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					       Centers for Public Health Preparedness Network




         Tribal Preparedness Resources
  Developing Collaborations with Tribal Nations


by the 2005-2006 ASPH/CDC Tribal Preparedness Resources
                  Collaboration Group




  September 2006
                                          Centers for Public Health Preparedness |1
Acknowledgments                                        Group Members
The Tribal Preparedness Resources Collaboration        •   Hal Marlow, Loma Linda University School
Group would like to thank Joe Coulter (University          of Public Health, Loma Linda University
of Iowa College of Public Health, Upper                    Center for Public Health Preparedness
Midwest Center for Public Health Preparedness)         •   Jesse Bliss, Loma Linda University School
for his valuable leadership as chair of this group,        of Public Health, Loma Linda University
and group members Hal Marlow ( Loma Linda                  Center for Public Health Preparedness
University School of Public Health, Loma Linda         •   Courtney Andrews, Saint Louis University
University Center for Public Health Preparedness),         School of Public Health, Heartland Center
Nedra Pautler (University of Washington School             for Public Health Preparedness
of Public Health and Community Medicine,
                                                       •   Jennie Mullins, University of Arizona
Northwest Center for Public Health Prepared-
                                                           College of Public Health, Arizona Center
ness), Vicki Cleaver (University of Oklahoma
                                                           for Public Health Preparedness
Health Sciences Center, Southwest Center for
Public Health Preparedness), and Jennie Mullins        •   Chris Atchison, University of Iowa College
(University of Arizona College of Public Health,           of Public Health, Upper Midwest Center for
Arizona Center for Public Health Preparedness)             Public Health Preparedness
who developed and presented the case
                                                       •   Vicki Cleaver, University of Oklahoma Health
studies for their respective Centers for Public
                                                           Sciences Center, Southwest Center for Public
Health Preparedness.
                                                           Health Preparedness

The contributions of each one of the group             •   Nedra Pautler, University of Washington
members also were critical to the completion               School of Public Health and Community
of this document. In turn, the group would like            Medicine, Northwest Center for Public Health
to thank practice partners, CDC liaisons, and              Preparedness
the ASPH coordinator for their guidance and
support. Note: while members may have
multiple affiliations, their relevant CPHP affiliation
is the one listed.

                                                       Practice Partners
                                                       •   Michael Allison, Arizona Department of
                                                           Health Services
Chair
                                                       •   Timothy Breshears, Choctaw Nation
• Joe Coulter, University of Iowa College of
  Public Health, Upper Midwest Center for              •   Ralph Bryan, Centers for Disease Control and
  Public Health Preparedness                               Prevention, Office of Strategy and Innovation

                                                       •   Gary Robison, Kaw Nation

                                                       •   Dean Seneca, Agency for Toxic Substances
                                                           and Disease Registry, Office of Tribal Affairs




                                                                    Centers for Public Health Preparedness |3
   CDC Expert Liaisons
   •     Chris Rosheim, Centers for Disease Control
         and Prevention, Office of Workforce and
         Career Development

   •     Craig Wilkins, Centers for Disease Control
         and Prevention, Coordinating Center for
         Health Information and Service




     ASPH Coordinator
     •    Kate Fleming




This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through
the Association of Schools of Public Health (ASPH) Grant Number U36/CCU300430-25.

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the Centers for
Disease Control and Prevention.

Copies of this may be accessed at: http://www.asph.org/cphp/CPHP_ResourceReport.cfm.




4 | Centers for Public Health Preparedness
Table of Contents



     BACKGROUND...................................................................................................................................1

     INTRODUCTION.................................................................................................................................. 1

     PRINCIPLES FOR COLLABORATION.................................................................................................. 2

     CASE STUDIES IN TRIBAL PREPAREDNESS......................................................................................... 2

            •    CASE STUDY 1: LOMA LINDA UNIVERSITY SCHOOL OF PUBLIC HEALTH, OFFICE

                 OF PUBLIC HEALTH PRACTICE AND WORKFORCE DEVELOPMENT................................. 3

            •    CASE STUDY 2: UNIVERSITY OF WASHINGTON SCHOOL OF PUBLIC HEALTH

                 AND COMMUNITY MEDICINE, NORTHWEST CENTER FOR PUBLIC HEALTH

                 PREPAREDNESS.................................................................................................................... 6

            •    CASE STUDY 3: UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER,

                 SOUTHWEST CENTER FOR PUBLIC HEALTH PREPARENESS................................................. 8

            •    CASE STUDY 4: UNIVERSITY OF ARIZONA COLLEGE OF PUBLIC HEALTH, ARIZONA

                  CENTER FOR PUBLIC HEALTH PREPARENESS.................................................................... 10

     TRIBAL PREPAREDNESS INVENTORY................................................................................................ 12

     SUMMARY AND CONCLUSIONS..................................................................................................... 15

     FUTURE WORK................................................................................................................................... 15

     DOCUMENTS FOR COLLABORATION WITH TRIBAL ENTITIES..........................................................17




                                                                                                           Centers for Public Health Preparedness |5
   BACKGROUND

The Centers for Public Health Preparedness (CPHP) are a national network developed by the Centers for Disease
Control and Prevention (CDC) and the Association of Schools of Public Health (ASPH) in 2000 to train the public
health and healthcare workforce to respond to threats to the nation’s health, such as bioterrorism, outbreaks
of infectious disease, and other public health emergencies. The program has grown to become an important
national resource for the development, delivery, and evaluation of preparedness education. To foster sharing
and exchange of information, CDC and ASPH established collaboration groups on topics of preparedness to
develop products to aid the public health workforce. In 2005-2006, CPHP collaboration groups continued to
focus on reviewing preparedness resources and to develop guides and reports responsive to the training needs
of the public health workforce for all-hazards situations.




    INTRODUCTION

The Tribal Preparedness Resources Collaboration Group (TPRCG) supports the promulgation of educational
and training resources and activities available to American Indian and Alaska Native tribes and tribal
communities to improve response to tribal public health emergencies and all-hazards events, and bioterrorist
threats. As a number of the CPHP are key collaborators with tribal entities, the group wishes to improve the
CPHP Network’s capacity and effectiveness to act as a key education and training resource to tribal
communities.

Included in this report are:

    • Principles for Collaboration between CPHP and tribal organizations;
    • Four documented Case Studies of CPHP education and training and technical assistance
      activities underway in Indian country;
    • A preliminary template assessment tool, the Tribal Preparedness Inventory, which the group
      developed to survey CPHP to identify and assess the current educational and training resources,
      activities, needs, and gaps in tribal preparedness and response;
    • A brief Summary and Conclusions pertaining to tribal preparedness and CPHP partnerships;
    • A list of Future Work that needs to be done to continue these important linkages between
      tribal nations and the CPHP; and
    • A compilation of relevant sharable Documents for Collaboration with Tribal Entities.




                                                                         Centers for Public Health Preparedness |1
   PRINCIPLES FOR COLLABORATION

The following Principles for Collaboration originated from extensive discussions among TPRCG members, from
the Case Studies, and from the Documents for Collaboration with Tribal Entities to identify essential components
in successful partnerships between CPHP and tribal nations and communities. These principles provide a
foundation for, as well as guidance to, any CPHP undertaking a tribal preparedness initiative by recognizing
the unique relationships of tribal organizations to federal, state, and local governmental and community enti-
ties involved in public health, bioterrorism, and emergency preparedness and response. It is anticipated that
as CPHP gains experience in tribal preparedness, these principles will be extended, revised, and re-
fined. Specifically:

    •   Tribes and tribal communities should be seen as one of the key partners in federal, state, regional,
        and local public health preparedness activities across the United States to ensure that American
        Indian/Alaskan Native concerns are appropriately addressed in preparedness planning and
        response.
    •   Tribal nations and communities are in the best position to determine the strengths, assets, gaps,
        and needs to respond effectively to an all-hazards event, a public health emergency, or a
        bioterrorist threat and must be consulted in ways consistent with accepted tribal consultation policies.
    •   Tribal nations are sovereign entities with laws and traditional practices and have unique concerns
        and experiences that need to be paramount in preparedness and response activities.
    •   Participation and official approval of tribal governmental authorities are essential for effective public
        health emergency preparedness and response training and plan development.
    •   Tribal preparedness activities need to be based regionally, while reflecting the priorities and
        uniqueness of each tribe and community and the role and contributions of federal, state, and local
        organizations.
    •   Tribal communities as sovereign nations also recognize the need to ensure coordinated command
        systems involving state, federal, international, and local tribal and non-tribal agencies.
    •   Identification of stakeholder agencies and roles is crucial to successful communication and
        coordinated preparedness and response activities.



   CASE STUDIES IN TRIBAL PREPAREDNESS

The following four case studies provide examples of the different contexts and challenges CPHP faces
in developing effective collaborations with tribal nations in public health and bioterrorism, emergency
preparedness, and response planning. The case studies describe how CPHP can engage effectively with tribal
programs and entities, assess resources and gaps, and develop culturally appropriate approaches. Promising
practices are identified and lessons are emerging from these case studies. These examples show how CPHP
can collaborate with tribal communities to promote competency and evidence-based approaches to
improve tribal preparedness and make positive contributions to the overall health of American Indian/Alaskan
Native peoples.




2 | Centers for Public Health Preparedness
Case Study 1: Loma Linda University School of Public Health, Loma Linda University Center for
Public Health Preparedness

Following is a brief outline of the activities taking place with Native American partners at the Loma Linda
University (LLU) CPHP, with focus on a memorandum of understanding (MOU) between the Center and Diné
College of the Navajo Nation in Shiprock, New Mexico.

LLU CPHP is headquartered in the Loma Linda University School of Public Health, within the Office of Public
Health Practice and Workforce Development. It includes academic partners that represent the schools of
medicine, dentistry, nursing, allied health, pharmacy, science and technology, and faculty of religion. This
southern California CPHP represents a partnership between Loma Linda University, tribal nations, the Riverside
County Health Agency and Department of Public Health, and the San Bernardino County Department of
Public Health.

The LLU CPHP is strengthening existing relationships with Native American nations established during the course
of Health Resources and Service Administration (HRSA) and CDC-funded activities at the LLU School of Public
Health (SPH). LLU SPH established relationships with tribal nations throughout the southwestern U.S., Hawaii,
and Palau. At present, the majority of the LLU SPH efforts are associated with the Pacific Public Health Training
Center, Regional Academic Resource Center, and Academic Health Department. Activities are focused on
building relationships, partnerships, and capacity through needs assessment, education, and training.

The LLU CPHP is collaborating with the California Tribal Nations Emergency Management Council on a
variety of activities, including a training-needs assessment. In November 2005, the LLU CPHP attended a regional
meeting and gave a presentation introducing the CPHP and outlining several projects for the consideration of
the council.

The LLU SPH and CPHP have an ongoing relationship with the Native American Environmental Protection
Coalition (NAEPC). Most of the efforts with NAEPC focused on environmental issues and geographic
information systems (GIS) applications. Several GIS workshops were planned for the 2005–2006 project year. In
December 2005, the LLU CPHP conducted a grant-writing workshop for individuals of several NAEPC member
tribes. The workshop addressed general grantsmanship and focused on proposals to private foundations. Ten
participated in the workshop. In March 2005, the LLU CPHP and partners (including NAEPC) hosted a
risk-communication workshop. More than 150 attended from tribal nations, governmental agencies, industry,
and academia. Dr. Peter Sandman anchored the first day and Dr. Deborah Glick anchored the second.

During the summer of 2005, LLU provided resources and personnel to Diné College of the Navajo Nation in
Shiprock, New Mexico, to assist in the redesign and re-establishment of Diné College’s GIS program. The
university helped the college to equip its GIS lab fully with up-to-date hardware and software and provided
GIS training to personnel.

In November 2005, LLU and Diné College signed an MOU as a commitment to the advancement of GIS
capacity through resource sharing, research collaboration, technical assistance, and academic
development. The MOU represents a formal agreement between LLU and Diné College that strengthens
existing relationships and helps to define jurisdictional, technical, and collaborative activities between the two




                                                                           Centers for Public Health Preparedness |3
institutions. Specifically, the MOU provides a vision and framework for the future, and flexibly is designed to build
capacity within the institution. It will provide a mechanism for ongoing research and training activities as well
as program and technical development. In addition, the MOU outlines an agreement that allows Diné College
graduates who earned an associate degree in science in public health to transfer to LLU to continue their
education. The document stipulates the financial obligations incurred by each institution.




4 | Centers for Public Health Preparedness
Memorandum of Understanding Between Loma Linda University School of Public Health and
Diné College
Loma Linda University School of Public Health and Diné College propose to continue the development of their
relationship through collaboration in the implementation of public health academic and research programs,
with a particular focus on the advancement of geographic information systems (GIS) capacity in resources,
faculty, staff, and students at both institutions. This is seen to leverage the efforts by each institution to build
capacity that will advance the public health programs of both institutions through the following agreements,
contingent on financial and personnel availability:

   I.    Sharing of Personnel: Faculty, Staff, and Students
         Understanding that each institution has different levels of faculty, staff, student, and other personnel
         resources, exchanges of faculty, staff, and students between the above-identified institutions, either
         on short-term or long-term bases, will serve to benefit both institutions in their development of public
         health programs through training and resource sharing, most notably with respect to GIS capabilities.

   II.   Research Collaboration
         Both above-identified institutions will collaborate, where appropriate, in ongoing research activities
         and in efforts to secure funding for new programs through preparation and submission of proposals
         in their respective and mutual areas of interest, or collaborative roles, such as advisory, faculty, and
         consultancy in funded projects. This will enhance the capacity of both institutions to provide services
         in geoinformatics applications in various disciplines, including public health and environmental
         health at both institutions.

   III. Technical Assistance
        Loma Linda University School of Public Health will provide, through students, faculty, staff, and
        already established relationships, technical assistance to Diné College to increase the technical
        expertise for further developing GIS capabilities at Diné College.

   IV. Development of a Transfer Agreement
       Both institutions will work together to articulate degree programs by developing transfer patterns
       that will allow Associate of Science in Public Health students from Diné College to transfer to the
       Loma Linda University School of Public Health Bachelors of Science in Public Health (BSPH) health
       geoinformatics program or other BSPH programs offered by Loma Linda University School of
       Public Health.

   V. Financial Obligations
      Each institution will bear its own costs and expenses incurred in the performance of this
      Memorandum of Understanding.

The undersigned agree to continue collaboration in joint planning and implementation of educational and
research services in the area of public health, especially regarding GIS applications in public health.


For Loma Linda University:                                        For Diné College:

____________________________________________                      ___________________________________________
Richard H. Hart, Chancellor        (date)                         Ferlin Clark, President           (date)




                                                                            Centers for Public Health Preparedness |5
Case Study 2: University of Washington School of Public Health and Community Medicine,
Northwest Center for Public Health Preparedness

Following is a brief outline of the activities taking place with Native American partners at the University of
Washington School of Public Health and Community Medicine’s Northwest Center for Public Health
Preparedness (NWCPHP), with a focus on expansion of the contractual training and needs assessment with
Native American tribes in the region.

Founded in 1990, NWCPHP focused on workforce development in Washington State for about a decade. With
new resources available in 2000 from HRSA and the CDC, the center was able to develop the Northwest
Regional Public Health Workforce Development Network (the Northwest CPHP Network), which is reliant on
the expertise and energy of public health leaders throughout the region. This network serves six states—Alaska,
Washington, Oregon, Idaho, Montana, and Wyoming—and 43 tribes in three of those states through formal
agreements with the state public health organizations and the Northwest Portland Area Indian Health Board
(NPAIHB), a private nonprofit organization representing 43 tribes in Idaho, Oregon, and Washington. NWCPHP
serves a geographical region comprising 30 percent of the United State’s landmass, 5 percent of its
population, and three time zones. In addition, NWCPHP has six unique state and local public health systems
and an equally complex array of tribal health organizations.

Before the NWCPHP Network was created, there was only a limited sense of a multistate, regional public health
workforce among leaders. There was also little sharing of training materials and approaches. There were no
regional needs assessments, training plans, and the like, no forum for such relationships to develop, and no link-
age with similar activities at the national level. Today the network is strong, with contractual relationships with
each of the states and with the NPAIHB. In addition, NWCPHP has a staff person designated as a tribal liaison.

A central challenge in developing the NWCPHP Network has been dealing with the complexity and variety
of public health organizations in the region. NPAIHB serves 43 tribes in Washington, Idaho, and Oregon and is
the NWCPHP communications link with those tribes. Nevertheless, there are many Native American tribes and
corporations beyond the scope of NPAIHB. In Alaska, there are five native cultural groups and 21 regional
corporations served by the Alaska Native Health Board and the Alaska Native Health Consortium, an
organization that somewhat parallels a state department of health. Montana has seven federally recognized
tribes and a system of seven tribal community colleges. Thirty-nine percent of the state’s population claim
Indian heritage, which seems to translate into a broad sympathy for Indian issues. Montana tribes and state
public health are well-integrated. In Wyoming there is an IHS Service Unit to serve the state’s one reservation,
Wind River ,which is the home of two tribes; the Northern Arapaho and the Eastern Shoshone. These two tribes
also rely on the state/county system.

The organization of state public health systems is equally diverse. Each state operates within a unique
organizational structure. Alaska has one state and two local health departments for its huge landmass. Idaho
has seven autonomous, multicounty health districts and a state department. Montana has 52 local health
departments in 56 counties, each of which may or may not have a board of health, and a state department
of health. Oregon has a state/county system, but three of its counties contract to private facilities for clinical
care; Its state department is located within the huge Department of Human Services. Washington has 35
local health jurisdictions in 39 counties, but they have a number of organizational formats (county health




6 | Centers for Public Health Preparedness
departments, city-county health departments, and multicounty health districts), and its public health de-
partment is a cabinet-level position. Wyoming retains many public health functions at the state level, and most
of the 23 local health districts are solely public health nursing offices.

To grow an ongoing collaboration among such diverse organizations requires a continual search for
shared priorities for NWCPHP activities. Priorities may focus on the development of curriculum, identifying, and
prioritizing NWCPHP participation to include on-site activities (such as summer institutes in four states,
participation/presentations at the Public Health Association meetings, or state meetings) across the
region or technical assistance activities (e.g., developing and implementing capacity or training-needs
assessment activities with partners from state health departments and local academic institutions). The
network includes tribal representation, sharing of NWCPHP resources (curricula, technical assistance, and
expertise) openly among all partners, and fostering resource sharing and collaborative planning among state
and tribal partners.

NWCPHP takes a two-pronged approach to working with Native American tribes. First, tribal members
participate in the array of training programs:

   •   Hot Topics in Preparedness, a monthly Web conference with tribal representation on the
       advisory board;
   •   Summer institutes and other on-site training, which draws tribal participation in Alaska, Montana,
       Oregon, Washington, and Wyoming;
   •   Northwest Public Health Leadership Institute, which has had tribal participants in each of its four
       partners to date; and
   •   CD-ROM and online learning modules and resources. These materials are useful in various
       Internet-connected environments. Topics include a food-borne tabletop exercise, bioterrorism
       training, public health law, and risk communications. They primarily are distributed through
       downloads from the CPHP Network website and designed to be easily modified for local jurisdictions.

Second, NWCPHP offers tribal-specific programs:

   •   Training needs assessments in Idaho, Oregon, and Washington, in collaboration with NWPAIHB
       (conducted in 2005);
   •   Training needs assessments in Montana and Wyoming; and
   •   Numerous environmental-health trainings through the Regional Academic Environmental Public
       Health Center (a program within NWCPHP) as the result of requests through NPAIHB, U.S. Indian
       Health Service, Alaska Native Tribal Consortium, and others. Tribal representatives serve on the
       advisory board of the Regional Academic Environmental Public Health Center, which covers the
       northwest region plus Nebraska, North Dakota, and South Dakota.

For more information on NWCPHP assessment work, see the journal article: Pearson, Thompson, Finkbonner,
Williams, D’Ambrosio. Assessment of Public Health Workforce, Bioterrorism and Emergency Preparedness
Readiness Among Tribes in Washington State: A Collaborative Approach Among the Northwest Center for
Public Health Practice, the Northwest Portland Area Indian Health Board, the Washington State Department of
Health. J Public Health Manag Practice 2005; Nov (suppl): S113-118.




                                                                          Centers for Public Health Preparedness |7
Case Study 3: University of Oklahoma Health Sciences Center, Southwest Center for Public Health
Preparedness

Following is a brief outline of the Southwest Center for Public Health Preparedness (SWCPHP) activities with tribal
partners throughout Oklahoma, New Mexico, and Colorado.

The overall mission of the SWCPHP is to help prepare the public health workforce response to bioterrorism and
emerging health threats by:

   •    Assessing the competency of the public health workforce in core public health skills and
        bioterrorism preparedness;
   •    Facilitating training to meet the assessed needs;
   •    Carrying out applied research on emerging health issues; and
   •    Participating and contributing to the Centers for Public Health Preparedness Network.

SWCPHP reaches out to the states of Oklahoma, New Mexico, and Colorado. The center’s numerous program
partners include the Oklahoma City Area Indian Health Service, Cherokee Nation, Choctaw Nation, Oklahoma
Inter-tribal Health Board, and Albuquerque Area Indian Health Board.

The center has a history of working with tribes in Oklahoma on a variety of projects and has maintained good
working relationships with them over the years. Oklahoma is home to 39 tribal governments, 38 of which
are federally recognized. The 2000 census indicated that the tribal population in Oklahoma is approximately
390,000, or 11.4 percent of the population. Because of the large presence of Native Americans in Oklahoma,
it is of the utmost importance that the SWCPHP and the tribal governments located within Oklahoma work
collaboratively to improve the lives of all of its citizens.

In December 2004, the Oklahoma Inter-Tribal Emergency Management Coalition (ITEMC) was developed to
help address preparedness needs specific to tribes and to sovereignty issues. The Kaw Nation of Oklahoma
provides the infrastructure for the organization, and various tribes rotate around the state to host the monthly
meetings. To date, more than 20 Oklahoma tribes participate in the monthly meetings. An SWCPHP
representative attends each meeting. Informal surveys and interviews were conducted concerning specific
training needs. SWCPHP responded by offering a variety of courses/seminars on an ongoing basis.

The following courses were offered to tribal members:

    • Bioterrorism and Emergency Preparedness for Indian Health Service (IHS)/Clinical Tribal Nurses;
    • Response to Crisis: Building an Effective Disaster Response Team, Mohawk Water Plant;
    • Tribal, IHS, and Public Health Emergency Preparedness Training (Tulsa);
    • Tribal, IHS, and Public Health Emergency Preparedness Training (McAlester);
    • Federal Emergency Management Administration (FEMA) E580 Emergency Management
      Framework for Tribal Governments;
    • CDC Crisis and Emergency Risk Communication for Tribal Representatives;
    • FEMA Mitigation for Tribal Officials; and
    • FEMA Operations Management for Tribal Governments.




8 | Centers for Public Health Preparedness
The SWCPHP New Mexico partner, located at the University of New Mexico Center for Disaster Medicine (CDM),
provides a variety of training programs for the medical community, including members of the New Mexico
Medical Reserve Corps (MRC). Sponsored by the CDM, MRC is initiating the establishment of units in New
Mexican communities, including tribal communities. The recently established McKinley County MRC will focus
its efforts on addressing public health issues that affect McKinley County and the Navajo Nation and train
medical professionals in disaster preparedness. CDM will be a valuable educational resource for this MRC,
providing culturally relevant disaster medical education. In addition, the CDM was invited to Arizona to attend
the inauguration of the newly elected Hopi tribal chairman. Because of the isolated location of the tribe, the
new administration recognizes the need for disaster preparedness education for tribal members. CDM was
invited to discuss educational programs for medical personnel in Hopi.

Working with SWCPHP Colorado partner, the Four Corners Tribal Preparedness Summit was held in Durango,
Colorado, on July 11–12, 2005. SWCPHP sponsored this event and worked with the Colorado Department of
Health on the planning team. Participants were members from several tribes in the Four Corners area who
attended this first summit to establish systems and processes that allow tribes to respond to a public health
emergency that crosses state and tribal boundaries. The summit objectives were to:

   •   Discuss the coordination of federal, state, local, and tribal response to health emergencies in the
       unique geography of the Four Corners region, recognizing the sovereignty of the tribal nations;
   •   Gain knowledge of the legal and cultural issues that impact response efforts; and
   •   Bring people together for key discussions on the who, what, when, and how of planning and
       response activities.

SWCPHP works closely with the tribes in Oklahoma and constantly strives to meet the unique preparedness
needs for this population. During the summer of 2006, SWCPHP worked with the Oklahoma City Area Inter-tribal
Health Board to sponsor a statewide Tribal Pandemic Flu Summit and Workshop geared specifically for tribal
and IHS personnel. The summit was held in August 2006 with approximately 250–300 people in attendance.




                                                                         Centers for Public Health Preparedness |9
Case Study 4: University of Arizona College of Public Health, Arizona Center for Public Health
Preparedness

Following is a brief outline of the Arizona Center for Public Health Preparedness (AzCPHP) activities with tribal
partners throughout Arizona. An overview will follow of a collaborative training project to develop, deliver, and
evaluate a tribal public health emergency preparedness and response training program.

Funded in 2005 by the CDC, AzCPHP aims to improve the capacity of the public health workforce to respond
to an all-hazards type of public health emergency in Arizona and the Southwest by providing comprehensive
competency-based education and training in emergency preparedness. Building the public health workforce
emergency preparedness capacity within Arizona requires training and educational activities, to including
border/binational issues, rural communities, and tribal public health. The AzCPHP training program is committed
to providing preparedness materials that are appropriate for these regions in Arizona.

There are approximately 300,000 Native Americans in 22 federally recognized tribes that cover 26 percent of
the state of Arizona. Public health and emergency preparedness challenges in Arizona include large distances
between communities and an insufficient response and communication infrastructure, particularly in the rural
areas that comprise 90 percent of the state. In addition, the international border and sovereign tribal nations in
the state present jurisdictional hurdles to overcoming disasters that may span tribal, county, and state
boundaries.

Participation and inclusion of tribal and Indian Health Service (IHS) partners were evident from the outset
of establishing the center:

   •   During the information-gathering process in the planning stage of AzCPHP, the tribal public health
       partners identified common public health emergency preparedness needs through an extensive
       needs assessment using a logic model process and face-to-face interviews.
   •   Tribal leaders from both tribal nations and the IHS are represented on the AzCPHP advisory
       committee to ensure relevance of the center’s educational activities. Key partners are the Navajo
       Nation Division of Health, Diné College, the Navajo Area Office, IHS and the Tucson Area IHS, the
       Tohono O’odham Nation Department of Health and Human Services, and the Tohono O’odham
       Community College.
   •   AzCPHP activities were promoted at tribal-specific preparedness conferences and meetings.
   •   The center collaborated closely with the Arizona Department of Health Services Office of Public
       Health Emergency Preparedness and Response (OPHEPR), as well as county and tribal health
       departments and area IHS offices, to ensure regional participation and cooperation at
       tribal-specific preparedness training conducted through the center.




10 | Centers for Public Health Preparedness
Tribal Public Health Emergency Preparedness and Response Training Project
The overall objective of this project was to provide basic public health emergency and bioterrorism
preparedness and response training for tribal personnel by developing and delivering three training mod-
ules and coordinating statewide implementation through five regional 1.5-day sessions. The purpose was to
ensure these communities are adequately informed, aware, and skilled to implement coordinated response
plans to a range of potential public health emergencies on tribal lands and in surrounding communities.
Training tribal public health professionals, emergency management personnel, healthcare system providers,
and representatives of tribal community networks is considered a priority to strengthen their public
health emergency preparedness infrastructure.



       Module 1: Description of the Roles of Public Health

          •   Prevention of epidemics and spread of disease
          •   Prevention of injuries
          •   Protection against environmental hazards
          •   Protection of public through assurance of quality and accessible health services
          •   Promotion and encouragement of health behaviors
          •   Disaster preparedness, response, and recovery assistance
          •   Health codes

       Module 2: Bioterrorism and How It Relates to Public Health

          •   Recognizing an emergency
          •   Disaster versus emergency
          •   History of bioterrorism
          •   Bioterrorism and public health
          •   Agents of bioterrorism
          •   Surveillance and disease tracking
          •   Other emergencies (chemical and radiological)
          •   Psychological response to emergencies

       Module 3: Community Emergency Preparedness and Response

          •   Incident command system
          •   Emergency response plans
          •   Collaboration with county, state, and federal agencies
          •   Memoranda of understanding
          •   Mass prophylaxis clinics
          •   Cultural considerations in the tribal context




                                                                       Centers for Public Health Preparedness |11
This training project was a collaborative effort between the OPHEPR, AzCPHP, and statewide tribal/IHS/local
partners. Relationships were established quickly among project personnel and the tribal bioterrorism
coordinators, particularly those identified from the host regional tribe. Each regional training drew upon the
local expertise of the public health and emergency management systems that allowed them to be tailored
to their unique public health concerns. Three comprehensive modules were developed and delivered, giving
an overview of public health to many diverse personnel. This was particularly useful for first responders, many of
whom were not exposed to this subject matter. All participants received an introduction to public health
emergency and bioterrorism preparedness and response, which created a basis for common understanding.

Trainings was well-received and highly rated in terms of quality and usefulness. Three distinct training curricula,
along with products and tools, were developed and adapted for Arizona’s tribes. The curricula incorporated
native concepts of health and traditional public health practices and presented practical examples of issues
facing tribal communities, making it relevant and responsive to tribal needs. Many tribal participants requested
sustainability of this training in local tribal settings. Additional training needs were identified for the tribes. As a
result of this project, the statewide tribal public health emergency preparedness network was strengthened.



    TRIBAL PREPAREDNESS INVENTORY

The Tribal Preparedness Inventory resulted from a conversation held during the TPRCG meeting in March 2006.
The intent of the group was to identify the information that would be most helpful in continuing to advance
tribal preparedness and to incorporate those points into a survey tool. The inventory that resulted asks CPHP to
document their experience in working with tribes and to solicit additional objective and subjective information
from their tribal partners. This collaboration group hopes the collection and examination of information
regarding current experiences and promising practices throughout the CPHP Network will lay a strong
foundation for continued work to benefit tribal preparedness.




12 | Centers for Public Health Preparedness
                                     Centers for Public health Preparedness
                                         Tribal Preparedness Inventory

1. Center for Public Health Preparedness (CPHP) Name:



2. Contact Person Name and Address:




3. Has your CPHP conducted or have plans to conduct any preparedness
   training/education with tribal partners?                                                                    Yes                No


4. How many federal/state recognized tribes exist within the region your CPHP serves?


5. How many of these tribes have your CPHP partnered with to conduct preparedness
   training/education in the last 3 years?
   *On a separate sheet list the names of these tribes.


6. How many tribal preparedness training/educational programs has your CPHP
   conducted over the last 3 years?


7. How many tribal members total participated in your CPHP tribal preparedness training/education
   programs?


8. Of the above tribal preparedness training/educational programs how many have been conducted
   in collaboration with:

       A. a regional tribal health board/epicenter?

       B. a regional or local Indian Health Service unit?

       C. state, county of local (non-tribal) governmental unit?

       D. national tribal organization, e.g. National Indian Health Board?

       E. non-profit/volunteer organization, e.g. Red Cross?

       F. federal agency, e.g. FEMA?


9. In which of the following areas of training/educational development has your CPHP collaborated with
   tribal partners?

     Needs                            Curriculum                         Training/Education                    Evaluation of
     Assessment...........            Development..........              Delivery....................          Training/Education..........


10. What does your CPHP and your tribal partners perceive as the three major threats to tribal safety and health?

      Terrorism...................              Geological...........................                    Fire.......................................

      Weather.....................              Biological/Communicable                                  Chemical/Radiological
                                                Disease...............................                   Exposure..............................


                                                                                                  Centers for Public Health Preparedness |13
11. In what threat areas has your CPHP conducted preparedness training/education with tribal partners?

    Terrorism...................            Geological...........................         Fire.......................................

    Weather.....................            Biological/Communicable                       Chemical/Radiological
                                            Disease...............................        Exposure..............................

12. How many of your CPHP tribal partners have Emergency Operations Plans/Emergency Response Plans?



13. Do these tribal Emergency Operations Plans meet the FEMA National Incident Management Standards (NIMS)?

        Yes ....                        No ....                            In-Part ....

14. For tribes with Emergency Operations/Emergency Response Plans:                                        Yes                           No

        A. are the plans coordinated with other local, county and state plans??

        B. are tribal members included in local, county and state advisory boards?

15. Does your CPHP have a tribal liaison(s)?




16. Has your CPHP encountered challenges/barriers in working with tribes?

         Yes ....                               No ....

16a. If Yes, please describe:




17. What are the most significant resource needs in developing tribal preparedness programs?
    Please describe:




18. What are lessons learned that have contributed to the success of your CPHP collaborations with tribes?
    Please describe:




  14 | Centers for Public Health Preparedness
   SUMMARY AND CONCLUSIONS

Principles of Collaboration TPRCG sought to articulate the important Principles of Collaboration between CPHP
and tribal organizations, which recognize the unique relationships of tribal organizations to federal, state, and
local governmental and community entities that serve as partners in public health, bioterrorism, and emergency
preparedness and response planning. As the group is identifying through case studies the best practices,
lessons learned, and challenges involved in CPHP collaborations in tribal preparedness, the Principles of
Collaboration will likely undergo revisions and refinement.

Case Studies The four case studies presented here illustrate the different contexts and challenges that the CPHP
faces in developing effective training and education programs in preparedness with tribal community partners.
They also illustrate how the Principles of Collaboration apply in diverse geographical and cultural settings and
the variety of ways tribal preparedness can be effectively conducted. The group recognizes that many other
CPHP are involved in tribal preparedness and that participation in tribal preparedness is likely to be quite
variable, with some CPHP having few or no tribal partners, while other CPHP may seem nearly overwhelmed with
opportunities for collaboration with tribal communities. Similarly, as recognized in the Principles of Collaboration,
tribal communities are extremely diverse in culture, language, traditions, relationships to non-tribal entities, and
in terms of need and resources for preparedness training and education.

Tribal Preparedness Inventory To identify the broad scope of tribal preparedness activities across the CPHP
Network, the group developed a draft of a Tribal Preparedness Inventory, which, after refinement and piloting,
will be used to survey all CPHP as to their involvement in tribal preparedness.

Documents for Collaboration with Tribal Entities Finally, the group has begun to accumulate relevant
documents and other resources to assist tribes and CPHP in identifying resources, grants and funding, policy
documents, and other opportunities to further tribal preparedness. These can be found in Appendix A
“Documents for Collaboration with Tribal Entities.” Much remains to be done in tribal preparedness, and it is the
intent of the group to pursue this aggressively as outlined briefly below.



   FUTURE WORK

   •    A number of CPHP have established collaborative projects with tribal communities. While the lessons
        learned from each of these joint endeavors can be valuable, so too can the development of
        standardized understandings and products, such as MOUs, assessment tools, and curricula that can
        help create a more consistent platform for broader collaborative discussions. This activity will focus on
        the identification of key generic elements that could serve as the basis for these further developments
        to assist CPHP to provide education and training in tribal preparedness. These standardized
        understandings and products will be shared with the CPHP Network.

   •    The Tribal Preparedness Inventory will be further refined and piloted on a small group of CPHP before
        using this instrument to survey all CPHP as to their activities in tribal preparedness. The survey results
        should allow the group to identify additional CPHP Network resources for tribal preparedness and
        track activities, challenges, needs, and gaps in tribal preparedness and emergency response.
        A modified version of the Tribal Preparedness Inventory also will be developed to survey the IHS




                                                                             Centers for Public Health Preparedness |15
        regional Indian Health Boards and Epidemiology Centers to gain tribal perspectives on CPHP
        collaborations in tribal preparedness.

   •    An online calendar of national training programs and events relevant for tribal public health
        emergency preparedness and response that is open to public participation will be created.
        The centers in the CPHP Network will be invited to submit dates coordinated by themselves or by
        other interested parties wishing to inform partners of opportunities. This calendar will be accessible
        online through the TPRCG website.

   •    TPRCG identifies the need to connect more closely with federal partners to discuss the many ongoing
        tribal preparedness activities occurring through each agency. The group would like to invite
        representatives from CDC, Agency for Toxic Substances and Disease Registry, IHS, Department of
        Homeland Security, and other federal agencies to an in-person meeting to give updates and share
        information on the various programs and activities that these entities are currently engaged in and
        identify opportunities to work together with tribal organizations and CPHP in the future. As appropriate,
        information and documents resulting from these discussions will be shared with the CPHP Network.

For more information regarding the CPHP Network preparedness training products, see the CPHP Network online
“Education Resource Guides” at http://www.asph.org/cphp/CPHP_ResourceReport.cfm and the searchable
CPHP Network online resource center at http://www.asph.org/acphp/phprc.cfm.




16 | Centers for Public Health Preparedness
   Appendix A: DOCUMENTS FOR COLLABORATION WITH TRIBAL ENTITIES

Following are samples of assessments, plans, statements of work, and CDC consultation information related to
tribal emergency preparedness activities. These documents are intended to serve as guides and tools for those
looking to collaborate with tribal entities.

Needs Assessments
   Questionnaires
   1. Alaska Native Tribal Health Consortium Emergency Preparedness Assessment
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=613
   2. Washington Tribal Capacity Assessment for Public Health Emergency Preparedness
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=614

   Results
   1. Health-Related Emergency Management Plans of New Mexico’s Native American Pueblos, Tribes,
      and Nations - An Assessment - 2.28.04
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=615
   2. Assessment of the Health-Related Emergency Management Plans of Native American Nations,
      Tribes, and Pueblos in New Mexico: An Identification of Training Needs/Gaps - 2.19.04
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=616
   3. Assessment of Tribal Radiological Emergency Response Capabilities 09.04
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=617

Emergency Response Plans
   Guides
   1. Public Health Emergency Response Guide for State, Local, and Tribal Public Health Directors
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=618
   2. Tribal Emergency Response Guide for State, Local, and Tribal Public Health Directors
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=619
   3. The Pandemic Influenza Workbook: A Planning Guide for American Indian/Alaska Native Communities
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=636

   Draft Template
   1. Example Emergency Response Plan - Draft (Sep 03)
       http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=620

   Examples
   1. Passamaquoddy Tribe - People of the Dawn - Emergency Response Plan
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=621
   2. Gila River Indian Community Multi-Hazard Emergency Operations Plan
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=622
   3. Tohono O’odham Nations/Sonoyta/Puerto Penasco/Carborca Biological and Emergency Response
      Plan for the Health Consequences of an Infectious Disease Outbreak and Other Emergencies
      (06.23.03)
      http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=623




                                                                        Centers for Public Health Preparedness |17
Scope of Work Samples
   1.   Inter Tribal Council of Arizona Scope of Work
        http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=624
   2.   Scope of Service Agreement Between Massachusetts Department of Public Health and the
        Wampanog Tribe of Gay Head (Aquinnah)
        http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=625
   3.   Puyallup Tribe of Indians Mutual Aid Agreement Between the Puyallup Tribe of Indians and the
        Tacoma-Pierce County Health Department Relating to the Disease and Contamination Measures
        http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=636



Centers for Disease Control Annual Tribal Consultation Information
   1.   The Centers for Disease Control and Prevention’s Annual Tribal Consultation Report FY05.
        This document explains various tribal activities across CDC that include emergency preparedness.
        Note page 10, tribal priority number five, and page 16, Workgroups and Task Forces.
        http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=626
   2.   Continuation Guidance for Cooperative Agreement on Public Health Preparedness and Response
        for Bioterrorism - Budget Year 5
        http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=627
   3.   CDC/ASTDR Tribal Consultation Policy
        http://www.asph.org/acphp/restricted/CPHPworkgroups/serve_file.cfm?CPHPwgDoc_ID=628



Tribal Contact Information Web Links
   1. American Indian Resource Directory
      http://www.indians.org/Resource/FedTribes99/fedtribes99.html
   2. National Congress of American Indians Tribal Governments
      http://www.ncai.org/Tribal_Directory.3.0.html
   3. State and Local Government on the Net Tribal Government Sites
      http://www.statelocalgov.net/other-na.CFM
   4. Tribal Leaders Directory Spring/Summer 2005
      http://factfinder.census.gov/home/aian/tribal_leaders_jun2005.pdf




18 | Centers for Public Health Preparedness
ABOUT THE ASSOCIATION OF SCHOOLS OF PUBLIC HEALTH

ASPH represents the 40 Council on Education for Public Health (CEPH) accredited schools of public
health (SPH) in North America. ASPH promotes the efforts of schools of public health to improve the
health of every person through education, research, and policy. Based upon the belief that “you’re only
as healthy as the world you live in,” ASPH works with the government and other professional organizations
to develop solutions to the most pressing health concerns and provides access to the ongoing initiatives
of the schools of public health. www.asph.org




                                                                       Centers for Public Health Preparedness |19

				
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