The Physician Scholar

Humanities
Reflections from Pine Ridge Indian Reservation and Hospital

By Mike Long and David Nash
Published: June / July 2008

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Service to Patient: Building Vocations and Humanism in Medicine

Good physicians are dedicated to serving others—this is, admittedly, an ideal of broad scope. It was with this perspective in mind that I approached this year’s Creighton medical student Spring break trip to the Pine Ridge Oglala Sioux Reservation in South Dakota. I organized and participated in the March 2008 weeklong Project CURA (Creighton Medical Students United in Relief Assistance) immersion experience with eight fellow students.

To plan, I prioritized the immersion experience on the Rez over a service experience in its strict sense. In so doing we set off on an experience foundational to our medical education. It is not enough for nine medical students to arrive at a place like Pine Ridge, pile out of a van and only provide a week of—ultimately—trivial labor and aid assistance. Instead, we experienced the necessity for being physicians in service. As a result of such lessons we students become enriched to influence real change in the lives of our patients through compassionate treatment. The results of service might not be immediate, but they have the potential, in time, to be profoundly long lasting.

Pine Ridge, located about 350 miles northeast of Denver, is steeped in history. The Lakota are proud of their heritage as one of the strongest and most influential tribes in the Great Plains. Strongest among the defenders against westward expansion, the Lakota defeated Custer at Little Big Horn. Tensions between the United States and the Lakota peaked at Wounded Knee with the cavalry’s massacre of over 300 men, women and children who had surrendered and were surrounded by cavalry guard. The legacy of this tragic history remains—there is intense cultural pride, but also the residual effect of justifiable distrust. The marginalization of reservation life has created a legacy of poverty and its concomitant ills—widespread alcoholism, endemic diabetes, short life expectancy, the list goes on. Ills aside, there are forces of change riding on tradition, pride, and optimism. As physicians for our patients—with appropriate cultural sensitivity, empathy, and caring effort—we have the unique opportunity to help support the restoration of autonomy and positive direction for the future.

Between Hardships and Optimism: Building Trust in Healthcare

The Pine Ridge Indian Reservation rests near the southwest corner of South Dakota. Driving through this area one sees the beautiful scenery of rolling hills, long patches of grassland sprinkled with yucca and the occasional grove of pine trees. Bluffs are dispersed throughout the country and increase in size and number as you reach the southern end of Badlands National Park, a sacred place to the Lakota people.

Along the roads, you may find many interesting things. The roadside fences look more like heavy clotheslines carrying plastic grocery bags instead of jeans and t-shirts. Every so often road signs labeled “Think! Why die?” mark where drivers and passengers have died in car accidents. In the ditch, a decomposing horse gets picked at by a couple of Rez dogs. Occasionally, men hug the shoulder of the highway looking for a ride to the next community. Abandoned houses without windows shelter men from the wind. Gangs, identifying territories, have spray-painted tags on the sides of buildings, signs and houses.

Driving through the city of Pine Ridge, you reach the hospital as you near the city limits. The Pine Ridge Hospital is the only hospital on the reservation. Several other clinics are spread throughout the reservation, but their presence can be misleading. Lack of staff prevents them from being open daily. Inadequate funding and poor use of resources limits the capabilities of the healthcare workers. Out of all the healthcare workers present, few stay on the reservation long enough to build effective relationships with their patients. Thus, turnover remains one of the reservation’s most difficult healthcare issues.

As one public health nurse put it, “Many of the medical staff here lack staying power.” Staying power. Longevity. Here, it takes more than a friendly smile to make a connection with the people of Pine Ridge. Patients need to know that their healthcare workers care about them. They come to know through actions such as follow-ups, contact in the community and consecutive visits with the same caregiver over a long period of time. The latter is especially important considering that the major medical problems facing many of the people of Pine Ridge tend to be chronic diseases such as diabetes, alcoholism, drug abuse and complications arising from very unhealthy lifestyles. Although these may be typical elsewhere in the United States, the prevalence and severity seems to be much worse here. The trusting relationship between the patient and health care worker cannot be taken for granted out here. It takes much harder work on the caregiver’s part to stay effectively involved.

Despite the seemingly endless string of statistics reaffirming the problems facing these people, they have an inspiring knack for keeping their heads up. They find strength through family and community. Laughter can be heard in all places, and the pride in their heritage is still alive and well today among certain circles.

I had the opportunity to see the pride of the Lakota people first hand at a send-off ceremony for the Red Cloud boys and girls high school basketball teams. The teams were working their way toward a state title and the elders of the school wanted to honor them in the right fashion. Fans packed into the gymnasium to watch Chief Oliver Red Cloud give words of wisdom and hand out eagle feathers—a symbol of nobility, honor, and pride—to each of the players. In his speech, he specifically addressed the difficult dichotomy in the student’s lives: being Lakota in a white world. He acknowledged the pressures of today’s society infused with alluring television shows, music, clothes and toys, but stressed the importance of staying true to their Lakota values and heritage. “Remember,” he said, “You will always, always be Lakota.”

What is most surprising and inspiring about the people of Pine Ridge is their resiliency through hard times. It is no secret that they have had their fair share of difficulties over the past hundred years or so. In spite of the hardships, there are many Lakota that continue to succeed in living their lives on their own terms, staying true to their culture, regardless of the hurdles that face them. They are fighters and it is encouraging to see such hope.

There are many things that could be done to improve life on the reservation. So many, in fact, it is difficult to know where to start. In terms of the healthcare system, it is clear that there at least needs to be a better effort to maintain a continuous relationship between the providers and patients. Long-term caregivers are few and far between on the reservation, but they are necessary to achieve sustainable healthcare. Their presence would help to rebuild the trust in the system and, hopefully, foster healthier lifestyles among the people of Pine Ridge.

The list of difficulties facing the people in Pine Ridge is long. Healthcare is just one of many, and upon visiting the reservation, it only becomes more clear that no one solution will solve all of the problems. One thing is clear, however, the Lakota people are anticipating the day when things will begin to get better. After meeting so many wonderful and driven individuals, I would like to think those days aren’t too far off now.

-- David Nash

As physicians, however, it is inadequate to arrive at a place like Pine Ridge to provide a limited duration of service, and then simply pack up and return to our own agendas a short time later. Genuine effort and a keen interest in the population must be taken in order to learn a patient population’s history, culture, and norms—we cannot effectively care if we choose to remain as outsiders. For example, we learned that for the Lakota there is a language behind a handshake. We need to be sensitive to the nuances of such commonplace pleasantries. Who would have thought that a firm handshake and direct eye contact might alienate a patient and compromise the doctor-patient relationship? To some Lakota it may. Furthermore, we are taught of the adverse health effects of tobacco usage; but for some Lakota there is a difference between traditional tobacco usage in a healing or ritual prayer and that of tobacco abuse. Physicians must be culturally competent to differentiate between the two and be respectful in their queries. It takes an investment of time and effort to learn, understand, and come to practice comptently in a given culture—by immersing ourselves, even briefly, in life at Pine Ridge, we have become aware of such cultural courtesies.

I had previously spent time on the Pine Ridge Reservation prior to this most recent excursion. Over the course of a year I spent about a month’s time on the reservation while visiting a volunteer. This time, in a trip of one week, no one in our group nor I expected to come away from the Pine Ridge experience with a proficient understanding of Lakota culture or the nuances of life on a reservation. However, the uniqueness of that community, its challenges related to healthcare and the complexity of possible solutions for this community did become apparent. Mindful of our primary commitment to service, it was clear to us how necessary it is to form a foundation of understanding of a people and their place—their history, culture, struggles and strengths. It was good for us to spend time listening, learning, watching and reflecting throughout that week on the Rez.

In medicine we aim to serve our patients by investing ourselves in their care. We owe our patients an honest commitment to understand their ailments. So too we must honor this responsibility of sharing in the lives of very real human beings who look to trust us. Though we did not have any patients in a clinical capacity while on the Rez, we could still empathize—a caring skill of openly and intentionally being engaged and attentive. On any single day on the Rez one witnesses the consequences of history and betrayal, the frustrations of federal bureaucracy and the disenfranchisements of life on the reservation. Nonetheless, one would be shortsighted to focus only on these ills. There exist rich and vital assets on the Pine Ridge. Family, tradition, spirituality and community are all strong. In the community one finds grassroots organizations and trusted, passionate individuals forming its pillars. Pride in the past is palpable and activity is directed toward the future.

From our brief stay on the Pine Ridge, the most important lesson we took away was the need to demonstrate our trustworthiness as physicians. People must know that we are invested in their holistic well-being—we care about their health, environment, and cultural community. We must give respect. We must acknowledge their dignity and integrity.

Mitakuye owasin is Lakota for “we are all related.” This reference extends universally. We are one in the family of humankind. Should we, the members of the 2008 Project CURA Pine Ridge group, never return to the Rez, lessons learned there have enriched our medical education. I can confidently say that each member in our group saw the need for sincere personal investment in the medical care provided to patients in the context of their community. Remembering this will surely enhance the care we will provide to any patient.

We are grateful for the generosity of everyone on the Rez who facilitated our experience, particularly to those who let us into their lives. The members of our group and I would look forward to spending more time on the Pine Ridge—either by rotation during the remaining years of medical school or in commitment to service thereafter.

-- Mike Long

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