By Alyssa Virtue

Cindy Gamble, MPH, is Tlingit of the Eagle Moiety, and a member of the Kaax’oos Hit Taan (Man’s Foot Clan.) Currently, she is a public health consultant for the American Indian Health Commission for Washington State focusing on maternal and infant health. Throughout her career, she has worked on the front line of health and healthcare in rural Tribal communities as a health director and community health educator in Alaska and Washington.

  1. What is the biggest obstacle when it comes to achieving health equity?

The first biggest obstacle is the complexity of the social determinants of health for each different racial and ethnic group. When we talk about Tribes, there are currently 567 recognized Tribes in the US and 29 recognized tribes here in Washington State…each tribe has a different language, religious practice, history and Tribal beliefs. When you look at that and want to do something it just gets really complex.

Another obstacle is the funding structure and how it was not there to really do more than a Band-Aid solution. In the past, founders wanted to apply a program that worked for one population to another group and when that didn’t work, people would get discouraged. Hopefully, that view point is changing now, and it is understood that different racial and ethnic groups require different solutions.

Another obstacle is that we know it is going to take much longer than anyone ever dreamed to develop trusting relationships now that we understand the manifestations of Adverse Childhood Experiences (ACEs), historical and intergenerational trauma, and ongoing discrimination. Even though people care about AI/AN people and have good intentions, our people have been betrayed and burned again and again. How many hundreds of years have some people (Tribes) gone through this? Will it take an equal amount of time to build the trusting relationships where we can really open up and freely, trustingly and wholeheartedly try to connect and talk with people and say ‘Yes, we do have some ideas that can help, and here they are and this is what we think can happen’?

Another obstacle is that speaking on behalf of American Indian/Alaskan Native (AI/AN) people, is that non-native people don’t understand us. They make assumptions about what “should” happen and how people “should” react. When AI/AN’s don’t comply with this stereotypical view, people get really frustrated and they don’t understand. A young native man I once interviewed said he felt that people think of AI/AN as extinct, that really our place in history was several hundred years ago, and that modern native people don’t match expectations of what native people “should” be.  I think it’s hard for non-native people to realize that.

Another piece is that people may feel guilty when they do think about the AI/AN story, or because they believe that the discriminatory practices happened a long time ago, they distance themselves from that whole experience or taking any responsibility for things that may be happening today.

One of the most important things is for people to acknowledge there are obstacles. Then you’re going to ask what are the obstacles and how can we get around them? If it’s sincere and people really want to know the answer to that question, then things can happen.

  1. Is there something you see about health equity that you feel others are not noticing or paying enough attention to?

We need to look at where the highest disparities are and have additional programs and funding go there. An example is a disparity in infant mortality rates of AI/AN being twice that the rest of the population. My public health training says the people in the neighborhood/community are the experts on what is going on in their community. I don’t know that we really utilize that knowledge and expertise enough.

One of the things that has been really frustrating in my past work life has been the structure of funding. Funding is always two, three, or five years, and honestly, can you really make significant behavior change within that amount of time? Then when you are looking at populations who have issues of trust, Adverse Childhood Experiences (ACEs), and historical discrimination, they are just not working at the highest performing, vibrant, trusting level and there must be an understanding that it’s going to take longer for work to happen in those communities. For example, seeing funding get pulled right when we are beginning to gain traction on a project is heartbreaking.  Our partners—people who live in the community- have trusted the process, have trusted us, and are a part of the team. They have gone to the community and have said ‘Yes, this is going to be a good thing.’ They put themselves out there, and then we pull the project. And then what does that do? It causes more distrust and people feeling betrayed and burned once again, and that’s a really big problem.


  1. What does your work mean to you? Why is it important? How does it connect to health equity?

In the twenty plus years that I was working as a health educator and Tribal Health Director on Prince Wales Island, my home country, I could see a change. I could see that people were very happy to have someone of their own background there. When its people from your community who are doing the public health work it has a whole different effect and impact. People listen to you differently. I would be in the office with a community family service worker who offers drug and alcohol counseling and when she had someone who wouldn’t show up for an appointment, she wouldn’t say, “oh well, non-compliant patient, write them up; they’re going to miss two and we’re going to kick them out.” No, she got on the phone and called them and said, “What are you doing, you’re missing your appointment…Well jump in the shower and get over here, I’m waiting for you.” She wouldn’t give up on them and they weren’t going to be a statistic for her.

My work was really to be a member of that community. Among AI/AN people we say, “it’s hardest to work for your own community,” probably because there are a lot of expectations. The community knows you, knew you when you were a kid, but they’re also very proud of you. It was important for me to work for my community because of the stories I knew of my family, of the people who died, who got cancer, who had lost their teeth. All these things happened because there was a break in culture and traditional knowledge didn’t come down to that next generation. There was discouragement because when you don’t have your language and your traditions, you are a little bit adrift. I think one of the most important things I did was to assist people to make healthier decisions, figure out how to be healthy within our culture, and to really believe in people; to never give up on them.

I have also learned to not believe in the concept of community readiness. We need to reach out to people and not just say, ‘Well, they weren’t ready’ if they don’t show up to our program. Instead, we need to engage people and see why they’re not participating in a health intervention; we need to reach out.

All of this connects to health equity because we have to advocate for ourselves and build resilience wherever we can. Part of this process is affirming that our ways, our people, are smart, important, and have expertise in all these things.

  1. What advice would you give to someone like me just entering the field?

First, I believe that health touches everything and everything touches health. We can be involved in almost anything and it would be under public health. Therefore, we must promote the importance of public health and what health means. You must also walk your talk for people to trust you and believe you.

Second, be clear what your intentions are about working with other ethnicities/races because if you are coming in to save us [i.e. the missionary complex], that’s not what we need; that’s keeping us under a thumb. We need partners, we need people who can support us, who can talk about our issues, and advocate for change instead of just these Band-Aid fixes. People really respond to that and appreciate it, but a lot has to do with how you come in to a community and how you approach them.

Third, respect is one of the paramount values for everybody- respect for self, others, elders, Mother Nature —those things are really important. We can see when people really respect us or they’re just ‘yessing us along’ or there’s not that true acceptance of equality and equity. I think people can work with communities of different race, ethnicity, socio-economic status, etc.

The issue is: how do you approach them? What are your intentions? What do you feel your part of the work is?

Overall, there’s a lot of work to do, and we need to start talking about it. That’s why I really love what happened with Standing Rock because people came together from all around the world to stand with the Standing Rock Tribe and showed that they care about clean water. It really is a very exciting time to be a young public health professional because of everything we’ve done and what we know now. You can be a part of real change.

Alyssa Virtue, a Master of Public Health Candidate at the University of Washington and a graduate fellow at Foundation for Healthy Generations. View LinkedIn Profile