By Rachel Biemiller, MD
As my first trip to a plains state, I had no idea how dramatic the landscape would be. Sandwiched between the Mississippi River and the Rockies, the great plains this far north are stark and beautiful with rolling land stretching out to the Black Hills. The endless fields create a sharp contrast to the little homes that dot the reservation. Most are places that look abandoned if it weren’t for the host of cars clustered around each small building. Many of the homes couldn’t be more than 800 square feet with a rusted propane tank hiding in the back. However, each home has at least 5 cars surrounding it. During orientation, we were told that the Lakota culture is very family oriented and that no one is turned away despite tight living conditions. I had no idea until I saw these little homes. Most are about the size of my dorm room in college.
Between each little home, large swaths of country side roll by. It takes us 40 minutes to get from our hotel rooms to the clinic. Despite these distances, every morning the clinic is already filling up with patients upon our arrival. The elderly, mothers with little ones and patients with limps enter the waiting room. The number of people far out number the few cars in the lot indicating many have walked. Back in Wisconsin, most of us would not think of walking miles along empty countryside to get to a doctor, but here there is no choice. Those vast spaces have to be covered by foot. It sounds obvious enough until you see the spaces they’re walking. This is my second day driving to the clinic and both mornings my mouth hangs open trying to fathom walking these roads to the clinic.
This highlights the main lesson I’ve learned about Wanblee Clinic: putting out fires. Most visits are urgent care for people who can no longer tolerate their symptoms. When I think about lack of routine medical care, I think cost and lack of education. Here the Indian Health Services are free and many patients know they should be coming in, but dragging a two year old three miles in a cold morning for your routine flu vaccine? You can see how the motivation may be lacking. Plus, many patients seem disinterested in surveillance for cancers or strokes. I’ve been refused exams, head imaging and transfers to the hospital. The mantra has been if it becomes an active problem, I’ll let you know. It’s quite the turn from practice in standard medicine where medical testing is over utilized. I’ve had problems understanding why many standard of care practices are being turned down especially when they may save lives or prevent crippling disability.
What I’ve learned in the last few days have helped answer this question. However, I had to look beyond the patient in front of me. First is quality of facilities. Not all clinics on the reservation have the same capability with each clinic miles away from one another. Secondly is time. As an army brat with a family heavily in the military, I can attest that nothing controlled by the government is easy or efficient. Most of my family avoids military hospitals and the VA like the plague. The Indian Health Service is essentially the VA for the reservation without the option to go elsewhere. That’s bad. It takes weeks to get normal studies done and there is twice as many forms to fill out. Many patients do not have the time, resources or drive to jump through this many hoops. Three is the distances. The most advanced imaging services are at Pine Ridge which is two hours away … by car. If one doesn’t have a car you have to get a friend or go to an office to demonstrate need to get a ticket for the health shuttle. The office and the shuttle are not in the same place, so you’ve made three trips instead of one. This with rampant poverty and depression make maintaining ones health almost impossible. Then there is the cultural aspect.
It all seems overwhelming. I did not come here with any romantic ideas and I felt I had a good handle on basic Sioux culture and history. However, my expectations and my supposed knowledge have been thoroughly upended. We went to the Oglala Lakota College yesterday and then tonight had a speaker, Dakota, teach us about Lakota history and culture. These two experiences have helped solidify some of what I’m seeing in my patients. Hearing the native perspective of the Battle of the Little Big Horn and the massacre at Wounded Knee is even more raw than I had learned in history class. They tell the impact of what the massacres, treaty violations and Indian Boarding Schools did to the Lakota as people. I almost cried after leaving the College and felt numb tonight. I won’t repeat the details of these lectures as some of it is deeply disturbing, but it explains the apathy that I have felt in my patients.They have been stripped of who they were as a culture and thus a loss of identity. There is subsequent depression which has lead to substance abuse. There is 95% unemployment and suicide rates higher than the national average.
On the other hand, things may be turning. After hearing these stories I don’t really like white people and I’m white. Not only that but my family came across the plains to settle in Washington state. At times I feel personally responsible for these tragedies. Despite that, every one I have met here has been exceedingly kind and gracious. I have been welcomed here with open arms, which I did not expect. Dakota spoke that his religion focuses on love and goodness. I see that in so many of the people here. There is a drive by many in the community to rebuild their culture and their people. Traditional Lakota practices are re-emerging and the language is being spoken again. Though I’m seeing lack of continuity of care, poor facilities and large spaces to travel, another way to look at is the people are still here to receive care, there are actual facilities and this space is a shelter to the Lakota families. The last two could not be said 39 years ago and the Lakota were barely hanging on. So, I’m trying to see the hope and all things good that are here as I argue about MRIs and beg people to attend follow ups. It will take time but I hope the worst is over for my patients and the Lakota. Overall, it has been a remarkable experience.