Tribal Epidemiology Centers: At the Forefront of American Indian/Alaska Native Public Health

In 2019, the Journal of Public Health Management and Practice published a supplement titled “Tribal Epidemiology Centers: Advancing Public Health in Indian Country for Over 20 Years,” which included articles from Tribal Epidemiology Centers (TECs) and contributions from other federal partners. ¹ The current supplement with Public Health Reports builds on the foundational work presented in the 2019 supplement, highlights further examples of TEC work with their Tribal partners, and describes other challenges working with American Indian and Alaska Native (AI/AN) data. Articles in this supplement offer examples of best practices and experiences that support culturally informed work in a Tribal setting, describe how data collection and analysis are community-based and meaningful to the people the TECs serve, and illustrate the value of the direct relationships TECs have with other Tribes, Tribal organizations, and urban Indian organization (T/TO/UIO) partners. Articles address gaps in state and federal data and share approaches to fill those gaps; describe barriers to accessing data and challenges in data quality, completeness, misclassification, and obtaining data-sharing agreements; and discuss how the COVID-19 public health emergency has resulted in increased awareness related to misunderstandings about data sovereignty and the role of TECs as public health authorities. TECs are also advocates for the T/TO/UIOs they serve and educate federal and other partners about major data-related issues. With this supplement, TECs aim to raise awareness of data gaps, challenges, and barriers; impart knowledge of the best practices in working with Tribal communities; and describe how current practices at the state and federal level and with other partners do not accurately represent how AI/AN populations have been affected by health disparities. The focus on data sovereignty, best practices, successes, and lessons learned in articles in this supplement shares a story of progress that is unique and not shared elsewhere.

TECs are housed within organizations that serve AI/AN T/TO/UIO communities. The TECs share the mission “to improve the health status of American Indian and Alaska Native people by: (1) identifying and understanding health risks and inequities; (2) strengthening public health capacity; (3) assisting in disease prevention and control.” ² TECs support these organizations and communities by using culturally relevant and appropriate approaches to manage public health information systems, investigate diseases of concern, manage disease prevention and control programs, respond to public health emergencies, and coordinate these activities with other public health authorities. ² Four TECs were initially formed at the request of Tribal leadership in 1996 to address public health capacity in Indian Country. ³ Over time, TECs were established in all Indian Health Service (IHS) Areas, and the 12 TECs were designated as public health authorities under the permanent reauthorization of the Indian Health Care Improvement Act in 2010.^4,5 This supplement features an article by O’Connell and Abourezk ⁶ that reviews current federal laws designating TECs as public health authorities.

TECs serve the AI/AN population and partner with governmental agencies, academic institutions, and various other entities to improve AI/AN health. As a result of these partnerships, TECs assist with many public health functions, such as monitoring health status and trends and promoting Tribal data sovereignty.^7-9 Some TECs have implemented sophisticated record-linkage methods that use enrollment lists and administrative hospital data. ¹⁰ These methods have improved the accuracy of AI/AN categorizations to ensure better estimates of AI/AN health measures than typically found in other datasets in which racial misclassification is a common concern.^11,12 TECs also support efforts to develop Tribally based data systems for disease surveillance and reporting.^13,14 The articles in this supplement provide a glimpse of some of the work conducted by TECs to improve the health and wellness of T/TO/UIOs and partners by highlighting several accomplishments.

Community-engaged and community-informed methods have been implemented with the support of various federal funding sources and in partnership with Tribal leadership to provide a more complete national picture of AI/AN health and focused programs to improve health status. These partnerships often identify public health priorities and generate culturally respectful interventions and communication. Reece et al ¹⁵ describe one of these unique programs: a cooperative agreement with the Centers for Disease Control and Prevention (CDC) designed to supplement the 12 TECs to strengthen public health infrastructure and capacity, improve health by identifying and addressing health risks, and support disease prevention and control. The COVID-19 pandemic highlighted the need for integrated multijurisdictional data systems, improved local disease surveillance, and access to accurate and timely infectious disease data.

TECs have been particularly instrumental during the COVID-19 pandemic by responding immediately with critical resources and supplies and promoting social distancing and vaccination. Le-Morawa et al ¹⁶ reported on the strategies used by the San Carlos Apache Tribe to achieve high rates of COVID-19 vaccination. The Tribe used a risk-stratified approach to vaccination rollout. The Tribe initially distributed vaccines to those with the highest risk for severe COVID-19 outcomes, including people aged >65 years, to promptly reduce the number of hospitalizations and deaths. The article describes several strategies used to increase COVID-19 vaccine access and uptake. By February 27, 2021, the vaccination rates in the San Carlos community were 47.6 doses per 100 population, compared with 25.2 per 100 population in the state of Arizona. ¹⁶

TECs worked with their partners to assess the accuracy and completeness of national data on race and ethnicity from COVID-19 case surveillance. In an article by Erickson et al, ¹⁷ the Urban Indian Health Institute responded to the pandemic by providing key information on the data quality of public health surveillance of the COVID-19 pandemic. The Urban Indian Health Institute identified issues related to the collection and/or transmission of race and ethnicity data from the CDC DCIPHER (Data Collation and Integration for Public Health Event Response) platform. ¹⁸ The authors found that the completeness of the data varied by state and identified gaps that affected the quality of race and ethnicity data submitted by states to CDC, especially for people reporting multiple racial and ethnic identities. They found that incomplete reporting may distort estimates of disease in groups that were disproportionately affected by the pandemic, thereby affecting public health efforts to improve health equity and inform decisions for effective public health strategies.

TECs also monitored data reporting and other important public health functions that have been important to Tribal communities during the pandemic, often filling needs not provided by federal, state, and Tribal public health systems. The Rocky Mountain TEC also conducted a study on COVID-19 data surveillance and data quality. ¹⁹ During the pandemic, the Rocky Mountain TEC was challenged by a lack of access to real-time data from federal agencies and state health departments. Duplicative surveillance systems and missing data to assess key trends in cases or vaccination rates were 2 main challenges that limited the Rocky Mountain TEC’s ability to make informed public health decisions and efficiently navigate the response to the pandemic. The results of this study highlight the importance of having established policy, guidance, and procedures to streamline timely access to data as part of a comprehensive and effective public health emergency response.

Additional articles in this supplement demonstrate how TECs tackled various complicated public health priorities, ranging from upstream factors (eg, building Tribal health infrastructure and telemedicine) to surveillance of colorectal cancer rates. The Alaska Native Epidemiology Center highlighted an increased risk of colorectal cancer among AI/AN populations. ²⁰ A retrospective review of initial colonoscopies among AI/AN adults living in interior Alaska revealed high rates of adenoma compared with an urban AN population and others. These findings may lead to enhanced screening methods with respect to age and timing, as well as investigations into risk factors to prevent adenomas among AI/AN in Alaska.

Exemplifying the 2 themes of collaboration and coordination from the model by Reece et al, ¹⁵ the Inter Tribal Council of Arizona, Inc (ITCA) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition services for families through partnerships with local vendors. ²¹ ITCA TEC applied guidance from the US Department of Agriculture for constructing WIC vendor peer groups to improve pricing and services and evaluated the national model with ITCA WIC; the team used national guidance to improve models so that they are culturally appropriate in Arizona. These changes may be important for other WIC programs to consider in serving Tribal WIC clients.

Another key theme that arose in multiple articles in this supplement was the importance of culturally adapted methods and intervention approaches. For example, the Albuquerque Area Southwest TEC analyzed data from the 2019 New Mexico Youth Risk and Resiliency Survey to characterize the risk and protective factors of suicide among AI/AN young people. ²² The authors identified family and community resilience factors that can inform school-based suicide prevention program efforts for young people, with the goal of reducing suicide among young AI/AN people in New Mexico. The Northwest TEC and partners evaluated the experiences of AI/AN Two Spirit and lesbian, gay, bisexual, transgender, and queer and questioning individuals about access to health care. ²³ The team administered a survey that was created with an Indigenous framework that provided both cisgender and gender-diverse participants an opportunity to gauge and share their experiences in interacting with health care systems. Gender-diverse participants reported more difficulties in accessing health care than did cisgender participants in every domain. Therefore, recommendations were made on providing culturally relevant health care provider education and gender-affirming inclusive care practices.

To meet the treaty obligations to AI/AN communities in the United States and improve public health, community-based approaches and Indigenous methods are critical. TECs that supported other public health authorities during the COVID-19 pandemic with additional staff to assist with contact tracing improved local, state, and national surveillance. This work can be used as a model for future pandemic response. This supplement highlights the continuing response of TECs to COVID-19 and many public health needs in AI/AN communities. Although each TEC may prioritize and operationalize work differently, based on the needs of the region and Tribal partners, the TECs work together collectively across the country. Sharing work collectively provides TECs and their partners the opportunity to tell a story as a whole and provides context to the daily work they do to support their communities. Guided by AI/AN leadership, culture, and values, TECs continue to support the public health work in Indian Country and hope to do so for many generations to come.