Working in Complexity and Doubt

This chapter studies how, when we are faced with complexity and doubt, we can make decisions about health that align with the approach of the Cherokee Nation and avoid some of the mistakes made by other leadership teams during COVID-19. Working in complexity and doubt requires, above all, balance. On one hand, we must be able to identify what we do know and respect the science enough to integrate this information into the choices we make. On the other hand, we must appreciate the limits of our understanding while not being paralyzed by them. It is important to cultivate a comfort with ambiguity and doubt, so we can position ourselves to make decisions that support health. Operating in a grey area between knowledge and ignorance is, in many ways, a common practice in science and public health. The chapter then raises the issue of cancel culture, polarization, and political groupthink, arguing that they reflect something core to the collective relationship to ambiguity, doubt, and complexity. They suggest how uncomfortable many of us are with these fundamental elements of life.

Development and Implementation of an HPV Vaccination Survey for American Indians in Cherokee Nation

Improving human papillomavirus (HPV) vaccination rates is a public health priority and a crucial cancer prevention goal. We designed a survey to estimate HPV vaccination coverage and understand factors associated with HPV vaccination among American Indian adolescents aged 9 to 17 years in Cherokee Nation, United States. The final survey contains 37 questions across 10 content areas, including HPV vaccination awareness, initiation, reasons, recommendations, and beliefs. This process paper provides an overview of the survey development. We focus on the collaborative process of a tribal–academic partnership and discuss methodological decisions regarding survey sampling, measures, testing, and administration.

Study Protocol For A Cluster Randomized Trial of A School, Family and Community Intervention For Preventing Drug Misuse Among Older Adolescents in the Cherokee Nation

Background: The national opioid crisis has disproportionately burdened rural White populations and American Indian/Alaska Native (AI/AN) populations. Therefore, Cherokee Nation and Emory University public health scientists have designed an opioid prevention trial to be conducted in rural communities in the Cherokee Nation (northeast Oklahoma) with AI and other (mostly White) adolescents and young adults. Our goal is to implement and evaluate a theory-based, integrated multi-level community intervention designed to prevent the onset and escalation of opioid and other drug misuse. Two distinct intervention approaches—community organizing as implemented in our established Communities Mobilizing for Change and Action (CMCA) intervention protocol, and universal school-based brief intervention and referral, as implemented in our established CONNECT intervention protocol—will be integrated with skill-based training for adults to strengthen social support for youth and strategic media. Further, we will test systems for sustained implementation within existing organizational structures of the Cherokee Nation and local schools and communities. This study protocol describes the cluster randomized trial, designed to measure implementation and evaluate effectiveness on primary and secondary outcomes.Methods: Using a cluster randomized controlled design and constrained randomization, this trial will allocate 20 high schools and surrounding communities to either an intervention or delayed-intervention comparison condition. With a proposed sample of 20 high schools, all enrolled 10th grade students in fall 2021 will be eligible for participation. During the trial, we will: (1) implement interventions through the Cherokee Nation, and measure implementation processes and fidelity; (2) measure opioid and other drug use and secondary outcomes every six months among a cohort of high school students followed over three years through their transition out of high school; (3) test via a cluster randomized trial the effect of the integrated CMCA-CONNECT intervention; and (4) analyze implementation costs. Discussion: This trial will expand upon previous research advancing the scientific evidence regarding prevention of opioid and other drug misuse during the critical developmental period of late adolescent transition to young adulthood among a sample of American Indian and other youth living within the Cherokee Nation reservation.Trial registration: ClinicalTrials.gov, NCT04839978. Registered April 9, 2021, https://clinicaltrials.gov/ct2/show/NCT04839978

Protocol for a cluster randomized trial of a school, family and community intervention for preventing drug misuse among older adolescents in the Cherokee Nation

Background: The national opioid crisis has disproportionately burdened rural White populations and American Indian/Alaska Native (AI/AN) populations. Therefore, Cherokee Nation and Emory University public health scientists have designed an opioid prevention trial to be conducted in rural communities in the Cherokee Nation (northeast Oklahoma) with AI and other (mostly White) adolescents and young adults. Our goal is to implement and evaluate a theory-based, integrated multi-level community intervention designed to prevent the onset and escalation of opioid and other drug misuse. Two distinct intervention approaches—community organizing as implemented in our established Communities Mobilizing for Change and Action (CMCA) intervention protocol, and universal school-based brief intervention and referral, as implemented in our established CONNECT intervention protocol—will be expanded, integrated, and supported with skill-based training to strengthen social support and strategic media to further enhance effects in preventing and reducing drug misuse. This new trial will build on our previous trials, improving design and implementation of the interventions with increased focus on opioids and other drugs. Further, we will test systems for sustained implementation within existing organizational structures of the Cherokee Nation and local schools and communities. This study protocol describes the cluster randomized trial, designed to measure implementation and evaluate effectiveness on primary and secondary outcomes.Methods: Using a cluster randomized controlled design and constrained randomization, this trial will allocate 20 high schools and surrounding communities to either an intervention or delayed-intervention comparison condition. With a proposed sample of 20 high schools, all enrolled 10th grade students in fall 2021 will be eligible for participation. During the trial, we will: (1) implement interventions through the Cherokee Nation, and measure implementation processes and fidelity; (2) measure opioid and other drug use and secondary outcomes every six months among a cohort of high school students followed over three years through their transition out of high school; (3) test via a cluster randomized trial the effect of the integrated CMCA-CONNECT intervention; and (4) analyze implementation costs. Discussion: This trial will expand upon previous research advancing the scientific evidence regarding prevention of opioid and other drug misuse during the critical developmental period of late adolescent transition to young adulthood among a sample of American Indian and other youth living within the Cherokee Nation reservation.Trial registration: ClinicalTrials.gov, NCT04839978. Registered April 9, 2021, https://clinicaltrials.gov/ct2/show/NCT04839978

Equal Footing

In 1796, the Southwest Territory became the first U.S. territory to become a state, joining the union as Tennessee. This new state promptly used its newfound status as a sovereign on “equal footing” with existing states to challenge the persistence of federal authority, especially over land and Indian affairs. A series of collisions followed: over ownership of the public domain; over William Blount’s odd scheme to use his supposed influence in Indian country to challenge federal power; and, above all, over the federal government’s attempt to survey the boundary of the Cherokee Nation, which threatened to dispossess white land claimants. Ultimately, the federal government preserved its formal authority even as it gave Tennessee what it wanted—a seemingly Pyrrhic victory that had important precedential consequences. In particular, when part of the Northwest Territory sought to become the new state of Ohio in 1802, the federal government sought to protect its authority. Most importantly, it decided for the first time to attach conditions to the new state’s admission that guaranteed federal land ownership, a practice that quickly became a constitutional norm; the new state also tacitly accepted continued federal authority over the state’s Native peoples. The result was that the federal government’s power to adjudicate property and jurisdictional conflicts survived despite state challenge; in the process, the federal government ironically became the most visible defender of the earlier, multipolar order against these states’ assaults.

A Preliminary Estimate of the Number of People who Inject Drugs in Cherokee Nation using Capture-Recapture Methods

Background: Injection drug use is an important public health issue in the United States, and estimates indicate that American Indian and Alaska Native people are disproportionately affected. Injection drug use is also the leading cause of Hepatitis C virus (HCV) infection in the United States, attributable to over half of all cases, and contributes to 44% of human immunodeficiency virus (HIV) acquisition in American Indian and Alaska Native females. Existing estimates of American Indian and Alaska Native people who inject drugs are limited. We aimed to estimate the number of people who inject drugs in Cherokee Nation.Methods: A two-sample, capture-recapture approach was used. The first data source was an abstraction of Cherokee Nation Health Services electronic medical records from February 2017 through December 2018. The second data source was an abstraction from Cherokee Nation’s HCV Elimination Program Database from August 2015 through December 2018. Individuals were included in the abstractions if they were asked if they had injected drugs in the past six months during their health visit. The indirect prevalence estimate of people who inject drugs was calculated in accordance with the UNAIDS/WHO Guidelines on Estimating the Size of Populations Most at Risk to HIV.Results: In total, 198 individuals across both data sources reported that they had injected drugs within the past six months. This included 123 unique individuals from the first source, 69 individuals from the second source, and six individuals who were included in both sources. Capture-recapture calculations indicated an estimate of 1,613 people who inject drugs (95% CI: 404, 2,821). Conclusions: This study was the first attempt at estimating the number of people who inject drugs in Cherokee Nation, and one of the few existing studies to estimate the number of American Indian/Alaska Native people who inject drugs in the United States. Gaining knowledge about the prevalence of people who inject drugs in Cherokee Nation will inform strategies to support addiction care and treatment among people who inject drugs living in Indian Country.

Estimating the number of people who inject drugs in Cherokee Nation using capture-recapture methods

Background: Injection drug use is an important public health issue in the United States, and estimates indicate that American Indian and Alaska Native people are disproportionately affected. Injection drug use is also the leading cause of Hepatitis C virus (HCV) infection in the United States, attributable to over half of all cases, and contributes to 44% of human immunodeficiency virus (HIV) acquisition in American Indian and Alaska Native females. Existing estimates of American Indian and Alaska Native people who inject drugs are limited. We aimed to estimate the number of people who inject drugs in Cherokee Nation.Methods: A two-sample, capture-recapture approach was used. The first data source was an abstraction of Cherokee Nation Health Services electronic medical records from February 2017 through December 2018. The second data source was an abstraction from Cherokee Nation’s HCV Elimination Program Database from August 2015 through December 2018. Individuals were included in the abstractions if they were asked if they had injected drugs in the past six months during their health visit. The indirect prevalence estimate of people who inject drugs was calculated in accordance with the UNAIDS/WHO Guidelines on Estimating the Size of Populations Most at Risk to HIV.Results: In total, 198 individuals across both data sources reported that they had injected drugs within the past six months. This included 123 unique individuals from the first source, 69 individuals from the second source, and six individuals who were included in both sources. Capture-recapture calculations indicated an estimate of 1,613 people who inject drugs (95% CI: 1,530.27, 1,694.7). Conclusions: This study was the first attempt at estimating the number of people who inject drugs in Cherokee Nation, and one of the few existing studies to estimate the number of American Indian/Alaska Native people who inject drugs in the United States. Gaining knowledge about the prevalence of people who inject drugs in Cherokee Nation will inform strategies to support addiction care and treatment among people who inject drugs living in Indian Country.