Travel, determination and trust prove crucial for reporting on gaps in rural and reservation health care

When I set out to understand the barriers to health care access in rural and reservation communities in South Dakota in early 2024, all reporting roads led to Sara DeCoteau, a medical administrator in Sisseton who has 50 years of experience working in tribal and community health in rural parts of the state. 

Several other sources told me DeCoteau was a mentor to them, in part because of her kindness and willingness to help others, but mostly due to her vast institutional knowledge and her understanding of the complex equation by which health care is provided — or not provided in some cases — to tribal and rural residents.

Obtaining an interview with DeCoteau, however, was not easy. And the path I took to connecting with her is one of the major lessons learned during my recent fellowship with the USC Center for Health Journalism: That building trust, preparing through research and data collection, being diligent in reporting and traveling to meet sources in person are all key elements of finding the truth on reservations and in remote communities.

The resulting two-part series — “Access to health care limited in SD rural and reservation areas” and “Rural and reservation health providers face major hurdles” — was important in revealing the challenges facing rural health care and in exposing the horrific health disparities faced by many residents of South Dakota. Examples include the fact that urban and non-reservation residents live decades longer on average than tribal residents; infant mortality is four times higher among Indigenous residents compared to white residents of South Dakota; and rates of various cancers are much higher in rural and reservation areas.

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A sign outside a youth center in Lower Brule, South Dakota refers to the goal of health care across South Dakota. The Wani Wacin are people trained to help youths and adults on the Lower Brule Indian Reservation obtain needed medical and behavioral health services.

(Photo by Bart Pfankuch/South Dakota News Watch)

The reporting found several causes for the disparities, which have worsened in recent years. Long travel distances, hospitals and clinics that are open only during daytime hours on weekdays, social determinants of health, and distrust of the system fueled by historical trauma among Native Americans are all barriers that limit access to preventative, emergency and specialist care in rural and reservation areas.

The reporting also looked for potentially replicable solutions to the problem, and I found brights spots within the flawed rural health system that provide hope for the future. Launching mobile clinics, improving health literacy, strengthening public health testing and treatments, and fostering greater cooperation among a patchwork system of providers are all ways to improve access to medical care.

In my work on this project, I drove more than 1,500 miles, spent several nights in rural motels, and visited nearly a dozen reservations and rural communities to better understand how health care functions in those remote regions.

Along the way, I uncovered a fragile health care system that often leads to negative and often preventable health outcomes.

I reported on a Native boy who died due to bad weather but also due to incomplete treatment by Indian Health Services providers. I told the story of how a small financially driven decision to reduce OB-GYN services in a rural area led to a local desert in critical birthing care. I discovered that it took eight months to replace a rural physician who left a rural clinic to be closer to grandchildren. And I found a handful of stories of how health care for individuals was delayed, limited or was cost prohibitive due to the travel needed.

I discovered that in many rural areas, medical care is available only from 8 am to 5 pm on weekdays, requiring those with emergency treatment needs to seek out helicopter service or to rely on rural ambulance services that are facing their own set of financial and regulatory challenges. I also reported on how heavy reliance is placed upon telehealth services that requires internet connectivity that is restricted in some remote communities.

Several of the breakthroughs in understanding the complexity and patchwork nature of the rural and tribal health systems in South Dakota led me back to my interactions with Sara DeCoteau.

In March 2024, I reached DeCoteau by phone, and she said she was too busy to talk. I emailed her a friendly request for an interview and provided both a list of potential questions and some of my bona fides in previous reporting on Indigenous issues. And yet, I couldn’t get through to her.

But that changed when I drove the 400 miles to the IHS medical facility in Sisseton where DeCoteau serves as medical director for the Sisseton-Wahpeton Oyate tribe.

I was allowed entry into the hospital only after receiving permission from the tribal president. Once inside, I strategically arranged an interview with a health provider whose office was across the hall from DeCoteau, and we spoke with the door open so DeCoteau could hear.

That helped break the ice when I finally crossed the hallway and presented myself in DeCoteau’s office. At first, she said she did not want to talk to me because she had been burned in the past by media members who parachuted into her community to report on the dire conditions, and then published articles that were overtly negative in tone and content. I assured her that I was seeking to report on both problems and potential solutions, and I agreed to call her back and run by her all facts and statements I intended to use to ensure accuracy and fairness prior to publication.

After a time, the tension eased, and we spoke for 90 minutes about the history of health care in the area, the current challenges, and about innovative efforts to reach more people, including the recent launch of a mobile health clinic that took two years of administrative planning and funding requests to become viable.

Looking back, the information, background and context provided to me by DeCoteau were critical to my understanding of the issues at hand, and she even let me take a photo.

The lessons other reporters can take away from my experiences is that doing your homework, preparing in advance, remaining diligent in pursuing the best sources, and ultimately meeting people in person are all critical to reporting effectively on sensitive topics with hesitant sources in rural and reservation communities. Travel and in-person interviews are also key to getting the quality documentary photos, video or audio needed to accompany the text and graphics in articles.

It also helps to be genuinely interested in telling a story from all sides and to seek out potential solutions. And, of course, by showing a little kindness and understanding to others along the way.