What we learned reporting on dangerously bad care on the reservation

A 12-year-old South Dakota girl attempted to hang herself after she was left alone in an emergency room, using her broken call-light cord and her shoelaces.

Doctors in the same emergency room restrained and pepper-sprayed a man overdosing on meth, which caused a fatal heart attack.

These two findings came from a federal health inspector’s report of a federal hospital in August. Taken alone, the report was shocking. But in the context of the Rosebud Indian Health Service hospital’s history of misdiagnoses and inadequate care, it wasn’t surprising.

The hospital and other Indian Health Service (HIS) facilities in the Great Plains have failed patients for decades. And there’s a long track record of federal inspectors citing them for struggling to meet the most basic requirements for care.

Three years ago, I read a report that many thought would be rock bottom for the rural hospital. Inspectors found that a baby had been born on the bathroom floor, and surgical instruments were washed by hand for months after a sterilizer broke.

Hospital administrators shuttered the emergency room for seven months and said they’d work to improve conditions. Meanwhile, tribal members died in the backs of ambulances on the way to hospitals 50 miles away.

While patients in other parts of the country could go to another facility for care, for many on the Rosebud and Pine Ridge reservations in South Dakota, that’s not an option. Both are in extremely rural areas with few medical providers. And federally enrolled tribal members who don’t have private insurance or enough money to cover treatment don’t have another choice.

Although top IHS leaders came to the state in 2016 and vowed to make improvements and tribal leaders and health advocates traveled to Washington, D.C., to make their case, little changed.

While reporters for years had written about the damning reports and the deplorable conditions at the Rosebud and Pine Ridge IHS hospitals, little had been written about the framework that allowed the inadequate care to continue.

And that’s where photojournalist Briana Sanchez and I sought to start our project with help from the USC Annenberg Center for Health Journalism National Fellowship.

We searched federal hospital inspection records and legal filings and we sat down with dozens of enrolled tribal members and health experts to understand what was standing in the way of meaningful improvements.

And we found that a perfect storm of state and federal policy failures, underfunding, geographic remoteness, and extreme poverty on the Rosebud and Pine Ridge Indian Reservations create unique health care challenges IHS has tried in vain to overcome.

Over the last decade, Congress has repeatedly flagged the abominable conditions in the South Dakota facilities but they’ve failed to make meaningful change.

Meanwhile, the U.S. government remains in violation of its treaty promise to provide health care to Native Americans.

And South Dakota lawmakers have refused to expand Medicaid, eliminating another funding source for the facilities. Of the 49,700 adults who would have received coverage under the Medicaid expansion, 30 percent were Native Americans.

There is one primary care provider for every 9,960 people in Todd County, a county on the Rosebud Indian Reservation with a total population of just over 10,000. That’s a doctor-patient ratio eight times that of the state average in what is one of the poorest counties in the nation.

And while the federal government, Congress, state lawmakers and others failed to fix problems at the hospital, dozens of patients have died needlessly due to errors made in IHS hospitals in South Dakota alone. Thousands more in the state’s rural Indian reservations face limited access to primary care providers, long wait times for basic medical treatments and outstanding medical debt for necessary care sought outside the federally funded facilities.

Since our project was published in the Argus Leader and USA Today, people across the country have called for a change. And members of the U.S. House Committee on Energy and Commerce cited the reporting as they called on Rear Adm. Michael D. Weahkee, the IHS interim director, to provide additional details about substandard care at IHS facilities in South Dakota.

“These recent press reports indicate that patient care does not seem to be improving at these IHS-operated hospitals,” they wrote. “We must find a way forward to protect IHS patients so that all American Indians and Alaska Natives receive the best care possible.”

As we set out to report our project we faced some challenges. Here are some pointers other reporters might consider:

• Try a survey: We found that it was very difficult to get some folks to open up about their experiences with IHS because they’d had traumatic experiences seeking care there. So to prevent people who weren’t comfortable from reliving that trauma, we opened up a confidential survey on our website for patients to share their stories and their contact information. The folks who shared their stories were eager to speak with us about what they went through and also connected us to other patients who wanted to open up about their experience.

While this might not work for every project, it is really helpful if you’re making trips out to visit sources and have limited time, or are dealing with a particularly sensitive subject.

• Keep calling or emailing: We faced challenges with getting in contact with IHS officials and with getting inside the hospitals. And while this was frustrating, we found that the best thing to do is to keep calling or reaching out to agency contacts and making the point about why their input is critical to an accurate story.

• Find a guide: Traveling out to the reservations, we knew we’d have a challenge getting people to know and trust us because we weren’t federally enrolled tribal members and we weren’t members of either community. In addition to explaining to each person what we were working on and spending time talking about what our hopes were for the project without going on the record, we were fortunate enough to have community leaders who helped us connect with sources.

If you can, get to know folks in a community who are well-known and well-trusted. They can be a huge help in connecting with more community members and in providing help in navigating local customs or best practices. It’s also valuable when you’re reporting on a community of which you’re not a member to acknowledge that with sources from the start.

Put in the face time: We found that it was vital to our reporting to spend time with our sources so they could get to know us and understand our intentions. We spent hours sitting down with tribal leaders and people who’d sought care or worked at IHS before pulling out the notebooks.