FRAMING THE DISCUSSION M AY 1 6 , 2 0 1 4

Protecting People through Tribal Public Health Codes: Legal Technical Assistance and Resources

for Tribes and Tribal Serving Organizations

Jennifer Giroux, MD, MPHMedical Epidemiologist

Great Plains Area Indian Health ServiceGreat Plains Tribal Chairmen’s Health BoardNorthern 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

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American Public Health System

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Surveillance of Infectious Diseases Among American Indians/ AK Natives Bertolli et al,

2008

Case reported to state/county agencies

IHS (%)n=45/68

2001

Tribal / Urban (%)n = 66/120

2004HIV/AIDS 96 67

STDs 98 71

Hepatitis A 93 62

Hepatitis B 93 65

Hepatitis C 91 67

Tuberculosis 96 71

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Surveillance of Infectious Diseases Among American Indians/ AK Natives Bertolli et al,

2008

Received state/ county surveillance report

IHS (%)n=45/68

2001

Tribal / Urban (%)n = 66/120

2004HIV/AIDS 29 29/16

STDs 37 27/12

Hepatitis A 35 27/12

Hepatitis B 33 23/11

Hepatitis C 32 23/11

Tuberculosis 32 21/11

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Multistate Assessment of Public Surveillance Relevant to AI/ AN, 2007, Bertolli et al 2011

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

“ 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 andindividuals."

Winslow, Charles-Edward Amory (Jan 9, 1920). "The Untiltled Fields of Public Health". Science 51 (1306): 23–33. doi:10.1126/science.51.1306.23. PMID 17838891.

Public Health Approach

Public HealthModel

Medical Model

Versus

1. Monitor health status2. Diagnose and investigate3. Inform and educate4. Mobilize communities to identify problems5. Develop policies and plans6. Enforce laws and regulations7. Link people to needed health services8. Assure a competent healthcare workforce9. Evaluate health services10. Conduct research

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Public Health Ten Essential Services

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Need for Integration of Tribal Nations into American Public Health System,

Reportable Disease Surveillance System

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

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Need for Integration of Tribal Nations into American Public Health System,

Reportable Disease Surveillance System

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 functionwithin the reportable disease surveillance process.

Tribes have no involvement in submission of reportable disease data where IHS provides direct services

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Need for Integration of Tribal Nations into American Public Health System, Reportable Disease Surveillance System

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

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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