Tribal, state, and local agencies define responsibilities for health emergencies on tribal land

In Brief

The Eastern Band of Cherokee Indians worked with the North Carolina Division of Public Health and five local health agencies to determine responsibilities during a public health event occurring on tribal land. A memorandum of understanding clarified roles without compromising sovereignty and resulted in clearly defined ways to share tribal, state, and local resources during an emergency.


The 56,698-acre Qualla Boundary (a geographic region next to Great Smoky Mountains National Park in western North Carolina) is home to the Eastern Band of Cherokee Indians (EBCI), and is considered to be ancestral land. More than 8,000 tribal members live on the Qualla Boundary, which spans five North Carolina counties.

The EBCI partners significantly with counties that overlap tribal land and offers an array of services that benefit both enrolled members and nontribal communities. Because the Qualla Boundary borders a national park, the EBCI is active in the tourism industry, and the tribe is the largest employer in western North Carolina. The EBCI also maintains a strong healthcare system and hospital on tribal land.

Specific issues
  • Assets can double as threats. The tribe's resources contribute substantially to the state's tourism industry, and large numbers of people visiting the area each year can be a public health risk. More than 2.2 million people enter the national park through ECBI land annually, and nearly 4 million people visit Harrah's Cherokee Casino each year.
  • Confused jurisdictional roles during public health events. In recent years, areas of the EBCI land have experienced water contamination (2007) and outbreaks of shigellosis (2007) and norovirus (2009). During these incidences, state, county, and tribal officials were unclear as to their response roles on tribal land.
The practice

The EBCI, in collaboration with the North Carolina Division of Public Health and five county health departments, developed a Memorandum of Agreement (MOA) to define and clarify jurisdictional response during a public health emergency.

In 2011, a collaboration involving state and local agencies, the ECBI, and tribal health systems began discussing formal ways that the EBCI and public health agencies could partner during an emergency on tribal land.

The goal of the MOA was threefold:

  1. Define roles in which North Carolina and relevant counties can respond to an emergency on land belonging to a sovereign nation.
  2. Clarify expectations with regard to responsibilities and oversight during an emergency.
  3. Formalize an emergency response partnership between the state, counties, and tribe.

Part of the process to arrive at a formal collaboration involved acknowledging and addressing the following barriers:

  • Confusion and lack of knowledge about the reach of tribal sovereignty during an emergency.
  • Geographic distance between ECBI lands and the state health agency that can make detailed situation monitoring and/or response difficult.
  • Organizational challenges, including defining the roles and responsibilities held by counties, the EBCI, and EBCI health systems during a disaster; personnel changes during the MOA-drafting process that led to loss of institutional memory; and balance of authority between counties and tribal leaders during emergency events that occur on tribal land.

The finished MOA focused on a variety of health emergencies, including communicable disease and chemical, biological, radiological, and nuclear events, along with potential responses, such as environmental health enforcement, investigation, and surveillance.

What made this practice possible?
  • Multi-jurisdictional collaboration between the North Carolina Division of Public Health; local health departments from Cherokee, Graham, Haywood, Jackson, and Swain counties; the ECBI; Cherokee Indian Hospital Authority; Cherokee Health & Medical; and the North Carolina Citizen Corps.
  • Special effort from ECBI's healthcare system, which serves a population of 11,000 people and maintains involvement in regional preparedness activities and public health law.

The MOA had the six following effects on emergency preparedness responsibilities at the tribal, state, and county level:

  • Enhanced state and county understanding of tribal culture and sovereignty.
  • A means to share resources at the state, county, and tribal levels.
  • Clearly defined jurisdictional responsibilities and roles in the event of an emergency.
  • Problem-solving tips for collaborations between the state, counties, and tribe.
  • Documentation of collaboration agreed upon by all groups.
  • Mutually agreed-upon processes that meet public health law requirements.

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