Raising Your Voice

Understanding a Pandemic's Unique Challenges for Native Americans with Chief Lynn Malerba

Contagious Conversations  /  Episode 16: Raising Your Voice

Tradition and Collaboration in Tribal Communities

Chief Lynn Malerba has served as a registered nurse, as director of Cardiology and Pulmonary Services at Lawrence & Memorial Hospital, as chairwoman of the Tribal Council and now as the first female Chief of the Mohegan Tribe. And she’s now drawing on this full history as the COVID-19 pandemic sweeps disproportionately through the Native American population.



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Below: Chief Lynn Malerba (left) presents President Barack Obama with a blanket during his final White House Tribal Nations Conference in 2016. | (Pete Souza/White House)





Claire Stinson: Hello, and welcome to Contagious Conversations. I'm your host, Claire Stinson. Every episode, we'll hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help CDC save and improve more lives.

Joining me today is Chief Lynn Malerba, the first female Chief in the modern history of the Mohegan Tribe, a sovereign, federally-recognized Indian tribe with a reservation in Southeastern Connecticut. Prior to becoming Chief, Malerba served as chairwoman of the Tribal Council, and served in Tribal Government as executive director of Health and Human Services. Preceding her work for the Mohegan Tribe, Malerba had a lengthy career as a registered nurse and as the director of Cardiology and Pulmonary Services at Lawrence & Memorial Hospital. Malerba is chairwoman of the Tribal Self-Governance Advisory Committee of the Federal Indian Health Service, a member of the Justice Department’s Tribal Nations Leadership Council, a member of the Tribal Advisory Committee for the National Institute of Health and a member of the Treasury Tribal Advisory Committee. Malerba also earned a doctor of Nursing Practice degree at Yale University.

In this episode, Chief Malerba discusses the disproportionate impact of the coronavirus on tribal nations, and the unique challenges and opportunities this presents to our country. She also shares background on how she has worked to provide education to the greater public about tribal nations and their history. Welcome, Chief Malerba!

Chief Lynn Malerba: Kutapatotamawus [thank you]. Thank you. And thank you for inviting me to be on your podcast today. I'm very excited about it.

Claire Stinson: We're really honored to talk to you today. So Chief Malerba, let's start by talking about your background. You've actually had a long career in public health. And prior to becoming Chief of the Mohegan Tribe, you worked as a registered nurse, and then ultimately as the director of cardiology and pulmonary services at Lawrence + Memorial Hospital. What led you to the field of nursing early in your career?

Chief Lynn Malerba: Well, I needed a career that made a difference every day in someone's life. I knew that that was a calling for me, but I'm also very practical. So when I looked at education, I thought, well how am I going to fund this education? I'm one of seven children. My parents kind of raised us rubbing two nickels together, so to speak. So I looked at nursing schools back in the day. There was such a thing. Hospitals had nursing schools. So I had a very economical education. I was able to work my way through school. So I went to school full-time and I worked part-time. And I always like to say that it was kind of nursing in the dark ages. There was not any of the electronic conveniences that nurses have today. There were no IV pumps and no automatic blood pressure pumps. We used mercury thermometers. We didn't have oxygen sensors. So nursing was just as much of an art as it was a science. And the patients were actually allowed to smoke at the bedside. So they had ashtrays by their bedsides so they could smoke.

So you can imagine it was a very different time. But for me, it was really liberating to receive an education and to be able to have a career that really touched someone's life every day. So it's an honor to be with people when they need you to help guide them through either a crisis or back to health. Or to help someone pass over into the next world. So I loved every bit of it. And I think that it really informs who I am as a person. Because it is such an immediate way to connect with other people.

Claire Stinson: I'm sure that was really valuable experience. And I'm sure you learned a lot without the use of technology.

Chief Lynn Malerba: Oh, absolutely. I think you learn how to really read a patient and understand how they were feeling, and know when you should investigate a little bit further into their circumstances. So obviously as time went on, technology was really a partner for nursing and a way to assess someone in a very technical way. So I parlayed my earlier career into critical care nursing, which is how I got my Mohegan name. So I specialized in cardiology. I eventually was the Director of Cardiology and Pulmonary Services at the local hospital, which encompassed diagnostics, inpatient care, and outpatient care. So for instance, the cardiac cath lab, CCU, ICU, the EKG department, respiratory therapy. All of those departments were my departments.

So when I became Chief, our medicine woman said, "Well you can't delay taking a Mohegan name any longer. So I've come up with a name for you, and I want you think about this." And she said, "Well, we're going to call you Chief Many Hearts because you've held many hearts in your hands in the past, which is very true. And today now as Chief, you will hold our hearts in your hands and care for us in a very personal way as well." So it really was the perfect name for me to take. So it's Nuteewees (I am called) which is Rock Woman translated, which is the name for a female Chief. And Sôqsqά Mutάwi Mutahάsh (Chief Many Hearts), which is Many Hearts. So I proudly carry that name forward.

Claire Stinson: Well, that's an amazing name. And thank you for sharing that. So tell me more about your work as Chief of the Mohegan Tribe. How did you become Chief?

Chief Lynn Malerba: Well interestingly, as you mentioned, I was the chairwoman of the Tribal Council. Having recently been reelected to that position, I was the vice chairwoman first. And I was quite happy kind of executing my plan. We had a strategic plan for where we wanted the tribe to go from both a governmental perspective, as well as a business perspective.

And our former Chief had passed about three years prior. So the council of elders are responsible to appoint a Chief and other traditional positions. So they had sent out a questionnaire to the tribal membership indicating that they were ready to appoint another Chief now that we had had a very long period of mourning for our former Chief. And they asked us who we all thought it should be. So being the diligent tribal member that I am, I submitted my letter. I thought my mother should be the new Chief because she had served on the Tribal Council for 30 years. And much to my surprise, the elders called me down to their office. And I didn't know what they wanted to chat about. And I thought, "Did the Tribal Council make the council elders angry about something? Quick, think about this."

But it really was to explore whether or not I would accept the position of Chief. And I had to think about it, because I was very happy with what I was doing. And I felt as though I hadn't really completed my task there. But if I said no, it would be no forever. And I thought well, maybe this is a really good opportunity for me. And the elders felt strongly that they didn't want the Chief to be on the Tribal Council and to be thinking with a political head. They really wanted someone who would be a little bit more neutral and who would be able to represent the needs, and desires, and wishes of the tribal membership, as well as perform some very traditional duties.

So I thought long and hard about it. And I thought it would be quite an honor to accept the position. And it was a position that then I could maybe craft in a way that would help take the assets that I had gained in terms of policy, and analytics, and critical thinking, and bring it to the role as Chief. So it really was an honor for me to be appointed Chief. And I hope that each and every day I make our current tribal members proud, but also future tribal members when they look at whatever record that I create, that they will be proud of the work that I've done.

Claire Stinson: What an honor. And that's so inspiring. What are some of your main responsibilities in your role?

Chief Lynn Malerba: Well, so what I've been focusing on really is good policy throughout Indian country. We have a Tribal Council that runs our government and runs the business. Our Council of Elders are responsible for our culture as well as for our constitution. And they also are our Supreme Court. So they have very defined roles, but mine is one that I'm allowed to define as I move forward. So I've decided to focus on the whole of Indian country and help to craft and create good policy and engage with the agencies that work with Indian country to do just that. And as you mentioned, I sit on the Tribal Advisory Committee for Indian Health Services as the Chairwoman and on the Department of Justice on the Treasury Department Advisory Committee, as well as the National Institute of Health Advisory Committee.

In addition to that, I also am the secretary for the United South and Eastern Tribes Sovereignty Protection Fund, which is all the tribes East of the Mississippi, plus one in Texas. We now number 30 tribes that together collaborate to also advocate for good policy at the federal level. So I work both locally, in Connecticut, regionally, and then nationally as the issues present themselves. And I find that it's important to raise your voice, and you need to be as clear as you can be about the things that you think should change, and how you think they can change. Because it's one thing to have an agency consult with tribes, but it's another to actually provide them the steps forward to make sure that they're meeting our needs. And it should always be a very collaborative practice. And it should be one of agreement. It's one thing to consult. It's another thing to actually take the information that you have, and then operationalize that into good policy for all of Indian country.

So it's been really interesting. I will tell you that growing up, I was a very shy kid. And you wouldn't have even known I was in the room right through high school. But I think my experience in nursing school really kind of made me feel as though I needed to be more outgoing, as well as assertive, in taking care of the people that I'm entrusted to take care of. So again, I go back to my nursing education and think about how it really does inform my ability to communicate in a very unique way.

Claire Stinson: It certainly sounds like your background in nursing really prepared you for all of this.

Chief Lynn Malerba: It truly did. And as I said, being a very shy kid, you learn very quickly in nursing school that you have to raise your voice. Because you are your advocate for your patient, and you need to make sure that their outcomes are going to be the best outcomes they could be. And you can't do that unless you're willing to challenge physicians every once in a while. Because although they think they know everything, they don't. And it's your job to protect your patient from any mistakes or any errors. And to make sure that whatever it is that they need, that you're able to provide for them.

Claire Stinson: Well, that's amazing and inspiring. Thank you for sharing that. Let's talk about COVID-19. As the COVID-19 pandemic moved through the United States, we saw many health workers on the front lines really sharing their stories. This pandemic has helped raise awareness about the critical role of nurses and other health workers in the field of public health. What have you seen in your community?

Chief Lynn Malerba: We've been fairly fortunate in my community. But I will tell you the whole of USET has really experienced much greater numbers per 10,000 people. As of last week, the counties that the United South & Eastern Tribes reside in had 113 cases per 10,000, as opposed to the national average of 79.97 cases per 10,000. So you can see that tribal communities are hit a lot harder. Being in southeastern Connecticut, we were fortunate. Not only did our tribal leadership take very proactive actions to kind of close down government, still provide the services, but do so at a distance. But our governor was very proactive in trying to kind of shut down the state. So that number one, we wouldn't overwhelm the health care institutions in the state. And number two, we wouldn't be spreading the virus throughout our communities. So we've been really fortunate about that.

And I will say that the departments that take care of our tribal citizens have been just wonderful. We have an assisted living facility, which we lovingly call our retirement community because none of our elders want to think that they're living in an assisted living facility. And not one of them have experienced the infection with COVID. And we're really pleased and proud about how well our elders have been cared for. And that's really the population that we worry about. And we've extended those services to all of our elders that live in our community as well. And so far, we've been really blessed to not have any infections. And we know that our cousins throughout Indian country have not been so fortunate.

Claire Stinson: Well, I'm really pleased to hear that your community is being protected. You mentioned that there has been a growing body of research and discussion on the disproportionate impact of the coronavirus on communities of color, which includes tribal nations. Prior to the pandemic, what would you say were some of the existing health challenges for Native Americans?

Chief Lynn Malerba: Well, I think the existing health challenges for Native Americans are number one, access. Number two, funding. And number three, really thinking about health in a very global way. Because if you think about the social determinants of health, the lack of good healthcare policy and the lack of funding for Indian people has really exacerbated this problem. There is a real disparity in terms of the funding for Indian health and other federal healthcare programs. And it's one that we really do need to address in a big way. Because tribes and Indian people have trust and treaty obligations for healthcare. We're the only population that actually has treaty obligations for healthcare. We ceded all of the lands in the United States in exchange for healthcare and for education, and for all of the other services that we expect. But when we look at the funding for healthcare in Indian country, we look at Indian Health Service's spending per user. And it's just a little bit over $3,000. When you look at national healthcare spending, it's a little bit over $9,000. So there's a 60 percent differential between what is spent nationally per capita, and what is spent for Indian Health Services. And we know that that really has affected our ability to have good healthcare. And when we think about the facilities and the access to health care. Throughout Indian country, only 46 facilities have emergency rooms, and only 20 facilities have operating rooms. And none offer tertiary care.

So what that means is when you have major health issues, tribal citizens have to drive, they have to go farther for their healthcare, and they probably don't have good funding for healthcare.

In addition to that, we live in states that not all have expanded Medicaid. So many tribal citizens would actually be able to access Medicaid, had their state expanded. So we think that there's about 200,000 native people that would be eligible for Medicaid under the Affordable Care Act that are not because their state has not expanded.

So that's problematic in and of itself. But when we think about the social determinants of health, we look at the lack of plumbing both on reservations and in Alaska, that number goes from 8 percent to 24 percent in Alaska. The lack of a complete kitchen goes from 7.5 percent to 33 percent. 18 percent lack a telephone. 14 percent to 27 percent live in overcrowded conditions. So when you think about some of those things, that's really what's exacerbated this crisis. If you do not have running water, how are you washing your hands? If you are living in overcrowded conditions in multi-generational homes, how can you self-isolate and quarantine if you are exposed? A lot of the tribal clinics don't have the negative pressure that's required to isolate someone in a room. So if somebody is infected, they are automatically going to be spreading that infection to their community members. And if you don't have a telephone and you don't have access to internet, how are you getting the good public health messages out to your tribal citizens so that they can protect themselves from COVID?

So one of the very creative things that was suggested to one of our tribal nations who is experiencing a pretty high rate of COVID infections is to put lawn signs out on all the lawns in their tribal communities with the public health recommendations on them. So as people are driving by, they understand, "This is what we need to be doing. And here's who we need to call. Here's where we need to go if we aren't feeling well, and here are the symptoms that we need to be addressing and dealing with." So tribes have tried really hard throughout the nation, I think, to address how best to meet their citizens' needs. And some tribes have gone to the point of even putting checkpoints at the edges of their reservations to stop people from coming in.

We have one tribe who lives on an island. And of course it's a very popular island to visit in the summertime. And they were very worried about the surge of infections that would come with all of the visitors that are coming to their island and really overwhelming their clinics on the island. So those are some of the things that tribes are concerned about, but I think they're being very creative in how they're looking to deal with those issues.

One of the things Mohegan has done is to actually reach out and call each and every one of their tribal citizens to see how they're being impacted, and to see how we can help them. And that's allowed us to develop a plan. Number one, to do outreach and actually understand who it is that we need to be talking to and staying in touch with. But two, then how do we develop our plans for the kinds of things that we would do to mitigate and to prevent a major COVID infection or outbreak.

Claire Stinson: We'll be right back with Chief Lynn Malerba.

Since this season of Contagious Conversations is about the COVID-19 pandemic, please visit the CDC website for information and resources for how to protect yourself, what to do if you are sick, and the most up-to-date guidance and information. Visit cdc.gov/coronavirus.

And now back to our conversation with Chief Malerba. These are all really important points, and I'm so glad you're a part of this conversation today. How has the budget process contributed to the health inequities Native Americans face?

Chief Lynn Malerba: So the budget process really is at the heart of what happens for Indian country. And it's disappointing that Indian Health Services has not actually asked for the true need for what is required to get everyone to 100 percent funded. And that's something that we continue to advocate for. Because you will see that on the other side of the budget, there is mandatory funding for veterans affairs, for Medicare, and for Medicaid. It's mandatory, meaning that it doesn't have to be reauthorized every year.

On the flip side, Indian Health Services is on the discretionary side of the budget. Meaning it could be wiped out with the stroke of a pen. And when you have discretionary funding, what happens is it doesn't keep up with population growth. It doesn't keep up with the census. It doesn't keep up with the CPI. It doesn't keep up with new technologies. So year after year, the funding that Indian Health Services receives actually provides for less care, not more care, because it's not keeping up with some of those drivers that would require increases.

We have been looking and advocating for moving the budget over to the mandatory side of the budget, but also to look at advance appropriations. Because what happens in the appropriations world is that Congress has to appropriate a budget, and it does so every year. But if you had advanced appropriations, then your next year's budget would already be taken care of. So you wouldn't get into that political foil of continuing resolutions.

And I want to say, I think the statistic is in the last 18 years, there's only been one or two years that we have not had a continuing resolution. Which means the full budget has not been approved all at once. And what happens is it reverts back to last year's budget, which means you don't have any increases that you normally would expect to have just due to inflation. So we're looking at how best to advocate for that. And I think it will require a congressional fix. And that's something that Indian country has been advocating for a while now.

Claire Stinson: So you mentioned existing health challenges earlier. How has COVID-19 added to those challenges for Native Americans?

Chief Lynn Malerba: Well, COVID-19 has added to those challenges because our health status is poor to begin with. So when you think about some of the issues and some of the preexisting conditions that are indicated to make your COVID infection much worse and more severe. Diabetes, we're 280 percent higher. We experience pneumonia and influenza 140 percent higher. We already have kidney issues due to untreated blood pressure issues and a lot of cardiovascular issues. Our life expectancy is already 4.2 percent less than all U.S. races. And in some of our communities, the average age of death is 47. So we are already at a disadvantage. So if you layer on all of those comorbid diagnoses, you can imagine that COVID is impacting Indian country in much more severe ways than the rest of the United States population.

Claire Stinson: Wow, those are stunning numbers. This is such an important conversation. And I'm so glad that you are bringing all of this forward for our listeners. There are many rich cultural traditions that vary between tribes. Do some of those practices present potential challenges during a public health challenge like coronavirus?

Chief Lynn Malerba: Oh, absolutely. When we think about some of our cultural traditions, it is all about communal activities. So whether we're doing potluck dinners, or we're celebrating an event, it is all very much related to your community. So when we think about some of the things that you would traditionally do, now you're being told well you have to isolate, you have to quarantine, you need to wear a mask. That's not something that would be a natural for anyone in the United States, but it surely would not be natural for our tribal people. If you think about pipe ceremonies, if you think about smudge ceremonies, you think about some of the blessings that you normally would do. It's hard to do those at a social distance. You would not do those six feet away from one another. So we are really having to kind of recalibrate and reeducate, and hopefully just temporarily think about how we may do things in a different way.

For instance, I conduct funerals sometimes. If a tribal member would prefer to have a more traditional ceremony, they would come to us and we would do a ceremonial fire where people would sit around the fire and share stories about the deceased as they prepared to go to the next world. That would be difficult to do and to be socially distant at the same time.

Typically, when I do a funeral, I smudge everyone as they come in to the circle. I'm not sure I would feel comfortable doing that, nor would I put our elders at risk for that. And I think that that's really where tribes are feeling very challenged. Number one, you want to support your elders. But number two, you want to make sure that you're keeping them healthy. Because they're the ones that are so essential to our understanding of who we are. And they are our bridge to our ancestors. So we would never want to put them at risk. So we have that inherent push-pull right now in terms of really wanting to care for everyone, but having to do it from a distance. And I think that that's very antithetical to who we are as a people.

Claire Stinson: Right. Absolutely. And these traditions are so important. So this is even more of a reason to get COVID-19 under control.

Chief Malerba, given the unique agreements tribal nations have with the U.S. Government, can you talk a little bit about ways that tribal nations have previously worked with the U.S. during public health emergencies?

Chief Lynn Malerba: Sure. So one of the ways that we deal with that, some tribes have what we call direct service from Indian Health, which means that the Indian Health Services will go to their lands and provide services using their own employees. Other tribes have what we call self-governance, which means they will take the funding that is obligated for that tribe. And they will be the ones that are upholding the treaty and trust obligations of the United States by providing the services to their own tribal nation. And what they do is they kind of look at the budget, they look at what their priorities are, and then they deliver their services accordingly.

But typically during public health emergencies, we work really closely with not only state and local public health authorities, but also with the CDC, the NIH, and Indian Health Services. So what we do is we try to understand what those best practices are. And we try to look at what the science is. And then we implement those kinds of initiatives in our own community in a way that is culturally appropriate, and in a way that makes the most sense based on what we're seeing on the ground.

So it really is a very collaborative approach to providing health care. And again, tribes are very holistic in how they provide their services. So we wouldn't think about health in a very just narrow way. We would think about the whole of health. So whether it is the sanitation facilities, or air quality, or transportation perhaps, do our tribal citizens have the ability to get to a clinic, do we need to provide transportation to them? And that's what we're seeing a lot throughout Indian country is people are really doing a lot of outreach to make sure that do their citizens have food, can they get their medicine? Can they get to a clinic if they are feeling ill? Do they need help within their home so that they can stay in their home independently throughout this? So we work really closely with FEMA and some of the other agencies locally to make sure that we understand what the best practices are, and that we are applying the science that we need to apply in our own tribal communities.

Claire Stinson: An important point. And you mentioned federal agencies. Tribal nations are also working with the Centers for Disease Control and Prevention to provide preparedness and response resources to tribal leaders. Can you talk a little bit more about some of these initiatives?

Chief Lynn Malerba: Oh, absolutely. And we're so pleased. And let me just say we're so pleased with CDC and the work that they're doing, and also the Foundation. I know that the Foundation is providing boots on the ground and assistance to tribes who have been hard hit. So let me just express my gratitude for that, because I know that that's been really important to those communities. So we really appreciate that.

In terms of the work that CDC is doing, I think one of the things that's really important is the health information technology aspect of some of the grant funding. So they're looking at how do we support the data systems that are going to be necessary to support and focus on the COVID-19 surveillance. Both the patient tracing, and the population building. And that's something that Indian Health Services has struggled with and are looking at as well, because they have a very old IT system and it needs to be modernized and upgraded. So we've been obviously working with Indian Health Services to do that.

I think CDC has been working really closely in surveillance and epidemiology. And we know that the tribal epidemiology centers have played a huge role in advising our tribal communities. And I know that they are loosely linked to CDC. And we think that the information sharing is just key to how we're working with one another. Obviously, laboratory capacity and making sure that the test kits are out and that testing is available has been huge. And looking at countermeasures and mitigation.

And then lastly, I think what's going to be even more important is recovery. How do we get back to this pre-event? How do we get back to life as our new normal may be? And how do we look at how we have functioned during this time, and what we might do based on the information that we gained from this huge pandemic?

So our work won't be done when this pandemic has a treatment and/or a vaccine. But what we need to do is to make sure that we're using the lessons that we learned to change how we operate at a tribal level. But also then how we look to streamline some of the response measures that we would have from the federal partners that we deal with. And I think that that's going to be key to continue those conversations long after this pandemic, hopefully, is in our rear view mirror.

Claire Stinson: So how has COVID-19 impacted your ability to do this important work and keep communities informed during the pandemic?

Chief Lynn Malerba: Well, I've become an expert at Zoom meetings. And in the morning I look at my calendar to see if well, am I on Zoom today or not? And if I'm not on Zoom, maybe I don't have to look quite as nice as I would otherwise. But I think we've worked really hard to make sure that we can do our work at a distance. So for instance, next week, I have a Tribal Self-Governance Advisory Committee meeting. Which would normally be a day and a half worth of meeting that we've now had to condense. But we're doing a lot more offline work and trying to do preparatory work so that we're going to use our shortened time more efficiently. And I'm also providing testimony next week for the U.S. Commission on Civil Rights. And we're going to be doing that remotely.

So while it's not ideal, the work continues. And I think the last thing we want to do is to lose sight of the work that we need to do, regardless of how we have to operate in the short term. I will look forward to seeing everyone in person, but I can't imagine we're going to be traveling anytime soon. Not until there's a good vaccine available.

Claire Stinson: Absolutely. And as long as the important work is moving forward, that’s the important thing. How are rural tribal communities overcoming the challenges they face to ensure good information is shared with their tribal citizens?

Chief Lynn Malerba: I think the rural communities are definitely having to do more face-to-face education. And I know that they are working hard to spread the message. I used the example of the lawn signs, which I think is just a great way to do that. And I think what they're doing is doing outreach through families. So that if you as a family member can talk to your family members, you were kind of fanning out that information as opposed to just kind of telling one person. I do think that technology is challenging though. There are many tribal communities that don't have access to broadband or have spotty access to broadband. That's a real challenge not only for getting information out, but it's a challenge for educating your children. You know that so many schools have closed and so many schools are providing instructions remotely. Well, how are you able to do that if you don't have access to broadband? So some of the challenges that we've seen and have been trying to address have only been highlighted through this pandemic. So we know that there's so much work that we have to do. And I think the urgency of this work has just been highlighted through COVID. So the rural communities are struggling, and we need to make sure that they have the supports that they need.

Claire Stinson: Thank you for explaining that challenge. There have been several recommendations from public health experts on key components needed for safely reopening the country. Among all of them, outreach remains at the core. What are some best approaches from your viewpoint for those in public health to reach tribal nations?

Chief Lynn Malerba: Well, I think they need to understand who the influencers are in tribal nations. And sometimes, it's the elected officials, and sometimes it's someone else. Right? And so I think that as we think about working with tribal nations, we need to identify who the community is and how best to reach them. And what's their tradition. Some tribal communities are only going to accept another tribal member giving them information and providing that service to them. So we need to be sensitive to that fact.

I will tell you it doesn't matter what role I've played within our tribal government. I still have people that I check their blood pressures when they ask me to. Because I'm a nurse first and a tribal leader second.

So I think that as we think about how we reach tribal nations, we have to understand where they're coming from. And we have to understand what some of the cultural barriers are. Tribal members and tribal citizens will struggle to hear that no, you need to wear a mask every time you're around more than your immediate family or your quarantine bubble, as I like to say. So we need to understand how to educate them and how to provide the message that you're protecting everyone by wearing a mask. And that good hand hygiene should always be at the top of your mind, regardless of whether we're in a pandemic or not. And perhaps, we should just all stop shaking hands forever. Because I don't think that that's a really healthy thing to engage in, in any given day.

So I think we need to think about how do we get that message out for us. We've been putting it on our tribal member website, we've been sending out mass emails. We have a newsletter from our health department that is sharing best practices and information. So I think what's really important though is to send messaging in multiple ways. And I don't think you can over message to the tribal membership. I think the more information that people have, and the more they hear it from trusted sources, the more compliant they will be with what needs to happen in order to avoid the spread of COVID.

Claire Stinson: Absolutely. And trust remains at the core. You are such an amazing advocate for tribal nations. So thank you for explaining all of this today.

One of the key areas you have focused on in your work is providing education to the greater public about tribal nations and their history, like you're doing today. What's the story you would like people to know about public health and tribal nations?

Chief Lynn Malerba: Interesting you should ask that. So when I started my last doctoral program at Yale, I was doing a presentation for my coworkers who were all doctoral students, all masters prepared nurses. And I said, "Well it's a well-known fact that Indian Health Services is sorely underfunded." And to a person they all said, "No, it's not well-known."

So that really struck me. And I guess one of the things that I want people to know is that tribes have treaty obligations for health care. Those treaty obligations have never been fully met. And we need them to be fully funded and fully met through the federal government. And until that happens, we're going to continue to struggle with all of the measures that we would consider a healthy community. And when we think about that, we need to think about social justice. It's a matter of social justice for tribes to receive the funding that they should have for healthcare. Because without that, our tribal citizens are diminished. And we need to make sure that we survive in the future. And our tribe got very small due to the inability to fight off the pathogens that we were exposed to in the 1600s and 1700s. So that was later in Western United States. But in Eastern United States, our population diminished by 90 percent between the 1600s and the 1700s. So we're still overcoming that. It's just now that our population is rebounding. But what we need to make sure is that we have a healthy population so that we don't experience the death, and the disease, and the diminishment that we experienced in the past.

As I mentioned, there are some tribes that their average life expectancy is 50. There are some tribes that tell me they only have three or four people over the age of 62 in their community. That's unconscionable in the United States. So we need to make sure that people understand what happened to tribes and how it happened to tribes, and why healthcare is such a key component to making sure that tribes don't experience that in the future.

And the fact that there is no national curriculum about American Indians and Alaska Natives, and that there's no required statewide curriculums for American Indians and Alaska Natives is unconscionable. Because people don't hear that history and they don't understand it. And I think that we need to do better with that.

Claire Stinson: This is such important perspective. We're so glad you're a part of this conversation today. I have one more question for you. What advice do you have for the future public health leaders of America?

Chief Lynn Malerba: Well, the advice that I have for the future public health leaders of America is number one, it's the best way to make an impact on your community as a whole and on the United States as a whole. So you should take that job very seriously.

But two, my advice would be to make sure that you understand the community that you're working, with whatever community that is. You need to be able to connect at a very individual level in order to be heard. And you need to understand how all of the pieces of health fit. You can't just focus on, as I call, the disease du jour. So whatever the disease of the day is, you can't focus on that. You have to focus on what constitutes social, spiritual, communal, and physical health. Because they're all related. So you can't just pull one piece of that out. You need to really think about what makes up that whole person, and how to create this healthy environment for that person, but also for the community. Because if we're creating healthy communities, those next generations are going to be so much healthier.

One of the Chiefs that I know says that the first environment that a baby experiences is the mother's womb. So if we don't have a healthy mother, that baby is already at a disadvantage. So we need to think about environmental health as well. So I would just say all of life is connected, and we need to celebrate that and we need to respect that. And then we need to encourage those connections to create the healthiest communities that we have.

Claire Stinson: Really powerful advice. Thank you. Chief Malerba, I really enjoy talking with you today. Thank you for sharing this powerful perspective on advocacy for tribal nations, and for being a part of this important conversation.

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