Stories From the Field:

GLOBAL PRIMARY CARE

Global Primary Care Allies with the Rosebud and Pine Ridge Lakota

Dr. Matthew Tobey, a senior resident in the Massachusetts General Hospital Global Primary Care (GPC) Program, spent four weeks in South Dakota building partnerships and assessing possible avenues of collaboration between Mass General and the Indian Health Service (IHS).

The Setting

On July 4th, after an Independence Day ceremony bursting with clever barbs at the U.S. government, the sun dance ceremonies in Rosebud, South Dakota commenced at a powwow, or tribal gathering. For the next four hours, children from age three to their late teens danced in traditional garb as their elders’ voices quavered the ancient songs, their melodies and drums amplified for the crowd of hundreds. A squadron of judges circulated, and almost every event ended in a friendly tie. The festivities kept on into the night.

The next day, on July 5th, in 100-degree temperatures, another day of the ancient and sacred sun dance commenced in a remote field. The dance is one of the tribe’s most sacred ceremonies, beginning around the solstice and ripe with symbolism and significance. In the dance that I watched, empty chairs sat in the dancing circle to commemorate tragic deaths from the past year: suicides, accidents, overdoses. Over a dozen chairs sat draped with blankets and covered with tokens from the individuals’ lives. The songs and dances represented prayers for those lost friends and family, for healing, and for the safety of others.

The Problem

In the 1870s, Native American tribes dwelled in South Dakota’s Black Hills, a picturesque and fertile area which is now a hub of tourism. Ultimately, when a gold rush brought prospectors, the U.S. government authorized a forcible removal of the tribes. After a war, the tribes agreed to move to the reservations where they dwell today. In exchange, the U.S. offered guarantees of health care, food and education. These tribes—Lakota is their name, though they are known widely as Sioux—have garnered fame for their pride, resilience and rich traditions. With a piercing look, they often ask visitors if they think our government has delivered upon its guarantees. There is no question. It has not.

South Dakota holds four of the five poorest counties in the United States, each part of a Native American reservation. The land is comprised of grasslands too dusty to farm and, as a result, unemployment rates top 80%. Epidemics rage - metabolic disease, depression, suicide and alcohol abuse.
There are hard truths in South Dakota. Two examples speak worlds:

  1. In 2009, Rosebud tribal president Rodney Bordeaux declared a state of emergency. A spate of suicides had driven the community’s suicide rate to among the highest in the world. Many of the victims were recent high school graduates. The themes of their lives were stark: lack of prospects; physical and sexual abuse; living in a milieu of substance dependence; unmet mental health needs.
  2. White Clay, Nebraska sits on the border of the Pine Ridge reservation and boasts a population of 20. In 2010, it generated more than $450,000 in sales tax. Its business? Alcohol. Alcoholic beverages have been prohibited from Pine Ridge for over a century. Its people drive across the border to White Clay and purchase a staggering 13,000 cans of beer a day. Crosses commemorating automobile fatalities dot the nearby roads. Despite an award-winning documentary, intense press coverage, and a recent lawsuit, White Clay keeps on.

How can this be turned around? Excellent health care could prove an important start. But, perhaps not surprisingly, the reservations are home to the Indian Health Service’s (IHS) worst health outcomes. Burnout and remoteness gut the hospitals and clinics of their staff. Little exists to entice leaders and physicians here instead of to IHS’s many better-performing and more comfortable posts. The result is what the IHS considers “the worst of the worst,” and a health system that a recent U.S. Senate investigation described as in “a constant state of crisis.”

The Response

IHS leadership, constrained by legislated barriers, has found one way forward through building academic connections. IHS hospitals and clinics stand to benefit deeply from academic centers’ intellectual capital, motivation to overcome barriers, and wider provider recruitment. In exchange, the sites offer a powerful experience for students and residents.
As part of this initiative, last year I had the opportunity to visit the Pine Ridge and Rosebud reservations in southwestern South Dakota with Susan Karol, the Chief Medical Officer of IHS, Dennis Norman, faculty chair of the Harvard University Native American Program, and Patrick Lee, founding director of the Mass General Global Primary Care Program. I remained afterward to explore possible means of collaboration, resulting in the development of a case for the GPC Curriculum and an elective experience for Mass General residents. 

The Global Primary Care Curriculum

In February 2013, Drs. Karol and Norman joined me in teaching a collaborative case study on Lakota health care that we co-authored. The case served as part of Mass General’s Global Primary Care Curriculum, which examines diverse health systems domestically and abroad. We hope to publish this work, as there are few similar educational tools, and to continue using it to teach interested interns.

Away Elective in Native American Health

In order to continue to develop a strong relationship between IHS and Mass General, we are working to develop an away rotation for internal medicine residents. Mass General’s residency program stands to benefit greatly from an experience so unlike those offered in Boston, and eager residents may prove to have much to offer the Lakota people.

Future Directions

The mutual interest in a collaboration between Mass General, IHS and the Lakota people appears to run deep. Harnessing that excitement into meaningful work is the challenge left to me and the GPC program. With time, mutual understanding, and dedication, perhaps a rich partnership will grow, connecting Mass General to a place where—it’s generally agreed—the only thing that’s infertile is the soil.