Building a healthy Navajo Nation
Healthy Diné Nation Act proves tribal sovereign nations can drive their own health policy
In an unprecedented move eight years ago, the Navajo Nation created the first-ever tax in the U.S. that supports health promotion and disease prevention through a law that collects a 2 percent tax on foods with little to no nutritional value and removes the 5 percent tax on fruits, vegetables and water.
Funding from the tax, which amounts to about $1.8 million annually, is given to the 110 Navajo communities, called chapters, to develop wellness programs, with 20 percent of the funding given to the Navajo Nation Permanent Trust, Veterans Trust, Land Acquisition Fund, and Tax Suspense Fund.
After evaluating the tax revenue and the funding disbursement of the Healthy Diné Nation Act (HDNA) through a Navajo-specific Behavioral Risk Factor Surveillance System Survey, a multidisciplinary team of researchers found that the success of the tax proves that sovereign tribal nations can drive their own health policy and use existing data sources and tribal-specific data to evaluate an intervention’s likelihood for success, implementation and impact.
They published their findings in Preventing Chronic Disease in an implementation evaluation titled “Practicing Tribal Sovereignty Through a Tribal Health Policy: Implementation of the Healthy Diné Nation Act on the Navajo Nation.”
The researchers are a multidisciplinary mix of medical doctors, professors, and community officials from Northern Arizona University, the University of Arizona, the Navajo Epidemiology Center, the Navajo Department of Health, the Diné Food Sovereignty Alliance, Brigham and Women’s Hospital in Boston, and the Navajo Division of Community Development.
A sovereign nation strives for hózhó
With more than 400,000 enrolled tribal members, the Navajo Nation covers 27,000 square miles that span across four states—Arizona, Colorado, New Mexico and Utah. It is separated into five regions called agencies and is organized into chapters.
The Navajo population has endured forced assimilation, removal from their tribal homelands and relocation to reservation lands due to colonization, which interrupted their access to nutritious foods that they once produced through farming, herding, hunting and gathering.
Poverty, unemployment, lack of transportation and living in remote areas with few grocery stores have also contributed to a lack of healthy food access. The results have been a reliance on process foods high in fat, sugar and salt that have led to preventable nutrition-related diseases such as obesity, diabetes, heart disease and cancer.
Through the HDNA, the Navajo Nation is working to restore hózhó, a holistic health and wellness, for its people. It also has its own Navajo Epidemiology Center that manages its public health data. Through the center, the Navajo Nation was able to monitor and conduct its own survey to evaluate the HDNA and produce a report of its findings, which allowed the nation to determine the success of the tax in order to adopt it permanently in 2020.
Using taxes to fund wellness activities
One of the results of their HDNA research that the lead author, Regina Eddie, found encouraging was the successful distribution of the HDNA tax revenue to chapters across the Navajo Nation, where receiving the funds was contingent upon them first submitting community wellness project proposals to the Navajo Division of Community Development.
“In some aspects, this shows local communities and chapters have taken action and assembled a proposed plan on ways to promote wellness within their communities, said Eddie, assistant professor, NAU School of Nursing. “Of the proposed projects, it was not surprising that nearly 40 percent of the projects sought to enhance the built environment, when in fact many communities need infrastructure investments to support healthy living.”
The most proposed activities across chapters include community food and water initiatives, such as farming and vegetable gardens; equipment purchases; wellness instruction, such as fitness classes; and funds for a built recreational environment, such as walking trails, basketball courts, parks and playgrounds. Between 2016-2018, chapters submitted approximately 1,000 proposed projects.
Working with a diverse research team
The publication authors also included Caleigh Curley, research specialist, NAU Department of Health Sciences; Del Yazzie, Navajo Epidemiology Center, Navajo Department of Health; Simental Francisco, project manager, Navajo Epidemiology Center, Navajo Department of Health Window Rock, Arizona; Ramona Antone-Nez, director, Navajo Epidemiology Center, Navajo Department of Health, Window Rock, Arizona; Gloria Ann Begay, executive director, Diné Food Sovereignty Alliance, Gallup, New Mexico; Priscilla R. Sanderson, professor, NAU Department of Health Sciences; Carmen George, project manager, Brigham and Women’s Hospital, Boston, Massachusetts; Sonya Shin, infectious disease physician, Brigham and Women’s Hospital, Boston, Massachusetts; Shirleen Jumbo-Rintila, legislative associate, Navajo Division of Community Development, Window Rock, Arizona; Nicolette Teufel-Shone, associate director, Center for Health Equity Research, professor, NAU Department of Health Sciences; Regents’ professor Julie Baldwin, director of CHER; and Hendrik “Dirk” de Heer, professor, NAU Department of Health Sciences.
Eddie said that the key to their successful evaluation work is the close collaborative relations among the research team.
“Our team consists of colleagues from different disciplines with varied experiences and expertise who were each valued and respected,” Eddie said. “While tribal and community partners guided the research, sharing their deep knowledge and insights of community and cultural protocols, academic partners mutually shared their research expertise, which included mentorship of junior faculty and students to help in the efforts to build research and community capacity.”
“As a team, I believe we shared the common goal to help and support the Navajo Nation, the first sovereign nation to exercise its self-determination authority to promote tribal health sovereignty,” Eddie said. “Our work focused on gathering and producing evaluation data for the tribe to use to inform tribal policymaking using existing tribal data and producing new research data.”
Eddie said she is interested in future research working on the HDNA and expanding on community- and chapter-level work with an emphasis on supporting effective community wellness programming.
For more information, read a recent feature in the National Institute on Minority Health and Health Disparities, NIMHD Insights feature, “A Partnership Between Researchers and the Navajo Nation to Study a Junk Food Tax.”
This research was supported in part by an NIMHD center grant to the Southwest Health Equity Research Collaborative at Northern Arizona University (U54MD012388).