Spring 2021

Over a year ago, the coronavirus hit Indian Country with devastating impacts that left Tribal communities mourning the loss of loved ones, community members, and elders as well as dealing with quarantine and isolation from family and friends. Though more than 600,000 lives were lost across the United States, COVID-19 vaccines from Pfizer, Moderna, and Johnson & Johnson have potentially saved many more lives from the disease. According to the Indian Health Service (IHS), as of July 4, 2021, 1,759,715 doses of these three potential vaccines have been distributed in eleven IHS areas, (Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma City, Phoenix, Portland, and Tucson), and 1,448,281 doses have been administered in those areas. See Table 1.

Tribes understand their communities are among the hardest hit by COVID-19. The importance of providing timely COVID-19 vaccinations is vital to the preservation of their cultural ways. COVID-19 vaccine distribution strategies employed by Tribes are largely based on American Indian and Alaska Native (AI/AN) values - prioritizing elders, Native language speakers, and keepers of the traditions. Some Tribes have also offered to vaccinate non-Tribal members who interact with Tribal citizens, including essential workers and school staff. Tribes hold education and educators in high regard and offered the vaccine to school staff members before they were eligible under state and national guidelines. Some Tribes leading the effort to vaccinate educators are the Mashpee Wampanoag Tribe, Stockbridge-Munsee Tribe, Cherokee Nation, Chickasaw Nation, and the Tulalip Tribe.

Tulalip Tribe Chairwoman Teri Gobin said, "Tulalip is proud to be able to take care of our community. The Marysville School District, their teachers and administrators are helping raise our kids. Getting back to school provides our youth with a sense of normalcy. Vaccines help make that return to in-person learning safer for the teachers and our students. So far Tulalip has offered all district employees, around 1,100 staffers, the opportunity to get vaccinated. We wanted everyone -- teachers, administrators, bus drivers, janitors, and support staff to receive a vaccine if they wanted one. In total the Tulalip Health System has distributed over 10,000 vaccines."

Success to the Tribal vaccine rollout can be captured succinctly: it relies upon jurisdiction and sovereignty. For instance, Alaska Native communities are exercising their sovereign ability to self-determine to vaccinate elders that include Native and non-Native residents. Various Tribes have also offered the vaccine to the outside community regardless of IHS eligibility.

As of July 12, 2021, according to the Center for Disease Control and Prevention (CDC), nearly 160 million Americans have been fully vaccinated and 184 million have received at least one dose. As of July 12, 2021, race/ethnicity was available for about 100 million people who have been fully vaccinated, of those, AI/ANs make up 0.9% (927,578) who have been fully vaccinated. See Table 2. Although the data seemingly shows a low vaccination rate, Tribes are showing great progress and innovation in ensuring AI/AN people are vaccinated in a timely and efficient manner. Many Tribes across the United States are leading the way in COVID-19 vaccination efforts and were among the first to offer the vaccine to groups that otherwise may not have been eligible to receive it. This includes younger Natives (12+ years), teachers, and essential workers.

The COVID-19 vaccines were welcomed in many Tribal communities as an integral way to prevent serious COVID-19-related infection, hospitalization, and death. The three potentially life-saving vaccines available are helping Tribal communities get back to normal and children back to school safely. "Soon, when Tribal communities are fully vaccinated, we can re-start the vital Tribal public health work necessary to improve the wellness and quality-of-life of all Native people. But, until then, we need to continue to wear masks, wash our hands and watch our distance," said NIHB Chairman William Smith who is also the Vice President of the Valdez Native Tribe of Alaska and Vietnam veteran.

Learn more about NIHB's advocacy and community efforts about the COVID-19 vaccine at: https://www.nihb.org/covid-19/vaccine-information-and-tribal-support/.

Table 1: COVID-19 Vaccine Distribution and Administration by IHS Area

IHS Areas	Total Doses Distributed	Total Doses Administered
Albuquerque	131,165	133,102
Bemidji	152,235	123,492
Billings	60,895	45,270
California	221,055	153,713
Great Plains	127,080	89,712
Nashville	90,905	71,275
Navajo	252,305	232,644
Oklahoma City	441,410	366,102
Phoenix	174,050	149,249
Portland	96,545	75,356
Tucson^	12,070	8,366
Grand Total	1,759,715	1,448,281

Note: As of July 4, 2021, the IHS is distributing vaccine allocations of the Pfizer, Moderna, and Johnson & Johnson/Janssen vaccine. The table above shows the total number of vaccine doses distributed and administered per IHS Area to date.Alaska Area – all tribes chose to receive COVID-19 vaccine from the State of Alaska. Administered Data Source: CDC Clearinghouse data from Vaccine Administration Management System (VAMS) and IHS Central Aggregator Service (CAS). Data in the CDC Clearinghouse reflects prior day data. Data may be different than actual data as there are known CDC data lags and ongoing quality review of data including resolving data errors. Data from: https://www.ihs.gov/coronavirus/.

Table 2:Race/Ethnicity of People Fully Vaccinated

Race/Ethnicity	Percentage	Count
Hispanic/Latino	15.2%	15,191,791
White, Non-Hispanic	60.4%	60,386,200
American Indian/Alaska Native, Non-Hispanic	0.9%	927,578
Asian, Non-Hispanic	6.2%	6,241,263
Black, Non-Hispanic	8.9%	8,918,347
Native Hawaiian/Other Pacific Islander, Non-Hispanic	0.3%	284,034
Multiple/Other, Non-Hispanic	8.1%	8,061,303

Note: As of July 12, 2021, 159,499,224 people fully vaccinated. Race/Ethnicity was available for 100,010,516 (62.7%) people fully vaccinated. These demographic data only represent the geographic areas that contributed data and might differ by populations prioritized within each state or jurisdiction’s vaccination phase. Every geographic area has a different racial and ethnic composition, and not all are in the same vaccination phase. These data are thus not generalizable to the entire US population. Percentages displayed in the table above represent the percent of people vaccinated for whom the demographic variable of interest is known, Data from: https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic.

Photos provided by Michael Rios of Tulalip News

The COVID-19 pandemic brought to the forefront the many health disparities experienced by American Indians and Alaska Natives (AI/AN). Tribal communities have been disproportionately impacted by the pandemic, which has made apparent the inequities facing AI/AN people and Indian health care providers. It has not only created new burdens in Tribal communities but has exacerbated existing health concerns--particularly those regarding behavioral and mental health.

Over the course of the pandemic, many have faced and are currently facing feelings of stress, worry, fear, anger, and frustration. Public health measures such as physical (social) distancing have increased these feelings as well as contributed to making people feel isolated or alone. These emotions can be overwhelming for adults and children. While physical distance is necessary to reduce the spread of COVID-19, it may also impact suicide risk, which is concerning for Tribal communities that may already experience high suicide rates. Suicide is the tenth leading cause of death in the United States; however, among racial/ethnic groups AI/AN people have the highest suicide rates and this rate has been consistently high over the years. Among AI/AN youth, suicide is the second leading cause of death. Factors that protect AI/AN youth and young adults against suicidal ideations and behaviors--such as a sense of belonging to one's culture, a strong Tribal/spiritual bond, and feeling connected to family and community-- have become difficult to maintain during the pandemic leading to some professionals' increased concerns that suicides may increase.

There is limited data on the link between the COVID-19 pandemic and an increase in suicides. Data from previous studies suggest that emergencies such as epidemics are associated with a rise in suicides. A recently published study found an increase in suicidal ideation among youth during certain months throughout the current pandemic. Research has also shown that young adults, racial/ethnic minorities, essential workers, and unpaid caregivers have disproportionately suffered adverse mental health outcomes, increased substance use, and increased suicide ideation during late June 2020. This data, despite its limitations, highlights the need to continue to take steps to help mitigate mental and behavioral health consequences associated with COVID-19 and to help people cope with the complex emotions felt over the past year which they may continue to feel. These mitigation efforts can range from maintaining connections virtually to seeking professional assistance using telebehavioral health services. Many Tribes and Tribal organizations have hosted virtual gatherings and encouraged their communities to stay connected via phone or video.

COVID-19 vaccines may provide "a light at the end of the tunnel," but it is important to continue offering services and tips to help Tribal communities cope with stressors from the COVID-19 pandemic. If you or someone you know is experiencing emotional stress, there are places that can help.

• Texting services are available through the Crisis Text Line by texting NATIVE to 741741 to be connected to a trained Crisis Counselor.
• The National Disaster Distress Helpline is available to anyone experiencing emotional distress related to COVID-19. Call 1-800-985-5990 or text TalkWithUs to 66746 to speak to a caring counselor.
• The National Suicide Prevention Lifeline at 1-800-273-8255 or your local crisis line.
• For coping tools and resources, visit the Lifeline website at suicidepreventionlifeline.org or Vibrant Emotional Health's Safe Space at vibrant.org/safespace.

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1. Centers for Disease Control and Prevention. COVID-19 Data Visualization. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html
2. Stone DM, Jones CM, Mack KA. Changes in Suicide Rates - United States, 2018-2019. MMWR Morbidity & Mortal Weekly Report 2021;70:261-268. DOI: http://dx.doi.org/10.15585/mmwr.mm7008a1external icon
3. Leavitt RA, Ertl A, Sheats K, Petrosky E, Ivey-Stephenson A, Fowler KA. Suicides Among American Indian/Alaska Natives - National Violent Death Reporting System, 18 States, 2003-2014. MMWR Morbidity & Mortal Weekly Rep 2018;67:237-242. DOI: http://dx.doi.org/10.15585/mmwr.mm6708a1external icon
4. Indian Health Service. Suicide Prevention and Care Program. https://www.ihs.gov/suicideprevention/
5. John A, Pirkis J, Gunnell D, Appleby L, Morrissey J. Trends in suicide during the covid-19 pandemic BMJ 2020; 371 :m4352 DOI: http://doi:10.1136/bmj.m4352
6. Hill, R. M., Rufino, K., Kurian, S., Saxena, J., Saxena, K., & Williams, L. (2021, March). Suicide Ideation and Attempts in a Pediatric Emergency Department Before and During COVID-19. Pediatrics, 147(3). DOI: https://doi.org/10.1542/peds.2020-029280

Intimate Partner Violence (IPV) describes physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse1. This type of violence does not require sexual intimacy and can occur among heterosexual or same-sex couples. According to a report from the National Institute of Justice, in 2016, 81.6% (more than 1.4 million) of the 1,505 American Indian/Alaska Native (AI/AN) men surveyed, have experienced violence in their lifetime. Out of the 81.6%, 43.2% have experienced physical violence by a partner, and 73% have experienced psychological aggression by a partner in their lifetime2. Like other forms of violence, IPV is preventable. Yet AI/AN men’s experiences with IPV are often overlooked. Understanding why this is the case, and how to bring attention to this overlooked population requires further investigation of the barriers that exist.

One of the biggest barriers to reporting IPV and seeking help for many populations is fear. However, in the case men, this manifests as a fear of not being believed. Literature on male help-seeking indicated that men are less likely than women to seek help and men who do seek help must overcome internal and external obstacles to do so, including the emotional aspect of seeking help and the thoughts or actions of others3. Often male victims will choose not to report because they feel is it shameful. Due to the societal control of gender norms and views on patriarchy, “men who report abuse from an intimate partner are viewed as cowards. Due to embarrassment, male victims do not approach professional services”4 for fear of being laughed at or scorned. A major component of the shame that male victims experience is a result of the conflicting Western traditional norms that are associated with masculinity. Society’s gender constructed roles are a factor in whether men choose to speak up or reach out for help. 

One in four AI/AN men expressed concern for their safety5, yet many feel that their abuse is perceived as less serious or untrue. Legal system biases further deter men from seeking help. According to George and Yarwood (2004), police have threatened 47% of male victims of IPV with arrest. They also found that police ignored 35% of male victims6. According to Muller, after randomly sampling 157 temporary restraining orders (TRO) involving intimate partners, judges were 13 times more likely to grant a TRO requested by a female against her male intimate partner, than a TRO requested by a male against his female partner8.This unfortunately occurs due to the disbelief that women cannot be perpetrators of this type of crime, often leaving male victims silenced. 

Of those who do speak up and reach out for help, many do not receive help. One in six AI/AN male victims could not access services, such as medical care, legal services, and victim’s advocate services.5. The lack of services for male victims is a huge health disparity. As of October of 2017, there were only two male-only shelters in the United States. While publicly funded shelters are required to take in men, they typically have a limited capacity or funding to do so. Also, many shelters use certain language in their name such as “Women and Children Shelter”, deterring male victims to reach out to those locations. While programs for AI/AN males specifically are limited, there are some that are available. The Substance Abuse and Mental Health Services Administration (SAMHSA) Native Connections is a five-year grant program that helps AI/AN communities identify and address the behavioral health needs of Native youth. Within this program, Alaska grantees have kicked off a Men’s Wellness Digital Story Series, providing perspectives from men about the importance of culture on well-being, embracing cultural values and traditions to heal and cope with trauma in their lives. Another program comes from the Kodiak Area Native Association (KANA). Their program COMPASS is a mentoring curriculum with adult male mentors working with Alaskan men ages 12-18 centered around violence prevention. 

IPV affects millions of Native and non-Native people across the country, but the disparity for AI/AN men is higher compared to non-Hispanic Whites2. According to domestic violence prevention experts, the prevalence of violence in Indian Country is a modern effect of the historical trauma that our people continue to experience7. Being able to heal culturally from previous and current trauma is a step towards reducing IPV prevalence in AI/AN men. Outreach and engagement with AI/AN men in the forms of mentorship and integrating culture is a beneficial way to help cope and heal. This includes teaching traditional values and empowering youth to respect others and make responsible choices. This also includes providing more support and programs for men who are dealing with IPV. Offering safe places to stay and rebuild themselves during this process is just as important as the healing. By separating victims from the risks associated with being in an unstable home, there is an opportunity to intervene. Implementing programs specifically for AI/AN men could provide an opportunity for men to speak out and for Tribal communities to develop strategies to prevent IPV in Indian Country.

(2016 NIJ, reference 2)

Image reuse-policy: https://nij.ojp.gov/reuse-policy

References

1. Intimate partner violence |violence prevention|injury center|cdc. (2020, October 09). Retrieved March 15, 2021, from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/
2. Five things about violence against American Indian and Alaska Native women and men. (2016, November 30). Retrieved March 15, 2021, from https://nij.ojp.gov/topics/articles/five-things-about-violence-against-american-indian-and-alaska-native-women-and-men
3. Douglas, E., & Hines, D. (2011, August 26). The helpseeking experiences of men who sustain intimate partner violence: An overlooked population and implications for practice. Retrieved March 15, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175099/#R22
4. Shuler, C. A. (2010). Male Victims of Intimate Partner Violence in the United States: An Examination of the Review of Literature through the Critical Theoretical Perspective. International Journal of Criminal Justice Sciences, 5(1), 163-173.
5. Rosay, A. B. (2016). Violence Against American Indian and Alaska Native Women and Men. Retrieved from National Institute of Justice Journal: https://nij.ojp.gov/topics/articles/violence-against-american-indian-and-alaska-native-women-and-men
6. George, M. J., & Yarwood, D. J., (2004) Male Domestic Violence Victims Survey 2001: Main Findings. Retrieved on March 11, 2021, from www.dewar4research.org/DOCS/mdv.pdf
7. Violence in Indian Country. (n.d.). Retrieved March 15, 2021, from https://strongheartshelpline.org/about#ViolenceinIndianCountry
8. Muller, H. J., Desmarais, S. L., & Hamel, J. M. (2009). Do Judicial Responses to Restraining Order Requests Discriminate Against Male Victims of Domestic Violence. Journal of Family Violence, 24, 625-637

Every person, including every American Indian and Alaska Native (AI/AN) has as a life story that began with a childhood and experiences that shaped their adulthood. Some of those experiences may have been traumatic, and these are called Adverse Childhood Experiences (ACEs). In August 2020, the National Indian Health Board (NIHB) launched a website hub of information and resources to increase awareness and knowledge of ACEs and expand Indian Country's capacity to address such adversities. The ACEs Hub offers Tribes and Indian health providers peer-reviewed research, planning resources, and screening approaches. 

Most people have experienced at least one ACE in their lifetime. ACEs, which can occur between the ages of zero and 17, are linked to poor health and social conditions in adulthood, but not everyone experiences poor outcomes. ACEs do not mean a life of pain or illness. Tribal communities have many protective factors against these negative outcomes, and connection to culture is one of them. Cultural and traditional practices link Tribal citizens to each other, providing a sense of belonging, honoring the past and tradition, and helping to build resilience. Research has shown that culture is a form of prevention. According to a study published in 2017, protective factors for AI/AN youth include: personal wellness, a positive self-image, self-efficacy, familial and non-familial connectedness, positive opportunities, positive social norms, and cultural connectedness.

There is not one cause of ACEs and each individual and community may experience ACEs differently. Therefore, it is important to provide an approach that understands how trauma can impact a person’s life and provides safe, compassionate, and holistic care. This approach should increase protective factors within Tribal communities and tie in culture when addressing ACEs, working to prevent the negative outcomes associated with them. 

Resources on ACEs or trauma-informed care:

• American Academy of Pediatrics – Trauma Toolbox for Primary Care (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx) 
• Center for Health Care Strategies – Implementing Trauma-Informed Care in Pediatric & Adult Primary Care (https://www.chcs.org/resource/implementing-trauma-informed-care-pediatric-adult-primary-care-settings/) 
• Centers for Disease Control and Prevention – Adverse Childhood Experiences (https://www.cdc.gov/violenceprevention/aces/index.html) 
• Centers for Disease Control and Prevention- Injury Prevention in American Indian and Alaska Native Communities (https://www.cdc.gov/injury/tribal/index.html) 
• Centers for Disease Control and Prevention – VetoViolence (https://vetoviolence.cdc.gov/apps/main/home)
• SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach (https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf)

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¹ Henson, M., Sabo, S., Truijillo, A., & Teufel-Shone, N. (2017, April). Identifying Protective Factors to Promote Health in American Indian and Alaska Native Adolescents: A Literature Review. Journal of Primary Prevention, 38, 5-26. doi:10.1007/s10935-016-0455-2

Visit NIHB’s Information Hub: ACEs in Indian Country website at www.nihb.org/aces-resource-basket/.

Public health programs promoting brain health focus on reducing risks posed by cognitive decline, such as Alzheimer’s and other forms of dementia. These conditions can develop slowly and cause changes in thinking, understanding, and remembering. Although some risk factors related to brain health cannot be changed, like age, one important way to prevent and slow down cognitive decline is through the prevention and management of chronic diseases, such as obesity, high blood pressure, and diabetes.

American Indian and Alaska (AI/AN) adults are nearly two times more likely to be diagnosed with diabetes than white adults. Based on clinical data from the Indian Health Service (IHS), diabetes prevalence is higher in older American Indian and Alaska Native (AI/AN) adults showing that in 2017 diabetes among AI/AN adults aged 65-74 was 34.7% and was 32.5% among adults aged 75+ compared to 22% among adults aged 45-64.

The Special Diabetes Program for Indians (SDPI) contributed greatly to the reduction in diabetes incidence and related comorbidities across Indian Country. According to a report from the Indian Health Service (IHS), there was a 5.2% decrease in diabetes prevalence between 2013 and 2017 and a 54% decline in end-stage renal disease caused by type-II diabetes, which is the greatest decline in kidney disease of any racial or ethnic group. Additionally, obesity rates have not increased in AI/AN youth in over 10 years. SDPI programs also promote key behaviors, specifically healthy eating and regular physical activity that can be leveraged to prevent other chronic diseases linked to cognitive decline.

The structure of SDPI aligns closely with key strategies presented in the 2019 “Healthy Brain Initiative: Road Map for Indian Country” (RMIC). “Brain health” refers to thinking, understanding, and memory abilities. It also can refer to the activities people do keep their brain healthy, like being physically active and consuming a healthy diet. The RMIC presents eight broad paths to increase brain health awareness and prevention while incorporating Tribal customs, practices, and needs. These strategies focus on strengthening the Tribal public health workforce, robust data collection, and community empowerment and engagement. 

When the SDPI program began over 20 years ago, few programs had the data, provider capacity, or resources for comprehensive diabetes screening, management, and education. Since the program’s inception, Tribes have witnessed enormous successes around implementing services and screenings, tailoring delivery models, and developing quality metrics to improve diabetes management and prevention. SDPI is considered a premier model for Tribal public health programs because of its 20-year success and its community-driven approach. This approach provides flexibility and adaptability to local circumstances and specific Tribal and regional cultures. SDPI programs have created proven, community-driven strategies and tools to spread knowledge of diabetes prevention through best practices in diabetes, physical activity, and nutrition education.

As Tribes seek to expand their healthy aging scope of services, they can look to SDPI for examples of community-driven, Tribally informed, primary prevention-focused programs. 

SDPI programs can use the RMIC tools to increase community knowledge of brain health while serving elders and those at risk of brain health challenges. Education and empowerment efforts can expand to include awareness of the early signs of cognitive decline or tools on how to talk with caregivers and Tribal leaders about brain health concerns. Like SDPI, the RMIC includes a focus on using both best practices along with traditional practices to address healthy aging. By pooling the knowledge and expertise from both diabetes prevention and healthy aging programs, Tribes can strengthen support for long-term health and wellness of cherished Tribal elders.

Over the last 30 years, Tribal communities have seen a significant increase in life expectancy among American Indian and Alaska Native elders. As families are spending more time with elders, brain health - an important component of healthy aging - must become a focus for Tribal public health.

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¹ Office of Minority Health: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=33

² Bullock A, Sheff K, Hora I, et al. Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006-2017. BMJ Open Diabetes Res Care. 2020;8(1):e001218. doi:10.1136/bmjdrc-2020-001218

³ Indian Health Service. (2020). SDPI 2020 Report to Congress: Changing the Course of Diabetes: Charting Remarkable Progress. Retrieved from https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/SDPI2020Report_to_Congress.pdf

According to the Center for Disease Control and Prevention American Indian and Alaska Native (AI/AN) populations are disproportionately impacted by serious health conditions, such as, chronic obstructive pulmonary disease (COPD), type 2 diabetes, chronic kidney disease and a compromised immune system. AI/ANs are also at increased risk of lower respiratory tract infections, obesity, complications from pregnancy and have high rates of habitual smoking, which make AI/Ans communities at higher risk for a more serious COVID illness. AI/AN youth and adults, unfortunately, have the highest prevalence of cigarette smoking among all racial/ethnic groups in the U.S.,. 

Tribal casinos, restaurants, bars, etc. are common places that a person could be exposed to second-hand smoke - a combination of smoke generated at the end of a cigarette and the smoke exhaled by smokers. Overall, there are 7,000 chemicals that are released from second-hand smoke and it is known that 70 of those can cause cancer. Also, exposure to second-hand smoke is linked to some of the serious health conditions experienced by AI/AN communities. 

In response to the contagious nature of COVID-19, Tribal nations across the country temporarily closed many economic and gaming facilities, making it tough to generate much needed revenue that often supplements funding for Tribal health and social services. For Tribes to stablish a safe re-opening plan for casinos, many of which allow smoking facilities, they must adhere to special requirements to mitigate the spread of coronavirus. can be as easy as posting signage, training staff, deep cleaning to remove tobacco residue and reminding patrons that smoking is no longer allowed within the facility. These steps may be easier to implement since many facilities have been closed for nearly a year due to the pandemic.

So, many Tribes are considering re-opening as smoke-free to help combat COVID-19 and promote an overall healthier community. Currently, there are over 500 Tribal casinos across the United States and over 160 of those Tribal casinos have re-opened smoke-free or they have plans to re-open smoke-free. Transitioning to a smoke-free environment gives Tribal gaming staff the bandwidth to focus on preventing the transmission of the COVID-19 by sanitizing their slot machines & chairs, re-filling hand sanitizers in the area, and attending to possible handwashing stations. There may also be a financial benefit to Tribal enterprises converting to smoke-free status. According to the American Cancer Society, employees exposed to second-hand smoke have higher average health insurance premiums and facilities exposed to smoking residue have higher maintenance costs.”

As part of its Commercial Tobacco Cessation Learning Community, the National Indian Health Board hosted a webinar featuring Hershel Clark from the Southwest Navajo Tobacco Education Prevention Project and Clinton Isham from the Americans for Nonsmokers’ Rights Foundation who shared the approaches and lessons learned in moving toward smoke-free gaming facilities. NIHB also works with Tribes, Tribal Organizations, public health leaders, and federal funders like the Center for Disease Control and Prevention to increase commercial tobacco cessation among Tribal communities.

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¹ U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, Hispanics: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998 

² Garrett BE, Dube SR, Winder C, Caraballo RS. Cigarette Smoking—United States, 2006–2008 and 2009–2010. Morbidity and Mortality Weekly Report 2013;62(03):81–4

³ American Nonsmoker’s Rights Foundation. “Reopening Smoke Free: The New Normal (updated 03/05/2021).” March 2021. https://no-smoke.org/reopening-smokefree-the-new-normal/

⁴ American Cancer Society, “Smoke-Free Policies: Good for Business.” November 3, 2018. https://www.fightcancer.org/sites/default/files/Smoke-free%20Policies%20Good%20For%20Business%20Factsheet%202018%20Final.pdf

Additional Resources:

National Indian Health Board https://www.nihb.org/public_health/tobacco_cessation.php.

American Nonsmoker’s Rights Foundation https://no-smoke.org/

Climate change continues to impact health across the United States in numerous ways. In the last year, floods, landslides, wildfires, storms, and droughts destroyed people’s homes and altered livelihoods, damaged nutritious food supplies, and reduced access to safe drinking water. These events played out in tandem with rising temperatures, water and air pollution, and the COVID-19 pandemic. American Indian and Alaska Native people are resource managers with a history of successful and sustained stewardship for ecosystems from time immemorial. Tribes continue to be the example of resiliency in the face of uncontrolled change. Even in the face of colonization and genocide, Tribes continued to preserve culture, language, ceremonies, and traditional practices as best they could. 

This past year, a new enemy threatened our People: COVID-19. Fortunately, Tribes have established sovereignty to address disease outbreaks. With the historical trauma of genocidal diseases still close to our hearts and minds, Tribal leaders took action to protect their people. After a long year of isolation and other public health measures to keep people safe, the country is seeing the highest vaccination rates are administered by Tribes. External entities are recognizing Tribal COVID-19 responses as potential frameworks for addressing other eminent threats, like climate change. 

The National Indian Health Board’s Climate Ready Tribes Initiative (CRT), funded by the Centers for Disease Control and Prevention, was developed in response to climate-related threats at with the overall goal of building Tribal capacity related to climate health. The CRT Initiative currently has three primary activities: 1) funding Tribes to conduct local climate health work or research; 2) host an environmental health and climate Track at the annual National Tribal Public Health Summit; and 3) share information and resources while connecting individuals and organizations through the Climate and Health Learning Community. Through sub-award grants, the CRT Initiative provides support for Tribes to take action and develop climate change responses that are localized and effective for their unique environment. 

Chronic stressors such as extreme poverty are also exacerbated by climate change impacts, including reduced access to traditional foods like salmon, shellfish, wild game, and medicinal plants which can lead to increasing health problems in Native communities. Furthermore, the alteration of fragile ecosystems by government or corporate entities, including destroying habitat for fish and wildlife, restricting drinking water storage, and damaging fertile soils adds to the unjust treatment of Tribal communities and their lands. 

Two CRT sub-awardees, the Lummi Nation in Washington State and the Sitka Tribe of Alaska, are both working with similar ecosystems to adapt to water pollutants in their coastal lands. With CRT funding, the Lummi Natural Resource Department (LNR) was able to respond to the increased risk of Harmful Algae Blooms (HABs) that are poisoning local shellfish—an important First Food for the Lummi people. In recent years, particular levels of biotoxins have increased and new biotoxin types have emerged, which leads to longer beach closures and limited harvesting times. As the climate warms, HABs are expected to increase, last longer, and cause more damage to marine wildlife and subsistence resources for AI/AN communities. In 2020, the LNR responded to the marine threat by developing culturally relevant educational materials for the Lummi Nation and partnering with local networks. Though the risks to First Foods are not minimized; the Lummi Nation hopes to see less occurrences of toxic shellfish poisoning among their people. 

Similarly, the Sitka Tribe of Alaska is working to address HABs in the context of shellfish poisoning. Due to the constant state of increased biotoxin risk in Southeast Alaska waters, the State of Alaska recommends that people purchase wild shellfish instead of harvesting. However, that is not a viable option in most coastal communities where people are reliant on First Foods as their subsistence. The Sitka Tribe of Alaska created a network of 15 Southeast Alaska Tribes, called the Southeast Alaska Tribal Ocean Research (SEATOR) to better understand the risk associated with shellfish harvesting. SEATOR partners represent villages as far north as Yakutat and way down south to Metlakatla—two villages that are separated by nearly 18,000 miles of coastline. SEATOR is establishing a standardized system for testing shellfish, and their findings have confirmed what Alaska Natives have known for years—shellfish cannot be harvested in the summer months. However, these findings have also confirmed that shellfish are not safe to consume year-round. Now, SEATOR is using education and partnership to address their findings. 

The Pala Band of Mission Indians, located in Southwest California, is another CRT awardee that is addressing climate change with an approach applicable to their unique environment and circumstances. In Pala, climate change affects the health of oak trees, making them more susceptible to drought stress and injury from invasive pests, which affects the production of acorns - traditional subsistence food. When people cannot collect acorns to make wiiwish, an acorn mush, for special occasions it has an impact on psychosocial wellbeing and can cause stress and grief about the potential loss of important cultural traditions and associated values.

In response to climate-related emotional and cultural stress, Pala produced a psychosocial resilience framework it and other Tribes can use to tailor adaptation responses sensitive to the unique needs and values of individual communities. CRT sub-awardees are only a few examples of how Tribes have been addressing climate change as a form of community and ecological resiliency. It is important to recognize that many Tribes are working with limited resources to address these impacts in their communities but are often leading the response to climate threats. AI/AN people have lived here for thousands of years and will continue to fight for the health of the land and peoples for thousands more. 

In the beginning of each year, the National Indian Health (NIHB) engages with Tribes to set forth a public policy agenda focusing on critical priorities for the Indian health system that requires targeted efforts and robust advocacy to advance. In February 2021, the NIHB Board of Directors approved the annual Legislative and Policy Agenda. It is the blueprint for NIHB's work to advocate with a unified voice for the top priorities regarding Indian Health. This document provides an outline of national consensus requests on a range of topics and includes both legislative and administrative asks.

This document provides actionable items in consultation and with Tribes. While the priorities within NIHB's Legislative and Policy Agenda change year to year, the overarching goals to represent the unified healthcare priorities of Indian Country and ensure that the federal government lives up to its trust responsibilities continue.

The agenda's administrative priorities reflect a response to the changing health care delivery landscape that has been brought on by the COVID-19 pandemic and a desire to work with the new Administration to ensure that Indian, Tribal and Urban (I/T/U) system is able to quickly adapt. Since the start of the pandemic, we have seen an unprecedented shift in health care delivery. For example, telehealth, once a niche health care delivery system, is becoming more prevalent. Ensuring that Tribes are fairly reimbursed for telehealth services is a top priority for NIHB. The pandemic has also highlighted the need to work closely with the Department of Health and Human Services (HHS) to ensure that the Department's programming is responsive to the needs of Indian Country and effective in addressing our needs.

Fundamentally, we ask HHS to be more responsive to the needs of Indian Country and create an apparatus to make that possible. Many of our asks involve asking the agencies to work closer with Indian Country and make sure that their programs are respectful of the federal trust responsibility, culturally appropriate, and responsive to our needs. We ask that agencies create Tribal set asides and end competitive grant making. These steps will ensure that Tribes are able to access funding, without having to compete with private entities and each other. We also ask that agencies work closely with Tribes to make sure that their programs are effective and responsive.

We also ask that HHS seat a Tribal representative in all HHS operating divisions, this will ensure that the operating divisions have subject matter expertise within close reach when emergencies, such as a pandemic, require quick action. It also ensures that the agency's on-going programming is responsive to Tribal needs and works to address many of the underlying issues that made the pandemic so much worse in Indian Country. We ask for an adviser in the Secretary's office, who can directly advise the Secretary on Indian health law and policy.

In the Medicaid realm we reiterate the importance of exempting AI/AN populations from policies, such as waivers of retroactive eligibility, that seek to limit access to Medicaid. This is important for a couple of reasons: the ability for Indian Health Service (IHS) and Tribal programs to be reimbursed through Medicaid is in recognition of the federal trust responsibility and, as such, care received through IHS and Tribally run facilities is fully covered by the federal government. State policies should not dictate access to a fully federally funded program.

The agenda's legislative priorities reflect legal and funding challenges the I/T/U system faces, which have been amplified due to the ongoing COVID-19 pandemic. Over the last year, the federal government has invested billions in emergency relief in the I/T/U system to combat the pandemic while giving tribes the ability to direct these funds themselves. As a result, Indian Country continues to lead the nation when it comes to vaccinating their populations. There have been a series of technical flexibilities due to the government's national emergency declaration that has made providing care easier, which can be made permanent through legislation. The legislative objectives in the agenda are fixes needed to address the structural challenges facing Indian Country as it pertains to healthcare and can only get done by working with Congress.

The most pressing objective of NIHB's Congressional advocacy focuses on the full, mandatory funding of the Indian Health Service (IHS). Based on the Tribal Budget Formulation Work Group the full funding level needed to fulfill the federal government's trust responsibilities would be $48 billion. The FY 2020 IHS funding level at $7.434 billion. With the long-term goal to reach the full funding mark, NIHB is advocating for IHS funding at $12.759 billion for the FY 2022 budget while making IHS funding subject to advanced appropriations. This would protect IHS from any lapse in services as a result of a government shut down and be a step towards NIHB's end goal of making IHS appropriations mandatory. Until full funding is made mandatory for the IHS, the care it provides will continue to fall short of the trust responsibilities owed by the federal government.

Given the chronic lack of funding for the I/T/U system, Indian Country has had to contend with inadequate infrastructure to meet the needs of its populations. According to the 2018 Annual Report to Congress on Sanitation Deficiency Levels for Indian Homes and Communities, over 31 percent of homes on Tribal lands need sanitation facility improvements, while nearly 7 percent of all AI/AN homes do not have adequate sanitation facilities. Without proper sanitation services, Indian Country remains vulnerable to the ongoing pandemic and any future disease.

Additionally, the expansion of telehealth offers a new tool in providing quality care throughout the I/T/U health system, but it lacks the resources to build a robust telehealth program and the lack of broadband infrastructure throughout Indian Country make the potential successes of any telehealth program limited.

Congress in the past has authorized special health programs for Tribes to address the chronic health disparities seen in AI/AN communities. The Special Diabetes Program for Indians (SDPI) is one example of a critical program designed to address the increased rates of type II diabetes in Indian Country. NIHB is advocating for increased annual funding, permanent reauthorization of the program and expand tribal self-governance throughout the program. Overall, the program has been a success and is claimed to be the most successful public health program in the country. The SDPI model, while imperfect, is also being used as a template for potential behavioral health programs. A special behavioral health program for Indians has the potential to combat the increased rates of substance abuse and stark disparities seen in mental and behavioral health outcomes in the AI/AN communities. The American Rescue Plan, which was signed into law on March 11, 2021, included $420 million for Tribal behavioral health. With this renewed enthusiasm, NIHB is advocating for a permanent program similar to SDPI for behavioral health that respects tribal self-determination and self-governance, and remains a top priority for 2021.

Medicare and Medicaid play an integral role in ensuring access to health services for AI/AN people and provide critically important funding support for the Indian health system overall. While some issues the I/T/U System experiences with Medicare and Medicaid can be fixed via administrative requests, many require legislative action. Many of these fixes center around reimbursement for services to the I/T/U system that non Tribal providers would bill the patient for, but because the I/T/U system does not bill for services results in a loss of income for the clinics. This compounded with chronic underfunding can strain I/T/U clinics that see patients enrolled in Medicare and Medicaid. The needed fixes encompass one of the largest legislative and administrative advocacy priorities.

As the 117th Congress with a new majority in the U.S. Senate hits its stride, NIHB's legislative advocacy offers new opportunities that were not present in the past, and our priorities have been met with renewed interest. With the approved Legislative and Policy Agenda, NIHB can advocate with the voice of a unified Indian Country for improvements and funding for Tribal healthcare in Congress. As seen in the American Rescue Plan, Congress included over $6 billion of relief for Indian health that will support the I/T/U system. The funding included all the priorities that NIHB had advocated for in multiple letters to Congressional leadership while taking into account our feedback on how best to get the funding to tribes quickly. NIHB is grateful to have allies in Tribal health on both sides of the aisle and is eager to continue working with Members of Congress to advance our tribal health priorities.