Recognizing suicide as a preventable public health problem

• In December 1993, in the midst of a youth suicide epidemic on the Apache reservation, tribal leaders petitioned John Hopkins University (JHU; Baltimore, MD), which had a 15-year history in the community jointly working with the Tribe to eradicate childhood mortality because of infectious diseases, for help to reduce the tragic deaths of many tribal youths.

• In January 1994, a meeting was held at JHU, which kicked off several years of work on the issue.

• JHU public and mental health experts assisted by conducting a quantitative and qualitative analysis of suicides for a 4-year period (1990–1993), which were identified as the “epidemic” years by the Tribal Health Authority (now called the Division of Health) and the Apache Police Department.16

• Between 1994 and 2001, White Mountain Apache Tribe (WMAT) experienced a decrease in suicide deaths. However in the first 6 months of 2001, the WMAT had another spike in suicide, with the deaths of 11 individuals, many of whom were youths.

Determining ongoing surveillance was the best first step of a public health approach

• In January 2001, the Tribal Council established a Suicide Prevention Task Force in response to this public health crisis, now referred to as the Celebrating Life team. It provided its leadership the authority to begin to educate the community and to collect and track data on suicide attempts and deaths—creating a suicide registry or surveillance system.

• Reports were made using a uniform paper intake form adapted from a suicide report form used by the Indian Health Service.

Garnering support among key stakeholders to pass community-based surveillance

• In February 2006, the tribal resolution that required (mandated) all community members to report the suicide ideation, attempt, or death of another community member to the Celebrating Life team was passed.

Maintaining and adapting the system over time

• In 2002, tribal members identified youth suicide as a priority issue for the Native American Research Centers for Health (NARCH) partnership to address during the NARCH III grant submission period (submitted June 2003, funded September 2004). Two of the goals of the grant were to computerize the surveillance system and expand the variables collected.

• In 2006, tribal stakeholders added the in-person follow-up and referral process. In addition, they expanded the surveillance system to include NSSI because many incidents originally reported as “attempts” were subsequently identified as nonsuicidal self-injury (NSSI) by the Celebrating Life team after direct follow-up with individuals.

• In 2010, binge substance use was added as discreet reportable behaviors with or without co-occurrence of other forms of self-injury because the follow-up process also identified that substance abuse was frequently co-occurring with intentional self-injury.