an emergence of new products. So cigarettes 

have always been the prominent tobacco product used but in recent years, 

particularly within the past five years we’ve seen an emergence of newly novel 

tobacco products, and one of the most prominent is E-cigarettes, and Ecigarettes are actually one type of a classic product we call Electronic Nicotine 

Delivery Systems. So E-cigarettes are just one of many and here’s just a few 

examples in this diagram. They include things like e-hookahs, e-vape, e-cigars, 

pipes,, and hookah pens and currently 400 brands. Regardless of the product, 

they all operate...essentially...and other substances like flavoring. So they don’t 

include tobacco as an active ingredient but the user inhales them and they 

include a liquid that usually contains nicotine. It’s heated and then the user 

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inhales it and then release an aerosol which comes out of the mouth from the 

person as they use the product. So regardless of what type of product, they all 

operate under the same mechanism. Now, there’s different ingredientsand at the 

bottom of this...is the disposable varieties. These are the ones that resemble 

cigarettes. You use them and then after the liquid is done, you throw them out. 

So they’re good for a day or two or some people will use them in a matter of - I 

don’t know - an hour depending on how much they smoke. 

The second generation is the ones in the middle, and these are closer to the ehookahs. And they’re a little bit larger. They consume a little bit more e-liquid 

and can be accessible and used several times. And the one on the far right is 

the tank systems, is what people call them, and these are rechargeable. And 

these are really becoming increasingly more popular among users, and one of 

the primary reasons is because they can be modified. So people can add flavors 

and any other ingredient that they find particularly appealing. There’s also been 

reports that people are including other substances in the product as well like 

THC, which is the acronym for marijuana. So there’s opportunity to modify these 

devices. As they get larger, there’s more opportunity to have them modified to 

your liking. 

Now, we’ve seen marked increases in the use of these products. They first came 

to the United States in 2007 and in terms of tobacco control the popularity 

increased more rapidly than we’ve seen for any other types of tobacco products 

including those previously mentioned. One of the primary reasons for that is 

advertising. And a lot of these products are manufactured by the tobacco 

industry which use traditional practices to make products appealing to people. 

And these are just a few examples. I like to include this because as you can see 

there’s a lot of parallels. So in the 1940’s and 50’s you see Lucy - Lucille Ball 

and Ronald Regan advertising traditional products. And on the right here you 

have some more recent Jenny McCarthy, who you may know from The 

View....actively endorses Blu, which is a cigarette brand by the company 

Lorillard,..... as well as Stephen Dorff on the bottom right. I’m not quite clear on 

what Stephen Dorff is famous for. I’m sure it’s something quite commendable. 

And so this is just an example of the advertising for these products. The 

increase in the advertising is mirrored by use and we’ve seen large uptips on the

use among both adults and youth, particularly youths. CDC released a report 

last year showing that the prevalence doubled among U.S. middle and high 

school students in only one year. In 2012, there was 1.8 million U.S. middle and 

high school students who have tried tobacco products......

And so there’s a lot of debate about these products, particularly even in the 

public health community, and so I’ve compiled a brief overview of the potential 

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harm and benefits of these products. And as you can see, the harms outweigh 

the benefits, but it’s important to understand these products and what the harms 

and benefits could be, particularly in the context combustible tobacco. When I 

say combustible, I’m talking about “burn products” like cigarettes and commercial 

products, cigars and anything else. So I’ll start off with the potential harms and 

provide a few brief points on each that will hopefully help us move into the 

discussion of these products. For the first of the potential harms, and that’s the 

lead to nicotine exposure among youth and pregnant women. So the products 

are currently not regulated although the Food and Drug Administration is now 

planning to regulate these tobacco products. So certainly it’s kind of a free-for-all 

in terms of what these products include. But one of the factors that is in most of 

these products is nicotine. And, of course, we know that nicotine is the most 

addictive ingredient...that’s the addictive agent in cigarette commercial products, 

but we also know that it’s not completely without risk, particularly among 

adolescents and pregnant women. So nicotine can have adverse health affects 

on the developing adolescent brain and it can also have adverse affects on 

pregnant women, particularly with regard to fetal toxicity. So the nicotine 

exposure through these devices, particularly among these two populations, is a 

concern from a public health standpoint.

The second bullet is leads to initiation of combustible tobacco use among nonsmokers or relapse among former smokers. So one thing that we’re seeing in 

the data - population data, particularly among youth, is there’s a lot of people 

who have never used traditional tobacco products like cigarettes that are using 

these e-cigarettes. And that’s a concern for us because it could potentially lead 

as a gateway to use these combustible conventional products. And there’s also 

concern with a relapse among people who have already quit that use e-cigarettes 

could potentially lead them to relapse back to using traditional tobacco products.

And the third item is delayed quitting among smokers. There is a lot of 

discussion back and forth about people using these products for cessation. And 

although anecdotally there are people who have used these for cessation in the 

population but the data is currently inconclusive if these products are effective. 

The studies are still emerging and particularly those that have found over time at 

the current point there’s no conclusive evidence that these products are effective 

at all in cessation.

The fourth item is discourage smokers from using proven quit methods. By 

proven quit methods we mean products like nicotine replacement method like 

nicotine patches andmedications that have been tested by the Food and Drug 

Administration which were shown to be effective. The FDA currently has seven 

approved medications for the purpose of cessation and e-cigarettes are not 

included on that list. So there’s a concern that people will start to use these 

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unproven methods like e-cigarettes instead of these proven methods that have 

undergone rigorous scientific testing.

And the next item is expose non-users to secondhand aerosol, and all this 

means is it’s similar to the secondhand smoke argument, and that these products 

are currently unregulated so what’s ever included inside the product could then 

be aerosolized into the environment and potentially expose bystanders. So the 

inclusion of nicotine in these products is concerning for the same reasons that I 

noted before, and the children and pregnant women and non-users could be 

exposed to the aerosol from these products that could potentially include nicotine 

among other hazardous - potentially hazardous things.

And then the next one is renormalization of tobacco use. We’ve worked for 

several decades in this country to implement interventions that we know work to 

reduce tobacco use. An example of that is things like smoke-free lounge and 

policies that address the use of cigarettes in your areas that expose you to 

secondhand smoke. So the introduction of these e-cigarettes has added a 

wrinkle to that work in that it potentially renormalizes the use of these products. 

Because you are technically using a product, it looks exactly like the traditional 

cigarette. It’s a vapor that looks similar to secondhand smoke inside you know 

indoor environments. For the most part, people can’t discern between those 

products, so there’s definitely opportunity for these products to complicate efforts 

to de-normalize tobacco use and even cessation.

And then the final note is regarding poisoning among users and non-users. CDC 

released a report earlier this year that addressed poisonings from these products 

and calls from poison control centers. And what that found was that in 2010 

there was about—September of 2010-about one call per month of poison control 

calls. And then in 2014, the first couple of months, it’s like all the way to over 200 

calls per month and about half of those calls were for children under the age of 

five. So these products have the potential to poison people, non-users—users 

and non-users alike but particularly the children. 

So those are the lists of the potential harms. But it’s important to note that 

there’s also potential benefits to these products and we recognize that, but the 

only way that there could be a potential benefit to these products is that there’s 

complete substitution by establishment and no relapse. So that would be of all 

the current combustible tobaccos, is to switch to e-cigarettes completely and 

never go back. So that would be a net public health benefit to know that there’s 

less carcinogens and toxins in e-cigarettes,so switching completely. But 

unfortuantely in the current data that’s not what we’re seeing. There’s a large 

prevalence of dual use, and what dual use is is people continue to use both 

products. They’re not quitting. So that’s problematic for a variety of reasons. 

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And then finally the second benefit is that these products will assist in rapid 

transition for society with little or no use of combustible tobacco products. So in 

the event that these products help us to achieve our ending goal to completely 

eliminate combustible tobacco products then that would be...public health 

benefits.....But as I noted before, there’s a lot of issues that complicate the ability 

to do so and if these products are allowed in indoor environments, then they can 

potentially complicate smoke free policies as well as other tobacco control efforts 

that we’ve implemented for several decades...... 

So those are the overview of the harms and benefits of these products and since 

they’re so new, the landscape of policies to address them is equally is new, but 

I’m going to include just a brief list of policy approaches that RB implemented at 

least at the local and state level, and in noting those it’s important that what we’re 

developing approaches to minimize the harms and we must also keep in mind 

the efforts to intensify efforts to address combustible tobacco use. That’s still the 

primary driver of the burden of tobacco users in states. So when we implement 

policies to address e-cigarettes, it’s important to keep them in context of our 

efforts to address combustible tobacco use

So in terms of one of the interventions that’s been implemented most prominently 

is youth access to the products. Currently there’s at the state level although the 

FDA has proposed a minimum age of sale standards at the national level. That 

has not gone into effect and it’s still under public comments, but in the meantime 

there’s about 30 states that have prohibited the sell of these products. In about 

20 states it’s still legal for a child under the age of 18 to walk into a mall kiosk or 

a convenient store and buy these products, and that’s concerning. Particularly, 

we know that these products contain nicotine and potentially could serve as a 

gateway to other tobacco use. So one policy approach to spend adopted by an 

increasing number of .... The second is the inclusion of these products in a 

smoke-free policy and there’s an increase in strides by states and localities to try 

to incorporate these e-cigarettes into our existing smoke-free policy so that these 

products cannot be used in any area where conventional tobacco products are 

prohibited. And that’s for the reasons I outlined earlier for the aerosol and 

exposure to these products. And then finally an important note is that effective 

regulations for these products is key. And in 2009 the U.S. Food and Drug 

Administration received the authority to regulate tobacco products, and earlier 

this year they proposed regulating e-cigarettes. So the products aren’t currently 

regulated and it could be awhile before those regulations. So in the meantime, 

it’s important as public health practitioners and professionals to kind of 

understand the importance of being on the frontline so that we do the least harm 

as possible, and considering the harms of these products and the benefits and 

making sure that we implement common sense strategies to address these 

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products until we have more information on their ultimate long term impact on 

public health, particularly with tobacco use. So with that I have provided my 

contact information in the event that anyone would like to follow up on this or any 

other tobacco-related measure. I have the misfortune of having my initials in my 

last name so my email is baking@cdc.gov. It’s very easy to remember, so I get a 

lot of interesting emails. I’ll note that CDC Tobacco also has Facebook and 

Twitter. There’s a lot of really great information. We’re working on expanding 

our e-cigarette content as well working on simple resources that are easily 

digestible by the public help inform them about this topic. So with that, do we 

want to do questions after me or wait for the second presenter?

Counselor Derek Bailey: (Speaks in Native language.) Director Abramson, CDC, 

TAC, (speaks in Native language). I’m wearing two hats here today. I see here 

on my thing it says Chairman. Derek Bailey, I’m a past tribal chairman for the 

Grand Traverse Band of Ottawa and Chippewa Indians. I got reelected in May 

so my title is counselor but you’re okay because I’m not on the clock. I just want 

to make that note. I also wanted, wearing the hat of the council member if I may 

bounce back, welcome to our property. I asked earlier if there was a welcome 

that was done from our tribal community and I heard that there wasn’t. So if you 

may, let me go back a few hours and imagine that we’re just kicking off the day. 

Welcome to our property. The Grand Traverse Band purchased the Grand 

Traverse Resort and Spa in March of 2003 and since taking ownership, we put 

about 18 million into the property, so we’re very proud of this destination. It has 

housed other events, the National Congress of American Indians, the National 

Health Board with Lt. Governor Keel here, Council Member Joseph, and other 

tribal leaders that I’ve been able to rub elbows with, and to have you in our home 

community for the tribal leadership here. We welcome you to the staff of CDC, 

and the presenters. We hope that your time here, you feel at home. I see on the

agenda tomorrow that you’re gonna be visiting the Grand Traverse Band. Oh, 

Thursday. There’s a lot going on this week here at this property. I don’t know if 

you’re aware but NIHB is in town, the Midwest Alliance of Sovereign Tribes and 

Health Services, and then we have a language camp going on, and then also this 

weekend is our annual traditional Jiingtamok Pow-wow. So it’s a busy week for 

our tribe here. I have the opportunity to present on the National Native Network 

as program director. I had an interesting lunch, as I reflected upon my team and 

working with the National Native Network, which is administered by the Inner 

Tribal Council in Michigan. It changed my views as a tribal leader. Dr. King’s 

presentation on electronic cigarettes and E-cigs and legislation and policies, 

definitely I’ve been impacted and so my presentation I’m gonna share and I hope 

that it helps and assists others in seeing that change can occur because it 

personally changed within me as a tribal leader and then coming back into the 

seat as a council member. 

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To start off, I want to recognize, too, a significant staff member for the National 

Native Network who’s in the audience. It’s Director Abramson’s niece, Robin 

Clark. Please stand. She’s part of the National Native Network and a citizen 

with the Sault Ste. Marie Tribe of Chippewa Indians. When we talk about a 

traditional concept of the work we’re doing in Indian country targeting 

commercial tobacco cessation, think about messaging. Now for the Nishnabec, 

Midwest tribes, the Odawa, Ojibwe or Ojibwa, and Bodewadmi, here more 

commonly referenced as Chippewa, Ottawa and Potawatomi. We say Seymah or 

Seymo, as some pronounce it. And it’s important because of all the partners of 

the National Network - National Native Network has a different type of message 

that goes into when working with tribal youth in our communities and also all the 

way to our elders, and we’ll see it this weekend – we’ll see it at our annual 

powwow, Jiingtamok as we say, and how that role of that medicine, our teaching, 

at least our direction comes into play as the ceremonies, education and daily life. 

Now daily life, what is that? If there is a disagreement in our teachings, you 

could take that, Dr. King, say he said something that perhaps didn’t settle well. I 

could take that Seymah or get that to him in a means to say I’m coming in a good 

way from my heart and let’s talk this through. If it’s asking someone to take a 

role at a powwow and to answer (Speak in Native Language).What we see, 

though, is commercial tobacco is in place of our traditionally grown Seymah. 

We’ve seen cigarettes that are given or a pack or a whole carton to a host drum 

or a drum that’s visiting. And you think about in that presentation, that delivery, 

what that really represents. To me, it represents almost giving someone cancer. 

Now, that’s a hard statement to make but I really want to have that type of depth, 

that degree of understanding right there. Like giving cancer to someone. I’ve 

been at ceremonies where people, someone has walked on, traveled on, and I’ve 

seen commercial tobacco, cigarettes given out, youth smoking right with our 

elders. And I think about really what are we teaching. Now, there’s elders in this 

room. I don’t look to offend but at some point we have to start messaging what 

we’re seeing in our communities. Is it okay for us to give that cigarette with all 

those additives this slide recognizes? Look at that last bullet point. Linked to 

high rates of disease, morbidity and mortality. And I bring that up as far as why 

my perception actually changed, and Chris, I’m going to go into some of our 

lunch discussion here, but we look at our communities as far as health risk, right? 

A lot of us have gaming facilities. At the Grand Traverse Band we have two, one 

out in Leelanau County, which we do the map of Michigan, it’s the Pinky. If you 

haven’t done that yet. But just down a few miles to the east is Turtle Creek 

Casino and Hotel. A smoking establishment. When I first became part of the 

National Native Network, I had the thoughts of, as a tribal leader, ADC board 

member, I’ll tell you what, we can’t touch the concept of smoke-free tribal casinos 

as a loss of gaining revenue. If you look at that last bullet point, the messaging 

that counters that is when our youth finish high school and they look to work. A 

lot of us come from rural reservations, tribal communities. Gaming facilities are 

the only means of employment because of limited resources, transportation. We 

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put them right into an environment, though, that has known health risks 

associated with them. When I first learned and started really identifying and 

saying, wait, I need to challenge my concept and perspective on—you know, as 

far as we’ve gotta have smoking in our tribal casinos. One thing I didn’t 

recognize is the cost later in life. If you think about, and you know individuals - if 

you look at the CDC TIPS campaign, how many have heard of Nathan or had 

heard or watched Nathan Lane’s story? He’s walked on in the light fog. I mention 

his name in honor and respect because he was out at the forefront messaging as 

a non-smoker being in a smoking environment, and the impact on his life. And 

for a family that may be here or that may hear that I’ve spoken regarding this 

individual, he was at the forefront though and think, wait a minute, we need to 

really rethink what’s happening in our tribal communities and what impact we’re 

having on our next generation and our future leaders as well. You can go to the 

next one.

So the health burdens that we’re talking about, if you look at commercial tobacco 

use in American and Alaska Native populations, the more prominent we come 

out with is heart disease, lung cancer, asthma, infant mortality. There’s another 

individual that’s a key spokesman for the CDC TIPS campaign, Michael George 

Patterson out of Alaska. Is anyone from Alaska here? I see that they’re 

represented on the board. Well, this is another individual that’s in a stage of his 

life, as he describes it, and he’s very public about it but he’s recognizing that his 

work needs to be done for what he suffers from. Now, if you look into—and 

Bemidji is targeted because we are in the Midwest region here today. When you 

look at the age-adjusted death rate due to malignant neoplasm per 100,000 

population, if you look at Bemidji, you can see one region of Indian Country and 

the health risk, and I mention this cancer burden. In the first five years of the 

National Native Network, we focused on commercial tobacco cessation. We 

have now refunded for another five years to maintain that but also to incorporate 

a comprehensive cancer component. So I mentioned Kris Rhodes here earlier 

and the work she’s doing. We are now into the next five years really making that 

not two silos but recognizing the overlap and how smoking or the use of 

commercial tobacco cessation leads to these increased health burdens or risks. 

If you look at Bemidji for the tribal leadership from the Bemidji region, we need to 

look at how it compares to the other IHS areas, and then for all of us in the room, 

compared to all United States - races within the United States. The American 

Indian Alaska Native commercial tobacco use—when you look at all this data and 

the collection methodologies, we recognize small population numbers, racial 

misclassification, regional, cultural and political variation. What does that all 

entail? We recognize that for data, sometimes we have the best intent in our 

tribal clinics and our health programs but if it’s—as mentioned at lunchtime—high 

turnover, new systems coming into place, there is lost data or there’s data that’s 

there but it’s not being obtained just because of perhaps staff turnover, a new 

system coming in, not adequately obtaining the prior data that was collected. 

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Now, this is important going forward. The Grand Traverse Band, we’re a 

checkerboard tribe- you’ve heard that phrase, our land ownings, aren’t all 

together. There are locations throughout our six county service area. We had to 

put in our tribal resources to gather the data, if it’s messaging about screenings, 

but getting out and being mobile—if that’s the word I’m looking for—into those 

outlying areas. And that’s also an important part, our tribal health clinic, part of 

our service area is an hour and a half drive. That’s a lot to ask of elders in 

today’s day and age with gas prices where they’re at as well. So we have to take 

it upon ourselves as tribes, too, to get out into those areas. Also our urban 

settings. We know that there’s high native populations within our urban settings, 

and it’s getting to those locations, too, to obtain the data that’s needed.

Funding. Scientifically rigorous and culturally appropriate. I can’t emphasize 

enough the culturally appropriate. When we look at the American Indian adult 

tobacco survey, now this was conducted and needs to be updated, but in person 

interviews were conducted by community members. In it was included traditional 

tobacco use and cultural cues. Each of the tribes administered it, so it was tribal 

specific data. And here’s the key thing, too. Tribally owned data. Ownership. 

Cause I’ll tell you what, I don’t know if you’ve heard it but I’ve heard it for quite a 

few years, our elders, they’re tired of being surveyed. Even within our own tribal 

government sending out surveys, they’re like we’ve been surveyed enough. But I 

think the key here is if you can get the ownership of why that data collection is 

necessary, and if you look at that last bullet point, approve services and 

surveillance, going back to changing perspective, if you have a council that is 

looking at not touching the smoke-free tribal facility, one way to message is if you 

look at though by putting an individual in an unhealthy environment, what are the 

health risks, what is the long health risks associated with that environment that’s 

gonna come back upon the government and the budget for healthcare services. 

Sometimes messaging isn’t as upfront as would be for us. I’m MSW so I say, 

heyDerek, don’t you want life to be better, have people you know be able to live 

longer? Yeah. But some individuals, they need to see numbers. They’ve got to 

be correlated in a means of if we don’t do this move here, we’re gonna pay that 

and/or more in meeting the healthcare needs as our tribal citizens grow older 

from working in a smoking environment. I think that’s key. And I’m sitting here 

as a council member telling you I have experienced both sides of that from a 

heartfelt message to someone needing hard numbers and making a decision on 

that. Some of the data that was collected in the Bemidji region—again, I 

apologize for those outside of it but we are in our home area here. If you can see 

the data that was collected here for never smoking, former and current smoker, 

these are rates that are also—if you look at throughout other parts of Indian 

Country, if it’s Plains, Southwest, and I mentioned Alaska, too. What’s 

interesting there is that we found out that our emphasis on traditional teachings 

on our website, if you’ve got your smart phones, keepitsacred.org. I’ll say it 

again, keepitsacred.org. A lot of information there. But in our work we recognize 

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that—and I didn’t know this—my wife is Alaska Native Ubic so I should have 

known this, but they don’t have the traditional teachings for tobacco that a lot of 

the tribes do, what they say in the lower 48 or, you know, throughout our regions 

here. But at the same time they utilize—and I wish someone was from here 

because I forgot what they call it but they have a tobacco farm and you see it 

within their youth use it, too. And I had a niece staying with us. She was in 8th 

grade at the time and here I was doing this kind of work and she came to visit 

and my wife said, yeah, she needs to chew. So for back home she did. I was 

like, wait, we’ve got a minor here, we’ve got a youth, I’m doing this kind of work. 

But that was a culturally appropriate from their trinity, their village that youth 

incorporated in their youth. I’m not saying it’s right or wrong, I’m just saying that 

we have to be very respectful of different regions throughout Indian country in the 

messaging that we’re doing to lower the use and recognizing the health risks 

associated with high use. That’s really - if you look at different regions you can 

see that high use is very prevalent and sometimes even by tribe, it’s amazing the 

numbers associated with use from youth to elders.

”Miigwetch” means thank you in this area here. And one of the information, talk 

about media resources and what messaging goes out, specific to Michigan, as 

this banner states, nearly 14,500 people die every year from commercial tobacco 

use in Michigan. Tobacco companies target youth to replace them. That’s key. 

How many of our tribal convenient stores, our C stores, our gas stations that they 

sell tobacco products, how many of them are at eye-level? Or candy cigarettes 

are at eye-level? Are we doing our efforts within our tribal communities? So it’s 

not an ease of association or it’s not an ease of acceptance. Are we really 

promoting the educational piece that we need and communicating what the 

health risks are? But, and if I can stress this again, but—the creator’s gift was to 

us as Indian people for that sacred medicinal property of Seymah or whatever 

you say, how you say it in your language, is that what we’re emphasizing, are we 

growing that? In our ways the men grow that. They grow that Seymah. Are we 

accepting that commercial tobacco in our ceremonies? Are we saying, wait a 

minute, no, we want to make a movement - a grassroots movement and say we 

grow our own in our traditional way, and then we gift it in that way. Those are 

messages, those are questions I can’t answer for everyone, but we can all do our 

part in that bigger picture. So miigwetch - thank you. I appreciate this 

opportunity to present on behalf of the National Native Network to the leadership 

around the table and those in the audience. Miigwetch.

Director Cathy Abramson: Thank you. At this time we’ll take questions.

Chairman Herman Honanie: Hi, good afternoon. (Speaks in Native 

language.)Thank you for being here to remind us and speak to us about the 

dangers of commercial cigarettes. I’m Herman Honanie, Chairman of the Hopi 

Tribe, and I really appreciate what you have to say from a cultural perspective in 

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terms of how much I’ve seen the presence of commercial tobacco in ceremonies. 

And I’d like to say that gradually, I’m seeing less of that now today because of 

our tribe had an educational tobacco cessation educator up until recently, but he 

was very involved in bringing attention to the dangers of smoking commercial 

cigarettes and tobacco, and as a result, I think a lot of men, especially men, have 

taken note and especially in the ceremonial settings. And I do agree with you 

that when prior to that education men who would bring cartons and packs of 

cigarettes into our ceremonial chambers, and many times, I heard our elders say 

in Hopi just what you said. You’ve brought sickness again. And they would go 

on to even say specifically you’ve brought what the white man calls cancer into 

our building again. And just little remarks like that have caught on, I believe, to 

educate our people that maybe there is truth to that statement and their 

observations of it. And so like I said, I think I’m seeing less and less of that 

because our ceremonial changes may be - might be a third of this area of this 

room here, and when natural tobacco and commercial tobacco was smoked, we 

were in a fog, a cloud of smoke within that and it seems to have really cleared 

up, if you will, much much so. And I think that as tribal leaders, I think when 

we’re looking at the health side and the dangers of commercial cigarettes, I think 

we owe our people that message that we have to advocate the less and less use 

of this commercial tobacco, that we should promote our own natural tobacco. 

That’s what we utilize anyway and so along came commercial tobacco. It just 

overcame the presence of natural tobacco. I’m a member of the Tobacco Clan in 

my community, in my tribe, so it’s my obligation to provide the natural tobacco for 

ceremonies. People traditionally would come to my clan and ask for natural 

tobacco and we were always responsible for always having on hand the tobacco 

and we would give to the people who were asking, and especially sponsoring the 

ceremonies. But now it seems like everybody wants to have that role and so 

that’s a cultural thing but that’s our issue but I think yourself talking about the 

dangers of commercial tobacco is a really effective way of addressing that and I 

just really want to applaud you and thank you for saying that and thank you for 

bringing that attention to our – matter to our attention. Thank you.

Director Cathy Abramson: You want to go Lt. Jefferson Keel.

Lt. Governor Jefferson Keel: Thank you. My name is Jefferson Keel and I 

apologize, I missed – I may have missed part of the presentation but my question 

is the difference between traditional tobacco and commercial tobacco—is 

traditional tobacco less likely to cause cancer? I mean is there less tar and 

nicotine and all those things in the traditional form of tobacco?

Dr. Brian King: The short answer is yes. So there’s about 7,000 chemicals and 

toxins in tobacco smoke including about 70 that we know cause cancer. So a lot 

of those ingredients are put in there during the manufacturing process by the 

tobacco company to make products more appealing and sustain addiction in 

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terms of the products. So a lot of those artificial ingredients and chemicals are 

not in traditional products. And yields a lower risk of chronic tobacco use. 

Lt. Governor Jefferson Keel: Okay, and the follow up to that is someone 

mentioned about regulation of the FDA regulating this. You know, there has to 

be a crossover there when we talk about the FDA being a federal—it is a federal 

agency and it does have a responsibility to consumers to either report its 

shortcomings or findings. But right now there’s the marijuana legal issues both in 

Colorado and Washington State. FDA doesn’t have any regulation on that. It’s 

not regulated yet. So in terms of how we develop a strategy in Indian Country to 

counteract, not just tobacco but the e-cigarettes and all those things, the ecigarettes from what I understand, are just as—they’re just as dangerous to your 

health. They create just as much of a health hazard as cigarettes. Is that 

correct?

Dr. Brian King: That, I wouldn’t agree with. So they’re not necessarily just as 

dangerous in terms of ingredients but it’s more of an aerosol but ....(inaudible)... 

significantly less toxins..... 

Lt. Governor Jefferson Keel: Is that true of the aerosol?

Dr. Brian King: They’re still investigating. In some of the aerosol studies, they’ve 

found things like metals and alkynes and Formaldehyde anda lot of it comes 

down to products aren’t regulated so there’s all sorts of things. But the studies 

are still coming out. The current science, they’re less harmful but not not harmful 

at all.

Lt. Governor Jefferson Keel: Well, I think that is the problem we have across the 

country is that people are confused. They think, well, if you use these ecigarettes,and they’re less dangerous, they don’t cause as many problems. So 

the marketing strategy there, it’s easy to catch on. How do we get past that, you 

know, particularly in Indian Country, and I understand the traditional use of 

tobacco in many cultures and I’m not saying it’s right or wrong, I’m not trying to 

be judgmental, I’m just saying how do we get to the point where Indian Country 

can say it’s safe to use these things when the studies aren’t complete.

Counselor Derek Bailey: I’ll speak to myself as well in my response. As 

sovereign tribal nations, regardless of FDA regulations, it’s upon—it’d be 

dependent upon ourselves to—in the activist legislation policies, if smoking, if 

use of commercial tobacco use, if we know the prevalence, the rates, the 

statistics just in one region isn’t alarming enough, we need to really step back 

and see what are we doing. What are we doing around this table? I’ve sat with 

you Lt. Governor, on different panels and committees, so I’m speaking to myself 

even looking past my work with the LDC. You know, what we do—are we just 

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going to go through the motions or are we gonna say, wait a minute, and we can, 

we are from sovereign tribal nations. You know, to hear someone from the 

tobacco clan speak, that was powerful to me as raising my awareness and 

understanding. I’m not at all responding in a negative way, but I know that we 

have to be more at the forefront. One of the questions I have been asked in a 

radio interview was can e-cigarettes be used in your ceremonies? You know and 

it’s like we have to start talking about what is contained, as Dr. King mentioned, 

you know, studies really aren’t that concrete yet on e-cigarettes, but if people are 

already trying to look around and say, hey, how can we incorporate in that liquid, 

you know, there’s tobacco so does that make that e-cigarette—can you use that 

in a sacred ceremonial way? There’s a spark, there’s a fire, you know, but I think 

I use that example of that question because we have to start saying within our 

communities are we giving that you know form of tobacco that’s got all the 

ingredients that Dr. King listed? Not all, because there’s 7,000 of them. But just 

think, 7,000 ingredients, powerful ingredients within that; or are we gonna take a 

stand and say, hey, let’s lead the way. The tobacco plant, the Seymah plant 

from the chairman’s nation, we’re going to grow it. And we’re not gonna accept 

commercial tobacco. We want that traditional you know used in our 

communities. That’s what’s gonna do it, regardless of waiting on regulations 

from the United States government.

Ramona Antone-Nez: Good afternoon. Thank you, members of the TAC and 

presenters. I’m Ramona Antone-Nez and I’m from Navajo Nation. A couple of 

items that I’d like to ask questions about. One is e-cigarettes in terms of you 

mentioned it as a gateway to conventional cigarettes. Is e-cig also considered a 

gateway to other drugs as before our conventional cigarettes have been 

categorized or identified as a gateway to other drugs? Is that a possibility? 

That’s one question. The other question is about chew tobacco. I appreciate 

that you had brought that up because in Navajo we had conducted the BRFSS 

which is the Behavioral Risk Factor Surveillance System in one of the agencies 

that we have five of them. In this particular finding, we found that there was a 

lower prevalence of commercial tobacco and the higher prevalence was tobacco 

- chew tobacco use. We found that to be very interesting because perhaps 

there’s a misperception that maybe it’s less harmful because there’s not that 

effects of secondhand smoke. My question is, are there prevention strategies 

that CDC is currently using targeting chew tobacco? The third one is about 

cessation programs. Is there one that CDC has or to be found effective? And if 

so, what is the success rate of that cessation program in terms of Indian 

Country? Thank you.

Dr. Brian King: Okay, so I can address all three and by all means interrupt if I’m 

not addressing them all. So the first one in terms of the gateway. In direct 

response to your question, there is potential, but we don’t have the data on that. 

And right now the studies that we have are cross sectional, which means that we 

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take information at one point in time, so we don’t get at something the 

scientists—the stuffy word is temporality, and what happens over time and what 

came first. So we don’t know if the cigarettes came first or e-cigarettes came 

first. So right now the product is so new that the science is still evolving but 

there’s a lot of studies currently in the works that would be able to assess people 

over time to see did they start conventional cigarettes first and then transitioned 

to e-cigarettes, or was it the reverse or when did it happen. Then also to ask 

people about why did you use it, when did you use it, what types did you use. So 

we’ve gotten to a point now where enough people are using the product long 

enough so that we can get at that question. So there’s definitely potential for the 

product in terms of a gateway, particularly among youth. And one intriguing 

finding that that study we did in U.S. middle high school students was that there 

was a large percentage among the middle school students that use the ecigarettes, 20 percent, one in five, have never used conventional cigarettes. And 

that’s concerning to us because these people have never had any susceptibility 

or exposure to these conventional products and now they’re using a product that 

is very similar in terms of use. So there’s certainly potential for that gateway, and 

hopefully over the next few years we’ll have some new information. In regards to 

your second question about chewing tobacco, and when you said harm 

perception, you really hit the nail right on the head. This is a very topical issue 

right now in tobacco control and the idea of reduced harm from the use of noncombustible products and e-cigarettes. And so there is an idea, a thought among 

some in the public health community and elsewhere that non-combustible 

products are less harmful and thus an effective way to promote cessation. And 

smokeless products like chew, dip, snuff and snus as well as things like ecigarettes are frequently included in that. And the response to that is that we 

know that all forms of tobacco use are dangerous particularly commercial ones. 

So there may be less harm with some of these products but with smokeless 

tobacco we usually start thinking about risk. We know that using tobacco 

products causes several diseases particularly oral cancer.

So there is a body of scientific work showing that it’s dangerous to use these 

products. So it may not be a dramatic decrease of the use of combustible 

tobacco but there’s still an added risk in that the commercial products that we 

know. In terms of the cessation program question, a lot of the evidence 

addresses all forms of tobacco use. So most of these products include nicotine 

and a lot of the times they’re quite similar in the ways to quit smoking and get off 

of tobacco use. So nicotine...therapy like the patch or the gum are still effective 

methods to reduce and quit all forms of tobacco irrespective of whether you’re 

smoking it or whether you chew. Similarly, there’s a lot of, you know, evidence 

based strategies at the population level that have been used to quit these 

products. So aside from medications, you go to counseling, even brief counseling 

but there’s one that has really added value and that’s mass media campaigns. 

And we touched on that in your questions and we know that mass media 

campaigns, such as “Tips from a Former Smokers” the CDC ran, can deliver an 

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effective message. A lot of that is through education. People may not know the 

risks of smokeless tobacco and so it’s getting the message across. And then 

also another issue is the tobacco-free policies. And there’s an increase across 

the country to include all forms of tobacco use including smokeless tobacco. And 

so particularly in healthcare facilities there’s large bans on all forms of 

commercial tobacco use whether it’s smoke, like a cigarette or a chewing product 

is not allowed. And that gets us to this whole theme of motivation(?) where 

people aren’t using these products and to shift society from a point where we see 

all forms of tobacco use including...... So the short answer to your question, 

really that we have proven interventions that we know work or implementing this 

broad landscape of tobacco products, not just cigarettes because the landscape 

is very driven by the year-to-year shift and people using other forms of tobacco 

besides cigarettes. It’s important to keep those in context .... If I didn’t answer, let 

me know.

Ramona Antone-Nez: Thank you. I asked a question about the success rate on 

cessation and perhaps your response is about the proven use of patch and the 

gum. So that helps. So just to help with my thought processes, members of the 

TAC, is in Navajo, we have a healthcare system, public health system that 

includes both federal IHS facilities and also the 638 facility. And I just am curious 

about looking into how this effect is back home; not just the rates, but whether we 

have effective programs and access to the effective methods to cessation in 

terms of the patch and gums. I’m just curious about that - how that looks in your 

neck of the country and as well as mine. So just that curiosity is now there. Just 

want to say thank you, and I do have many of the issues that were brought up in 

terms of ceremonial uses and the social gatherings and the powwow’s, etc., in 

the form of gift, and we share that as well. Thank you.

Director Cathy Abramson: I just wanted to bring one thing up. I was gonna 

announce it towards the end, but I decided to bring it up now. Keeping in mind 

the discussion about smoking traditional tobacco versus commercial tobacco, 

there is a public health - tribal public health law training that is sponsored by 

NIHB on Thursday which is free to everyone. I know that TAC members will be 

going on their site visit, but anybody else who’s interested, we’ll be doing the 

training in the end, we’ll be discussing how to draft public health law and working 

with participants to workshop-specific language that they can take back to their 

own communities. And tobacco would be perfect, you know, like the perfect 

topic, so I know in our community, so you might want to keep that in mind when 

you go to this training keep that in mind. So I just wanted to bring that up.

CAPT April Shaw: I had a question for Dr. King. So when you were talking about 

the secondhand smoke and you mentioned e-cigarette, there’s also the 

secondhand smoke; how do the potential harmful effects, how do they compare 

between the e-cigarette and then the commercial tobacco?

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Dr. Brian King: So the response to that is similar to the active use of the 

products. So right now studies that are out, it’s far less. It’s not 7,000 toxins, it’s 

70 carcinogens. There’s been 100 studies and some have found a diverse array 

of different ingredients..But in that conversation I think it’s important to think that 

our standard is really what’s in the air. And so even though there is less risk from 

....aerosol....they’re still not without any risk at all, particularly there. .....So in all 

the debates and conversations..... And so the discussion isn’t necessarily 

comparing the two so much as we really want clean air standards and so many 

of our efforts to address these products in closed environments is really to keep 

clean air as opposed to one is safer than the other. But there’s still emerging 

science on the topic but the aerosol-produced product is not without any risk at 

all.

CAPT April Shaw: Did anyone else have any questions because I have a few, 

but your questions need to come before mine. Anyone else? 

Chairman Robert Flying Hawk: Thank you. Just one question. I thought I heard 

you say - oh I’m - Robert Flying Hawk, the chairman of the Yankton tribe -there 

was a study or survey done on the native tobaccos or use? Is that what I heard 

you say or did I misunderstand that?

Counselor Derek Bailey: The American Indian Adult Tobacco Survey- it covered 

the use, prevalence, history, association with smoking but it also had parts in 

there for—others have talked about with the traditional use, ceremonial use, daily 

- incorporation on our daily lives. So that information, and it goes back to—

because again it was tribal administered and the ownership of that data 

recognizing that you’re not being surveyed by an entity somewhere, who knows 

where, but it came from within. The leadership wanted to see that within their 

tribal community was key to And I misspoke earlier. I wondered why Dr. King

kicked me under the table. I said there was tobacco in that liquid. I meant 

nicotine, and that was that association there.

Chairman Herman Honanie: Herman Honanie. I just have a question with regard 

to some of the commercial cigarettes produced. I assumed or I’m being told that 

by companies that have—I don’t know whether they’re Indian owned or whatever 

but there’s a couple of companies that put out cigarettes, are they any less 

harmful or contain less of those toxic ingredients in their production of the 

cigarettes?

Dr. Brian King: I’m not aware of any studies. I know that there have been some 

advertisements in particular saying that these products are less harmful but I’m 

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not aware of any studies that specifically said that. I’d be surprised if they were 

without any type of risk at all but it’s something like that. .... It’s important to 

remember that any time you have a manufactured product that you want people 

to purchase, it’s in your best interest to make it particularly appealing to them and 

that’s why a lot of manufacturers whether they are big (inaudible word) or 

smaller company, you know, include (inaudible word) to make products enticing 

and easier to use to build up on clientele. But in terms of specific studies 

addressing that, I’m not aware of that.

Chairman Herman Honanie: I ask that simply because about a year ago, we had 

a couple of representatives that were on the reservation going from business to 

business advocating that particular brand. Gosh, I can’t even think of the name 

of the brand, but they were saying that it’s not so much toxic-free but very, very a 

lot better than the comparable commercial cigarettes that everybody else 

produces.

Dr. Brian King: Spirit maybe? American Spirit?

Chairman Herman Honanie: Yes, I think that’s one of them.

Dr. Brian King: Yes, and that’s probably the most prolific advertisement for that. 

I’m not aware of any studies.. 

Yes, yes, certainly. So Ursula, she noted that our lab investigated that and I’m 

not aware of the findings of that so we can certainly look into that as well. 

Another issue that she noted was the filtered products, and that’s also something 

interesting to note because the filters have been modified over the years and 

they’ve located them in spots where you put the fingers that are—you actually 

have to inhale harder, and so they’ve manufactured to the point where the filter is 

in the exact location where your fingers are so that also makes it more enticing to 

the user and they have to inhale harder to actually get a kick from the product. 

So there’s a lot of manufacturing to these products that are along the lines of 

what I noted before these products are more enticing to the user. And that’s 

gonna include anything from the filter all the way toflavoring, particularly menthol.

Chairman Robert Flying Hawk: So, again, related to Chairman Honanie’s 

question of the studies. If there was a request made to have a study done of 

native cigarettes, our area in the Plains is called kinnikinnick and I’m not sure of 

the other areas but—and then the use of it was ceremonial with a pipe in a 

ceremony in moderation, I guess, was a word or in the use of it. But no studies 

have been done of tobaccos or ceremonial tobacco that was used. And I’m not 

sure if kinnikinnick what we use in Plains could be considered tobacco. It’s not a 

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leaf or anything like that but no studies, anything like that have been done, and 

could one be done?

Dr. Ursula Bauer: I’ll make a couple of points on this issue. Tribally-produced 

commercial cigarettes versus traditional commercial cigarettes and then the 

traditional tobacco versus the commercial manufactured tobacco. And one is—

so the first point is, regardless of the substance, if you burn something and inhale 

that burned smoke into your body 10, 15 times over the course of a smoke, 15, 

20 times a day, you’re going to do a lot of damage to your body, regardless of 

what that substance is that you’re burning because the products of combustion 

are inherently harmful to the body. When you manufacture that substance 

commercially and you put a filter on it, it makes it very easy for you to inhale that 

product very deeply into your lungs, you’re gonna do a whole lot more damage 

and that’s one of the differences between traditional tobacco and how you use it 

ceremonially and commercial tobacco and how you’re smoking that to the filter 

deep into your lungs versus smoking through a pipe, keeping that smoke largely 

in your mouth and exhaling it in your ceremony. But as soon as you take—and 

then there’s the difference of the ingredients in tobacco, the tobacco plant with 

nicotine versus some of the ingredients in traditional tobacco which may include 

some of the nicotinyl plants but may include a lot of other natural plants as well, 

so the nicotine levels are very different. Maybe non-existent in the traditional 

tobacco. In terms of a product like American Spirit cigarettes, there are lots of 

additives in that manufacturing product and they are trade secrets and they are a 

secret sauce from Marlboro to Camel to American Spirit, but they all contain 

nicotine, they all contain tobacco, they all contain a lot of these products that 

make it easier and smoother for you to smoke, and they all burn the smoke into a 

filter and into your lungs. So the health difference between a tribally 

manufactured commercial cigarette and a Phillip Morris commercial cigarette is 

not going to be detectible, likely, in any kind of study.

Counselor Derek Bailey: I think the key words that come down to me is 

manufactured and homegrown, and if it’s any type of manufactured—you have 

the statements that Ursula just mentioned and Dr. King went through that are 

homegrown. I go back to that’s a gift from the creator. However you, in your 

own language, traditional language,visionist language, how you speak to that—I 

want to be very clear here, too, Director Abramson, that I am in no way 

advocating for the non-use of Seymah in our ceremonies because that was given 

to us in those teachings. I carry a pipe myself and we’re taught—when you talk 

about inhaling this. Those are English words to describe our ceremonial use of 

Seymah, and I don’t want to be putting a light but I’m saying we can’t use that in 

our ways. In fact,I advocate strongly for that because that’s what the creator gave 

us as the Nishnabic people to help with our spirituality and our ways and our 

beliefs and to draw from that and know what we do with that and why that goes 

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on. And we know that in this room. So I don’t want to get to the point where I’m 

saying we be free of that in our ceremonies and that’s why the messaging within 

Indian Country is different for the National Native Network as it is to others within 

the National Network. We can’t lose sight because that’s who we are-(speaks in 

Native language)- who we are, as the ways and the teachings that our ancestors 

held. As ancestors today of future generations, we’ve got to keep that in mind, 

too. I appreciate those comments but I just had to say that. I couldn’t not 

respond to that.

dDirector Cathy Abramson: Oh, I didn’t think—I wasn’t thinking in that way. We 

just have to sit down and have a long discussion, that’s all. My mind is going ten 

million miles an hour, too. Any other – okay, Andy?

Council Member Andy Joseph, Jr.: I guess myself, I can’t stand smoke. It’s hard 

to be around it when we know that there’s all these ingredients in the different 

tobacco products. To me, that little warning on the package isn’t good enough 

and I think our government should do something more severe about it. At home, 

we do have our traditional type of tobacco and it isn’t anything like what is grown 

back this way. We go in our mountains and pick different plants that are out 

there that we use in our pipes. I was given a pipe in one of our sacred 

ceremonies that we have in the wintertime and when I use it, I use it for prayer 

and for healing, asking for things to go good for our people. But seeing children 

buying or getting access to cigarettes is something that I think the government 

really needs to get a handle on. I know our tribe benefits from tobacco taxes and 

things like that, and it just drives me nuts because I know it’s probably causing a 

lot of the deaths that happen throughout our area. And to me, it just don’t seem 

right - that all those ingredients should be outlawed. At least if it was natural and 

people took part in it, I think you’d probably cut down on maybe half the people 

that it kills. But they keep allowing those big companies to put all them 

ingredients in there. We’re just gonna be talking about it again next year and the 

year after.

Director Cathy Abramson: For the committee’s interest, a Great Lakes Epi Center 

study recently published in the Journal of Preventative Health featured 

permission to access the casino patron database to investigate patron 

perceptions of smoke-free preferences when visiting a casino. Results and 

patrons prefer a smoke-free environment and would visit more frequently. So if 

you want more information, call Kristin Hill at the Great Lakes Tribal Epi Center. 

She’s right over there in the front row. Wave Kristin.

Chairman Herman Honanie: I just want to share something. I was down in 

Prescott, Arizona a week ago and we stopped up at this little mall and right 

across from the Yellow Pie Tribal Smoke Shop—and I didn’t know that was there 

but we just parked right across, a Target was next door. So I just stayed in my 

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truck, and I watched and I realized that that was a smoke shop and I watched it 

for about 15, 20 minutes. I just could not believe the number of people going in. 

At the end of that 20 minutes or so, I was talking to my grandson and says, 

watch - help keep count because I can’t keep up, I said. But within that 15, 20 

minutes we saw about—I’d say at least 110 people come and go from that place. 

I was just amazed at the number of people there. And then some of these 

people weren’t just coming out with packs, they were coming out with cartons. 

So I told my son, I’m gonna go into the tobacco business and make a lot of 

money, I said, because they had to have been making a lot of money. I mean, 

you know, individuals would come out with two or three cartons of cigarettes, and 

there were at least a half a dozen that I saw do that. So there’s a lot that we 

need to do among our own communities. Most of these—or in fact, all of these 

individuals, were not Indian but it just kind of gives you a picture of how much –

how many people do engage in cigarette smoking and so forth. So I wouldn’t 

doubt it if we - our own people are just as much—a very, very active part of that 

population. But that was really interesting that I saw and observed sitting out 

there looking at people.

Director Cathy Abramson: Anybody else? Thank you very much. That was very 

interesting. Yes?

Counselor Derek Bailey: Only two things here. Just to recognize that also this 

week, Friday from 9 to noon IHS director of the Bemidji area listening session 

going to be held at this resort and a flyer for this weekend powwow, our tribe’s 

powwow, going to pass that around. Please see me if you have any questions.

Director Cathy Abramson: And just a reminder, please silence your cell phones 

to anybody out there that has cell phones. And we get a 20 minute break 

because we are so good.

END.

Environmental Health Panel

Director Cathy Abramson: We’ll start with our Environmental Health Panel. We 

have James Stephens, Acting Deputy Director for the National Center for 

Environmental Health, and Judith Qualters, Ph.D., Director of the Division of 

Environmental Hazards and Health Effects. And they’re both from CDC. Was 

there somebody else that might join them? I’m not sure.

Director Cathy Abramson: Okay, welcome. Thank you.

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Dr. James Stephens: Thank you for the invitation to come and speak. I’m Jimmy 

Stephens, Acting Deputy Director of NCEH/ATSDR. I understand from some of 

the past TAC meetings you expressed an interest in environmental health. I’m 

really delighted to be here today and there’s sufficient interest for us to come out 

and have a nice chunk out of the schedule. I was also delighted to hear that you 

wanted a relatively few number of slides in our focus on discussion. That’s great. 

This is my first TAC meeting in my position in NCEH/ATSDR but I did attend a 

TAC meeting a couple of years ago in a different job, and I was really amazed at 

how much I learned from that meeting and how useful it was and how important it 

was to be able to hear your concerns and challenges and to understand how to 

better engage, and I think we should keep it all in. So I’m really looking forward to 

the discussion this is a very important. So Judy is here. Judy is the Director of 

the division that houses in partner and hold two of the main issues that I 

understand the TAC is interested in the past and it’s water and climate change. 

So I’m gonna go through the slides, but we’ll all be available for discussion and 

questions after.

So the first topic that I understand there is great interest in was water. Of course, 

water disinfection is a great public health success story from the last century and 

led to a dramatic decrease in water-borne diseases since 1900. Currently, water 

is regulated, in large part, by EPA under the Safe Drinking Water Act, and 

through the Safe Drinking Water Act, EPA regulates drinking water supplies in 

about 155,000 water systems, and that covers about 85 to 90 percent of the U.S. 

population. Through the Safe Drinking Water Act, the EPA sets maximum levels 

for over 80 contaminants and that includes both organic and inorganic chemicals, 

metals, and all sorts of organisms. But the Safe Drinking Water Act does not 

regulate drinking water systems that serve fewer than 25 people or are in 

different connections, so these private wells and unregulated small drinking water 

systems and the federally unregulated drinking water systems serve about 45 

million Americans. So the problems with the unregulated systems, of course, in 

the first place, there’s a lot that is not known about these systems including basic 

things like where the locations are, the populations that are served, and the 

potential contaminants and other risks that are associated with these unregulated 

drinking water systems. There are some small studies that have found in specific 

instances unsafe levels of contaminants in private wells, and they’re a few listed 

on the slide. But there’s still a lot we don’t know about the unregulated systems. 

Some of CDC’s activities around unregulated drinking water includes 

characterizing exposure to health risks and health impacts, and our role in 

NCEH/ATSDR is in the non-infectious drinking water contaminants. And we 

currently have worked with USGS and academic partners to model potential 

contaminants in private wells. We are developing guidance on developing 

effective evidence-based interventions around drinking water and really working 

with various groups to identify ways to get people to test their well water and 

implement it in emergencies if necessary. And then we are also responding to 

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environmental emergencies that impact regulating drinking water. For example, 

there was a recent publication looking at resulting focus work - focus groups with 

individuals in Arkansas, Indiana and Oklahoma, looking at public health concerns 

around drought and how has affected the drinking water supply. 

Two tribal activities that I wanted to highlight. The first is the Navajo Water 

Hauling Studies, which is from 2006 to 2010, and there’s about 14,000 

households, which is about 30% of the households in the Navajo Nation, that are 

not connected to public water, so the majority of the households are using water 

that’s not regulated in the Safe Drinking Water Act. In some remote places, 

water is hauled to households from untreated sources, such as ditches and 

agricultural crops. So between 2006 and 2010, CDC worked with Navajo Nation 

and EPA to characterize the risk of drinking water in certain areas. Conducted a 

survey of households to confirm the sources of water and potential health risks, 

identified unregulated water sources that exceeded allowable arsenic levels 

under the Safe Drinking Water Act. Worked with the Navajo Nation and EPA to 

develop education materials for the community on health risk and water testing, 

and the results of this work will be used to inform water hauling services.

The second activity, as I mentioned, is an ongoing effort for the National Tribal 

Water Council, and this is a project to assess the knowledge, health attitudes and 

practices related to water systems among tribal members.

Let me move on to the second area that I was told was of great interest to this 

group, and that’s climate change and health. So there’s a lot of concern about 

climate change. Our specific role is looking at the health affects that might be 

associated with climate change, and I’ve listed sort of four major categories of 

health risks here. The first one is extreme heat. It’s interesting that extreme heat 

is actually the leading weather-related cause of death in the U.S. So, for 

example, from 1999 to 2009, extreme heat exposure caused almost 8,000 

deaths in the United States. And then there was also additional morbidity 

associated with that and increased hospital admissions, for example. As one 

example, in 2006 the California heat wave resulted in 16,000 visits to the 

emergency departments. And we know that extreme heat events are increasing 

in the United States, not only in frequency, but also intensity and in how long they 

last as well. 

The second area of health impacts is related to reduced air quality. So increased 

temperatures can increase things like ground level ozone, smog that’s why in the 

summer, of course, you have more bad air days, especially in urban 

environments. Also those expected to increase the frequency and severity of 

wildfires. There is some evidence wildfire season has already increased by 7 or 

8 days on average and the duration of fires is, like I said, due to the increase of 

smog. And, of course, wildfires traditionally obviously starts with the fires 

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themselves create particulate matter in ozone and you have health impacts far 

beyond the location of the wildfires. 

The fourth area I want to talk about is vector-borne diseases, so diseases that 

are carried by, transmitted by insects, and that includes things like for instance 

increase in Lyme disease due to increasedtick populations or mosquito-borne 

diseases from increase in mosquito populations. And then finally, extreme 

weather itself can have an effect from extreme precipitation events, heavy 

rainfall, flooding or on the other side drought, deaths from drowning, respiratory 

illnesses related to having damp indoor environments, dust storms. And then 

also related to previous slides on water quality, these events can also reduce the 

quality of water sources. CDC has the climate-ready states and cities initiatives. 

This is looking at enhancing the capacity of state and local health agencies to get 

the feel of challenges. We have the BRACE framework, Building Resilience 

Against Climate Effects, which can be used by organizations to help prepare for 

the results of climate change, and Judy can talk about that in more detail when 

we get to health effects.

Let me just go through just a few other things quickly, there’s a - which you may 

or may not be aware of - there’s the Navajo Birth Cohort Study. This is looking at 

areas, which since the 1930’s, have had extensive uranium mining and milling in 

the Navajo nation. And while there’s been many studies of environmental and 

occupational exposures to uranium associated renal affects in adult populations, 

there’s very few studies of other adverse health effects. The goal of the study is 

to recruit 1,500 pregnant mothers, evaluate their exposure and the exposures of 

their unborn child and then follow the children for adverse birth outcomes and 

development delays and the goal is to follow these children for two years after 

birth. The results of that are anticipated 2015, I think. Landfills is another area 

we’ve done, we’ve had some site-specific work on landfills a number of places 

around the country. Some of the common exposures concerns here are listed on 

this slide. Probably the leachate contamination probably is the most common. I 

did also want to point out this third bullet on odors and air quality. ATSDR has 

recently posted a website that’s on odors, and it’s a great resource. You can go 

and you look up, even search for odors that maybe smell like such-and-such that 

it’s just likely we have a lot of frequently asked questions and advice on what you 

can do if you’re concerned about odors. And then finally I’ll just mention a couple 

of other things we’re working on. Environmental Public Health Tracking. So 

public health tracking is the ongoing collection, integration, analysis and 

interpretation of data about environmental hazards, exposures and health effects 

that are potentially related to exposure to environmental hazards. And I wanted 

to highlight this year, the environmental public health tracking program launched 

in partnership with the Bemidji Area Tribal Environmental Public Health Advisory 

Committee and the Great Lakes Inter-Tribal Epidemiology Center to assess and 

begin to plan how different data sources can be brought together to link 

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environmental and health outcomes to the tribal level and work towards 

enhancing information sharing and collaborations and communications in the 

agencies. One final topic is radon. Radon is the second leading cause of lung 

cancer after smoking. And there’s a Federal Radon Action Plan with the goals of 

raising awareness and creating centers on the use of radon exposure in homes, 

incorporating radon testing and mitigation with federal partners investing in new 

standards practice and updating codes for the measurement and mitigation of 

radon and establishing the center’s dry...testing and mitigation in private and 

public sectors. And CDC has been working with EPA and others on helping to 

raise awareness of radon and encouraging people to incorporate radon to 

healthy home activities and encouraging partnerships around radon.

So with that, that’s a very broad coverage of a lot of different things. I mean, if 

there are other environmental health issues that this group is interested in that I 

didn’t list on the slides, I will be more than happy to respond to any questions.

Chairman Herman Honanie: Hi, good afternoon. Herman Honanie, Hopi Tribe. 

I’m just kind of curious about the arsenic matter. I think a lot of tribes in the 

Southwest, including Navajo, has that challenge, has that issue and problem at 

present. So my question generally is, is there any component from your 

department that’s really strictly putting a lot more study of this particular issue, 

and what progress has been made in studying arsenic? I think someone did 

explain where it comes from or where it generates and so what can really 

effectively be done to water systems now at this point when they’re being found? 

I know it’s supposedly a really, really costly step to be able to mitigate the 

presence of arsenic. So could you speak about that a little bit more?

Dr. Judith Qualters: So arsenic is actually a priority for us in moving forward in 

our strategic plan in my division. Arsenic, uranium and the nitrates is the other 

area that we’re concerned about, too. Those two, arsenic and uranium can be 

naturally occur and cause significant health risks. So we are doing a couple of 

things. Jimmy mentioned one. One is, you know, a lot of this is private wells, so 

we have been trying to get a better handle on the data that’s available that’s out 

there and what isn’t available so we can get a better handle on what’s really 

going on with private wells. This was started a couple of years ago with what we 

call the Private Well Initiative, and we’re continuing to move forward in looking at 

how we can utilize data that’s working with states and states have been able to 

identify in order to understand what the level of contaminants are, so not just

arsenic but other things. The other thing that we’re doing is, since these are 

private wells and it is hard to get that type of data, we’re also working with USGS 

and others to look at some of the ground water sampling that they regularly do to 

see if there’s a way to statistically model that data so that we can get an idea of 

who would be vulnerable to higher levels of arsenics based on some of these 

statistical miles so we can target where to do interventions. The third thing we’re 

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doing is really looking at and working with the National Private Water Council, 

and getting a better idea of how some of the tribal communities, what their sort of 

knowledge, attitudes and beliefs are around the water that they’re using and not 

only their private wells in terms of how they test them or what sort of testing is 

done, but also sort of the infrastructure, the water system infrastructure and how 

sort of their ownership of it and what may be blocking a more sustainable 

infrastructure for tribal communities. And then, I could say the other thing we’re 

doing is we’re looking at what are potential interventions, and we hit on it - one of 

the ones we know we have tested in some places is related to what’s called 

reverse osmosis that can be used to remove arsenic. It works well for one type 

of arsenic. We need to add another piece of equipment for another. It can be 

installed inside the home or outside the home as a whole system, but it can be 

expensive and the parts can be expensive. So are there more cost effective 

ways and what are the cost effective interventions that can be utilized. And if 

that is the best thing, what are ways to partner with others to try and get 

knowledge about that. So I hope that answers your question.

Chairman Herman Honanie: To a point it does, yes, because we have a huge 

presence of arsenic on the reservation, and right now, we’re doing what’s called 

a Hopi Arsenic Mitigation Program. All we’re doing is basically drilling a couple of 

wells away from all the communities, and we’re going to have to pipe it into the 

communities that are adversely affected by that which is really going to be costly. 

It will, I guess, resolve the situation but at the same time right now people are 

consuming it, so the question with regard to health is what happens when people 

have been drinking water with arsenic all their lives pretty much?

Dr. Judith Qualters: I think it depends on the level of arsenic in the water. 

There’s certainly - there’s a standard for arsenic that the EPA has set, so it’s not 

zero. Off the top of my head I’m blanking right now on what it is, but so it 

depends on the standard that has been set and what the level is in the water. 

You know, there have been studies that have looked at very high levels of 

arsenic as it relates to skin issues and cancer, other things like that. But again, 

it depends on the levels that people are exposed to, so there is a considered safe 

levels that are regulated change but there is a safe level right now or a level that 

is considered acceptable. So I think it would depend on what the levels are to be 

able to say what the risk was. I know this is an issue for your part of the country, 

it’s an issue certainly for the Northeast and other parts of the country, too. It 

seems to be sort of a cross country issue.

Chairman Herman Honanie: So one final question. You state, and I’ve heard this 

before, too, it’s naturally – it occurs naturally. What and how does it occur?

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Dr. Judith Qualters: It’s some of the heavy metals like arsenic, uranium and 

others are part of the earth’s crust. So whenever you dig into the crust and you 

get to areas where those metals tend to be available, and so that’s where they 

come from. Now, that doesn’t mean that there aren’t manmade and other 

processes that also generate those types of metals, but really the private well is 

one of the biggest issues is just digging into the earth’s crust where those metals 

exist.

Council Member Patty Quisno: It wasn’t mentioned in part of your presentation, 

but I’m wondering about mold because it is water connected. We’ve had several 

floods in Montana and several reservations have been affected very, very much 

by mold. Can you tell me about the different kinds of mold? I mean there’s mold 

that doesn’t seem to be harmful and yet there’s mold that just—there’s a man in 

our area that is - he’s lost 40 pounds. He is very, very sick from some kind of 

mold.

Dr. James Stephens: I’m not an expert on these different kinds of molds. I know 

we have, we hear a number of different documents and there are some 

guidelines developed after Hurricane Katrina and a few were around mitigation. I 

know there are some documents out there I can connect you up to some of them. 

I think, I know the last time I worked in the community there’s a lot of unknown in 

terms of mold exposure including and what the health effects are but I think there 

is a pretty well established process).

Council Member Patty Quisno: That are left, aren’t there? I mean I hear about 

toxins in relation to mold.

Dr. Judith Qualters: I have to defer to our mold expert.... But I think part of the 

issue is the days and days after flooding that there’s really—there are guidelines 

in terms of how to clean up. We went through this with Sandy and other after 

storm response in terms of being sure that things dried out appropriately and 

making sure people have the correct guidance....and others to, you know, how to 

clean up so that they .....

Council Member Andy Joseph, Jr.: Up on Colville Indian Reservation, we have 

the Great Columbia River and our neighbors across in Canada, Teck Cominco 

has a mine up there and they dump their slag into the Columbia River, and I 

believe it’s affecting a lot of our people because of the different cancers that are 

coming up, but also when they run their smelter, the air-borne chemicals that drift 

down into the United States are – you know, it settles and goes into the streams 

and up into our lakes and the bottom, the fish that have to live in that water have 

high levels of mercury and different other toxic chemicals that I guess it could 

lead to like irritable bowel syndrome and different illnesses. That’s one issue. 

Another issue that I really worry about nationally is the clean water, what you’re 

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doing to, I guess, regulate what’s being allowed with all of the oil and gas 

exploration, the fracking that happens. I’d like to see a map of how much area 

there is of the United States that has - actually has any clean water left. 

Hopefully, we’re not going to end up like China and have to clean seawater to 

bottle up for people. I’d hate to see these great lakes around here become 

contaminated with all of the different fracking that they’re doing. It’s gotta go 

somewhere, and I think we need to be let known what chemicals are being put 

into the aquifers and if they’re gonna cause us even more harm than what it’s 

really bringing forward.

Dr. James Stephens: Thanks for those comments. We’ve had a little bit of 

engagement on fracking, for the most part, our goal has been to support EPA 

because EPA regulates the contaminants in water. We have done several sitespecific—I think we’ve done some health assessments at about 10, I believe, 

fracking sites. It’s turned out to be fairly challenging for a couple of reasons. 

One is that in a lot of cases, we don’t have the baseline data, so we can’t go and 

look at the same thing when the fracking started...affecting the water quality and 

sorting out it was due to fracking. And then the other thing is these - forget what 

it’s called - the liquid that’s used in fracking is a proprietary mixture so we don’t 

always know what’s in there. But there have been a number of discussions 

among federal agencies and we’ve been at the table based on the health impacts 

because there’s a lot of concern about fracking involving these health impacts.... 

Like the GSBS, EPA and EDOU that are leading the efforts looking at fracking 

run-off.

Dr. Judith Qualters: They actually just published their plan, so we can provide the 

link to that...

Ramona Antone-Nez: Ramona Antone-Nez, Navajo. Thank you for your 

presentation. In a follow up question to what was brought up by a tribal leader 

about mold, what are the significant impacts of health when exposure to mold 

happens as related to asthma? Does your office have such information? In 

addition to the question, what activities or programs are available from your office 

or from CDC to Indian Country regarding mold? Another question that I have 

about fracking is I understand that you just provided the other offices that provide 

guidance, and I’m curious about the published plan in terms of whether there’s 

research that’s available through your office or if you could assist us with access 

to resources on the health impacts of fracking water - to the water supply. In 

addition to those two questions, I just want to also share with you that we do 

appreciate the Navajo Birth Cohort Study that is being conducted here at the 

Navajo Nation, and the Navajo Nation has continued to advocate for a long term 

study on the health impacts of uranium contamination exposure and 

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environmental health cleanup efforts. We understand that there are some efforts 

that are being made; however, because of the long, the half life of uranium and 

the byproducts of uranium, we will continue to advocate for that need to be 

addressed. I do have a question about the comparison of uranium in the 

Southwest regions, as you had put it, as you have talked about your Navajo 

water study in comparison to the non-Southwest regions. Are the contaminants 

much greater than other regions? And I also think that—I can imagine in my 

mind that there’s a mapping of the different regions of Navajo and there are 

places where are identified for water wells to not be used by humans, like it’s 

regulated. However, the water is still being used for consumption by our 

livestock. So I’m just curious if those connections are with your office or not. 

That’s a background question I had for you. The other is, as you will hear in our 

testimony tomorrow, that the Navajo Nation recommends to ATSDR to provide 

additional funding to support a position such as an epidemiologist, a statistician, 

a data manager or demographer and health educators that would address both 

the Navajo Birth Cohort Study but also the other health issues, or environmental 

health issues that are on Navajo. Just want you to be informed since we’re 

talking person to person that these are part of the testimonies that we have. We 

also have another leading cause of mortality is unintentional injuries on the 

Navajo Nation, and we see this as an environmental issue and we will advocate 

as we did during the February meeting that funding allocations be increased to 

prevention activities, how your program or your ATSDR relates to and helps with 

the funding allocations is one of - something I need to learn and understand 

better but because of the unintentional injuries as related to how our 

environmental health and public health issues are addressed, that would be part 

of the justification for additional funding. Thank you.

Dr. James Stephens: So I’ll try to respond to the things. Some of the points I’d 

forgotten so Ms. Antone-Nez let me know. So the first one’s on the mold, I think 

maybe the best thing would be if there’s a particular mold, maybe you can get 

some materials that have already been developed that will be number one ...so if 

you are interested you can talk to me and we can get you some of that material.

....Or if you identify any gaps in material may need to develop additional material 

You asked about fracking, and I’m sorry, I’ve forgotten what was the specific 

question

Ramona Antone-Nez: I just want to go back to the mold issue in terms of the 

relationship to asthma, if you have the rates on those as it impacts health? And 

back to the second one about fracking just to continue on is what research and 

guidance is available regarding the impacts of fracking to the water supply? 

Thank you.

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Dr. Judith Qualters: So I can’t give any numbers on how much asthma is 

attributable to molds, but I can tell you that mold is a trigger for asthma attacks, 

along with other indoor allergens and outdoor allergens. So it is a trigger. You 

asked specifically if we have some programs related to mold or asthma, specific 

for Indian Country. And right now we do not, so I think you have to work with 

many a number of states but we do not have any programs that are specifically 

targeted to Indian Country so that’s another gap. I think that was all the asthma 

things.The other is the health impacts related to fracking and specifically related 

to the water supply. I think there’s not a – I’ll start - .... So there’s kind of a 

dearth of epi, epidemiologic literature on fracking. I think that we don’t know a lot 

about the exposure to begin with to really know about the health impacts. As 

Jimmy said earlier, ATSDR had done some health consultations and public 

health assessments and those will be available on the web, and we can get you 

a web link for those. Those would be very site-specific in addressing specific 

questions. There was—if I could find it—there was, I know, a recent review of

the literature and there’s not a lot of literature but I’ll see if I can find that link to 

share with you guys about fracking and what we know and don’t know related to 

health. And then in terms of water supply, I think the issues that have arisen in 

the general discussions have all been around two areas. One is obviously does 

it result in contamination of ground water and then the other one is related to 

water availability and resources especially when you have areas that are 

impacted by drought because it uses a lot of water.

Dr. James Stephens: I think we have – I think up to ten sites where we’ve done –

10 or so sites - we’ve done fracking, I think all of those publications are available 

on our website, I think all of those with the exception of one of them is ready for 

public comment. I think you’ll look at it and you’ll see what some of the 

challenges are. I think as Judy said, in a lot of cases—normally our role is to 

support EPA. So EPA is going in and doing the sampling and looking at sort of 

what the exposures would be and looking at the health impacts. I guess my 

general take at this point with fracking is that there’s—as Judy said, there’s a lot 

to learn about the exposure so I think we’re still in the very early stages. One of 

the other points you mentioned was unintentional injuries. I actually just recently 

came from my previous job as deputy director at the injury center, so I won’t try 

to speak on their behalf. Of course, that would be in their area. 

Council Member Andy Joseph, Jr.: I always wanted to know if there’s ever any 

studies on boarding school children that—I know for a fact that the big boarding 

school that I went to down in Brigham City, Utah, Inner Mountain Indian School, 

was shut down because all of the pipes were wrapped with asbestos. I just - we 

didn’t know what those pipes were wrapped with and we used to do chin-ups on 

them. Being kids, we were - used what we could to exercise with. But I know 

there was a lot of risks that we’re exposed to asbestos for quite a few years in 

our lives, and I was always wondering if anybody ever studied to see if that 

impacted the students. They shut that school down because of it.

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Dr. James Stephens: Yeah, I don’t - I haven’t heard of anything. I mean, there’s 

certainly a lot of literature and a lot of information on. asbestos exposure and 

remediation. I’m not familiar with any study specifically.

Dr. Judith Qualters: You had one other question related to uranium and the water 

hauling studies. Those were a series of studies over time with the Navajo Nation 

and Navajo EPA, and I know the results of one of them—well, one of them 

actually did supply one and so they looked at the levels ....samples, and what 

they found was that the levels were higher than the U.S. population and probably

comparable to the Southwest population.....

Chairman Herman Honanie: Herman Honanie. On what you just stated with 

regard to the water hauling system and so forth, since I guess we’re in the 

neighborhood of Navajo and we still have a lot of people hauling water for 

domestic use as well as for our lifestyle. Now, could that same assessment in 

the study be applicable to a general area?

Dr. Judith Qualters: I think I’d have to look at the studies again and read because 

I know the original study identified, sort of five regions that were of higher 

risk...And then the second study went in and looked more specifically at what 

people were actually being exposed to. And I think there was a third study and 

then there was a study since then..So I think it’s - it was targeted at specific 

areas and I would have to go back to investigators to get a better idea of how 

generalizable they thought the results were to other areas.

Director Cathy Abramson: Have there been any studies done on finding crafter 

ways to mitigate pharmaceuticals to clean water?

Dr. Judith Qualters: We have not done any. I do not know. I’m sure that there 

have been some. We could probably look and see what’s out there but we have 

not done any.

Dr. James Stephens: Yeah, the studies I’m familiar with were not done—were not 

our studies essentially the studies looking at trace wells and water supplies. I 

don’t have a good sense of what the studies are, I think that’s a technicalstudy.

Dr. Judith Qualters: I was saying I don’t know if the focus was really mitigation at 

this point. Just trying to quantify what was in the study.....

Director Cathy Abramson: Is, could you illustrate how you worked with IHS 

Environmental Services? Do you?

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Annabelle Allison: For the Navajo Birth Cohort Study, we are working with the 

Navajo Area Indian Health Service. We’ve actually provided some funding to 

them to be able to get the necessary equipment in the 

laboratories......templates.. And then we’ve also worked with them in terms of 

recruiting and then the National Tribal Water Council, they are working really 

closely with IHS.....

Dr. Judith Qualters: Thank you. Ancient history. I know when we were first doing 

some information gathering, these are requirements gathering, around the 

tracking network we actually pulled some folks in from Indian Health Services 

trying to get an idea of what type of data they could use and how they would do 

something like that 

Board Member Cathy Abramson: Thank you. 

Chairman Herman Honanie: I have a question with regard to your landfill 

presentation. Could you explain the first bullet that you have there regarding 

Leachate contamination of surface and ground water?

Dr. James Stephens: Yeah, so basically what that’s - so landfills normally—at 

least modern landfills, have liners and an open path to prevent water from 

leaking through the landfill and taking contaminants off and they’ve got barriers in 

place for decontaminationeither if it’s an older landfill that doesn’t or something 

that barrier’s...so concern ...if not being held there...water’s coming through and 

taking contaminants off . And, of course, then this can be a special concern if this 

is going to create some sort of hazard.

Chairman Herman Honanie: My other question has to do with the long drought 

that especially the Southwest is having - experiencing and I used to hear about 

rain cloud seeding and things like that but it just seems like there’s so much talk 

about the drought but in effect, what, if anything, is being done to mitigate it in 

any way whatsoever to work with mother nature?

Dr. James Stephens: I’m not sure we have an answer to that. But I know we talk 

about that ....and also the drought. 

Dr. Judith Qualters: I don’t think we have an answer to how to mitigate mother 

nature, but I do think part of the work of funding a health program is to help 

communities identify what their vulnerabilities are, who the vulnerable 

populations are and what their efforts would support. So in the Southwest, in 

California, the last few years, there’s been a drought that’s hitting hard. Last year 

was a big year for facilitation and flooding in other areas. So what we’re trying to 

do is work with folks in terms of predicting what is the biggest problem they’re 

going to face and to think about how to address that. So if it’s drought, what do 

we need to think about in terms of (inaudible). What are we thinking about in 

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terms of hauling water to keep the population healthy? It’s flooding, it’s storms 

you know it’s (inaudible word) to work with partners to (inaudible word) the 

buildings, (inaudible), and to take other actions that helps impact our health of 

the communities. (Inaudible) droughts, sandstorms probably. That’s not a good 

answer. We don’t have any way to mitigate the drought. We just have to talk 

about in terms of whether.. systems can be put in place that actually help people 

that are affected by it. And it is something that will have a health effect.

Ramona Antone-Nez: Thank you. This is Ramona Antone-Nez. I am just 

thinking about my home and that is in Navajo. We recently were – we recently 

combated, if you will, a wild forest fire that had taken place and what our 

emergency command officer had informed us about through the emergency 

preparedness is the next thing that we should – the next events that we should 

expect is floods from the thunderstorms and the rainfalls that come, and we have 

a lot of wash-away that happens from the erosions and flashfloods, etc. I’m just 

curious about this - your slide that talks about climate and health, Climate Ready 

States and Cities Initiative, Building Resilience Against Climate Effects 

framework, and I’m curious about that possible framework working with 

emergency - public health emergency preparedness. Is that part of the 

collaboration in that framework? And secondly, in that same light, can you see 

down the road that perhaps your center, the ATSDR, would be able to put on this 

particular bullet climate ready states, tribal and cities initiative to bring us to the 

forefront in terms of our territories, our lands, how can we address these climate 

changes and preparedness, because part of the issue that we have is states 

might get funded through a federal agency; however, the services and the 

objectives and activities that are claimed in those funding streams may not 

necessarily get to the tribes, which have been identified in the actions plans, the 

activities, or we’re brought to the table after the fact, or we are consulted via 

telephone ten minutes, and it’s a checkmark that, okay, that’s tribal consultation, 

that’s tribal advisory, that’s the way we worked and therefore make that particular 

scope of work activity. So I’m just doing a down-the-road, is there a possibility to 

see climate ready tribes, state and cities initiative? Thank you.

Dr. Judith Qualters: So I’ll take the last one first and I’d say yes. I think there’s an 

opportunity to see climate ready states - local, state, territorial and tribal initiative, 

and we are actually—it wasn’t on the slide—we do have one project right now 

that is working –doing some work in Alaska looking at some three different sets 

of communities and seeing how climate and the changes around it may impact 

the severaldifferent sections of the states. I think it’s seven communities. So 

they’re looking at groups in the southeast, west, they’re looking at some groups 

in the interior and then in the (inaudible word) regions to see, you know, what 

they’re observing in terms of changes as it relates to weather and how it’s 

affecting them. And certainly in the northern part, it is primarily Tribal Native

Alaskans and other groups and certainly a big issue for them is food security and 

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additionto changes as it relates to pollen and other allergens and increase in 

respiratory diseases that they’ve heard before. So we are doing some work in 

that and I could see that expanding also to other tribal groups. What’s the other 

question? Oh, emergency response. I think we think of the climate and health 

program and the work that we’re doing as definitely having a link to emergency 

response but not being totally an emergency response situation. So definitely 

thinking about it when we get into those situations of extreme weather and what 

might be the health impact of those. And then issues around wildfire, and then 

also the other issue is, you know, the issue around climate is that we are looking 

at is if you increase CO youincrease heat you have longer pollen seasons. So, 

we have other things going on with—for instance, we have geographic framing 

for Lyme disease and other things. So emergency response is definitely linked 

so we try to link to that but we also try to go beyond that in terms of 

preparedness.

Ramona Antone-Nez: Thank you so much for all the time that I’m taking. I just 

want to say another addition to your climate change and health slide when you

talked about the vector-borne diseases. In the Southwest, particularly one of the 

vector-borne diseases that we are precautioned of in preventing or treating is the 

Rocky Mountain spotted fever. As you just described how with the climate 

changing and having shorter winters and one way of having the ticks are living 

longer or they don’t have a die-off season, etc. So I’m just - for this tailoring, I’m 

not really sure how Rocky Mountain spotted fever may or may not affect other 

Indian communities but in ours, I could see that as an effect in our region. Just 

FYI. I’m sure you already know thatthank you very much.

Chairman Herman Honanie: Part of what she said, it’s interesting and one of my 

personal challenges is having to do with vectors and other small animals and 

their presence and their impact on our farming. I’m talking about packrats and 

especially prairie dogs. Years ago, my dad would bring some strychnine and mix 

it up with some ground corn and spread it around the outskirt of the field and the

problem would go away. But now we can’t have access to any of that thing, so 

it’s really a challenge. I farm along with about seven individuals totaling about 

maybe – I don’t know - maybe 15 acres of corn, and I’m on the outskirts of it and 

I have a colony and I’ve been battling these varmints for years. I’ve tried 

everything, literally everything, and sometimes I’d sit out there and shoot them 

and my son was out there too. So I’m just wondering because they’re damaging 

our livelihood, our subsistence, our corn. And then this past summer, my corn 

has been wiped out. It’s been my whole acre—one acre of corn has been wiped 

out just because of the lack of rain and then plus these presence there. So I’m 

just wondering what can we do and how can you all, when you’re talking about 

working in this area, what can be developed or what can be done and what are 

other parts of the countries doing to deal with this kind of challenge?

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Dr. James Stephens: So a lot of that is kind of getting outside of the scope of our 

Center-NCEH,..... USDA but I did want to make a point though, I think related to 

both of those last two .around climate change. I know that Judy and her 

folks...told me. The other thing, I was handed a sheet here that’s talking about 

partnership for prevention of Rocky Mountain spotted fever on tribal landSorry? 

Report?

Okay, yeah. Good point there. We also partner with the Division of VectorBorne Diseases...NCEZID .........

Chairman Herman Honanie: Okay, thanks. Well, I just bring that up in hopes 

that—I know this is kind of outside your scope but I just bring it up just so that 

maybe you and others can knock on somebody else’s door and somebody else 

can knock on somebody else’s door and we can get some information at some 

point in time. Thank you.

Director Cathy Abramson: Was there anything else you wanted to share with us? 

Thank you...anything else? Well, thank you very much for presenting and being 

here. Before we have Romana come up and do our final wrap up of the day, we 

are going to go ahead and go into the—okay, well, I’ll just inform you that we’re 

gonna have Romana do the special wrap up and then we’ll have our special 

session for smoking right after that. Then we’ll probably be out of here sooner. 

So Ramona?

Ramona Antone-Nez: Chair members of the community, this is Ramona AntoneNez. Before we actually close for the meeting and do the wrap up, I’d like to 

propose to the TAC committees, a Tribal Caucus of Tribal Leaderships tomorrow 

morning at 8:00 to 8:30 prior to the actual start of day two. I’d like to make that 

recommendation and request for support from the tribal leaders in that tribal 

caucus. I would like to also invite technical advisors to the tribal leaders just for 

caucus along the tribes prior to meeting with the federal representatives and 

guests. Thank you.

Director Cathy Abramson: Okay, so there’s a motion to have a - to meet a 

caucus with the TAC and the technical advisors tomorrow morning at 8:00 

o’clock. Is there a second to that?

Secretary Shawna Shillal-Gavin: I’ll second that. Shawna Gavin.

Director Cathy Abramson: Second from Shawna. So motion and support. All 

those in favor signify by saying “I”. Those opposed? Oh, well. Abstain. So how 

many do we need for—well, anyway our leadership wants to have a caucus 

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tomorrow whether we have a forum or not, we will have it at 8:00 o’clock, 8:00 to 

8:30 so be there. Okay. Pardon? Now we’ll get our wrap up with Romana.

Romana Fetherolf: Good afternoon. I’m Romana Fetherolf giving the afternoon 

highlights. We talked about tobacco usage and the use of traditional tobacco in 

ceremonies promoting that instead of commercial tobacco. Director Abramson 

mentioned the federal public health law training sponsored by NIHB on Thursday 

for anyone who’s not attending the site visit. It’s free to attend, and we’ll be 

discussing how to draft public health law which could be a good use for the 

tobacco topics that we discussed. And Director Abramson also mentioned an 

article recently published by the Great Lakes Epi Center on Patron Perceptions 

of Smoke-Free Environments in Casinos. If you’re interested, contact Kristin Hill 

with the Great Lakes Epi Center. Following that, we had the environmental 

health panel and a lot of discussion came up on fracking and mold, and we will 

work with Dr. Stephens and Dr. Qualters to get information out to the TAC 

members. And there was a motion to have a caucus with the TAC members and 

tech advisors tomorrow morning from 8:00 to 8:30 which was voted on and 

passed. If I have missed anything, please let me know, and I’ll add it to the 

minutes. Thanks.

Director Cathy Abramson: Okay, we’ll do a closing ceremony, a closing blessing 

at this time. Andy, would you like tosay a closing blessing for us, and then we 

will stay here so we can have the special session ....

Closing Blessing 

(Not Recorded)

CAPT April Shaw: So for the special panel – I mean, I’m sorry, special session 

from Office of Smoking and Health, they are going to give us a ten minute break, 

and then they will sit where the presenters were sitting, but this is an open 

meeting where dialog can be with everyone. This is not anything official with the 

TAC, but they would love as many people as can to stay. Thank you.

END.

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