North To The Future: Angel Dotomain (B’99) on The Power of Tribal Self-Governance in Healthcare
If you’re trying to get to know Angel Dotomain (B’99), Director of the Indian Health Services (IHS) Alaska Area, she’ll tell you a conversation won’t cut it.
“To know who I am,” she says, “you have to know where I come from.” When you grow up on the lands of Alaska—its beauty and its challenges—the reverberations of each become a distinct part of the lives of the people who call it home.
The Dotomain family—Cup’ik and Inupiaq—grew its roots in the small villages of Alaska. Angel’s grandfather—a reindeer herder and one-time seminary student—married her grandmother in Mekoryuk, and the young couple made their way up the Alaska coast to Shaktoolik, a small Inupiaq village on the west coast of Alaska. Dotomain’s father was born along the way, and the new family settled into the one-street village, quietly adding to its population of just over 200.
When Dotomain was five, her parents moved her and her siblings to Anchorage, but every summer, the Dotomain children headed back to Shaktoolik, to the family fishing camp to spend their days playing outdoors and helping their grandparents fish and collect the berries, greens, and eggs that Alaska offered.
The Dotomains were hard working— Angel’s father, a journeyman electrician, her mother a human resources director. They valued education—the move to Anchorage was an effort to give the Dotomain children an education outside of their rural family village. So when Angel’s acceptance letter to Georgetown came in the spring of 1995, her parents were thrilled for her. But the costs—even with a healthy financial package—would be tough for the family to navigate.
“This is going to strap us, but we’re going to support you however we can,” Angel’s father told her. But that support would come with a few stipulations. “Number one, once you go, you’re there. You are there until you get your degree,” he said. “Number two, you have to pay as much as you can—you have to work while you’re in school and every summer. Number three, you can’t transfer—you can’t drop out. And number four, you must be done in four years.”
Angel shook on it with little thought. But her Georgetown experience didn’t always feel like the dream she had been after. The move was, as Angel puts it, a “culture shock.” More than 4,200 miles away from her family, Angel often thought about the fact that the entire village of Shaktoolik could fit on her dorm floor. For months, Angel would call her dad and beg to come back home—to the indigenous Alaskan people she knew, to the rural village her family called home, to her culture, to her land. “Please just change my ticket. I can’t do this,” she told him. “Bring me home. I’ll go to work.” But her dad’s response, every night: “We shook on it. You gave me your word.”
Years later, Dotomain learned that her father would hang up the phone and sit with her mother while they both cried. Telling their daughter that she couldn’t come home was painful—but they also knew she would be back in four short years with a business degree that could make a difference in her own life—and in the lives of the people around her.
Those summers in Shaktoolik were happy for Dotomain—comfortable, comforting. But as a child, she didn’t always recognize the challenges such communities faced. The rural land of Alaska was giving—especially in those summer months in the more temperate regions—but it could also be terribly harsh. Accidents are one of the top five causes of death among tribal populations. Access to clean water and sanitation and lack of infrastructure are major challenges. Mental health—and resulting substance use and abuse, cancer, and cardiac conditions affect Alaskan tribal populations at much higher rates than those living in the lower 48.
Dotomain can rattle off these stats today. It’s part of her job with the IHS (an agency of the U.S. Department of Health and Human Services) to know the needs of the tribal populations which either govern or participate in the governance of all the healthcare facilities and programs in Alaska. It is also her job to offer all 228 federally recognized Alaska tribes three paths to work with the IHS: one, receive direct services from the IHS; two, assume responsibility for parts of their own healthcare program and facilities with supporting funds from the IHS; or three, supplement and self-fund programs within their own tribes. “We strongly believe that tribes are in the best position to understand the healthcare needs and priorities in their own communities,” says Dotomain.
In Alaska, 99% of the IHS budget is transferred using self-governance agreements made possible through the Indian Self-Determination and Education Assistance Act, which was passed in 1975 to allow tribes autonomy in the governance of their peoples’ healthcare, education, and welfare through contracts and grants with and from the federal government.
“When the IHS alone was running programs, we had kind of a broad worldview of what healthcare needs were,” says Dotomain. “But what’s really great about self-governance is that tribes in specific regions can say, ‘What’s impacting us right now is mental health and behavioral health.’ And they can redirect funds that we give them. Tribes running the programs, and partnering with us, get the opportunity to rebudget, reprogram, and redesign as they see fit.”
Though individual tribe numbers vary, the overall patient population with which Dotomain and her team work consists of nearly 175,000 people and includes IHS-funded,tribally-managed hospitals in seven areas of Alaska, as well as 58 health centers, 160 tribal community health aide clinics, and five residential substance abuse treatment centers.
In some ways, it is a job that only someone like Dotomain can do—someone who grew up fishing and berry-pickpicking with her elders; someone who studied international business at Georgetown and earned a an MBA in health services administration from Alaska Pacific University; someone who knows her way around the cities and villages of Alaska just as well as she knows her way around the business of U.S. healthcare and government. But a larger part of that experience may come in Dotomain’s ability to bridge cultural gaps—that culture shock she first felt at Georgetown is familiar to her fellow indigenous people as they try to navigate a healthcare system once built for the lower 48. Sometimes that bridge comes in the form of a tactical transfer of funds from D.C. to a small village program and sometimes it comes in the form of trust.
To explain, Dotomain tells the story of escorting seventh and eighth-grade kids on a field trip to the Alaska Native Medical Center in one of her early jobs with Alaskan healthcare. As they passed a small lake on the campus teaming with ducks and Canadian geese, a young boy announced to a friend in his Cup’ik language that he would like to wring a duck’s neck to take it home to dinner. Though Dotomain couldn’t speak Cup’ik, she could certainly understand it. When she started to laugh, an elder in the group turned to her. “You’re one of us?” she asked. “I’m glad good people—who are us—are here to run this place.”
Dotomain wasn’t exactly running the place—this early job in Alaska healthcare was just a pit stop on her way to her dream job of working in the Russian oil business for a native corporation in D.C. or New York. But it was in that moment, she says, that she tossed that initial dream aside and decided, instead, to stay right where she was in order to represent her own population in healthcare.
“Once tribal health kind of grabs you, it doesn’t let you go,” she says. “And at that point, I realized I could probably make a difference.”
In COVID the difference that Dotomain and her team at the IHS Alaska Area could make became critical—and it relied heavily on the partnerships she has fostered between the federal government and tribes of Alaska. Just two weeks after assuming her role as director of the IHS Alaska Area, COVID sent Dotomain and her staff home, not just to continue their work, but also to navigate the global health crisis. Like healthcare organizations in the rest of the United States, the IHS’ focus completely shifted to the pandemic: finding PPE; education around this global threat; trying to find the pharmaceuticals to help people who were coming down with COVID.
But unlike most areas of the United States with easy access to water and sanitation infrastructure, the IHS partnered with tribes to get back to basics. “The way you combat COVID is to wash your hands and stay six feet apart from people,” says Dotomain. “But in most of rural Alaska, those things are hard to do. I mean, we had communities who have not had running water… ever. How do you wash your hands with no water?
The mission of the IHS and its tribal partners became building bridges to communities to get them the tools they needed to stay healthy. It also meant education—not just of patient communities about COVID, but of congressional counterparts in D.C. about the needs and challenges of Alaskan native people in a pandemic.
“I had to say to my colleagues: ‘I get that we need to get people to wash their hands, but we’ve got to find a way to make that happen.’” In most cases, the distribution of sanitizer was the answer and continuing the important work of infrastructure around water and sanitation.
“Water and sanitation is a major part of what we do,” says Dotomain. “That’s not something you’re going to find Kaiser doing.” Last year alone Dotomain’s office of 27 negotiated 35 ISDEAA contracts and transferred more than $2 billion to tribes to support COVID efforts and infrastructure projects.
Like many in the United States, the pandemic brought Alaskan people memories of other pandemics. “The Iditarod in Alaska celebrates the transportation of medication from one part of the state to another to save a community from diptheria,” says Dotomain, applauding the Alaskan natives’ resilience and innovation in times of crisis. “The Iditarod was going right through my home community at the time that the COVID pandemic first hit. And the tribal elders made the choice to shut the community and not allow outsiders into the village. They ensured that mushers who were coming through the community had what they needed, but there wasn’t the normal mixing of villagers coming to the checkpoint and having that interaction with mushers and others. But the elders did it, specifically, because of remembering what it was like with the Spanish flu.”
Dotomain watched the resilience and innovation of Alaska tribes again when COVID vaccines were made available.Just as health needs may differ among tribal populations, so too, were the challenges each faced through COVID. “When the vaccine was coming into Alaska there were times where the weather was not cooperating and planes were unable to fly, so our providers were finding different ways to get it where it needed to go,” says Dotomain. “Providers in the Yukon–Kuskokwim Delta were taking vaccines by snow machine and sleds to rural villages because the weather was too bad to fly. And then, in Southeast Alaska, we had an island where they couldn’t float planes into their community because of the weather, so instead, they took the vaccine by boat from their hub community to their island. Today that island has a 90% vaccination rate.”
Dotomain and the IHS could provide the vaccines and the funds, but the work of vaccine distribution was governed by tribes who knew best how to reach their people. The essence and beauty of self-governance was on full display throughout COVID, says Dotomain, just as it was when mushers brought diphtheria antitoxin to the small village in Nome in 1925, and when tribal leaders shut villages to outsiders in the Spanish flu, and when they redistribute funds to build new water tanks in rural areas or establish mental health programming for their people. Dotomain gets to be a partner in it all—and she wouldn’t be anywhere else.
This story was originally featured in the Georgetown Business Fall 2022 Magazine.