IHS Testimony on Veterinary Services to Improve Rural Public Health

Good afternoon, Chairman Hurd, Ranking Member Leger Fernandez, and Members of this Subcommittee.  Thank you for the opportunity to submit a Statement for the Record on behalf of the Indian Health Service’s (IHS) with respect to H.R. 8473, the Veterinary Services to Improve Public Health in Rural Communities Act.

The IHS is an agency within the Department of Health and Human Services (Department), and our mission is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives (AI/ANs) to the highest level.  This mission is carried out in partnership with AI/AN Tribal communities through a network of over 600 Federal and Tribal health facilities and 41 Urban Indian Organizations that are located across 37 states and provide health care services to approximately 2.8 million AI/AN people annually.

The IHS was established by statute and is the principal federal health care provider and health advocate for AI/AN people.  The IHS was established to carry out the responsibilities, authorities, and functions of the United States, as provided in federal statutes and treaties to provide health care services to Indians and Indian tribes.  IHS is the 18th largest health care system in the United States.

Background

The Department and the IHS agree that the increase of injuries and zoonotic disease spread by domesticated and wild animals in Indian Country represents a significant public health issue for tribal members in these rural communities.  There are an estimated 70 million stray dogs and cats in the U.S., Tribal Lands, and territories, which contribute to traumatic events and injuries, zoonotic disease spread, and road traffic accidents.  In recent years, free-roaming domestic animals have contributed to rabies outbreaks on Tribal lands, human deaths due to zoonotic diseases, and severe injury and death due to mauling.

The Department is working as a whole through diverse offices and mission areas to address the public health concerns related to zoonotic diseases, including rabies.  The IHS already coordinates with and assists tribes with animal population control efforts to the extent practicable within its authorities.  Additionally, the Centers for Disease Control and Prevention (CDC) and the Commissioned Corps of the United States Public Health Service (USPHS) help to lead Department efforts on the national surveillance of and education about rabies and other zoonotic diseases.

As you may know, appropriated funds to the IHS are used to provide health care to IHS-eligible AI/ANs –– the IHS’ defined service population.  The Department and the IHS have worked hard to prioritize resources provided by Congress to ensure that patients have access to accessible – and affordable – quality care.  The IHS works every day to ensure that limited resources are used wisely to ensure the greatest impact on its defined service population – from direct care services to sanitation and facilities construction, and health care facilities construction.

While it recognizes the importance of this emerging threat to Indian Country, the IHS has to balance its limited resources to deliver direct services to its defined population while combating a number of unique public health issues facing Indian Country, including the fentanyl and opioid crisis, the maternal mortality crisis, domestic and interpersonal violence, and high diabetes rates – to name a few.  The Trump Administration has advocated for additional resources to combat these growing threats in Indian Country and is committed to fighting to reduce health disparities impacting tribal members.

IHS Health Issues Related to Rabies Incidents in Rural Communities

The IHS has examined first-hand and heard directly from tribes about the real public health risk from the high rates of dog bite injuries in AI/AN communities.  Over the past five years, there have been over 200 patients hospitalized from dog bite injuries or attacks at IHS clinics.  The Navajo and Alaska Areas have had the highest number of bites requiring hospitalizations.  During that same period, there were over 24,000 patients receiving ambulatory care from dog bites.  In addition to the Navajo and Alaska Areas, the Great Plains, and Phoenix Areas have had the next highest numbers of bite-related hospitalizations over the last 5 years.

A multitude of challenges have created a perfect storm for risk of injury and disease spread from animals, especially in rural areas.  AI/ANs living on reservations often have little to no access to veterinary care.  Gaps exist in the availability of free rabies vaccines to rural pets, resulting in a higher risk of rabies exposure in humans and animals.  The lack of regular parasite control for pets in these areas has led to an increased risk of exposure to transmissible parasites to human beings.  There is also a lack of access to veterinary spay-neuter surgery to reduce unplanned litters, which has led to an overpopulation of strays and abandoned dogs – thus increasing exposure to disease, parasite infestation, and dog bites.

The Indian Self-Determination and Education Assistance Act (ISDEAA) only authorizes contracts for certain programs prescribed by Congress.  The IHS’ foundational purpose is to provide health care for AI/ANs.  As IHS’ authorizing statutes do not currently convey authority to carry out veterinary services, there is no authority for a tribal health program to add the activity to its ISDEAA agreement.

HHS Public Health Surveillance, Education, and Partnerships

Within their authorities, the IHS, the CDC, and USPHS collaborate in careful coordination with other tribal, federal, state, county, and external partners to reduce the risk of zoonotic disease spread in Indian Country.  The IHS Division of Environmental Health Services staff work on surveillance, training, and capacity building, and have been involved for decades with novel vector borne and zoonotic diseases not previously identified in Indian Country.  This Division has implemented Hantavirus and Rocky Mountain Spotted Fever prevention strategies, conducted arbovirus surveillance and risk reduction strategies, and assisted tribal communities in the development of and adoption of lay vaccinator programs for the rabies virus.  It has also coordinated with outside partners to facilitate the delivery of spay, neuter, and rabies clinics for domestic dogs and cats.  The U.S. Department of Agriculture’s Animal and Plant Inspection Service has collaborated with the IHS Division of Environmental Health Services at the local level as needed on zoonotic disease prevention or risk factor reduction projects.

The CDC collects data on domestic human rabies cases and conducts near real-time animal rabies surveillance in 54 jurisdictions, including Alaska, through the National Rabies Surveillance System.  No Tribal communities have their own rabies laboratories and therefore they rely on relevant state laboratories for all testing.  This may present a barrier to sample collection, testing, and reporting, which further obscures the burden of rabies in these communities.  CDC has conducted several surveillance evaluations to characterize rabies risks in Tribal Lands.  In several high-risk Tribal communities in the southwestern U.S., rabies testing and reporting rates are up to 15-times lower compared to their adjacent non-Tribal communities.

An evaluation of the risk of rabies re-introduction into the U.S. found that the highest risk is in Tribal Lands where free roaming dog populations remain a major public health issue.  The evaluation also found that the Navajo Nation is home to approximately 250,000 free roaming dogs, with many remaining unvaccinated against rabies.  Rabies risk mapping performed by CDC, which considers road connectivity, urbanicity, and human-to-unvaccinated dog ratios found that up to 185,000 unvaccinated dogs likely reside in areas that could support and sustain dog-to-dog transmission of rabies.  This highlights the realistic potential for reintroduction of dog-mediated rabies or spillovers from local rabies reservoir wildlife in the Navajo Nation.  These findings likely reflect similar vulnerabilities in other Tribal Lands across the United States.

H.R. 8473, Veterinary Services to Improve Public Health in Rural Communities Act

The Veterinary Services to Improve Public Health in Rural Communities Act would amend the Indian Health Care Improvement Act to combat zoonotic disease outbreaks and advance public health preparedness for Native communities, Alaska Native villages, or Indian reservations, including by providing spay and neuter services and vaccinations for animals.

Specifically, H.R. 8473 would authorize the Secretary to expend funds for public health veterinary services to prevent and control zoonotic disease infection and transmission in IHS Service areas where the risk for disease occurrence in humans and wildlife is endemic.  The bill would also enable the Secretary to deploy veterinary public health officers from USPHS to IHS Service areas to combat, prevent and control zoonotic disease infection and transmission in IHS Service areas where the risk is endemic.

H.R. 8473, as drafted, would not mandate IHS to carry out these services directly. However, if the IHS does choose to operate a veterinary services program it would likely make these services contractible under ISDEAA.  If contracted under ISDEAA, Tribes may be able to seek the IHS funding the Secretary would have otherwise provided for the operation of the program, which may include funds for a vet’s salary, salaries for support staff, spay/neuter services, equipment and supplies to run its services successfully, etc.  H.R. 8473 does not provide any additional funding for these services, so IHS would have to use its existing appropriations to fund a program.  Additionally, if Congress expressly authorizes the activity, Tribes may be able to use existing redesign and/or rebudgeting authority to fund a program under their ISDEAA contract or compact.

The proposed legislation provides the Secretary the discretion to coordinate and implement activities in providing public health veterinary services under the legislation with the Director of the CDC, and the Secretary of Agriculture.  Further, the bill would require the Secretary of HHS to submit to certain Committees in Congress on a biennial basis, a report on the use of funds, the assignment and deployment of veterinary public health officers from the USPHS, data related to the monitoring and disease surveillance of zoonotic diseases, and related services provided under the proposed legislation.  Finally, H.R. 8473 would amend the Prepare for and Respond to Existing Viruses, Emerging New Threats, and Pandemics Act, to include the Director of the IHS, in the “One Health framework.” 

While the bill would expand IHS authorities to carry out veterinary services, it does not include any additional resources necessary to stand up a new program to ensure that IHS does not have to redirect resources from other important programs, services, or activities.  If the intent is to authorize funding for such activity, drafters may want to consider language to authorize such sums that may be necessary to provide these services in Indian Country.

Controlling the pet population would decrease the incidence of dog bites, which have caused increased injuries and deaths on Tribal Lands.  This bill would potentially limit the incidence and spread of zoonotic diseases and also allow people to walk safely in their communities.  The Department shares the same goal as the drafters – to combat zoonotic disease spreading in IHS Service areas and ensure that tribal members throughout Indian Country are protected with robust public health outbreak prevention.  The Department and IHS are looking to improve response to any zoonotic related disease and improve safety in tribal communities.

We look forward to continuing our work with Congress on improving the health of AI/AN populations including the issues related to this bill.  As always, HHS welcomes the opportunity to provide technical assistance as requested by the Subcommittee or its members.

Thank you again for the opportunity to submit this Statement for the Record. HHS is committed to working closely with tribal communities and other external partners and understands the importance of working together to address the needs of American Indians and Alaska Natives.