2010-01-19 / Headlines

Indian health care: 'Historic failure'

Native Americans face long waits, rushed doctors, questionable care
by Steve Young - Part one in a series Argus Leader
ST. FRANCIS Cleveland Kills In Sight fears the night.

He fears the nightmare that visits him in the darkness of his St. Francis apart ment, bringing with it the terror of a morning two months ago when he lay in his hospital bed and a doctor pressed her fingers against his nose, trying to stop his breathing.

Trying, the 72 year old Lakota elder says, to end his life. "We're trying to get him to a counselor," Kills In Sight's son, Umpo, says of his father. "He's been having a lot of dreams, nightmares, about that woman."

On the Rosebud reservation in south central South Dakota, the story of an In dian Health Service doctor who allegedly suffered a mental breakdown and attacked Cleveland Kills In Sight in his room at the Rosebud Comprehensive Health Care Facility is well known.

But just as troubling to the 29,000 people living on the Rosebud indeed, to the 120,000 Native Americans in North Dakota, South Dakota, Iowa and Nebraska who fall under the umbrella of care of Indian Health Service's regional officein Aberdeen is that too many have horror stories such as Kills In Sight's.

They're written in the chronic under funding of IHS, and in its regulation heavy bureaucracy both of which give rise to the sobering fact that at 1,642 per 100,000 people, the death rate for Na tive Americans in South Dakota is the highest of any race or ethnic group in the U.S., according to 2007 Centers for Disease Control and Prevention numbers.

Here and across America, tribal people know they must be dying or about to lose a limb to get serious care. Otherwise, their stories are of rushed providers failing to test them for potentially fatal dis eases despite obvious symptoms, long waits in clinics without ever being seen, and credit ratings ruined when IHS makes referrals to specialists but then doesn't pay for the care.

"To me," said Tommy Thompson, emergency manager for the Crow Creek Sioux Tribe, "it seems like they're hell bent to provide the cheapest possible health care at the expense of our peo ple."

It's not supposed to be that way. When the tribes ceded their lands to the white man centuries ago, the government promised as it did in Article XIII of the 1868 Fort Laramie Treaty "to furnish annually to the Indians the physician, teachers, carpenter, miller, engineer, farmer and blacksmiths. ... and such ap propriations shall be made from time to time ... as will be sufficient to employ such persons."

The white man didn't keep his word, tribal people say, creating instead ar guably the closest thing this country has to a single payer public option what Health and Human Services Secretary Kathleen Sebelius also calls "a historic failure."

Democratic Sen. Byron Dorgan of North Dakota, chairman of the Senate Indian Affairs Committee, went even further in a committee hearing this month.

"We have a population in this country that are recipients of full scale health care rationing, which I find abominable, especially since the government has made a written promise," Dorgan said. In Washington, D.C., President Obama is promising to do better. His 2010 budget for federal Indian Health Serv ices includes an additional $454 million, or a 13 percent increase, over this year's $3.3 billion budget. Within the $500 million in stimulus money IHS has re ceived for construction, repairs and equipment is money to help pay for a $111 million health center in Eagle Butte. And Congress, wrangling over national health care reform, seems poised to enact sweeping improvements that would apply standards to ensure the modernization and improvement of health care in Indian Country.

"When you look at the disparities" in health care for Indian versus white America, said Rep. Stephanie Herseth Sandlin, D S.D., "and you look at what we spend per capita for each group, and what we've found in fraud abuse within the Indian health system that's been un covered, the opportunity is right for digging ourselves out of this hole."

The dynamics of reservation life make that a daunting proposition. Especially in the rural, isolated Indian Country of western and central South Dakota, ex treme poverty and joblessness breed malnutrition, alcoholism and chronic illness, which in turn create crime, acci dents and disease.

According to the National Institutes of Health, Native Americans are 510 per cent more likely to die of alcoholism than the general population, 189 percent more likely to die of diabetes, 229 per cent more likely to die of motor vehicle crashes, and 600 percent more likely to e of tuberculo


Dr. Jeff Hender son, an internal medicine doctor who runs the Black Hills Center for American In dian Health in Rapid City, said if poverty and health disparity on South Dakota's reservations ex isted in every other state, "I would think that ... in at least half of those states, or at least a third,

ople would be tting their minds and hearts together to say: 'Enough is enough. This is a black mark, a scourge on our reputation, and we're going to do something about it.' "

"But we haven't heard that kind of di alogue from our legislative leadership," Henderson, enrolled in the Cheyenne River Sioux Tribe, continued. "And we haven't heard it from the citizenship." That doesn't mean the dialogue is silent. From building bike paths and planting gardens on the reservations to bringing in mobile examination rooms, efforts to bridge health disparities for native peo ple are ongoing across South Dakota and include state, private and nonprofit partners.

But the inherent shortcomings of the Indian Health Service remain, namely: • High vacancy rates of health care providers on the reservations. • A lack of specialists, resulting in ra tioned care and often ruined credit as patients are referred off reservation. • The uneven collection of third party reimbursements such as Medicaid and Medicare that creates inequities in IHS service unit budgets. • IHS mismanagement that has resulted in almost $20 million in lost or stolen property in the past five years. • Burdensome federal rules that make it difficultto bring in visionary and inno vative leadership, or to get rid of do nothing bureaucrats.

Horrifying night highlights scarcity of good medical help

All of which meant nothing to Cleve land Kills In Sight as he checked into the Rosebud IHS hospital Oct. 16 for yet an other bout of pneumonia. His second night there, he said, he became aware of a woman doctor entering his room and staring at him. He thought she just was making her rounds. But as night turned into the next day, she began behaving more erratically, Kills In Sight said. She would stand by his bed, looking at him. Then she'd stare out the window, or pace the floor in his room.

"She sat down on my bed beside me and started crying," he said. "I asked her what was wrong. She didn't answer me. She touched my forehead, then put her hands around my neck and started pushing her thumbs into my throat." he same time, she jabbed her fingers into the sides of his nose to cut off his air, Kills In Sight said. He managed to push her hands away and hit the call button. When the nurses came in and advised the doc tor to leave, she sim ply threw a tablet on the foot of his bed and "was crying, re ally loud," Kills In Sight said. Later, after security had escorted the doc tor out of the room, Umpo Kills In Sight said he was told by two physicians at the hospital that the woman was mentally ill and was being take p

Earl Cournoyer, chief executive officer at the Rosebud IHS hospital, would not respond to the Kills In Sight incident, citing patient privacy. But Lenard Wright, a tribal council member from Rosebud who sits on a tribal health board that works with the hospital in Rosebud, said he was told by IHS offi cials that the doctor had been removed and would not be returning.

The family is considering a lawsuit.

In many ways, the story typifies a common complaint on the reservations

that the difficultyin luring high qual ity health care providers often results in questionable hires. That seemed especially true years ago, said Emil Red Fish, an enrolled member of the Rosebud tribe who worked at the IHS facility in Rosebud in the late 1970s. Red Fish, who is a physician's assistant in Arlington today and mayor of that community, remembers two Filipino doctors hired at Rosebud who "could not get licensed in the U.S., period. So they were hiding in the government sys tem. We got them into our budget by classifying them as medical supplies."

In a system where physicians don't want to live on reservations but will contract to provide their services for a few days or a few weeks at a time, all manner of good and bad physicians passed through, Red Fish said.

"The one I remember the most is a psychiatrist who came from Florida for a week," he said. "He hadn't practiced in I don't know how many years. But he needed to make some money for a new sail on his sailboat."

Tighter restrictions help but also cur tail timely hires

Perhaps because of those issues, IHS has tightened its background checks and credentials process for physicians. But that creates its own problems, notably the ability to hire quality doctors and nurses in a timely fashion. Medical di rectors complain that the hiring process can take six to nine months. By then, health care providers who might have come to the reservations have signed on somewhere else.

Inevitably, the patchwork that in cludes a few permanent doctors and the changing faces of contracted physicians and nurses leads to the kind of distrust with which Christy Red Bird of Spring Creek on the Rose

d Reservation

w views IHS.

She went to the Rosebud hospital Aug. 31 to have her gall bladder re moved. Within the next week, she said her stomach had bloated, the skin around her belly button was turning dark red to black, and she was on her way to the Sanford USD Medical Center in Sioux Falls for surgery on a cut in her intestine that apparently had oc

urred during the g p n.

"The doctor at Sanford said I had made it just in time," Red Bird, 31, said. "All that stuff had been leaking into me from my intestine. I could have died. Now, if I didn't have to go back to the Rosebud hospital, I wouldn't."

Red Bird said she now will be suscep tible to infections and hernias the rest of her life. IHS officials did not respond to a query about her case.

Charlene Red Thunder, director of In dian Health Service's Aberdeen Area of fice, does say she stands behind the the quality of doctors, nurses and others at her area's seven hospitals, eight health centers and various satellite stations and the care they provide.

The fact is, her region's total recurring budget of $292.3 million is about half of what is needed, Red Thunder said. That means there are health services tribal people receive that IHS can't pay for. That means rationed care decisions are made.

"And I understand that it's very frus trating for us as Indian people to see that," she said. "But If there is no money, we can't obligate something we don't have the funds for. Those are just the guidelines we have to adhere to."

In other words, they have to play by the rules the government sets down, Red Thunder said, and the nightmares that potentially come with it.

At least until Congress and the federal government say otherwise.

But the inherent shortcomings of the Indian Health Service remain, namely:

High vacancy rates of health care providers on the reservations.

A lack of specialists, resulting in rationed care and often ruined credit as patients are referred off-reservation.

The uneven collection of third-party reimbursements such as Medicaid and Medicare that creates inequities in IHS service unit budgets.

IHS mismanagement that has resulted in almost $20 million in lost or stolen property in the past five years.

Burdensome federal rules that make it difficultto bring in visionary and innovative leadership, or to get rid of do-nothing bureaucrats.

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