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.