One April evening last year, Kathy Boyd stepped onto her deck and lit a cigarette, as she often did after dinner. She loved the quiet and majesty of the nearby forest, even if it was remote and cell towers were too far away to service her house. But that evening she didn’t linger to watch the sun dipping behind the pine and cedar trees — her heart was going berserk.
Boyd had lived on the Rosebud Indian Reservation in South Dakota for all of her 58 years and sought out tribal healing whenever possible. Like most of her neighbors, she was leery of Rosebud’s government-run hospital, which had a reputation for harming rather than healing, and whose medical disasters had been making headlines for more than 30 years.
But now she needed a hospital. Her heart was beating rapidly, and she couldn’t catch her breath. Something’s not right, she told her husband, Wayne Boyd. The couple hopped in their car and drove 25 minutes to Rosebud Hospital, a three-story building that sat like a concrete layer cake on fields once used as camping grounds.
They arrived just after 7:15 p.m., according to emergency department records. Electrodes placed on Kathy's chest logged an irregular heartbeat as high as 160 beats per minute. Nurses asked, “Was she in pain? How bad, on a scale of one to ten?” “Eight,” she said. Her aunt, son, and grandkids started pouring into the room.
Federal rules require staff at Medicare-funded emergency department's to examine every patient, to determine how urgently they need attention. Boyd didn’t get a medical screening exam until 8:15 p.m., an hour after she arrived. According to government inspectors who later reviewed ER records, the staff did not give her a chest x-ray or do an ultrasound — procedures that are routinely done on patients arriving with heart complaints.
At 8:45 p.m., the doctors said Kathy needed to be airlifted to a larger hospital in Sioux Falls, about 250 miles away, to see a cardiac specialist.
By 9 p.m., as Kathy’s pulse raced and her back ached, doctors told her family that her transfer to Sioux Falls had been denied. (When her family called Sioux Falls later, they were told no request was made that night.) She would instead need to ride an ambulance for three hours to a hospital in Rapid City.
At 9:50 p.m., the ambulance turned up. But now the paramedics wouldn’t take her — she was too unstable for transport, they said, and needed an airlift.
At 11:10 p.m., an airplane arrived and took her to Rapid City Regional Hospital. She went into surgery the next day, and was unconscious for the next nine days before waking up with a breathing tube in her throat and a zipper scar down her chest. She was told that her heart’s mitral valve had been replaced with a mechanical part.
“If you’re really close to me you can hear me tick — it sounds like water dripping,” she said.
Kathy Boyd at her home in the Grass Mountain community on the Rosebud Indian Reservation.
Kristina Barker for BuzzFeed News
Besides botching her ED transfer, Kathy believes Rosebud could have spared her the surgery, the scarring, and the handful of pills she now has to swallow daily. Back in 2009, Rosebud doctors had sent her to a hospital in Valentine, Nebraska, to get an echocardiogram. After that, she had called repeatedly to get the results. She said she was always told that Rosebud did not have the report, or that they couldn’t give her the results over the phone, and then that she was fine. She went back to regular life — until her heart episode last April.
“If you believe how I believe, that day, something was taken from me that I can’t ever get back,” she said.
Kathy’s story of incompetence, bureaucracy, and neglect at Rosebud Hospital is not unique. Dozens of stories like hers are included in a landmark lawsuit lodged by the Rosebud Sioux tribe against the body that controls the hospital: the federal government.
More than a century ago, President Andrew Johnson promised all Native Americans free health care, in exchange for moving to reservation lands and ending war. And now, after more than 60 years of underfunding and neglect, that program — called the Indian Health Service — has become what one senator has characterized as “horrifying and unacceptable.”
At the heart of the dispute is this: What weight do decades-old treaty agreements between the US and tribal governments carry in the modern day?
In the past decade, at least six federal government investigations of Rosebud Hospital have found that poor management, insufficient staff, and lax record keeping are endangering patient lives. Last year, threatened with funding cuts because of unsafe conditions discovered there, the IHS shut down Rosebud’s emergency department. Between December 2015 and July 2016, at least five people died while being transferred to other hospitals more than an hour’s drive away, and two women gave birth in ambulances on the road. The problem plagues other IHS facilities, too: The ED at Sioux San Hospital in Rapid City shuttered this year. Pine Ridge Hospital, south of the Badlands, was flagged for not meeting Centers for Medicare and Medicaid Services standards, and Winnebago, six hours east, lost accreditation altogether.
Many rural communities across the US are struggling to keep their hospitals open and hire doctors from bigger cities. But Native American tribes like the Rosebud Sioux tribe say they are in a unique position: Over a century ago, the federal government promised them care. The tribe’s lawsuit alleges that the shutdown of the Rosebud emergency department, as well as the hospital’s long history of violations, breaches the government’s obligations to some of its most vulnerable citizens.
At the heart of the dispute is this: What weight do decades-old treaty agreements between the US and tribal governments carry in the modern day? Native people living on reservation lands are still living out the consequences of those pacts — if the US government shrugs off its side of the bargain, the tribe says, legal action is their only recourse.
“When you lose your emergency room in a large land-based reservation, it blatantly translates to lives lost,” said Jerilyn Church, chief executive officer of the Great Plains Tribal Chairmen’s Health Board, which assists 18 tribal communities, including Rosebud, in health education and access.
Evelyn Espinoza, a former Indian Health Service registered nurse, is the health director for the Rosebud Sioux Tribe.
Kristina Barker for BuzzFeed News
The Rosebud Sioux tribe has 29,000 members living on the reservation. It’s one of the poorest and most remote areas of the country — some 300 miles south of Standing Rock, where their kin are protesting the Dakota Access pipeline. The reservation’s unemployment rate is 85%, and life expectancy in the county is nearly two-and-a-half years below the national average.
Last month, the federal government submitted a response to the suit, arguing that it does not, in fact, have any legal obligation to provide health care to the tribe. From the Rosebud health board’s perspective, this is only the latest in a long list of injustices committed by the government against Native people.
“It’s genocide — it’s just another way of killing our people,” said the tribe’s health director and Boyd’s stepdaughter, Evelyn Espinoza.
The IHS declined multiple requests for an interview with Rosebud Hospital executives, but did offer an eight-minute interview with the agency’s principal deputy director, Mary Smith. “It’s not business as usual at IHS,” Smith told BuzzFeed News. “I’m trying to create a culture of leadership, quality, and accountability.”
In a subsequent emailed statement, IHS spokesperson April Hale added that the agency will “continue to strengthen services” at Rosebud Hospital. In April, facing the loss of funding from CMS, the IHS signed an agreement with CMS that pledged to improve services at the hospital within 12 months.
“In the Great Plains and across the agency,” Hale wrote, “the Indian Health Service is committed to pursuing short- and long-term solutions to address long-standing issues that will be sustainable over time.”
Signage along BIA Road 7 directs drivers to Rosebud, where the Rosebud Indian Reservation tribal headquarters are located.
Kristina Barker for BuzzFeed News
“Rosebud” was the name the US government gave the reservation, but its residents call themselves Sicangu Oyate — for “Burnt Thigh Nation.” Wildfires are common on the open grassland, and this band of Sioux derived its identity from a blaze that tore through an ancestral settlement and marked the limbs of those who survived. Or so the story goes.
Today the reservation spreads over 1,600 square miles, with most of its residents living in small communities separated by hundreds of miles. The center of the reservation — a few square blocks holding a courthouse, elementary school, and Lutheran church — feels like a sleepy small town. The nearest Walmart is 90 miles away.
The reservation is governed by the 24 members of the Rosebud Sioux tribal council, who work in a small brick building across from the fire station. Inside, teal walls are papered with portraits of tribal elders going back 200 years. Nine council members and two Rosebud residents are on the health board, which serves as the intermediary between the IHS and the tribe. For the last 10 months, four of those members have been prepping the lawsuit against the government.
One of them is O.J. Semans, who was born in Rosebud 60 years ago and drove me around the reservation one day this September. A jolly ex-cop whose salt-and-pepper hair runs into a skinny ponytail down his back, Semans spent a career investigating crime and narcotics on tribal reservations in South Dakota and New Mexico before coming back here, in 1992, to retire. “You wake up in the morning and you have 100 head of buffalo around your house,” he said.
A few minutes up the road from the tribal headquarters, Semans turned his silver truck up a mud path to a reservation cemetery. On a hillside of yellow prairie grass, a tall, fenced-in headstone memorializes Chief Spotted Tail, who led Sioux warriors in battle against the US Cavalry in the 1850s and 60s. On April 29, 1868, in what would be called the Treaty of Fort Laramie, Spotted Tail and other Sioux leaders agreed to make peace with the US government.
“We would allow settlers to cross through the Oregon trail without killing them,” Semans explained. And in exchange, the US government would provide a few things to newly demarcated native settlements, including a blacksmith, a school, and a physician.
Horses on the Rosebud Indian Reservation.
Kristina Barker for BuzzFeed News
Ever since the first European diseases decimated tribal communities and settlers destroyed their traditional ways of life, Native Americans have struggled to keep their health. Today, they are more than twice as likely to be diagnosed with diabetes than white Americans are, and 30% more likely to have high blood pressure. The suicide rate among young Native adults is 1.5 times the national average. Mental health and substance abuse disorders occur nearly three times as frequently in Native communities than elsewhere in the country.
Providing treaty-promised medical care was initially the responsibility of the US Department of War, then the Department of the Interior, and finally, the United States Public Health Service, which created the Indian Health Service in 1955.
Just as the Department of Veterans Affairs provides government-funded medical care to military recruits who have returned from combat, the IHS, now a division of the Department of Health and Human Services, runs 117 clinics and hospitals with a staff of about 15,400. Another 545 facilities of various sizes are funded wholly or in part by the IHS, with tribes assuming responsibility of management. Typically, a reservation hospital medical staff can include tribal members who trained as nurses or clinical staff and returned to serve their community, doctors who may have never lived on a reservation before, and temporary staffers sent by companies under contract with the IHS.
Rosebud Hospital was built in 1989, replacing an older facility near the council building. After our visit to the cemetery, Semans drove me there. Inside it looks a lot like any other drab regional hospital, though sketches of warriors going to battle and murals of tribal gatherings add a touch of warmth to the fluorescent-lit hallways. Between notices about breastfeeding, or directions to the dental clinic, grey-blue notices taped to the walls say, “— Violence — Verbal, physical, and/or gestures are not tolerated in this facility. Report all incidents to security.”
“You don’t want to be in room 6 and 7 — that’s the forget-about-you-room.”
We walked through the waiting room, where a few patients sat on plastic chairs looking at their phones. In one corner, three toddlers who had just gotten their shots wailed in tandem.
Nurses in scrubs emerged to call on patients, while khaki-clad Public Health Service Commissioned Corps — called in from around the country to fill the hospital’s staffing holes — walked the corridor in twos and threes.
Debbie, a 56-year-old Rosebud resident, waited near the entrance for her son to arrive on the school bus so they could pick up a refill of meds. Like many others in the community, she is fed up by the hospital’s long wait times. “It’s like waiting for a wake,” she said.
Debbie tries to accompany her kids and grandkids whenever they visit Rosebud, to make sure they don’t wait too long to be seen. “You don’t want to be in room 6 and 7 — that’s the forget-about-you-room,” she said.
We took the elevator to the second floor, which opened into a small atrium with a window overlooking the waiting room below. “See all that stuff over there? That’s part of our surgery room,” Semans said, pointing across the way. “I don’t think it’s very active,” referring to the recent closure of the surgical department. The OB/GYN department was also closed, he said.
In its statement to BuzzFeed News, the IHS spokesperson Hale acknowledged that “Some services at these departments are unavailable and patients needing those services are being diverted to other facilities.” She did not know when full services would resume.
Back on the first floor, Semans and I walked past the eye clinic. For more than a year, he said, he has tried and failed to get an appointment there because slots book up on the first day of the month. Passing the mental health department, he added wryly, “You’ve got to be crazy if you have to go there.”
O.J. Semans at a cemetery overlooking Rosebud.
Kristina Barker for BuzzFeed News
The Indian Health Service’s stated mandate is “to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.”
About 2.2 million members of the 567 federally recognized tribes are entitled to use the IHS. Although some opt for private insurance instead, the agency is the sole health care provider in some of the country’s poorest counties. It received $4.6 billion from Congress in 2015, or about $3,688 per patient served — far less than the $6,644 spent by the Federal Bureau of Prisons, or the $12,000 spent by Medicare.
“The anorexic budget of IHS can only lead one to deduce that less value is placed on Indian health than that of other populations,” wrote the US Commission on Civil Rights in a scathing 2003 report on tribal relations.
“The anorexic budget of IHS can only lead one to deduce that less value is placed on Indian health than that of other populations.”