Make Important Connections to Integrate our Public Health and Health Care Systems

Native American concepts of health and well-being not only include an individual’s physical and mental health, but the person’s emotional and spiritual health. This holistic understanding also situates the individual within the context of relationships to family, community, and the environment. However, as currently practiced, most health services delivery only address a specific symptom of illness, leaving out other important, sometimes causative, factors that are absolutely necessary for good health outcomes. 

Incorporating the various Native American understandings of health and well-being would mean that tribal health departments integrate the often separate strands of health services delivery: Health care, treatment centers, behavioral health, and public health. 

How Integration and Holistic Wellness work in concert with other values:

• A holistic approach to health and well-being acknowledges the Indigenous understandings of health and honors Native culture and identity.
• Integrating health care and public health is an “outside-the-box” service delivery model that is a concrete expression of tribal sovereignty and enlightened tribal governance.
• An integrated, holistic wellness model is the pathway to better health outcomes, which leads to healthier individuals & families and healthier communities.
  

Reclaim, Revitalize, and Reaffirm Indigenous Knowledge and Traditional Practices

Ways of life that have sustained Indigenous communities for thousands of years have been assaulted through colonization, genocide, assimilation, and discrimination. Despite this history of loss, many longstanding cultural practices and traditions remain and serve as the basis for cultural renewal and revitalization. These practices and traditions are important for affirming Native Americans’ unique identities, connecting people with the environment, and supporting intergenerational sharing, all of which contribute to good health and well-being.

Reclamation and utilization of these practices can take many forms: the incorporation of tribal healing practices into a treatment regimen; addressing intergenerational trauma through community-based cultural activities; growing & harvesting, or hunting & fishing for traditional, healthy foods; and developing asset-based approaches to research and intervention.

How Culture and Identity work in concert with other values:

• Cultural activities—whether it be use of the spoken tribal language, the preparation and partaking of a traditional meal, or participating in ceremonies—are centering aspects of family and community life.
• Culture and identity define the tribe, and legitimizes its governance & sovereignty.
• Cultural practices manifest the holistic integration of body, mind, and spirit.
• Indigenous knowledge, e.g., the harvesting and use of medicinal plants, understandings of health and well-being, etc., inform and sustain cultural practices.
  

Support Native Family and Community Well-Being by Creating Healthy Environments

The health and well-being of families and communities is at the crux of the public health agenda. Our ability to create healthy environments that support family and community well-being depends on our ability to govern for health, integrate physical and mental health services in a holistic manner, incorporate cultural understandings of what it means to be healthy, and develop and foster positive relationships with local, state, and federal agencies and other important partners.

Because government funding for tribes and urban Indian communities flow through different agencies with different missions, the result is often service delivery in “silos” that are not necessarily coherent with other services. Recently however, the “Health in All Policies” movement recognizes the value of working across sectors to address socioeconomic, cultural, and environmental factors that contribute to health at the individual and community levels. This approach aligns with Indigenous approaches to health.

How Families and Communities work in concert with other values:

• Healthy Indigenous families and communities support flourishing Indigenous culture and identity
• Indigenous knowledge of the land and its resources promotes environmental stewardship, as well as the healthier communities that live in that environment
• Healthy tribal communities thrive in infrastructures created and maintained by strong governance and sovereignty.
• Families and Communities are necessary components of an integrated, holistic wellness program.
• Healthy families and communities are likely to raise tribal members who will want to give back to their community.
  

Expand Advocacy and Influence on Federal Policy to Protect AI/AN Health

The 573 federally recognized nations are legally sovereign according to treaties in which Native tribes ceded land and resources to the U.S. government in exchange for the federal government’s provisioning of health care, education, housing, and other services. All of these programs are severely underfunded.

Instead of competing with other tribes for resources, tribal nations need to work together in inter-tribal groups and national organizations to advocate for rights promised by treaties, including adequate funding for the Indian Health Service, the largest provider of health services for tribal members, as well as for tribal health departments. These organizations can also inform state and federal legislators on the health status of tribal nations, provide relevant tribal data, research the health impact of federal policies, and propose policy recommendations and solutions.

How Respect for Sovereignty works in concert with other values:

• Respect for sovereignty means improving and solidifying government-to-government relations to ensure that federal and state resources are rightfully allocated to fund tribal health services. This is a necessary condition to sustain and actualize all of these values that comprise the Indigenous public health agenda.
• Tribal sovereignty preserves and promotes tribal culture, identity, and Indigenous knowledge in the community.
• Tribal sovereignty allows space for an integrated model of health services that fully incorporates Indigenous understandings of health and well-being.
  

“Grow Our Own” Public Health Workforce and Capacity

Having tribal community members as health services providers brings greater assurances of culturally competent treatment, and with that a greater chance of better health outcomes. Encouraging careers in medicine, nursing, health research, and public health from within the community will go a long way in addressing the chronic shortage of skilled health service providers in rural areas.

Even if there are adequate educational opportunities, however, there still is a lack of funding and workforce investment to place qualified or in-training community people in tribal health departments, and once there, to retain them and provide opportunities for further professional development. Marshalling support for funding additional health care personnel is critical for ensuring that workforce capacity and growth benefit the community.

One way to sustain and maintain personnel would be to create connections laterally across similar tribal departments nationally in a “community of practice,” where professionals would share their expertise and experience, and ask for assistance and opinions from peers. 

How Service works in concert with other values:

• Training community members to provide health services at local facilities increases bonds within the community.
• Health services providers who come from within the community are better able to utilize tribal healing practices in concert with Western practices in treatment regimens.
• Greater in-house workforce capacity leads to increased authority of the tribal health department to exercise sovereignty over tribal health affairs, as opposed to having outside health departments control policy and action.
  

Access and Use Data and Information in a Meaningful Way

Data is power: What we collect, how we collect, and how we use data in a health care context affects the quality of care in tribal communities and families. Indigenous peoples have collected and used data for thousands of years to make decisions that affect community survival and community well-being. Data collection must take into account Indigenous perspectives to truly address community needs, reflect community values, and ensure that the community’s ethical principles are met. Data becomes valuable knowledge when it is used in a meaningful way to tell a story about health, develop programs, inform policy, measure impact, and evaluate services.

A major challenge is the lack of funding for developing data infrastructure at all levels—from community clinics, tribal health departments, and even at local and regional levels. Furthermore, when data is collected, it is often stored in isolation: There is a lack of integrated systems to share data that is necessary to place a community’s health story within a larger context, and to source problem-solving solutions employed by other tribal communities. 

Tribal Epidemiology Centers (TECs) provide valuable information systems management and surveillance for Tribes and Urban Indian Health Organizations at a regional level.  A coordinated effort to build an integrated data infrastructure at a national level can improve quality, increase access, reduce redundancy, and build local capacity. With quality information, we can better understand community health, advocate for policy and systems change, and take measurable action toward improving Native health.

How Indigenous Knowledge works in concert with other values:

• Data infrastructure and management should be harnessed as important tools in tribal nation building and governance.
• Incorporating Indigenous knowledge into community and patient databases strengthens integration of treatment.
• Indigenous knowledge is an integral part of a tribe’s culture and identity.
• Knowledge of and utilization of data increases the tribal community’s workforce capacity.
• Data is a powerful tool to identify gaps in community and family well-being, as well as measure progress of the same.
  

Strengthen Public Health Authority as a Function of Sovereignty

A fully functional tribal public health agency has the legitimacy to exercise authority through public health laws, codes, ordinances, and policies. Public health laws and policies support safe environments, for example motor vehicle safety, emergency preparedness, commercial tobacco control, and environmental quality.

One major issue, however, is that the federal and state governments do not recognize tribal public health authority in all realms of public health, often deferring funding to state health departments in the form of block grants; it is therefore the states that often determine how much is granted to tribal health departments. 

Another issue is that not all tribes have the infrastructure, capacity, or funding to conduct surveillance or respond to public health emergencies such as outbreaks of disease or natural disasters.

In addition to marshalling resources to fund a robust public health agency, tribes must develop formal relationships with county, state, and federal officials to ensure tribal health issues are addressed with the best possible coordination of personnel and resources

How Tribal Governance works in concert with other values:

• Codifying regulations for safer and healthier environments encourages the development of stronger and healthier communities and families.
• Tribal public health agencies can place tribal knowledge and tribal healing practices on the same plane as Western healing practices, thus promoting holistic integration of health services.
• A fully resourced tribal public health agency is a potent symbol of sovereignty, especially when the community is confronted by outbreaks of disease or natural disasters. In these situations, tribes are more capable of working in concert with federal and state agencies to better direct the disbursement of resources and efforts.