In 2020, CNN grouped Indigenous peoples under the category “SOMETHING ELSE” in reference to exit polls in the presidential election. This type of data aggregation obscures and makes invisible meaningful data on Native peoples. It happens across disciplines, including in public health. In this blog post, we outline three examples specific to public health, and we discuss how Native Nations and peoples are affected. We also discuss recommendations for how we can begin to address this issue.

Photo credit: Rebecca Nagle

First, though public health has a long history of enumerating, or counting, its workforce, Tribal health organizations tend to be excluded from these endeavors. For example, the most recent comprehensive enumeration, conducted in 2024, did not include the Tribal public health workforce, focusing only on federal, state, and local workers. The reasons for this were many, including lack of readily available Tribal workforce data. Most public health enumerations dating back a hundred years to their first iterations also tended to exclude Tribal workforce counts. However, the most recent Public Health in Indian Country Capacity Scan (PHICCS II), which was already underway when Enumeration 2024 began, did examine Tribal health organization (THO) workforce capacity. Responses from 133 of the 282 THOs surveyed were included in the analysis (many THOs did not respond to the survey, and there were two THO responses that were excluded from the final analyses). According to PHICCS II:

At the time of the survey, these THOs employed 5,079 full and part-time staff and had 674 positions that were created but vacant. An additional 1,238 new roles must be created and funded for THOs to operate at full capacity. To meet the needs of the THOs surveyed, a 21.5% increase in funded positions will be necessary to reach full workforce capacity, in addition to filling vacant roles.

Thus, the most recent data we have on THOs indicate that these workforces are underfunded and understaffed, and limitations in these data suggest we don’t have an accurate understanding of exactly how underfunded and understaffed they are. This makes it difficult to know which Tribes need what resources and how to best allocate those resources.

Second, invisibility of public health data representing Indigenous communities has led to a data genocide. Despite Native people being the first scientists on Turtle Island – the name that many Indigenous people use for the land currently called North America – past and ongoing colonialism has obscured and erased “original Tribal data practices in all current public health systems,” such as Traditional Ecological Knowledge that guides access to traditional foods and medicines. In a similar vein, the Urban Indian Health Institute issued a report card in 2021 that assessed each state’s quality of COVID-19 racial data, specifically focusing on data for American Indian and Alaska Native peoples. No state received an A+, and only four states received an A or A-. The United States overall received a D+. Without these data, or without access to these data, public health authorities’ abilities to make decisions on resource allocation were severely limited, likely contributing to disparities in COVID-19 infection rates, which were particularly high on reservations and in Tribal communities. For example, Navajo Nation was a COVID-19 hotspot, with Diné experiencing some of the highest infection rates in the country.

Third, data erasure contributes to physical erasure. Because violence against Native peoples is a public health issue, failing to collect and analyze these data means that we, as public health researchers and workers, are failing in our mandate to protect the health of populations. This is particularly concerning for Indigenous people, especially considering the Missing and Murdered Indigenous People crisis, which Interior Secretary Deb Haaland has called an epidemic. This lack of data has further implications as well. Genocide doesn’t happen overnight; rather, it has multiple phases that can take place over many years, and the last of these phases is denial. Denial includes 1) people not knowing about the problem as well as 2) structures that obscure or otherwise make the problem invisible. Thus, by failing to fully and correctly represent Native people in the data we collect in public health, the public health system as a whole is contributing to genocide.

So, what can we do? First, funding and resources for Tribal public health data collection should be prioritized, especially considering the federal government’s trust and treaty obligations to Tribes. Next, colonial tables where conversations take place should be dismantled, and new structures for having these discussions should be built. It’s not enough to add a seat at the table, colonial or otherwise. Rather, these structures should be built with Tribal voices centered and emphasized from the beginning. We must also consider the role of Tribal collaboration in public health systems, as well as the role of critical Tribal Epidemiology Centers. Both provide examples of what authentic collaboration with Tribes could look like. So too does Anishinaabe Giigewin Miikana (Healing Pathways), a longitudinal community-based participatory research collaboration between reservation communities in the US, reserve communities in Canada, and Johns Hopkins Center for Indigenous Health. For Healing Pathways, many interviewers and researchers are members of the communities they study, and Tribal community research councils must approve all articles generated from this research before they are submitted for publication.

These recommendations are, of course, not exhaustive, but they are a place for public health systems researchers to start.

Nikki Weiss, PhD, is a biocultural anthropologist specializing in mixed methods research. She completed her undergraduate education in biology at the University of Wisconsin-Eau Claire, and she earned her master’s and doctorate in anthropology from Ohio State University. Before arriving at CPHS, Nikki worked for the Johns Hopkins Center for Indigenous Health – Great Lakes Hub, as well as for the CDC Foundation. Her research interests include health equity and making health care accessible and attainable for all.

Feather LaRoche, MTAG, focuses his attention on the underlying disparities and imbalances that affect Native American communities. He holds a Master’s of Tribal Administration and Governance from University of Minnesota – Duluth and has been working with the School of Public Health since this past June (2022) to bring awareness to the Public Health Administration and Policy MPH to Native American professionals and students. Mr. LaRoche is an enrolled member of the Kul Wicasa Oyate Tribe from Lower Brule, South Dakota.