Broken Promise? Idaho Native American Populations Struggle for Health Care 

Decreasing budgets and physical isolation create a health care vacuum on the Duck Valley Indian Reservation

Mark Sope spends his days waiting. Waiting for the next emergency dispatch call. Waiting for a Life Flight helicopter to land. Waiting for the miles of sagebrush and desert scrub to fade into the distance as he delivers sick patients via ambulance from their Duck Valley Indian Reservation homes to a hospital in Elko, Nev., or Boise. Sope feels the remoteness of tribal life with each mile, each ticking minute, and in the faces of the sick and injured he calls his neighbors, friends and family.

"Usually, the calls come in waves," the EMT said during a pause in the parking lot of a pared-down Western Family grocery store and gas station--one of the reservation's few local hubs for the population of roughly 1,100, and sometimes the only draw for commuters passing through the vacant landscape at the Idaho-Nevada border. "One week, there will be no calls, and then they come one after another."

And call after call, the odometer ticks the 115-mile drive to a Boise hospital.

"During blizzards or whiteouts, it may take three hours, but we'll get them there. We usually call a chopper if it's real serious," he said.

Sope feels the vacancy left by the physician shortage on the 289,819-acre reservation. It's the same shortage that has longed plagued rural Idaho, making it one of the most medically underserved regions in the nation. But as the state pushes to attract more doctors to its sparsely populated towns, and the country talks of Obamacare, this native sovereign nation remains on the fringes of modern medicine and health care reform--isolated by disparities that make tribal populations some of the sickest demographic groups in the United States.

Treaties, land grabs and the forced removal of indigenous populations from their lands ended in a string of promises: promises to provide tribal members with an education, cash annuities and hunting rights. The U.S. government also promised to ensure health care to the more than 300 sovereign tribes in the country.

"Those promises were made when we left our homelands--when we agreed to come out here, even though they didn't give us anything for our land. They told us that it would provide us health care; it would provide us education and such. And it has not," said Ted Howard, cultural resources protection authority director with the Shoshone-Paiute tribes of the Duck Valley Indian Reservation.

A 2004 study by the U.S. Commission on Civil Rights found that old wounds still fester on reservations, and that "our nation's lengthy history of failing to keep its promises to Native Americans includes the failure of Congress to provide the resources necessary to create and maintain an effective health care system for Native Americans."

The commission's study of care provided on reservations by Indian Health Services and the Centers for Medicare and Medicaid Services found that Native Americans have lower life expectancies than the U.S. population as a whole and face mortality rates that are more than twice those of the general population. Diabetes, accidents, homicides and suicides in IHS areas also substantially outpace those of the average American, and many Native Americans face health care outcomes similar to those in developing countries. Little has changed in the last decade.

The annals of social research and public health illustrate a well-established correlation between health and wealth that is intrinsically wrapped around race and culture. Wealth equals health and the poorest are often the sickest. Class stratification mirrors race stratification, with whites and Asian Americans residing at the top of national income brackets and enjoying some of the lowest morbidity and mortality rates. Natives, as a demographic group, occupy a long-held position as the lowest income earners. Poverty rates as high as 50 percent plague some reservations, and overall, nearly one-third of Native Americans live in poverty, compared to roughly 15 percent of the general population. Native Americans are 70 percent more likely than the general population to be obese and have the highest diabetes rates of any race. They're also more likely to get sick and die at younger ages.

This isn't news to the Shoshone-Paiute. And they don't need a commission report or academics to draw the connections.

"This community being so remote, it's been a difficult path for us. If you look at other tribes around here, they have casinos. It's hard for us to even keep a little store afloat because we don't have the traffic. So it's difficult for us to set up anything and hope to get rich off of it," said Howard, of the Shoshone-Paiute.

The Duck Valley Indian Reservation has also seen government funding for health care come, go and dry up since its inception in 1877. Dollars that once funded specialty doctors on the reservation slowly disappeared. Funds that once kept the community clinic open 24 hours per day are gone. The money that had once funded a full hospital no longer exists, and there's nothing to fill in the gaps.

"It's dwindled down to practically nothing. And it worries me should something really bad happen. And we've had people die here because of that. The medical care is just too far away," said Ann Jimmy, a Shoshone-Paiute elder who has called Duck Valley home her entire life.

The health care disparities that plague the Duck Valley Indian Reservation in many ways mirror the problems afflicting rural Idaho. In 2008, a legislative interim committee convened to discuss solutions to the doctor shortage that ranked Idaho last in the number of physicians per person. The committee noted lower wages and a lack of medical hubs and health care teams in rural areas--compounded by the absence of an in-state medical school--as deterrents to attracting and keeping physicians in the state.

Boise Weekly found country physicians remain a rare breed (BW, Feature, "Country Medicine," Oct. 18, 2008). Requiring a love of the outdoors, a willingness to generalize and specialize with little or no peer consultation, a commitment to work long hours and propensity to practice the kind of maverick medicine that sometimes has rural doctors doubling as pilots to see patients, makes practicing rural medicine in the far reaches of the state a job not many medical school graduates are cut out for.

But Dr. Tim Brininger made the cut and was willing to commute from his Mountain Home-based obstetrics and gynecology practice to the Duck Valley Indian Reservation to meet the needs of underserved expectant mothers.

"I think they needed care desperately," Brininger said.

Before Brininger took the Duck Valley assignment, which had him commuting nearly 200 miles round-trip on a weekly basis, he saw expectant mothers from the reservation show up at the Elmore Medical Center in labor and in crisis.

"They had no prenatal care," Brininger said.

For five years, Brininger cared for the reservation's mothers-to-be and delivered their babies. But Brininger recently stopped making the commute to Duck Valley when the money that funded his contract dried up and the community lost its only OB/GYN. He worries that a Life Flight medic or EMT may be the first and only medical care provider to serve the area's pregnant women.

"My concern is for the care of the girls. The risk is pre-term labor," Brininger said of would-be mothers who delay or never receive specialized medical care. And that could translate into high-risk pregnancies, which turn into emergencies once labor sets in.

"Even if they're not paying me, they're paying for a Life Flight. And the cost of two Life Flights is how much I made in a year."

But when the government makes funding cuts, the tribe cuts health care.

"The way I see it is, if you have a landlord, the very first thing you do on payday is you set aside your rent, you set aside for things that need to be paid. And I feel that's the way it should be with the tribes and the government. That's the agreement that they made. But that's not what happens. If there are cuts, it's the tribes that will take the hit first," Howard said. "And we don't appreciate that."

Tribal leaders and health care officials didn't respond to Boise Weekly's request for interviews, and residents of this tight-knit community reluctantly chatted about health care and medical services at the deli, outside the gas station and in the aisles of the local hardware store, but shied away from giving their names. Everyone knows everyone, they said. And they don't want to complain.

But they pointed to health care barriers. Some delay going to the local clinic as long as possible by using traditional medicine. Hours are sparse and once they get to the clinic, they know they'll likely end up with a referral to a Boise specialist, then face the burden of finding transportation for the daylong round-trip commute. Some worry about the next emergency that might land them in a Mountain Home, Elko or Boise hospital, and the friends and family forced to figure out how they'll make the drive to pick them up after discharge.

"Transportation is a big problem. A lot of people don't have good cars," said Rose Dick, who raised her children on the reservation but now takes comfort in their good Boise jobs and the health insurance that comes with them.

Dick and her neighbors say it's hard to ward off those Life Flights and Boise medical visits. Preventative health isn't an easy practice on the reservation, they say. Limited jobs on the reservation translate into an unemployment rate of 40 percent and not a lot of extra cash for staying healthy and eating right in a town that watches cars whiz by a scattering of bare-bones rectangular tract homes and the local grocery that sells more varieties of chocolate chips and hot dogs than fruits and vegetables. While other reservations fund their health care systems and supplement incomes with casino revenues, Howard reminds people to visit a nearby reservoir next time they're in the area, which counts the tribe, hospital and school as the biggest employers. It's stocked with fish, he said.

Howard tells stories of a time when the Shoshone-Paiute could canvas the high desert and walk the banks of the Boise, Snake and Owyhee rivers and find everything they needed for subsistence and good health. Rituals spawned remedies in the Bruneau and Boise valleys of the past and medicine grew and bloomed in sync with the seasons. The Shoshone-Paiutes enjoyed good health through tradition, culture and the natural wealth that sprang from the land. But for some, those traditions faded, culture morphed and they became surrounded by a society that no longer measured wealth by what was left for those yet to be born. And their health began to change.

"This is certainly a special place to us because it's where our people have survived for centuries. Everything that we needed was here," Howard said.

"Traditional people are connected to their land, to their environment," he added. "When people are not connected to their environment, it's more about them. They don't really have a connection to anything. Mainstream society today is that way. It's about making a profit today, and it doesn't matter what you leave behind. We're always concerned about what we're leaving for the next generation. We don't own this land. We're borrowing it from our children. So we want to leave it better than we found it."

The glimmer of gold slammed against those traditional values when prospectors discovered their first nugget below the surface of the Boise Basin in 1862. Where Native Americans saw a loan, gold diggers saw a profit.

"They wanted the Indians out of the way. We were in their way. So we were forced out of there," Howard said.

The Shoshone-Paiute who once scattered across the high desert of Oregon, Idaho and Nevada and followed the salmon migration into the tributaries of the Snake River were squeezed beyond the far northeastern reaches of the Treasure Valley, along parts of the Boise River now submerged beneath the reservoir water of Arrowrock Dam. The lure of natural resources wrestled away that last hold, and in 1877, the U.S. government corralled the Shoshone-Paiute onto the barren borderland desert south of Bruneau. The tribes entered into two treaties with the U.S. government, but Congress never ratified them, leaving southern Idaho technically in the hands of the tribes.

"The Boise Valley and the Bruneau Valley were never given to the United States. There's no legal exchange of land title. We still hold title to those lands," Howard said.

Treaties and loose agreements brokered land deals and the beginning of an introduction of Western medicine to Native American life. The first full-time physician joined the Duck Valley reservation in 1882, and in 1897, the reservation erected a one-room infirmary that later gave way to a hospital, compete with 20 beds, a laboratory and X-ray facilities in 1937. That facility operated until 1976, when the reservation opened the Owyhee Community Health Facility, which still operates today under limited hours.

The unratified agreements between the Shoshone-Paiute make the tribe a self-governing entity, meaning it doesn't fall under jurisdictions serving treaty-bound sovereign nations, including Indian Health Services. The tribe lobbies directly to the government for health care funds, and how the tribe appropriates and manages those funds remains up to elected tribal leadership. While funding spurts spawned the growth of the first local hospital from a one-room infirmary during the first half of the 20th century, the Shoshone-Paiute watched those sources dwindle as the tribe moved into a new century.

"We are seeing more and more cuts," said tribal elder Ann Jimmy.

"We used to have a full hospital. And it was really nice because you could be at home. But slowly, by slowly, they started taking things away from us because they couldn't afford it. And now it's down to probably the bare minimum," she added. "What's sad about it is because they can't treat us, either because they don't have the doctors to treat us, or because they're no longer open 24 hours like they used to, if you have an accident on the weekends, you have to get an ambulance to drive you out or you have to call a Life Flight helicopter to come in. And that costs thousands of dollars."

Some residents visit the local clinic but find health care gaps between the local primary care and the specialized care found in cities across the desert. Marissa Dick's last trip to the clinic included a pregnancy test and tuberculosis screening. Dick, 20, found out she was expecting her first child, received instructions to come back at 12 weeks gestation and given a due date.

"I'm not sure that's even my due date," Dick said. "I just go to them and they don't tell me anything. I guess I'll just Google."

Boise Weekly asked if she planned to confirm the due date and receive prenatal care from an OB/GYN.

"What's that?" she asked.

Boise Weekly told Dick about the funding cuts that left the reservation without the weekly visits from Brininger.

"That's crazy," she said. "Those are the people you need to keep hired. Being pregnant and having a baby for the first time, you want to know everything."

Duck Valley residents know that doctors come and go. They praise the skills of some of their favorite physicians. Some doctors appear fresh from residency. Some are recent immigrants who serve after just securing their medical licensure. And some land in Duck Valley for a moment before moving to a higher level in their medical career.

As a self-governing tribe with a medical system operated by tribal leaders, rather than IHS, the management and ultimately hiring of staff remain in the hands of the elected leadership. Community members say this doesn't give would-be docs a lot of job security on the reservation. A change in leadership could mean a change in doctors.

"It's hard to keep physicians around," Howard said. "For a lot of people, it's the remoteness that gets to them. Or sometimes a doctor will come for a while but their family doesn't want to come with them or there's no place for them. There's a variety of things that make it difficult here."

So they all seem to come and then go, Jimmy said.

"It makes it real hard to get a doctor-patient relationship going. You just a get a doctor who knows your history, that knows you, and then they go on. And then you get a new doctor in and they want to change everything. They want to change your medicines, everything. It's a merry-go-round," she said.

Native Americans are the only people born with the right to health care in this country. But their mortality and morbidity rates more closely parallel those of people born in Third World nations. The average American can expect to live to 78.2 years of age. A Native American's life expectancy varies greatly, with some tribes' average life span barely reaching 55 years old. People in Ghana and Bangladesh enjoy longer lives.

"When I was a child, someone dying from cancer was virtually unheard of. That was something that was not here. Our people mostly died of old age. But now we have even young people who are dying from cancer. Is there something in the environment? Is there something in the water? I don't know," Howard said.

Diabetes also draws concern on the reservation, he said.

"I think a lot of that is the result of the loss of traditional foods or the lack of using traditional foods. And a lot of it has to do with modern technology," Howard said. "Back in the olden days, people had to work for what they needed. Technology takes away the physical aspect of doing things. And also our kids are not getting out and being active. They're sitting at home, playing video games."

Howard, 65, grew up on a ranch, raising cattle across the expanse of the Owyhee desert. Chores and plenty of physical labor came with a lifestyle that faded out as fewer ranchers began running larger herds.

"And back then, we didn't even have inside plumbing. We had to cut wood and milk cows. Being the eldest, I was always out there working with my dad. And by the time the school bus came around, I had already put in a couple of hours of work. You go to school and come back and do your chores before it gets too dark. We did that every day. Now, looking back, I'm so grateful for that," he said.

"One day I said to my wife, 'Look at that ice out there. As kids, we used to ice skate a lot. You don't see anyone out there anymore," he added. "And when it was snowing, we'd be out sledding. You see a few kids out there sledding every once in awhile. But you don't see kids out doing physical things any more. I think a lot of that is leading to obesity and diabetes."

The impact of media is also changing the way of life on the reservation--particularly for the young.

"Those are the things our community is dealing with now," Howard said. "And of course, drugs. We don't have a lot of it, but we have some. A lot of these kids start looking at movies and such and start dressing like gangs and taking on that lifestyle. But we tell them, you don't have to be someone else. You have a lot to be proud of being yourself.

"We try to teach them that life is a gift. It is a gift from the Creator--you only have one body and you need to take care of yourself and not to consume things that aren't good for you. We always tell them that everything ends and begins with you."

Somewhere between the medicine man, whose traditions and knowledge of the Owyhee's plants and roots remedied the ills of Howard's ancestors, and the anticipated arrival of a health care system to cure the modern-day ailments of a people distanced from tradition, stands Mark Sope beside the ambulance, waiting for the next call.

"I know when I'm waiting for a helicopter, it can feel like forever, especially if it's critical," he said. "You make a connection with them. You feel for them. You may help someone you know. Or your family member. It's hard. But if you don't do it, no one else will."

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