Achievement of the Centers for Disease Control and Prevention's (CDC's) public health mission hinges on strong partnerships and a robust public health infrastructure at every level of the governmental public health system, including tribal jurisdictions. Partnering with tribes presents opportunities and unique challenges for CDC to address significant health disparities in a population with a distinctive and rich history. Based on treaty rights, legislation, and executive agreements and orders, federally recognized American Indian tribes and Alaska Native villages have a unique legal status as sovereign nations to whom the US government has a federal trust responsibility for the provision of health care, funded primarily through the Indian Health Service (IHS).
To honor this trust responsibility, CDC has, for several decades, supported American Indian and Alaska Native (AI/AN) communities with technical assistance and the placement of field staff, and in 1981, financial support to 2 tribes through the Preventive Health and Health Services Block Grants.1 In 1993, tribes and tribal organizations became eligible to apply for a CDC Breast and Cervical Cancer funding announcement2 and, by 2000, were often included in CDC's funding opportunities. Despite the progress made, CDC has limited funding and capacity to reach most of the 573 federally recognized tribes. In response, CDC's National Center for Chronic Disease Prevention and Health Promotion launched 3 public health funding announcements intended solely for AI/AN communities: Good Health and Wellness in Indian Country (GHWIC) in 20143; Tribal Epidemiology Center Public Health Infrastructure (TECPHI) in 20174; and Tribal Practices for Wellness (TPWIC) in 2018.5
Representing CDC's largest investment in Indian Country to date, these cooperative agreements expanded the reach of funding and support to AI/AN communities to strengthen tribal public health capacity and improve health outcomes. As an example, 12 Tribal Epidemiology Centers (TEC) are currently funded through TECPHI to increase their capacity to deliver public health functions to tribal and urban AI/AN communities with the tribes and AI/AN health organizations in their IHS Area. As outlined in the Cresci and James6 introductory editorial, TECs were established by the IHS to increase availability of timely, accurate health data for AI/AN populations in order to identify and address health issues in these communities. Several articles in this supplement highlight the critical role TECs play in supporting tribal sovereignty by providing actionable public health data to tribes. The role of TECs, however, has expanded beyond epidemiology and the collection and dissemination of data to include other public health services such as program evaluation and research to improve the delivery of health care and implementation of prevention programs. The establishment of TECs as public health authorities as pertains to the HIPAA Privacy Rule for data sharing in 2010 and identification of the 7 core functions of TECs7 reflect this expansion of TEC activities and illustrate the role of TECs in building the public health infrastructure for and with tribes.
As directed in the permanent reauthorization of the Indian Health Care Improvement Act,7 CDC provides technical assistance directly to the TECs to support their core functions. This model was first employed in GHWIC, which currently funds 12 tribes and 11 tribal organizations to implement chronic disease prevention activities and funds the TECs to support GHWIC evaluation activities. By providing funding to tribal organizations and TECs at the regional level, more than 100 additional tribes and tribal organizations received resources and assistance.3 Building on this model, in 2017, CDC launched TECPHI, which funds all 12 TECs and also funds 1 TEC as a Network Coordinating Center to support coordination, collaboration, and communication across the 12 TECs.4 This journal supplement is a product of that collaboration, highlighting the critical role of TECs in supporting tribes to create healthier communities.
Articles in this supplement demonstrate a wide range of activities and support TECs provide to the tribes in their region and the growth of their role from supporting data collection and analysis to conducting program evaluation and research. The breadth and depth of expertise demonstrated in this special issue highlight the importance of TECs in strengthening tribal public health infrastructure to better address tribal public health priorities. Porter et al,8 Doxey et al,9 McGrew et al,10 and Cunningham et al11 describe the use of existing state and national surveillance data to better describe health burdens and identify health disparities for the AI/AN population. Joshi et al,12 Dougherty et al,13 Duke et al,14 and English et al15 explore data quality and data collection challenges and offer suggestions to improve data for AI/AN communities and ensure tribal data sovereignty. The capacity of TECs to support program evaluation and inform program improvement is demonstrated by Dilekli et al,16 Davis et al,17 and Reilley et al,18 who describe evaluations of a broad range of existing public health and clinical programs serving AI/AN populations including tobacco quit lines, supplemental nutrition programs, and telehealth to support hepatitis C treatment. These articles and others in the supplement highlight the opportunity for unique partnerships19 and provide guidance on strategies for gathering accurate health information and engaging with tribes to design, implement, evaluate, and improve the public health infrastructure needed to deliver essential public health services to tribal communities.20,21
CDC is committed to strengthening public health infrastructure in tribal communities across the United States by providing resources, expertise, and technical assistance in a manner that respects tribal sovereignty and honors the moral and legal responsibility for tribal engagement. Strong partnerships with TECs and the tribes they support are critical to accomplish these goals. As demonstrated by examples published in this supplement, TECs play an essential role in partnering with and supporting tribes to strengthen tribal public health infrastructure and advance efforts to create healthier communities across Indian Country.
2. Espey D, Castro G, Flagg T, et al Strengthening breast and cervical cancer control through partnerships: American Indian and Alaska Native Women and the National Breast and Cervical Cancer Early Detection Program. Cancer. 2014;120(suppl 16):2557–2565.
6. Cresci V, James R. The role of Tribal Epidemiology Centers in serving the public health needs of American Indians and Alaska Natives. J Public Health Manag. 2019;25(suppl 5):S1–S2.
7. Indian Health Care Improvement Act of 1976 (2017), 25 US Code § 1621m.
8. Porter M, Cirillo Lilli A, Schellinger C. The burden of unintentional injury mortality among American Indian/Alaska Natives in Michigan, Minnesota, and Wisconsin. J Public Health Manag. 2019;25(suppl 5):S20–S28.
9. Doxey M, Chrzaszcz L, Dominguez A, James R. A Forgotten danger: burden of influenza mortality among American Indians and Alaska Natives, 1999-2016. J Public Health Manag. 2019;25(suppl 5):S7–S10.
10. McGrew K, Peck J, Vesely S, et al Effect modification of the association between race and stage at colorectal cancer diagnosis by socioeconomic status. J Public Health Manag. 2019;25(suppl 5):S29–S35.
11. Cunningham J, Ritchey J, Soloman T, Cordova F. Cigarette use among American Indians and Alaska Natives in large metropolitan areas, rural areas, and tribal lands. J Public Health Manag. 2019;25(suppl 5):S11–S19.
12. Joshi S, Warren-Mears V. Identification of American Indians and Alaska Natives in public health data sets: a comparison using linkage-corrected Washington State death certificates. J Public Health Manag. 2019;25(suppl 5):S48–S53.
13. Dougherty T, Janitz A, Williams M, et al Racial misclassification in mortality records among American Indians/Alaska Natives in Oklahoma from 1991-2015. J Public Health Manag. 2019;25(suppl 5):S36–S43.
14. Duke C, Hendrix B, Reaves T. Improving tribal nation-specific mortality numerators in the South and Eastern Tribes. J Public Health Manag. 2019;25(suppl 5):S44–S47
15. English K, Espinoza J, Pete D, Tjemsland A. A comparative analysis of telephone and in-person survey administration for public health surveillance in rural American Indian communities. J Public Health Manag. 2019;25(suppl 5):S70–S76.
16. Dilekli N, Janitz A, Martinez S, et al Spatiotemporal analysis of Ok-lahoma Tobacco helpline registrations using Geoimputation and Jo-inpoint analysis. J Public Health Manag. 2019;25(suppl 5):S61–S69.
17. Davis J, Jossefides M, Lane T, Pijawka D, Phelps M, Ritchey J. A spatial evaluation of healthy food access: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants. J Public Health Manag. 2019;25(suppl 5):S91–S96.
18. Stephens D, Leston J, Terrault N, et al An evaluation of hepatitis C virus telehealth services serving tribal communities: patterns of usage, evolving needs, and barriers. J Public Health Manag. 2019;25(suppl 5):S97–S100.
19. Mohelsky R, Redwood D, Terrault A, Provost E, Dalena C, McGuire L. An innovative tribal-state partnership: the development of the Healthy Alaskans 2020 Statewide Health Improvement Plan. J Public Health Manag. 2019;25(suppl 5):S84–S90.
20. Nash S, Peters U, Redwood D. Developing an epidemiologic study to investigate risk factors for colorectal cancer among Alaska Native people. Journal of Public Health Manag. 2019;25(suppl 5):S54–S60.
21. Kelley A, Piccione C, Fisher A, Matt K, Andreini M, Bingham D. Survey development: community-involvement in the design and implementation process. J Public Health Manag. 2019;25(suppl 5):S77–S83.