The magazine of the UW School of Public Health

Protecting Health: Government to Government

Thomas Locke

In January 2010, the elected representatives of seven federally recognized American Indian tribes and three Washington State county public health jurisdictions (see below) entered into a historic public health agreement. This agreement created a detailed framework for sharing resources and expertise in a public health emergency.

Early Efforts

In 1994, Washington State published the first of its biennial Public Health Improvement Plans (PHIP) as part of a fundamental reorganization of its public health system. The plan envisioned three types of public health jurisdictions: state, local, and tribal. There was broad agreement that tribes, as sovereign governments, had the same public health authority and responsibility as neighboring county governments. Yet early efforts to turn the vision of fully functioning tribal health jurisdictions into reality were hampered by a number of unresolved issues. These issues included the applicability of state and local public health codes within tribal jurisdictions, resolution of disputes between county and tribal governments, and mechanisms for dealing with financial and professional liability concerns.

Since 2001, the capacity of public health to respond to a bioterrorist event, global pandemic, or other large-scale health emergency has become a national priority. Multi-year appropriations have allowed a significant expansion in the ability of state, local, and tribal governments to improve their response capabilities. This investment in public health capacity has created new opportunities for partnership building with tribal governments.

A Partnership Begins

In 2008, the health officers of Region 2 (Clallam, Jefferson, and Kitsap Counties) of Washington State’s Public Health Emergency Preparedness and Response system decided the time was right for a major effort to engage the seven tribes that shared boundaries with their respective counties. The health officers submitted a proposal to develop a first-of-its-kind mutual assistance agreement (MAA) involving tribes and local governments. The project was approved with facilitation support from the Washington State Department of Health and funding from the US Department of Health and Human Services Assistant Secretary for Preparedness and Response as well as the Centers for Disease Control and Prevention.

To start, project leaders recruited a skilled facilitator with experience in developing county-to-county mutual assistance agreements. The next step was to contact each tribal chairperson and seek his or her support for the project. The strong support of tribal leaders and the appointments of trusted tribal representatives to negotiate the agreement were essential to the success of the project. It was also important that county commissioners and local boards of health supported the project. To remove any logistical obstacles to participation, MAA partners received direct support from grant funds to pay for staff time, travel, and other costs associated with the effort.

Another key strategy was to identify legal issues that had derailed past partnerships. The MAA partners agreed that the worst time to resolve questions of authority, financial responsibility, and legal liability would be during an actual emergency. The need for advance clarity about these issues helped to guide the drafting of the MAA. 

The drafting process took most of  a year. Meeting sites rotated among the facilities of the participating organizations, including the remote tribal villages of LaPush and Neah Bay. Once the core agreement took form, tribal and county attorneys were invited to comment on key provisions of the draft agreement.

Key Issues

Among the issues the MAA addressed was the question of how public health officials would exercise necessary emergency authority within a neighboring tribal health jurisdiction. This authority could include isolation and quarantine, testing and treatment of certain communicable diseases, and supervision of health care workers. While tribes were encouraged to develop public health expertise, the group agreed that in a major public health emergency, it would be desirable to access the expertise of county health officers from neighboring jurisdictions.

For tribes with a public health code, the tribal council would grant the local health officer of the neighboring county the authority to enforce those regulations. For tribes that lacked a public health code, the tribal council was given the option of adopting relevant federal, state, or local public health laws during the emergency.

To address potential future disputes that might occur during or after an emergency response, the MAA created a dispute resolution process based on direct communication, mediation, and binding arbitration. This binding arbitration would be enforceable by tribal, state, or federal courts. In adopting this dispute resolution framework, tribes signing the MAA agreed to a limited waiver of sovereign immunity.

During the fall of 2009, the agreement was presented to tribal councils, local boards of health, and county commissioners. Support for the goals of the agreement was unanimous, and participating public health jurisdictions signed onto the agreement.

The MAA in Action

In the summer of 2010, the Makah tribe hosted an event known as Tribal Journeys. At this event, thousands of tribal members from Washington State and British Columbia travelled by canoe to the small coastal village of Neah Bay to take part in a week of traditional activities. The dramatic population increase this caused had the potential to overwhelm the fragile sanitation infrastructure of the village. The Makah tribe responded to this potential health threat by setting up an incident command system and activating the recently adopted MAA with neighboring Clallam County. A public health nurse and two environmental health specialists from Clallam County were dispatched to assist the tribe identify and rapidly respond to public health threats. The local health jurisdictions of Jefferson and Kitsap County were also on call to contribute resources should a large scale outbreak response be needed. Tribal Journeys 2010 went off without a hitch. Participants stayed healthy and tribal and local health jurisdictions gained valuable experience in government-to-government cooperation. In addition to this initial activation of the MAA, tabletop exercises were conducted at four of the participating tribal reservations to practice implementation of the agreement during a simulated measles outbreak.

Future Challenges

The concept of a fully functional tribal health jurisdiction continues to evolve, and with this evolution will come new challenges and opportunities. In addition, local and state governments are profoundly shaped by ongoing budget crises and significant workforce layoffs. As public health jurisdictions reorganize for an uncertain future, the case for expanded multi-jurisdictional partnerships grows more compelling and urgent. It is hoped that the MAA forged by the 10 public health jurisdictions of northwestern Washington will serve as a model for other tribal and county governments as they struggle to maintain their capacity to respond to public health emergencies.

MAA Members:

  • Hoh Tribe
  • Jamestown S’Klallam Tribe
  • Lower Elwha Klallam Tribe
  • Makah Tribe
  • Port Gamble S’Klallam Tribe
  • Quileute Tribe
  • Suquamish Tribe
  • Kitsap County Public Health District
  • Clallam County Department of Health and Human Services
  • Jefferson County Public Health


Thomas Locke MD, MPH, is the Health Officer for Clallam and Jefferson Counties. 


  1. The complete MAA document is available for review at the CDC Public Health Law Program’s Mutual Aid web page:
  2. More information about Tribal Journeys 2010 (