In This Issue
Upcoming Events
January 24-27, 2016
Phoenix, AZ 

NIHB Welcomes New Public Health Team Members!
As the Public Health Programs and Policy Department at the National Indian Health Board continues to grow, we are excited to welcome two new members into our circle.  
Jamie Ishcomer joined the team in September.  She comes with a lot of academic and real world experience having both a master of public health and a master of social work from Washington University, and having previously worked at the California Rural Indian Health Board.  She is an enrolled member of the Choctaw Nation.  Jamie will be working on public health accreditation-related projects, and designing a new training curriculum on strategic planning for health equity.   
Shervin Aazami joined the team in October.  He is a CDC employee that has been assigned to NIHB for a two year term as part of the Public Health Association Program (PHAP).  He recently earned his undergraduate degree  and previously worked with the Washington, DC Department of Health on their HIV and infectious disease prevention programs.  Shervin will be launching an obesity prevention project at NIHB over the next two years.  We are all excited to have them join our public health team!

Tribal Leaders Diabetes Committee NEW Area Representatives!

The TLDC provides leadership, guidance, and recommendations to the IHS and other government agencies on issues related to diabetes and related chronic health conditions among AI/ANs. One (1) Tribal leader member and one (1) Tribal leader alternate from each IHS Area is selected by the respective IHS Area Director in consultation with Area Tribes. There have been four (4) new Committee members appointed in the past several months, including:

Great Plains Area
Chairman Harold Frazier, Cheyenne River Sioux Tribe

Navajo Area
President Russell Begaye, Navajo Nation

Phoenix Area
Chairman Thomas Beauty, Yavapai-Apache Nation

Tucson Area (Alternate)
Beverly Coho, Navajo Nation

To view the entire TLDC directory, please visit
. SDPI grantees can contact their Area TLDC representative with questions or input on SDPI that they would like addressed by the Committee or Committee workgroups. For more information or to contact a TLDC member from your Area, please email Michelle Castagne
Native Children's Policy Agenda

Four national Native organizations - the National Indian Health Board (NIHB), the National Congress of American Indians (NCAI), the National Indian Child Welfare Association (NICWA), and the National Indian Education Association (NIEA) - have come together to update the joint policy agenda for Native youth. The Native Children's Policy Agenda was released on September 22, 2015 at NIHB's Annual Consumer Conference. The goal of this policy agenda is to set forth specific recommendations to improve the social, emotional, mental, physical, and economic health of children and youth, allowing them to achieve their learning and developmental potential. In short, this initiative calls on key stakeholders to put First Kids 1st.
Read the Native Children's Policy Agenda HERE.

NIHB Supports Seven Tribes to Further Work
on Public Health Accreditation

The National Indian Health Board (NIHB) is pleased to announce the selection of seven Tribal health departments for the Tribal Accreditation
 Support Initiative (Tribal ASI). This is the second cohort
of Tribal ASI awards, and NIHB is excited about being able
to support two more Tribes in this cohort than in the previous
cohort. Between October 2015 and June 2016, Tribes will work to address their
various needs in preparing and applying for accreditation through the Public Health Accreditation Board (PHAB).

Each of the Tribes have constructed their own individual workplan that will
accomplish specific and concrete steps towards achieving
one or more of the standards for public health accreditation.
The following is a list of the Tribal ASI awardees:

Chickasaw Nation, Oklahoma 
Forest Country Potawatomi, Wisconsin
Ho-chunk Nation, Wisconsin
Northern Cheyenne Nation, Montana 
Nottawaseppi Huron Band of the Potawatomi, Michigan
Oneida Tribe of Indians of Wisconsin
Pascua Yaqui Tribe, Arizona

The Tribal ASI project is made possible by funding and support from the 
Centers for Disease Control and Prevention (CDC),
Office for State, Tribal, Local, and Territorial Support, and is administered
by NIHB. More information on the Tribal ASI can
be found here.
NIHB Presents at National HIV Prevention Conference
NIHB staff were proud to present as part of a research team led by the Great Plains Tribal Chairmen's Health Board at the recent National HIV Prevention Conference in Atlanta, GA, December 6-9.  The research team submitted an abstract, which was accepted, for an oral presentation on the preliminary outcomes of an implementation and evaluation of an adaptation to a popular HIV prevention intervention for youth.  The resulting intervention, titled Rez Smart, displayed some promising outcomes, most noticeably in the areas of self-efficacy to use a condom and intention to get an HIV or and STI test.  NIHB attended the conference with two employees of the Great Plains Tribal Chairmen's Health Board, and presented the findings as part of a panel on culturally competent population engagement. 
Tribal Epidemiology Centers (TECs)
Anchorage, Alaska

Albuquerque, New Mexico

Sacramento, California

Lac du Flambeau, Wisconsin

Phoenix, Arizona

Window Rock, Arizona

Rapid City, South Dakota

Portland, Oregon

Oklahoma City, Oklahoma

Billings, Montana

Nashville, Tennessee

Seattle, Washington
Public Health Digest 
A Publication of the National Indian Health Board 
Mission of the National Indian Health Board

One Voice affirming and empowering American Indian and Alaska Native peoples to protect and improve health and reduce health disparities.

This Publication
The National Indian Health Board (NIHB) invites you to learn more about the latest developments in Tribal public health, including updates on NIHB's current projects.  We also invite you to share your news items, comments or questions. 
Public Health Accreditation and Health Care Accreditation:  What's the Difference?
The main difference between public health accreditation and health care accreditation really boils down to the difference between the function of health care and the function of public health.  "Health care" is what you receive when you visit a physician's office, a clinic or a hospital when you are sick or injured.  Health care treats individuals through medicines, therapies, surgeries or other procedures.  The health care system consists not only of the providers and facilities involved in treating individuals, but all of the supports that go with it, such as patient education, health record management, and infection control for patient safety.  "Public health," on the other hand, refers to activities that prevent disease and injury before it happens or to contain the spread in a population.  The key difference is that public health functions to protect and promote the health of entire populations, such as a community or a Tribe, whereas health care focuses on the individual (Figure 1).  

Figure 1

The public health system is a large umbrella that includes facilities, disease surveillance, health promotion programs, public health codes and laws, and community partnerships, often referred to as the 10 essential services of public health (Figure 2).

Sometimes, and often so in Tribal communities, the organizations that make up the public health system are not contained in one building. The program that monitors the environment or water may be separate from the injury prevention program and the laws that govern health may be set by the Tribal Council, but they are all part of the public health system. However, it is not uncommon that public health programs such as the Community Health program or the Sanitarian are housed in a health center that also provides medical care. So, when trying to understand the difference between health care accreditation and public health accreditation it might be better to ignore the walls of the buildings and think about the services that are being provided and whether it is medical care provided to individuals or prevention or protection aimed at the entire community. 
Tribal clinics may be familiar with health care accreditation through Accreditation Association for Ambulatory Health Care (AAAHC) or Joint Commission on Accreditation of Health Care Organizations (JCAHO). It is the systems and supports for patient care that are generally contained in one facility and provided by one organization that get accredited through AAAHC or JCAHO. On the other hand, the Public Health Accreditation Board (PHAB), the accrediting body for public health departments, accredits the network of supports for protecting and promoting health in the population as a whole and may include the functions delivered by many organizations, such as Tribal, local, county and state organizations working for the betterment of a community. PHAB does not require that all of the public health services in a community be delivered by one organization as that is not how public health generally works. So, even if a Tribal public health or community health program is small and only provides some or a portion of the 10 essential public health services, that program can still apply for public health accreditation as the Tribe has the authority to ensure the health of the members. What matters more in public health accreditation is that the responsibilities for providing the 10 essential public health services are clearly defined and formally agreed upon by the various agencies providing and receiving those services, whether those services are provided by the Tribe, the county or state.

Figure 2

Consider this scenario:  A Tribe has the public health authority to protect their population from infectious disease and there is a whooping cough outbreak in the state in which the Tribe is located.  The state also has a responsibility to protect all citizens in the state which includes Tribal members.  The state, by law, is required to provide the surveillance of a whooping cough outbreak by tracking the number and location of cases, which may be on or off Tribal lands.  The Tribal health program may have a memorandum of agreement with the state that the Tribal health center will report positive cases to the state surveillance system and the state also agrees to inform the Tribe of positive cases of whooping cough on Tribal lands. The Tribe may also have a memorandum of understanding with the county health department that both the Tribal and county public health nurses and health educators will collaborate on providing education to the Tribal population on preventing the spread of infectious diseases, in this case, whooping cough.  That the agreements are in place demonstrates that the public health system is prepared to adequately monitor, diagnose, investigate, inform, educate, and mobilize community partnerships in order to protect and promote the health of the community.  It is these services and the formal arrangements that are of consideration in meeting public health accreditation standards.  
Tribal Epidemiology Center Spotlight: 
Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC)
The Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC) serves a diverse population of 27 Pueblo, Navajo, Ute, and Apache Tribes in the four state region of New Mexico, Texas, Colorado and Utah. Established in 2006, AASTEC is the only tribal entity that serves all 27 IHS Albuquerque Area Tribes in a public health capacity, and provides leadership, technical assistance, resources and support in the fields of epidemiology, program evaluation, public health surveillance, community health assessment, training, student development and health promotion/disease prevention intervention. As a Tribal Epidemiology Center, AASTEC has public health authority status as mandated in the Indian Health Care Improvement Act, permanently reauthorized under the Patient Protection and Affordable Care Act (PL 111-148).

AASTEC's parent organization is the Albuquerque Area Indian HealthBoard, Inc. (AAIHB), an intertribal organization with over 30 years of experience in health service delivery, research, training, and leadership. Tribal input and technical assistance are provided to AASTEC via its Executive Council, which meets quarterly and includes a representative from each of the 27 Tribes served by AASTEC, and a Tribal Advisory Council, which includes partners from the scientific and academic community in our region including the New Mexico, Colorado and Texas Departments of Health, the University of New Mexico, Indian Health Service, and Urban Indian Health organizations. 

Toilet training for faecal occult blood test (FOBT)
Toilet training for faecal occult blood test (FOBT)
Some current projects led by AASTEC in partnership with the tribal communities we serve include:   1) Tribal BRFSS (Behavioral Risk Factor Surveillance System) with 13 Tribes to date, which collects information on health status, risk behaviors, preventive health practices, and health care access to identity community needs/assets, monitor health status, and plan and evaluate community health programs. Most of these Tribal BRFSS surveys are conducted through in-person interviews where AASTEC trains community members to serve as BRFSS interviewers; 2) Good Health and Wellness in Indian Country, which provides leadership, technical assistance, training, and resources to tribal communities to facilitate policy, system and environmental approaches to prevent/manage heart disease, stroke, type 2 diabetes and affiliated risk factors, such as commercial tobacco use, physical inactivity, and unhealthy diet; 3) Tribal Colorectal Health Program which aims to build knowledge and skills among Community Health Representatives (CHRs) to provide outreach and patient navigation, develop culturally appropriate colorectal health education materials, and explore promising colorectal cancer control interventions in tribal communities, including FluFIT, which bundles colorectal cancer screening (Fecal Immunochemical Test) withFlu shots for a double dose of prevention among eligible tribal members; 4) Tribal Database Project, which partners with 16 Tribal SDPI and CHR programs to build customized databases for electronic monitoring and evaluation of client health status and programmatic activities; and 6) Tribal Injury Prevention and Control Program to address the burden of unintentional injuries among the American Indian population in our region with a particular emphasis upon motor vehicle and falls-related injury prevention. 

BRFSS interview training
Behavioral Risk Factor Surveillance System (BRFSS) interview training
Another project which demonstrates the unique role of AASTEC towards improving data quality and access for the American Indian population in our region, is our Southwest Tribal Youth Project. This initiative is a partnership with the New Mexico/Colorado Departments of Health and Education, and the University of New Mexico/University of Colorado to oversample American Indian youth in the New Mexico Youth Risk and Resiliency Survey (NM YRRS) and the Colorado Healthy Kids Survey. An overarching aim of this project is to increase the participation of American Indian youth in these important statewide public health surveillance systems. AASTEC achieves this by conducting a classroom census in 40-50 middle and high schools with high American Indian student enrollment located within or adjacent to tribal communities. This oversampling approach has resulted in the inclusion of an additional 4,000 to 5,000 American Indian students during each biennial survey cycle, which ensures that data that is generated from this survey is representative for American Indian Tribes. Implementing a classroom census, where all students at a particular school participate in the survey, also promotes the availability of tribal and school specific data.

For the 2015 administration of the NM YRRS, currently underway this fall, we are also pilot testing a new tobacco-specific question to better differentiate between ceremonial/traditional tobacco and commercial tobacco among American Indian high school students. While Native people differentiate between traditional and commercial tobacco use, instruments utilized in public health surveillance, including the NM YRRS make no such distinction. Therefore, rates of American Indian youth tobacco use in New Mexico may be inaccurate. The subsequent analysis from this pilot test will yield two critical pieces of information that have been previously unavailable to tribal stakeholders engaged in commercial tobacco control and prevention, including: 1) the extent to which American Indian youth report ceremonial tobacco use in standardized public health surveillance activities, and 2) the actual burden of recreational, commercial tobacco use among American Indian high school students in New Mexico. To our knowledge, this is the first time that such a question has been included in a statewide public health surveillance system. Armed with accurate and representative data, tribal programs, leaders, schools and health facilities can more effectively prioritize youth commercial tobacco prevention, design, implement and evaluate tobacco prevention and control programs, leverage additional resources, and advocate for culturally appropriate policy and system change to curtail commercial tobacco use among American Indian youth.
The State of Obesity in Indian Country, and the Cultural Tools to Combat It
Obesity is a pressing concern within the American Indian/Alaskan Native (AI/AN) population. Although it is a major issue in the medical field nationwide, it continues to affect the Native community at a substantially higher percentage. Moreover, the AI/AN population are at 1.6 times greater risk of obesity in comparison to the general population, with some estimates placing the obesity rate at a devastating 80%. In addition, roughly 50% of youth under the age of 19 are rated as being above a healthy weight limit.

As is solidly established in the medical community, obesity is the leading determinant of Type II diabetes, cardiovascular disease (CVD) and hypertension. Although surveillance research is lacking in regards to CVD and hypertension, Type II diabetes is a well-documented epidemic in Indian Country with roughly 30% of AI/AN classified as pre-diabetic, and 1 in 2 youth on track towards developing diabetes in adulthood. These numbers are truly alarming, and without properly developed interventions, they are slated to continue.

Given the multitude of sociocultural and socioeconomic stressors that uniquely affect communities living on reservations, it is imperative to introduce culturally competent interventions that embrace the cultural and spiritual practices that surround the gift of food for Native Americans. Special attention must be paid to the traditional native diets that have been trumped by less nutritious alternatives high in refined sugars, carbohydrates and saturated fats. Simultaneously, funding measures must prioritize locally grown options in order to empower small businesses and further reinforce Native rights to self-determination. 

NIHB is working on an obesity intervention program that highlights the diversity of Native Tribes, and focuses on communal growth and camaraderie as the driving force behind healthy change. Many existing interventions have either overlooked or only marginally included a community approach highlighting the Native values of family, solidarity and holistic healing. As pointed out by the U.S. Department of Health and Human Services in their April 2007 report on Native obesity levels, "...intervention researchers have emphasized the importance of using Native traditions and values in devising intervention strategies. It is the creative incorporation of [these] and other Native values, culture and traditions that make obesity interventions with AI/ANs unique and more likely to result in positive outcomes."[i] NIHB has laid the preliminary groundwork for a program known as First Kids 1st, which will focus on obesity (among other issues) through both programmatic and policy approaches.

Through further research, policy scans and collaborations with Tribal leaders, NIHB aims to complete a national report on the state of Native obesity levels by Spring 2016, and commence program implementation by early Fall 2016. This intervention will focus on combining the quantitative variables such as BMI, blood insulin levels and waist circumference, with the more qualitative measurements such as connectedness, community engagement and spiritual wellness. These more subjective aspects will be integrated through traditional talking circles, sharing of stories, involvement of elders, and so forth, as a means of promoting weight loss and health as a communal goal. Moreover, NIHB looks to introduce a program that utilizes the diverse and enduring practices of Tribes as the mechanism for reducing obesity levels. In order to effectively bring forth change, programs must appreciate the Native viewpoint of food not as a commodity, but as a gift. Intervention methods must tap into the traditional Native understanding of sustenance as inseparable from spirituality. In the words of Vanessa Cooper of the Lummi Tribe, "Food is at the center of our culture... it feeds our bodies and it feeds our spirit."[ii]

As the leading national public health organization dedicated to Tribal issues, we look forward to partnering with and advocating on behalf of our Native and non-Native allies. Moreover, we must recognize this crisis not as one isolated to Indian Country, but as one that affects the integrity of the United States as a whole. In the words of the Lakota Tribe's "Instructions for Living", "...And the hurt of one is the hurt of all. And the honor of one is the honor of all."

[i] Halpern, Peggy. "Obesity and American Indians/Alaska Natives." U.S. Department of Health and Human Services, 1 Apr. 2007. Web.
[ii] Cooper, Vanessa. "Part I, Traditional Foods in Native America." Centers for Disease Control and Prevention. Web. 
The Applicability of the National HIV/AIDS Strategy for Indian Country
In July 2010, the Obama administration released the first comprehensive National HIV/AIDS Strategy (NHAS).  Looking back, the impact of the NHAS can be outlined in four areas: 1.) it changed the American perception of HIV; 2.) it organized HIV prevention and care services; 3. ) it explained clinical and other related services that supported people living with HIV, and; 4.) it encouraged their engagement in HIV treatment and care.[i]  The 2010 NHAS was a five year plan, and earlier this year, the Obama administration released an updated NHAS to carry the country through 2020.  The new strategy mirrors the same vision and goals described in the 2010 version.

The NHAS goals for 2020 are as follows: 
  • Goal 1: Reducing the number of people who become infected with HIV 
  • Goal 2: Increasing access to care and improving health outcomes for people living with HIV
  • Goal 3: Reduce HIV-related disparities and health inequities
  • Goal 4: Achieving a more coordinated national response to the HIV epidemic 
These goals will continue to shape HIV prevention, care, and treatment for the foreseeable future - including programmatic and policy efforts alike.  Health care providers and community health providers, including providers working with and in American Indian and Alaska Native communities. 

According to the Centers for Disease Control (CDC), an estimated 222 American Indian and Alaska Native (AI/AN) people were newly diagnosed with HIV in 2014 with a rate of 9.5 per 100,000.  This is the 4th highest rate of new infections, and represents the rise in the rate of new infections from 2010 to 2014 - a distinction only shared by the Asian population in the United States.  The rates for blacks/African Americans, Native Hawaiians/other Pacific Islanders, and persons of multiple races decreased. The rates for Hispanics/Latinos and Whites remained stable.[ii] 

The nature and landscape of HIV prevention work has significantly shifted in the past five years.  There is heightened attention on cost effectiveness, structural interventions, biomedical interventions, policy efforts, and the integration of HIV prevention into clinical settings.  Financial and funding struggles have also forced many community-based organizations, including Native and Native-serving community-based organizations, to close or severely shift their focus in order to remain viable.  The 2020 NHAS provides an excellent blue print for Native prevention programs to meet the demands of escalating HIV infections, and continue to align with the shifting priorities of the field. 

Tribal programs can examine their existing efforts through the lens of the NHAS and ask, "What are we currently doing to support these goals?"  Tribes should feel comfortable reporting to their funders, health administrators, and Tribal leaders on efforts underway that align with NHAS goals and objectives. Future program planning and community health planning should also incorporate the National HIV/AIDS Strategy as a guidepost for developing local HIV indicators and goals.

Local activities that directly address NHAS goals can include:
  • NHAS Goal 1 - Reducing the number of people who become infected with HIV:  conducting community outreach; targeting prevention efforts to gay and bisexual men; transgender men and women, and two spirit individuals; expanding access to condoms, pre-exposure prophylaxis, and syringe services; implementing age-appropriate HIV and STI education; implementing best and wise practices for HIV prevention in your community that are locally and culturally relevant; and promoting National Native HIV/AIDS Awareness Day as a day of action.
  • NHAS Goal 2 - Increasing access to care and improving health outcomes for people living with HIV: adopting and implementing a relevant linkage to care model; expanding testing opportunities; construct a strong regional referral network that includes all manners of services; expanding capacity to provide (and bill) for a wider variety of public health services of benefit to people living with HIV; provide training to local clinicians and clinic staff on HIV and HIV care; integrate prevention messaging and programs in clinical operations (including HIV testing reminders in electronic health records, high risk screening indicators, and brief interventions).
  • NHAS Goal 3 - Reduce HIV-related disparities and health inequities: Facing the fact the HIV impacts all Indians and every Native community, regardless of gender, sexual orientation and/or transmission risk; openly discussing HIV as a community public health concern; linking programs addressing the social determinants of health to HIV and those living with HIV
  • NHAS Goal 4 - Achieving a more coordinated national response to the HIV epidemic.  While this goal lies firmly within the hands of the federal government, Tribes should not ignore the fact that there is an opportunity here for Tribes to communicate openly and honestly with federal agencies that operate HIV prevention and care programs (like IHS, CDC, SAMHSA, and HRSA) to talk about their needs and how a coordination national response can best meet the needs of Indian Country.
The 2020 NHAS is applicable to all health care providers, administrators, outreach and education staff, and Tribal leaders in Indian Country - because HIV is applicable to all people within Indian Country.  Only by bolstering HIV prevention and treatment efforts, as outlined in the updated NHAS, will AI/AN communities be able to stem the tide of rising rates of new infections.   

[i] Yehia, B., & Frank, I. (2011). Battling AIDS in America: An evaluation of the National HIV/AIDS Strategy. American Journal of Public Health, 101(9), E4.
[ii] Centers for Disease Control and Prevention. (2015). HIV Surveillance Report, Diagnoses of HIV Infection in the United States and Dependent Areas, 2014, vol. 26.  Accessed from 

Diabetes Awareness Month:
November 2015
NIHB released over 14 new Special Diabetes Program for Indians (SDPI) local impact stories throughout the month of November in celebration of both Diabetes Awareness Month and Native American Heritage Month. The SDPI is going into its nineteenth year of funding diabetes treatment and prevention programs in Indian Country. After almost two decades of continuous funding, there are many personal successes to be shared and improved data outcomes to be celebrated. For example, innovative SDPI programming success stories include a diabetes support group, community gardens, foot care services, and nutrition classes. View the new stories HERE.
For Diabetes Awareness Month, NIHB Public Health staff also staffed a booth, in partnership with the Inter-Tribal Buffalo Council, at the National Bison Day Reception on November 4, 2015. There were over 500 attendees at the reception and many stopped by the NIHB table to learn more about the impacts of SDPI in Tribal communities and the benefits of using bison and traditional foods in school lunch programs.

Did you host an event for Diabetes Awareness Month or have an SDPI success story to share? Let us know through this online form or email Michelle Castagne at