FRAMING THE DISCUSSION MAY 16, 2014 Protecting People through Tribal Public Health Codes: Legal Technical Assistance and Resources for Tribes and Tribal Serving Organizations Jennifer Giroux, MD, MPH Medical Epidemiologist Great Plains Area Indian Health Service Great Plains Tribal Chairmen’s Health Board Northern Plains Tribal Epidemiology Center The findings and conclusion of this presentation are those of the author and do not represent the official position of the IHS, GPTCHB or anyone else

American Public Health System 2

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Surveillance of Infectious Diseases Among American Indians/ AK Natives Bertolli et al, Case reported to state/county agencies IHS (%) n=45/ Tribal / Urban (%) n = 66/ HIV/AIDS9667 STDs9871 Hepatitis A9362 Hepatitis B9365 Hepatitis C9167 Tuberculosis9671

Surveillance of Infectious Diseases Among American Indians/ AK Natives Bertolli et al, Received state/ county surveillance report IHS (%) n=45/ Tribal / Urban (%) n = 66/ HIV/AIDS2929/16 STDs3727/12 Hepatitis A3527/12 Hepatitis B3323/11 Hepatitis C3223/11 Tuberculosis3221/11

Multistate Assessment of Public Surveillance Relevant to AI/ AN, 2007, Bertolli et al Assessed collaboration between state health departments and AI/AN Tribes and agencies  On-line survey by State Epidemiologists  39 states with federally recognized or state-recognized Tribes or federally funded urban Indian Health centers  25/39 (64%) responded 19/25 (76%) had discussed PH surveillance with AI/AN gov’t in last two years 10/19 (53%) had ongoing, regular discussions about public health surveillance 9/19 (47%) had discussions as needed 9/25 (36%) had a state POC for PH surveillance with Tribes 4/25 (16%) had an active MOU with AI/AN gov’t Functional relationships between state health departments and AI/AN gov’t / agencies have not been consistently established

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Public Health 8 “The science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals." Winslow, Charles-Edward AmoryWinslow, Charles-Edward Amory (Jan 9, 1920). "The Untiltled Fields of Public Health". Science 51 (1306): 23–33. doi: /science PMID "The Untiltled Fields of Public Health"doi /science PMID

Public Health Approach Public Health Model Medical Model Versus

1. Monitor health status 2. Diagnose and investigate 3. Inform and educate 4. Mobilize communities to identify problems 5. Develop policies and plans 6. Enforce laws and regulations 7. Link people to needed health services 8. Assure a competent healthcare workforce 9. Evaluate health services 10. Conduct research 10 Public Health Ten Essential Services

Need for Integration of Tribal Nations into American Public Health System, Reportable Disease Surveillance System 11 Inadequate local Tribal public health infrastructure and State public health codes to respond to surveillance results Need for Tribal-designated public health authority, Need for Tribal public health codes, Need of modernized state public health codes that interface with Tribal governments

Need for Integration of Tribal Nations into American Public Health System, Reportable Disease Surveillance System 12 Absence of formal agreements between Tribal governments and state departments of health. Multiple jurisdictions involved (IHS, Tribes, states) that may not know each other’s role and function within the reportable disease surveillance process. Tribes have no involvement in submission of reportable disease data where IHS provides direct services

Need for Integration of Tribal Nations into American Public Health System, Reportable Disease Surveillance System 13 No standardized methodology for the analysis of reportable disease data for the 566 Tribes, including: Agreement on denominators, Models for small area estimation, Need for incidence and trends but need to aggregate years to stabilize data, and Laws that take into account both state laws on reporting small numbers and Tribal need to know of even single cases of some infectious diseases

Acknowledgements. 14 Thanks to Dr. Corey Smith Dr. Jeanne Bertolli Tribal Health Directors I have learned along side with This project has been made possible through a grant to the University of Pittsburgh Graduate School of Public Health Center for Public Health Practice from the Centers for Disease Control and Prevention Public Health Law Program through a sub-award from the Association of State and Territorial Health Officials