Keywords

Public Health Ethics Issue

Despite decades of well-intentioned work, public health interventions can fail to achieve desired outcomes among Native American communities. These failures are not due to a lack of motivation on either side. Rather, they stem from a history of colonization which continues to impact the fundamental structure of public health and Native American responses to public health intervention. We purport that there are discrepancies between the tools provided in much of public health’s core training and the reality and needs of work in Indian Country. These discrepancies may contribute to continued experiences of health disparities by Native Americans. This paper offers an example of this schism using narrative, followed by actionable steps that individuals working in settler public health institutions can take when approaching work with Native nations and communities, particularly when addressing the impacts of historical trauma events.

Notes on Author Orientation and Terminology

We ask for cultural humility and respect of Indigenous experiences, attitudes, and perspectives both as you read this paper and as you work in Indian Country. We write from the position of Indigenous women who are trained in accordance with mainstream, settler public health. We mention our identity because it profoundly shapes our understanding of the world, including our interpretation and application of public health. In the United States, settler colonization refers to the non-Indigenous power structures and processes that, since European contact, influence how the United States historically and contemporarily functions (Wolfe 1999). While public health has recently made strides towards inclusivity and allyship, we are intentional with our choice of the settler colonial modifier to public health. Public health, as commonly practiced in the United States, is built upon a Western-centric worldview that values positivist science and objectivity, among other characteristics. These foundational values have made it possible for traditional public health to be complicit in processes of colonization, including a history of conducting researchon, rather than with,Indigenous people (Reid et al. 2019; Sherwood 2013). Additionally, we recognize that Indigenous people work in public health and that there are tribal public health departments, however, the conversation around public health’s role in addressing historical trauma within an intratribal context is beyond the scope of this paper.

Indigenous people have preferences regarding the terms used to describe themselves and may use terms interchangeably, depending on context. Throughout this paper we use “Native American”, “Native”, “Indigenous”, and at times “Indian”, to refer to the first peoples of what is now the United States. With a few exceptions, we cite only Indigenous authors throughout this paper to center and amplify the voice of our communities (Simpson 2017, 37).

Background Information

This section serves as an introduction to the settler colonial origins of public health and historical trauma. It is intended to provide enough background knowledge to grasp the significance and connections between theory, history, and contemporary experiences of health and disease.

Linking Colonialism and Public Health

Both historically and contemporarily, public health has been complicit in processes of colonization, contributing to the persistent adverse physical and psychological health outcomes that pervade Indian Country. This colonial legacy calls for a fundamental shift in the way that public health approaches Native nations. We suggest that, given professional obligations – respecting community values and differences in worldviews, addressing root causes of disease, and acting with transparency (Dillenberg et al. 2002) – public health professionals are responsible for addressing this legacy of colonialism, or at the very least, of seeking to understand and acknowledging the colonial context in which they work. The need for acknowledgement is particularly salient for government-associated public health professionals. Anyone who works for the State may be seen as an actor, or appendage, of the government which dispossessed Indigenous peoples of land, enacted policies of Indigenous erasure, and failed to formally apologize for the aftermath. Government-associated public health professionals, as direct representatives of the State, carry their relationship with the settler State, even if only symbolically, with them into communities.

Links between colonialism and public health have been written about elsewhere (Paradies 2016; Reid et al. 2019). We discuss five relevant links below to highlight the colonial history of public health and demonstrate the ways in which public health is entrenched in systems of oppression (Wilson 2008) and therefore cannot, we believe, be viewed as apolitical. As such, we suggest that the application of public health knowledge cannot be viewed as inherently neutral or value-free. First, early public health efforts focused on disease control in colonizers’ homelands thus ensuring that colonizers could survive and settle new lands. Second, scientists helped define racialized hierarchies that identified Indigenous people as less human than those with Western European ancestry. This devaluation smoothed the way for colonial expansion while simultaneously providing justification for federally-sanctioned relocation and genocide (Simpson 2007; Dunbar-Ortiz 2014). Third, public health research stigmatizes by declaring deficits, often using Native communities as disparity case studies (Smith 2012; Brough et al. 2004). The identification of disparity provides justification for public health intervention (O’Neil et al. 1998). Historically, public health interventions tend to overlook structural causes of disparities and instead target “problematic” behaviors or theorized genetic contributions. Such targeting unwittingly upholds assimilationist and racialist ideologies and, in turn, colonialism (Pacino 2017; Kowal and Paradies 2005; Ehlers et al. 2013) (see Wexler and Gone 2012 for more examples).

Fourth, the public health research legacy with Native peoples primarily consists of data extraction and exploitation for the benefit of Western science and academic careers over Indigenous interests. Such research frequently fails to meaningfully engage tribal communities in the identification of issues, methodology, study design, data analysis, dissemination of findings, intervention development, or appropriate follow up (LaVeaux and Christopher 2009) (for a particularly egregious example, see Pacheco et al. 2013 for a summary). Lastly, public health science values statistics and quantitative approaches over other forms of knowledge generation and dissemination such as ethnographies or oral histories. When sharing information, public health defaults to means of communication that practitioners find most comprehensible: graphs and scientific messaging. Indigenous communities may also value and not readily adopt a biomedical frame or knowledge (Ninomiya et al. 2020). Likewise, Indigenous communities have their own notions of well-being. The combination of these five factors reinforce unequal power dynamics between public health and communities, whether Indigenous or otherwise marginalized, and predispose them to mistrust public health research and interventions.

Current efforts in public health, such as community-based participatory research (CBPR), aim to address some of these concerns. Notably, CBPR places cultural humility at its center and values community expertise in pursuit of shared research goals (Wallerstein et al. 2018). These efforts, however, remain situated in settler-colonial systems of knowledge, limiting their ability to address Indigenous health (Chino and DeBruyn 2006; Simonds and Christopher 2013; LaVeaux and Christopher 2009). Well-intentioned CBPR can also produce unintended consequences that perpetuate cycles of victimization (Kowal and Paradies 2005).

Researchers interested in conducting research with tribal nations and communities would do well to make space for additional epistemologies and follow suggested guidelines laid out by Parker et al. (2019), including framing work within a Native American historical context, reflecting Indigenous moral values, linking Native American cultural considerations to ethical considerations, and providing Indigenous-based ethics tools for decision making. Relatedly, we remind readers that, as federally-recognized tribes are sovereign nations, public health professionals working for government organizations must approach work with tribes in the same way that they would work with a foreign country, and consider research, negotiations, and interventions to be government-to-government interactions. In fact, many tribal nations have their own Institutional Review Board (IRB) that must be consulted before the start of any research project (Kelley et al. 2013).

Historical Trauma as Events and Responses

The narrative we recount involves historical trauma. Though “historical,” the trauma’s impact reverberates into the present, with implications for public health research and practice with Indigenous communities. The concept of historical trauma originated in research on the enduring impacts of the Holocaust (Brave Heart et al. 2011; Weinfeld 1981). It refers to a massive negative group experience that intergenerationally impacts survivors and their families but can also exacerbate contemporary stressors and traumas (Mohatt et al. 2014, 1). In the Indigenous context, trauma specifically includes the shared violent experience of colonization (Brockie et al. 2013). Examples of traumatic events Native peoples in the United States experienced include land loss, forced relocation, and family separation, most notably through child removal policies and forced boarding school enrollment (Dunbar-Ortiz 2014). Some State-sanctioned policies were intentionally genocidal (Ostler 2019). For many, the impact of these events transmitted intergenerationally through both physiological, including epigenetic, and psychological mechanisms, as well as socially, politically, and economically (Brave Heart and DeBruyn 1998; Evans-Campbell 2008; Lajimodiere 2012; Matthews and Phillips 2010; Myhra 2011; Roy et al. 2012; Yehuda et al. 1998). Historical trauma events are associated with historical trauma responses such as increases in mortality and morbidity from heart disease, hypertension, alcohol abuse, depression, and suicidal behavior (Bombay et al. 2014; Brave Heart 1999). Not all historical trauma responses are destructive; some coping responses focus on recognizing signs of resilience and on strengthening and maintaining it (Evans-Campbell 2008).

Approach to the Narrative

This narrative, while intended to serve as an illustrative story, is neither fictional nor anecdotal. Rather, it is first person testimony drawn from the authors’ experiences (Deloria et al. 2018). The people are not characters but beings whose experiences live on and come to life through these retellings. The people in this narrative are a combination of real people, whose names have been changed for privacy, and amalgamations of conference attendees we have interacted with over the years. This narrative is an offering to all our relations. For our readers, it illuminates some of the challenges that may arise when conventional public health is applied to address historical trauma in Indian Country and how public health research in Indian County can fall short.

Narrative

I never sleep well in hotel beds or, really, ever when traveling. But last night was particularly rough. Anxiousness and uncertainties about this project took over my dream space. They conjured forth palpable doubts about the effectiveness of public health research to serve my people. The sinking pit in my stomach was my body bracing for worlds to collide. My auntie always preached the importance of walking in two worlds: having a strong footing in my Native identity yet knowing how to navigate the mainstream, settler culture. As a white-coding Native, my privilege has allowed me to negotiate when and in what ways to walk these paths. But the unrelenting feeling of doubt has me questioning whether my feet have ever been planted firmly in either. It is tiring. This constant maneuvering exhausts the spirit. One saving thought pierces my anxious state: get coffee!

Hot, black, liquid medicine. This fancy hotel provides a single serving espresso machine. A great invention, indeed, yet so much plastic and waste. Staring at the wall, clutching my hot cup, more anxieties weigh on my mind: limit your coffee intake because cardiovascular disease runs in the family. Avoid eating that immensely carbohydrate-packed bagel on account of impending diabetes. But tomorrow’s a new day and modifications can happen then. I probably need this coffee and breakfast; besides, too much thinking and self-criticism so early in what will surely be a long day can’t be good for the spirit. It is a chilly morning and the steaming hotel shower helps me wake up and focus. How did my ancestors live through so many cold and dreary mornings like this? Even outside with my bougie $400 puffy coat I’m chilled. What a chump. My ancestors were badass.

Shu’-shaa-nin~-la, Miigwetch, thank you for joining me today and for providing the opportunity to speak with you. I am honored to be able to share the draft of this report with you and hope that it doesjusticeto this topic. I’ve spent several months pouring over articles, books, and reports to summarize what’s out there regardinghistorical traumaand how its impacts reverberate and persist throughout Indian County.

Years of training have prepared me for today. With so much time spent in the academy there’s a familiarity and comfort to public health research, its ins and outs. But my hands are still shaking. I’ve given so many presentations. Yet this feels different.

I’m excited to get your feedback. You are leaders in your communities, and I hope that this report is useful to you. If it is not, I hope that you share thoughts on how to improve it because you are the experts. I summarized what has been written in academic texts, but, as you know, these texts provide only a few perspectives and researchers don’t speak for you.

Standing at the podium, the anxiety resurfaces and some familiarity also creeps in. These are my people looking back at me, weighing my words and their impact on their experiences, the lives of their family members, and their communities. There is an immense amount of love and acceptance in this room, but despite that, or maybe because of it, even more pressure to do this right. But how? The information I’m presenting is only the tip of the iceberg. It is couched in academic language, methods, and results that are a far cry from the personal experiences that each of the conference attendees has with historical trauma, experiences that many Native people better articulate as Soul Wound.

As you all know, the removal of Native children to federalboarding schools, starting in the 1870s and continuing through the 1930s is a more recenthistorical traumaevent. At its peak in the early 1900s, up to 25,000 Native youth per year were enrolled in more than 350boarding schoolsin twenty-nine states. While the federal boarding schoolpolicy ended in the 1930s, independent states and religious organizations continued to run the schools into the 1970s. These programs removed children from theirfamilieswith the intention of assimilation and eradication through cultural erasure and the disruption of familyties. This review of theresearchfound that the boarding schoolera is associated with the interruption of traditional parenting techniques and familial roles leading to intergenerational abuse, loss ofIndigenouslanguage, systemicpoverty, as well as a plethora of mental and physical health problems.

Behind me a slide flashes, showing a graphic on the number of children and families who were impacted by boarding schools. The slide that follows presents cold, impersonal statistics on the ways that boarding school interrupted parenting techniques and knowledge, and the abuse and neglect that sometimes resulted from this. Another slide presents a graph showing the higher incidences of drug and alcohol abuse associated with boarding school attendance, while a fourth is covered by a dizzying list of health impacts which studies have shown result from attendance: epidemics of youth suicide, depression, and anxiety. Tears form in the corners of the eyes of many elders. Breathe. I pause to acknowledge the weight in the room. These statistics are overwhelming, and this information offers nothing new to this audience. While much of this literature was published recently, and the field of historical trauma is considered new and trendy in many academic circles, for people who lived through these events, and have witnessed the impacts directly on themselves and their families, this is old news. The blur of numbers underscores the utter insufficiency of the information I’m presenting. The audience is gracious.

Many of you have personal experience with theboarding schools. Instead of standing up here telling you about them, would anyone like to share your experiences or thoughts?

A younger woman stands up and everyone shifts around to face her, forming an impromptu circle more appropriate for the sharing of stories and knowledge. “My Great Grandmother, Odetta, attended a boarding school. We don’t know a lot about her experience because she didn’t talk about it. My mothertells me that Odetta and her older sister ran away from the school because they were miserable. She eventually settled in a very small town and then never talked about being Indian. I think she was afraid of being found out, because life would have been harder had people in the town known she was from across the river. I get the sense that Odetta tried to cut ties with her past. My grandmother, Odetta’s daughter, remembers visiting her grandparents only once. How much of this fissure was because of her boarding schoolexperience? In some ways, three generations later, I still feel cheated by the schools and what they stole from us. A tribal community claims me, but I didn’t grow up with our people’s practices and language. When researchers study just one impact ofhistorical trauma, they look at how our history impacts specific health conditions, but no one talks about the emotional toll, the way that our history impacts every aspect of the way that I live my life each day.”

Obligated by my training to adhere to my allotted speaking time, I reclaim the podium. But there is no feeling of nervousness now. I am providing a backdrop and space for the audience to talk about historical trauma. They make it real. A person stands and offers their family’s experience.

Theboarding schoolsconfuse me a little. I hear about all the bad stuff that happened and I know those schools were terrible. But I remember my great uncle talking about trying to get into a boarding school. He wrote letter after letter to the social workers asking for admittance because he wanted to become a doctor. It never came to fruition, though. This experience makes me think differently. We knew how to use this system to our advantage. Also, I recently came across some of the records that the governmentkept. They have his letters and also the letters written in response.

Looking around the room, he continues, “They might have your family’s stories too. These are ours and we deserve to have them. Come talk with me after and I’ll share how I found the letters.”

The presentation is no longer mine. My colleagues at the school of public health would think I’m losing the room, but I know that this is more effective than sticking to script. “Thank you for sharing that insight, and like Brenda Childs has said, we’re still sorting out the legacy ofboarding schools. The emotions are complex and can create tensions. It is rare for public healthresearchto acknowledge this, but we know theboarding schoolsdidn’t erase us and that means something.”

After pausing to gather some thoughts and noting that we’re in Northern California, or as many refer to think of it, land currently called California, I provide a new backdrop for further testimony:

Historical traumain what would become the United States began with European contact in the 1500s. One instance took place in California, when settlers migrated west, drawn to the southern part of the state by the potential for large cattle ranches, and to the north by newly discovered gold. These settlers were pre-conditioned to hate and fearNative Americansby generations of racist propaganda which portrayed Indians as dangerous and less than human. This perception, combined with the belief thatNative Americansfailed to use the land to its potential, paved the way for genocidal policies. Settler activities destroyed land and resources through logging, mining, and livestock production, leavingNative Americansto starve whether on or off of newly developed reservations. In order to address conflict between settlers and Natives, the state sanctioned the creation of volunteer militias. These paid militias slaughtered any Native people that they met on the pretext of distributingjustice. Bounties, paid by the state, were between twenty-five cents and five dollars for the scalps of Native men, women, and children. Between 1848 and 1900, the Native population of California plummeted from 150,000 individuals to less than 15,000. For those who survived, slavery was a common fate, particularly in the southern part of the state where coerced labor enabled the development of large ranches. Slaves were typically taken as children, with boys sold as manual laborers and girls as domestic help.

This time it is an older woman who stands. Her silver hair curls around her face, and while her eyes are almost hidden in a lifetime of wrinkles, her clothes are immaculate. That blouse is from one of my favorite Native-owned fashion businesses. Good choice. She tells us that she was drawn to come to this conference, her first, because of her desire to understand not only how the traumas of the past may continue to impact her family, but also how to embrace the strength and resilience of our people in order to heal. As she speaks, she turns to look at those around her, and her voice takes on the well-worn cadence of a story.

This is the story of my ancestors and relatives, as told to me by my mother, Clara Smith. My mothertold me the settlers came into her Grandmother, Tom-Watt-Welsuni’s, village and that Tom-Watt-Welsuni seen them kill herfather, along with other male members of the tribe. One of the other settlers, Thomas Smith, took Tom-Watt-Welsuni as his wife even though she was only eleven years old and was married by Indian custom. She was only five foot tall and of slight build and spoke only Indian. She had III tattooed on her chin. They had 11 children. She always resented her husband for being in the group who killed herfatherand other relatives and friends. My mothersaid she had a very hard life.

Later, when I was an adult, I looked up Thomas Smith and found a letter that he wrote to the General of Oregon in July of 1856, the same year he attacked my Great Grandmother’s village. I brought the letter here today and want to read the end of it to you. He writes, ‘At the request of the citizens of Crescent City I have written to you for a commission to raise a company of good men for the purpose of clearing the trail on the coast and to Illinois Valley. There is no peace until these devils is smitten from the face of the country. I take no buck prisoners. The treaty that I make is everlasting. I have had considerable experience in fighting Indians. My manner of fighting has always been successful’. I also found his obituary, which includes a mention of Tom-Watt-Welsuni, ‘Thomas Smith wooed, and, with the required wampum, won a dusky maid of the forest.’

The traumas Tom-Watt-Welsuni, or Amelia, as she was re-named by Thomas, experienced as a young girl, and throughout her life, were passed on to her children, and how could they not be? She lost her familyas a child, and raised her own children, the children of a forced union, in a time when Indians could still be killed on sight. These experiences made an impact on her children, and were passed on, along with her stories, to my motherand to me. I can see the ways they have impacted my life. Some of these impacts have been negative, but some have also been positive. They have shown me the strength of our Indian women. Even though the most horrible things in the world happened to my Great Grandmother, she raised eleven healthy children. And my mother, when she was born, because she was an Indian, she wasn’t a citizen of the United States, even though she had never left California. But when she was in her fifties, she walked almost a hundred miles to Crescent City to register us as U.S. citizen. I get discouraged by numbers like those you’re showing up there on that screen, and I think about our old folks dying early ofdiabetesand heart disease, and our young people stuck in cycles ofaddiction. I sometimes think that is all that White people think we are. It seems like medical professionals and public health researchers come to study us, and they only see the bad things. How come university researchers never study our strength and ourresilience? How come they never ask how we are still here? That is what I want to focus on when we talk abouthistorical trauma– celebrating our strength.

Heads are vigorously nodding around the room. There are a few audible “ahos.” The young man sitting next to the elder stands to steady her, her voice beginning to shake in a way that mimics the growing unsteadiness of her stance. He adds, “I wonder if researchers spent more time in our communities, if they’d be more able to see our strength, our survivance? I also don’t understand why the focus of our interactions has to be onresearchoutput rather than on building relationships. Relationships take time and energy to build. We learn how to be in good relation as youngsters. All of us are connected to each other and to the Creator. I can’t exist without you and you without me. Everything we do impacts everyone else. Listen. Be patient. Show respect. These are fundamental ideas that seem too easily to get lost.”

The room monitor shakes the “Time is Up” sign at me in a way that signals I should have ended a while ago. Nodding and facing the older woman and younger man, I give the deepest form of thanks that I can offer, which is to say so in my people’s language. Frantically pressing buttons to scroll through the rest of my slides I arrive at the last one, which provides my contact information.

Shu’-shaa-nin~-la, Miigwetch, thank you for making space for this conversation, sharing your insights and experiences. They have enriched my spirit and I hope yours as well. I’d love to hear more about what great things you are doing in your communities to addresshistorical traumaand nurtureresilience. You know better than anybody what your community needs to live well and be healthy.

My plane leaves soon, so I dash out of the room. Class starts in 5 h. I’m cutting it too close. Why do I do this to myself?

Within 2 h, sitting at a window seat in coach cradling a cup of tea in a paper cup, I’m looking out at the expanse of clouds stretching out below me. It is so rare in my discipline to have to report findings back to community. Resentment towards my program is growing for not setting me up better, by not providing opportunity to practice accountability to communities rather than fellow public health professionals. How could my mentors have taught this?

I am reminded of a saying one of my elders shared with me, “data are just stories with the tears wiped off.” After this presentation the saying resonates strongly. The presented report is our people’s experiences of historical trauma as portrayed by numbers; stories stripped of their humanity. It is a special kind of heartbreak to know that this report does not contain the testament of today, because stories are an N of one, they aren’t generalizable, and are too embedded in personal experience to be seen as “objective”. I wonder if non-Native people that read the report will be able to fully comprehend the intergenerational and enduring impacts of historical trauma events in Indian Country. Hopefully it isn’t too easy to dismiss the impersonal statistics, the stories with their tears wiped off. In my mind I see the faces of the audience members who shared their stories, see both the traumas and the strength, the Blood Memories of both shining through.

Discussion: Towards a Solution

Many health disparities stem from the United States’ history as a colony and Native American’s position as a people who have experienced colonization. The United States government has never offered a formal apology to Native communities for past mistreatment. Individual public health practitioners cannot apologize adequately for the government; yet they carry the lack of apology with them when entering Indigenous spaces. This lack of apology fractures trust, which can adversely impact public health practice. Failure of public health to deepen its understanding of past and continued fallout from colonization has the potential to lead to the continuation or promotion of health disparities among Indigenous communities. To begin to address these health disparities, we believe it is necessary to acknowledge this history, and for public health professionals to reflect on the ways in which the structural forces of colonialism continue to guide their practice.

The narrative highlights some of the schisms that exist between common public health training and work with Native communities and, through this, begins to identify feasible approaches to addressing some of the discrepancies. The notions brought up in the narrative are incredibly complex and intertwined, and we cannot properly unpack them in a single paper. Despite this, we name a few here. First, work to be good stewards ofIndigenousnarrative as they can make space for stories of survival, resilience, and health that are not captured by standard indicators used in public health. Narrative also offers an opportunity to retain the power, control, and ownership of information by Native people so that they can contribute to the evidence base on their own terms (Simpson 2007; Doerfler et al. 2013). Second, focus onrelationship building as it is essential in re-defining the ways in which Native communities and public health interact to support wellness. Native communities must lead healing efforts, including cultural revitalization, and public health practitioners can demonstrate support for Indigenous-based self-determination by providing expertise and resources when asked. If the focus is on relationship building, practitioners can then become grounded in locally appropriate histories, culture, and protocols. There is undoubtedly immense diversity across Indian Country, however, an emphasis on relationship building will be particularly powerful if accompanied by an openness and willingness to create space for alternative approaches (Gartner et al. 2021).

Third, understand the variation inhistorical traumaresponses and nurtureresilience because not all communities, families, and individuals have experienced or responded to the experience of trauma in the same way (Evans-Campbell 2008; Ehlers et al. 2013; Walls and Whitbeck 2011; Whitesell et al. 2012). While many historical trauma responses include poor health outcomes, responses are not inherently negative. Some positive responses to historical trauma include dedicated re-investment into cultural revitalization efforts, a recognition of the strength and resilience of ancestors, community, and family, and a deepened commitment to community and culture (Bombay et al. 2014; Whitbeck et al. 2001, 2004; Colmant et al. 2004; Evans-Campbell 2008). Lastly, know thathistorical traumaresponses can permeate all aspects of daily living. Responses to historical trauma events are not limited to a single disease at a single time point. Their very nature as a disrupting force means that their impacts reverberate across time throughout every element of daily life by impacting social structure (Grant 2008), economic stability (Gregg 2018), and cultural continuity for contemporary communities (Heart et al. 2011). Only after completing each of the four steps detailed above can public health practitioners begin to consider ways of addressing health disparities as they relate to historical trauma.

In hopes of generating further consideration and critical reflection, we offer the following discussion questions.

Questions for Discussion

  1. 1.

    How might public health professionals negotiate the tension of being professionally obligated to protect the public’s health (including Indigenous communities’ health) while also upholding Native sovereignty and self-determination?

  2. 2.

    Why are statistical summaries of population health privileged by the public health profession? What are alternative approaches to capturing and disseminating population-level health-related information?

  3. 3.

    Who benefits from the telling and re-telling of summaries of Native ill-health and disease? In what ways might they benefit?

  4. 4.

    In what ways can public health practitioners support Native communities to heal from historical trauma without perpetuating settler-colonial knowledge and power hierarchies?

  5. 5.

    How might knowledge of diversity in historical trauma responses impact the manner in which public health professionals approach work with tribal communities?

  6. 6.

    In what ways would centering relationship building, rather than data collection, alter the trajectory of standard public health research and practice?