By: Carol Sullivan
Statistics are slippery—they can describe, decry, and defy what is happening. At a recent two-day health fair on the Pine Ridge Reservation, an RVU medical team offered screening and education for health issues. The number of persons who came to the health fair was small, but the team has been invited to return September 1-2 during a pow wow. What happened?
Porcupine School hosted the event May 4-5, 2018, billed as the Power of the Community Health and Wellness Fair. A series of screenings (Hx, P.E. vitals, some finger sticks) and patient education were offered, and no diagnoses and treatments (except OMT) were given. The medical students underwent hours of training and prep for the event. While RVU global track students have ventured to Ecuador, Guatemala, Kenya, and Nepal, the Pine Ridge event was the first medical trip to a developing, sovereign country located within the continental United States.
Small clusters of sixth, seventh, and eighth graders from Porcupine School participated during school hours, and a handful of Pine Ridge adults also came. Patients were so scarce that three medical students in the men’s screening room reported they each saw “one-third of a patient”—assessing various aspects of a single patient. Yet 20 RVU medical students, preceptors, and Professor Camille Bentley have been invited back over Labor Day weekend. Dr. Bentley explains, “Due to the friendship and trust we are building with this particular native American tribe, we were invited back for the Porcupine pow wow, to learn more about their culture and share our knowledge and concern for the improvement in the health status of the people living on the Reservation, and to advertise for the second fair early May, 2019.”
What does it mean to look at a patient through human eyes?
The numbers show a stark need for medical care on the Reservation, site of the Oglala Lakota (Sioux Nation).* Some 50 percent of Pine Ridge residents over the age of 40 have diabetes. Blindness, amputations, and kidney failure are common. The tuberculosis rate on the Reservation is 800 percent higher than the U.S. national average, and figures are also disproportionately high for heart disease, malnutrition, alcoholism, infant mortality, and drug abuse. Preventive healthcare programs are rare. **
Second-year medical student Matthew (Matty) Zemel observed that “There’s a component of cultural shock when one considers that there is such pervasive poverty in a nation [whose borders are] within [the U.S.] nation.”
Keven Meyer, a volunteer on many RVU global medical treks, suggested that Native Americans might hesitate to come to the health fair because, “They might feel we’re looking at them through white man’s eyes rather than human eyes.”
What does it mean to use human eyes? A popular Lakota mythological figure is Iktomi, the trickster spider-god who upsets conventional ways of seeing. Did Iktomi inspire a question from seventh and eighth graders who came from their classroom to the health fair? The cluster of seventh and eighth graders stood in a doorway with their hands over their mouths, curious. Giggling, they asked medical students which animal they favored—beavers or turtles? This query led to a discussion of favorite animals, including dogs and pandas. Rather than introduce themselves, the girls began to introduce each other. Second-year medical student Torri Igou said that when the girls ventured beyond the door into the women’s health area, they looked at condoms that were on display— “What are these?” Condoms and gels were explained. Torri said, “We also told them that the condoms could protect them from STIs (sexually-transmitted infections).”
Second-year medical student Richard Rodriguez-Brizuela had a small encounter that may have been culturally-inflected. During an eye exam, he asked an eighth grader, “Please look at me.” She looked away. “She didn’t want to look at me, so I asked her to look to one side, and then the other.” That worked.
Eye-to-eye contact can be misunderstood. Andy Iron Shell said that attentiveness in Lakota culture cannot be gauged by Anglo-American standards. Elders may close their eyes while listening to a speaker, for example. In Richard’s situation, the young patient may have been nervous around an outsider or deferring to him as a male in a position of authority.
Greeting a huddle of Porcupine seventh graders, one medical student smiled. A quick retort came, “Have you never seen an Indian before?” That quip may boomerang from generations of historical and cultural clashes.
Pine Ridge suffers from “historical trauma,” said Andrew (Andy) Iron Shell at the Thunder Valley CDC (Community Development Corporation). “But trauma is not who you are.”
Trauma is not who you are
Trauma did show up at the health fair. Second-year medical student Alexandra (Lexi) Lee saw a patient who was “very quiet.” Her blood pressure reading was extremely high. As Lexi turned over the girl’s arm to take her pulse, she spotted scars from cuts. Arm exposed, the girl “got up and ran out of the room.”
Second-year medical student Roxana (Roxy) Valles said that a sixth grader listed “sadness” as one of her concerns on a health questionnaire. Roxy asked the student about her friends as well as “stuff at home,” and she replied that no one was helping her cope. Roxy said, “It sounds as if you feel there’s no one in your corner, no one you can go to.” The girl nodded. While she was troubled by “lots of recent suicides,” the girl did say that she wasn’t thinking of killing herself. Suddenly she spotted her classmates in the hallway, and she stopped talking. “She was done,” first-year Amanda Anderson observed.
Second-year Jenna Hoobler was surprised to see “depression in 13 and 14-year-olds.” One young student said that her classmates were making fun of her because of her weight, “yet she was skinny,” Jenna said. “I felt unqualified to treat her, and felt she needed to talk with someone else.”
Ali Rakestraw, a second-year who worked in the mental health section, said that standardized screens are used to identify depression, suicidal tendencies, mental status, and substance abuse. She recommended that a screen be added for anxiety, which seems prevalent. Ali also noted, “Our hands are tied by the amount of knowledge we have as first years, which is pretty small.” When more expertise is needed, “We call on the doctors here.” After a student left abruptly, Dr. George Ceremuga followed up with the school counselor.
Kiara Blough, a second-year, saw a woman who had hypertension, thyroid disease, headaches, pre-diabetes, and anemia. Her father had died of diabetes. Displaying a list of medications, the woman said she took them sporadically. The patient struck Kiara as motivated and needing help to coordinate her care. The medical team took her history and vitals, and helped her focus on specific ways to improve her health through diet, regular intake of medications, and doctor visits.
The sole patient on the first day at the men’s screening area was a 37-year-old construction worker. Receptive and curious about “getting healthy,” the man said he’d been eating a high-carb, high-fat diet and had gained weight. He wanted to move toward a healthy diet and return to a regular exercise regimen, which used to include running. He was counseled about diet and exercise and given printed information and resources. The man’s chief complaints were vision problems and itchy toes. Austin Forbes, a second-year, said the man described classic symptoms of glaucoma—seeing a halo that had appeared a few days earlier. After examining the patient, the medical team consulted Dr. Dave Gray, and they came to a diagnosis of glaucoma and athlete’s foot. “We wanted to refer him for ultrasound here, but he had a prior engagement,” Austin said.
Offering easy stretches to relieve a long history of back pain
Andrew Wojtanowski, a second-year, used his ultrasound skills in the imaging section. While not always diagnostic, “We can use ultrasound to rule out things,” such as masses. “We get certain negatives out of the way,” he said. When there were no patients, Andrew benefitted from imaging other medical students as he worked with Dr. Phil Sullivan. Another doctor allowed the medical students in ultrasound to take a look at his artificial lens.
As part of the educational experience, Dr. Jan Pryor from the Utah campus, an expert in osteopathic manipulation treatment, worked with students to offer OMT to patients and to the medical team. This included working with a teenage male who enjoyed playing basketball but had a long history of low back pain, which sometimes made it difficult for him to play. In addition to appropriate OMT, he received instructions on some easily performed stretches that he could use as part of a routine to lessen the frequency and severity of his pain.
Dr. Cody Guggenmos contrasted the Reservation to other communities where he has traveled to deliver health care. In Ecuador, for example, those living in the High Country are likely to have both family support and jobs, whereas jobs are scarce at Pine Ridge.
Rohindeep (Harry) Singh, a second-year, noted, “They’ve been repeatedly duped by the U.S. government,” and it’s difficult to muster ways for the economy to thrive. “They have land but pervasive poverty.” Endeavors such as those undertaken by the Thunder Valley cooperative are aiming to rebuild the culture and the economy, Harry noted.
At Thunder Valley, Andy Iron Shell had told the group, “It’s not an endemic Indian problem. It’s a systems problem.” Improve systems of health care, agriculture, business, housing, marketing, and education to call forth transformation. Confronting dysfunctional systems, the cooperative “launched into hundreds of hours of listening and visioning sessions with our community. We engaged youth, elders, political leaders, parents, together to plan a vision for our future. We challenged our community to think about what was possible instead of the challenges that would get in the way. We took all that information for our community and began to plan a Regenerative Community… that has Oglala Lakota creativity, imagination, and interests at the center of its design.” ***
Second-year Lexi Lee said that the Reservation reminds her of inner cities where she has encountered food deserts. “There they can’t afford fresh vegetables; here they can’t get them [because stores don’t stock them] unless they are willing and motivated to grow them.” Lexi was impressed when visiting the Oyate Teca Project and learning about its Medicine Root Farmer’s market.
Oyate Teca offers green gardens, a greenhouse, year-long gardening classes for adults, as well as instruction in financial literacy, traditional food storage, and seasonal entrepreneurship. The project’s Executive Director Rose Fraser said the Medicine Root Farmer’s Market offers fresh produce, jellies, jams, dried meats, salves, lotions, salsas, and starter tomato plants to take home. Classes on how to grow indigenous foods at home are given.
A native-led non-profit, the Oyate Teca Project was founded 25 years ago for the benefit of Lakota youth and their families. Financially supported by Running Strong for American Indian Youth and private donors, Oyate Teca has a youth center, and provides homework help and prom dresses. Classes include instruction on Star Quilts, hand drums, and beading techniques. Rose said, “We help reconnect children and families with traditional Lakota cultural values and arts and crafts.”
Molly Hunsberger, administrative assistant for the RVU global track, observed each of the medical stations, and she noted patients who seemed “super-excited about the time we spent with them. It’s not-boom-boom-boom.” Molly has volunteered previously at Pine Ridge for projects with her church, and she stated that RVU’s health fair could nurture trust and more participation from the community but only if it continues year-after-year.
Time with patients isn’t boom-boom-boom!
Dane Rana, a second-year, speculated that the dearth of patients might be related to the need for approval from elders. Whatever the reasons for the sparse turnout, Dr. Jill Pitcher observed that the total number of patients understates the event’s value for both medical students and patients. Doctors of Osteopathy are trained to listen. She emphasized, “The need is to slow down, to zero in on the patient’s particular needs. DOs are trained to engage the patient wherever they are.”
First- and second-year medical students have a unique opportunity at the health fair to interact with patients, Dr. Pitcher said. The students have good medical knowledge from classes. “With actual patients, their challenge is to lift that knowledge out and apply it to a given person. They get to translate their skills to a patient from the community.” Non-urgent care, which is typical at a health fair, can also be of enormous benefit to the patient. They receive what may be a novel experience: discussing health care with someone who listens. “Listening opens the door for education, prevention, and treatment,” said Dr. Pitcher.
To plan the RVU health fair, Dr. Ceremuga, who practices holistic medicine in Rapid City, met beforehand with Pine Ridge leaders and Dr. Bentley, who directed the health fair. Among the community partners on the Reservation were Pahin Sinte Owayawa/Porcupine School, Re-Member, Oglala Lakota School of Nursing, and Medicine Root Farmer’s Market/Oyate Teca Project.
Dr. Bentley’s sway at RVU will boost the medical school’s continuing relationship with this particular tribe. She is a DO, Chair of the Department of Tracks and Special Programs, Director of the Global Medical Track and Medical Outreach, Professor of Primary Care, and President of Hands for Health Foundation/ Achieving New Heights in Medical Education.
Other RVU students were Kayla Gray, Krysta Sutyak, Austen Anderson, Alexis Grasse, Annie Szmanda, Michael Klepadlo, and Sarah Peterson. Yoga teachers Luke Willis and Carol Sullivan offered yoga to Porcupine students and families. Luke emphasized yoga postures that build strength and flexibility in athletic pursuits, and Carol led breathing exercises and yoga to alleviate stress and abide in calm.
Looking uphill, feeling so short, or back downhill to see where I came from
Jen Daniels, a first-year, compared the tendency to feel inadequate as a budding health care provider to “looking uphill, and feeling so short.” However, she said that this health fair offered her “a chance to look back [downhill] to where I came from, and to use the tools that I have learned so far.”
Similarly, the medical team gleaned a wider perspective. Dispensing no pity, medical students, doctors, and other volunteers were able to experience the strength and fortitude of the Reservation. Dr. Bentley observed that what held true for this trip applies to the next one, “The RVU students are all committed and are excited to volunteer their weekend for the event.”
In the evening after the health fair in May, the NGO Re-Member, which has worked for 25 years on the Reservation, hosted a dinner for the RVU medical team and for newly-arrived Re-Member volunteers from churches, schools, colleges, and corporations. Director Ted Skantze said that Re-Member volunteers from across the country usually work for one-week stints, helping to build housing, bunk beds for children, outhouses, and trailer skirts. The dinner included plenty of traditional Indian fry-bread. Stories were swapped by Pine Ridge residents, Re-Member volunteers, and the RVU medical team.
A Lakota singer performed, and what transpired epitomized serenity, truth, and beauty. After dinner he guided the group to form a big circle, hold hands, and dance. His drumbeats and soulful chanting permeated and uplifted the gathering.
Circles are auspicious in Lakota culture. In fact, the regional development plan that is being nurtured by Thunder Valley is called Oyate Omniciye, which may be translated as “The Circle Meetings of the People.” According to the Thunder Valley web site, regeneration began with conversations among a small circle of Lakota Elders who gathered to talk about what Lakota people do when getting together to plan something important. “During the conversation another dialogue emerged about whether the Lakota language had a word for ‘sustainability.’ Ultimately, the group came to the simple words: OYATE OMNICIYE…the Circle Meetings of the People.”
This trip from Rocky Vista University to Pine Ridge has created circles of medical students, their professors, and other volunteers as they work with the Lakota community which is itself planning and sustaining something important. At day’s end, the planning, the people, the pathways of the Lakotas, their visitors, the land, and the Black Hills encircle the horizon, ablaze in luminous colors of blue, purple, pink, and red.
* The Pine Ridge Indian Reservation (Lakota: Wazí Aháŋhaŋ Oyáŋke), is an Oglala Lakota Native American reservation in South Dakota. Originally included within the territory of the Great Sioux Reservation, Pine Ridge was established in 1889 in the southwest corner of South Dakota on the Nebraska border. Today it consists of 3,468.85 square miles of land and is the eighth-largest reservation in the United States, larger than Delaware and Rhode Island combined. — Wikipedia
** South Dakota Department of Tribal Relations. www.sdtribalrelations.com/docs/oststatprofile2011.pdf
*** Thunder Valley Community Development Corporation (TVCDC) states, “Our mission is ‘Empowering Lakota youth and families to improve the health, culture and environment of our communities, through the healing and strengthening of cultural identity.’” —thundervalley.org. Tatewin Means recently became the cooperative’s new Executive Director. She has served on TVCDC’s Board of Directors and was the organization’s legal counsel over the past year. Also see former Executive Director Nick Tilsen’s TED talk, “Building Resilient Communities.” July 14, 2015. Tilsen is currently on Thunder Valley’s Board of Directors. https://www.youtube.com/watch?v=e2Re-KrQNa4
www.4aihf.org/id40.html American Indian Humanitarian Foundation.
www.oyatetecaproject.org Oyate Teca Project, Kyle, Pine Ridge Reservation, SD.
www.olc.edu/departments/nursing.htm Oglala Lakota School of Nursing.
www.porcupineschool.org Pahin Sinte Owayawa/Porcupine School
www.re-member.org Re-Member, Pine Ridge Reservation.
www.sdtribalrelations.com South Dakota Department of Tribal Relations.
indianyouth.org Running Strong for American Indian Youth.
www.thundervalley.org Thunder Valley CDC, Porcupine, SD.
en.m.wikipedia.org/wiki/Pine_Ridge_Indian_Reservation Pine Ridge Indian Reservation