Editor's note: This is the first part of a two-part series.

SISSETON — All it took in spring 2024 was two small, unrelated medical service interruptions to put women’s health at risk and expose the fragility of the health care system in rural and reservation communities across South Dakota.

First, the local public hospital in Sisseton, the Coteau des Prairies Health Care System, cut back its OB/GYN program and stopped delivering babies due to relocation of its obstetrician, high expenses and because a low number of annual deliveries raised concerns over the expertise level of existing medical personnel.

Meanwhile, the Indian Health Service hospital in Sisseton, a reservation community of 2,400 people in the northeast corner of South Dakota, for a time did not have anyone certified to operate its mammogram machine.

While the public hospital and IHS took steps to minimize the disruptions, it became more difficult for female tribal members to get screened for breast cancer. And any pregnant woman who wants a hospital delivery will now have to drive an hour to Watertown or to Fargo, North Dakota, to give birth.

"When it comes to obstetrics in northeastern South Dakota, we're in a maternity care desert here right now," said Sara DeCoteau, tribal health coordinator for the Sisseton-Wahpeton Oyate tribe.

Similarly, when a physician at a Horizon Health clinic in Bison moved to Sioux Falls, it took nine months to find a replacement doctor.

"When one thing breaks in the chain, it creates this question all of a sudden of, 'Now what do we do?'" said Wade Erickson, CEO of Horizon Health, “because everybody, regardless of where you live, work or raise your family, deserves access to primary health care."

And yet, many rural and reservation residents in South Dakota and other states are suffering devastating, often preventable, negative health outcomes.

Long driving distances, a shortage of medical staff and the expense of maintaining medical facilities in low-population areas all prevent the estimated 46 million Americans who live in rural areas from getting the health care they need to live healthy lives.

According to a recent study by the Centers for Disease Control and Prevention, the death rate in rural areas of the U.S. was 21% higher than in urban areas in 2019, and the mortality disparity grew larger over the past decade despite major improvements in medical care and technology.

Death rates in rural areas were higher than urban areas for heart disease, cancer, injuries, respiratory disease, stroke, diabetes, suicide and other causes, the study found.

"Rural health is America's health, and we need policymakers to understand that the American Medical Association (AMA) is deeply concerned about the ever-widening health disparities between urban and rural communities," said Bruce A. Scott, M.D., president-elect of the AMA.

Problems magnified on reservations

Data from the South Dakota Department of Health (DOH) illustrate the depth of the health care disparities between Native and non-Native residents of the Rushmore State.

The DOH reports that while 50% of white South Dakotans will die before the age of 80, half of all Native Americans in the state will die before the age of 58. Native Americans have much higher rates of cervical cancer, lung cancer and incidence of syphilis, a growing health crisis in reservation areas.

Native American infant mortality (17.2 deaths per 1,000 births) is more than four times higher than for white infants (3.9 deaths per 1,000 births.)

A 2022 report by the American Hospital Association said access to health care in non-urban areas has worsened due to the closure of 136 rural hospitals in the U.S. between 2010 and 2021..

Scott added that the health care industry must also acknowledge, and work to overcome, barriers that many Native Americans face.

"We have to recognize, and the AMA is acknowledging upfront, the years of discrimination and racism that these populations have faced," he said. 

State launches mobile health program

The state health department recently launched a new program, called Wellness on Wheels, to provide mobile health services to rural communities, particularly those "facing socioeconomic barriers and social determinants of health."

DOH Secretary Melissa Magstadt said the five mobile clinics will provide immunizations, testing for sexually transmitted diseases, and birthing and parental services to bridge gaps caused by geography and lack of available services in rural areas.

"It's literally returning to the roots of taking health care out to the patients," she said.

In South Dakota, only 15 of 66 counties did not have a shortage of primary health care providers in January, according to the state Office of Rural Health. The vast majority of the underserved areas are outside urban centers.

The Association of American Medical Colleges recently estimated that the U.S. will see a shortage of 87,000 physicians nationwide by 2036, due in part to mass retirement of aging doctors and a lack of medical school graduates to replace them.

Long distances create barriers

The issue of geographical challenges and the need to travel to get preventative, emergency or specialist care has hampered health care access in rural areas for generations, and the problem is particularly acute in reservation communities where poverty rates are far higher than average.

"Outside of (cities), a gas card can be the difference between life and death,” said Michelle Comeau of the Great Plains Tribal Leaders' Health Board.

On the Crow Creek Indian Reservation and the Lower Brule Indian Reservation just across the Missouri River, both home to main cities with about 1,000 population, primary health care is administered at IHS clinics that are open from 8 a.m. to 4:30 p.m. Monday through Friday. 

In Faith, a ranching town of 600 in west-central South Dakota, medical care is available at a Horizon clinic only during daytime hours Monday through Thursday. If the clinic is closed or specialist care or surgery is needed, patients need to make a 250-mile round trip journey to Monument Health Rapid City Hospital.

Erickson said stronger relationships and greater cooperation among rural clinics, small-town hospitals and major health providers are one way to reduce barriers to rural health.

"It's not OK as it is. And we have to figure out a way to fix that because people don't just get sick from 8 to 5," he said.

This article was produced by South Dakota News Watch, a nonpartisan, nonprofit news organization, online at sdnewswatch.org, where readers can sign up for an email to get stories as soon as they're published. Contact Bart Pfankuch at bart.pfankuch@sdnewswatch.org.