BuzzFeed News reporter Nidhi Subbaraman knew almost nothing about the long and troubled history of tribal health care in the United States when she began covering the lawsuit that the Rosebud Sioux tribe was bringing against the U.S. government for its failure to provide treaty-mandated health care to tribal members. As she dug into the story during the summer of 2016, she read “seriously horrifying stories” of substandard care, neglect, and the human toll that the lack of basic medical care had taken. At hearings in Washington, DC, Subbaraman remembers, “There were people coming up to the mic and openly weeping about family members that they’d lost because, the way they saw it, they hadn’t received basic attention when they needed it.”
When she learned that the Indian Health Service (IHS)—part of the U.S. Department of Health and Human Services (HHS)—would be holding its next annual meeting in Rapid City, South Dakota, the following week, she booked a ticket to the Great Plains so she could attend the meeting, visit tribal areas involved in the lawsuit, and learn how both sides were addressing the crisis.
The trip turned out to be revealing in ways Subbaraman could not have imagined. While IHS officials mostly stonewalled, Subbaraman’s conversations with tribal health board representatives and, later, Rosebud community members uncovered a narrative of not only hurt and outrage but also resilience and activism.
“The Tribe That’s Suing the U.S. Government to Keep Its Promises” was published by BuzzFeed News on November 17, 2016. Here, Subbaraman tells TON editor-in-chief Siri Carpenter the story behind the story.
How did you end up reporting this story?
I started looking into healthcare as it affects the tribes when we got a tip from a reporter on the campaign trail, about something quite different. It was about a loophole in the Obamacare mandate, which said that tribes were required to provide health insurance for tribal members. Some felt that this was an unfair imposition on tribes, especially because many tribal members actually have access to federal healthcare.
So this is the first that I learned that many rural reservations have facilities where most or all of their members went to get basic services. But when I was reporting this story, nobody wanted to talk about the Obamacare loophole—the bigger story on everybody’s mind was the fact that the system was broken. There were all these awful anecdotal stories about substandard interactions that patients had with doctors at these facilities. And so I said, “Oh, maybe since 16 people pointed that out as a problem I should look at that instead.”
I did end up writing the other story, in June of 2016. But then quickly Googling the issue of tribal health care, I found that earlier that year, the Indian Affairs Committee in the Senate had a bunch of hearings where they had invited tribal health representatives from various reservations to testify about the state of health care on the reservations. There were videos of these hearings on the Hill. And on the one hand there were these very controlled people laying out a litany of just horrifying anecdotes; and then in these listening sessions, there were people coming up to the mic and openly weeping about family members that they’d lost because, the way they saw it, they hadn’t received basic attention when they needed it. (This interview has been edited for length and clarity.)
“There were people coming up to the mic and openly weeping about family members that they’d lost because, the way they saw it, they hadn’t received basic attention when they needed it.”
And this didn’t seem to be a new problem. Back in 2010, more Googling revealed, there had been this investigation. The chair of the Indian Affairs Committee, a North Dakota senator at the time, had produced a 70-page report that again had seriously horrifying stories, about a woman who was discharged from the outpatient clinic and gave birth in a bathroom stall, and about a nurse who had a drug habit and was assisting in surgeries when she was high. This just seemed really incredible, the fact that this had been recorded but the same sort of stories kept coming up, six years later.
In August, I learned that there was [another] meeting happening in Rapid City. The Indian Health Service essentially was taking its annual meeting to the Great Plains, to the center of this crisis—it was a forum for exchange of information between the agency and the tribes themselves. So it seemed like a good opportunity to go there to see how both sides were addressing this narrative that had been developing over the past several months. And it also made sense to combine that with a reporting trip to the reservations themselves, which were a couple of hours’ drive from Rapid City.
What made you decide that this story was worth investing in for BuzzFeed News?
It didn’t really seem to be getting coverage. The local AP reporter would cover it, the local papers would have sort of incremental updates about the status of these facilities, but no one had sort of zoomed out and taken a look at both the descent into crisis and the team at Rosebud [one of the affected reservations] that, as I’d been learning, had been actively trying to make the situation better.
Also, the fact that there was so much documentation about contentious claims really helped. There was a paper trail of all of the bad stuff that was happening. There was the report in 2010, there was a whole host of [Office of Inspector General] reports from the HHS, there were the [Centers for Medicare & Medicaid Services] reports, and now there was this lawsuit. But nobody had taken the story approach that put all of these pieces together.
Before you went to South Dakota, how much time did you spend getting up to speed about the treaty history that’s a central issue in this story?
We decided that I’d make the trip about a week before it actually happened, so much of my reporting prep had to do with logistics … which routes do I take to get to Rosebud, where are the gas stations, where’s the last Subway. And I hadn’t actually realized how central the treaty issue was to the story and how central it was to the argument that the tribe was making in its lawsuit. So a lot of that I learned later.
What did you see at the IHS conference? Was there open discord between the IHS officials and the tribal health board representatives there?
That was very interesting. For the most part, it surprised me that the opening remarks from agency administrators was extremely cordial. In a way, it almost didn’t acknowledge the crisis that they had sort of arrived here to talk about. It was valuable to see this difference between the stories that I’d been hearing from tribal health representatives—which were very raw and very angry—and how the agency representatives seemed to almost not address it. They were very chipper, talking about new programs and new directions, and barely acknowledging that they were at the physical epicenter of this crisis.
What did you hope to learn at the meeting?
I thought this would be a chance to get an insider’s tour of an otherwise opaque and mysterious agency. I wanted to know about the roles of local administrative heads, who they reported to, what the management chain looked like up to HQ. I wanted to understand how this lofty federal mandate to keep tribal members in their best health translated to day-to-day basics: How did the money flow to reservations? Who were the key administrators? Where did they work? What role or power did the doctors have among the bureaucrats?
I also wondered how the agency suits would reply to the tribal members who brought up these heartbreaking stories.
Were you able to report freely at the conference?
I was quickly told by the agency representatives that dealt with press queries that most of the rest of the day and a part of the next day would be closed to press. So that was a wrinkle.
How did you deal with that?
I called Ginny Hughes, my editor, and we talked about it. It seemed like if I sat in the foyer and did all of my interviews with the tribal representatives who were coming out of meetings, that would fill in for what I would be missing. We weren’t going to go in there and then have me thrown out, or whatever, because there were other ways to use my time at the conference that didn’t require a contentious interaction with the agency press rep. For example, there was the local nonprofit that served as an intermediary between area tribes and the IHS. I had a very good interview with the chair of that group, who is typically really busy. Also, the conference was a rare moment when most of the Rosebud group that was leading the reform effort was under one roof. So I got to speak to them too.
[The IHS] did also give me an eight-minute interview with the acting head of the agency, but that was me in a conference room with several representatives, and I was shuffled out as soon as the eight minutes were up. And I was told in advance that I couldn’t ask her about anything that she hadn’t already presented about in the morning. So it gave me a sense of how the agency was going to respond to the story.
Besides the conference, you were in South Dakota to see what was going on in some of the tribal communities and at the hospitals where the crisis was centered. How did you decide to focus on Rosebud?
Rosebud was high on my list because I’d already spoken to one of the lead characters in the story, O.J. Semans, for a different story, so I knew I’d have a guide who would show me around and sort of be available to talk to me about the issue once I was on site. I actually started in Pine Ridge, though—I landed and rented a car and drove straight to Pine Ridge for a reporting day at the hospital there, which was the other hospital in South Dakota which had also been facing problems. But I was somewhat unsuccessful.
Why is that?
I was an unfamiliar face with a recorder and a notebook, and people were very, very wary of talking to me. And those people who did talk to me didn’t want their names in the story. And I didn’t have much time to spend there. So my focus turned to Rosebud because I was able to talk to more people there and have more consistent contact with the folks there.
How much time did you spend in Rosebud?
It was just a day. I drove down early morning and stayed for the day, and then drove back in the evening.
That’s surprising. The story paints a very textured picture of the places you visited, which makes it seem as if you must have spent more time there. For example, there’s a scene where you go with O.J. Semans to a cemetery on the reservation:
A few minutes up the road from the tribal headquarters, Semans turned his silver truck up a mud path to a reservation cemetery. On a hillside of yellow prairie grass, a tall, fenced-in headstone memorializes Chief Spotted Tail, who led Sioux warriors in battle against the US Cavalry in the 1850s and 60s. On April 29, 1868, in what would be called the Treaty of Fort Laramie, Spotted Tail and other Sioux leaders agreed to make peace with the US government.
“We would allow settlers to cross through the Oregon trail without killing them,” Semans explained. And in exchange, the US government would provide a few things to newly demarcated native settlements, including a blacksmith, a school, and a physician.
The cemetery visit also provides an anchor for more historical context about the health disparities that today affect tribal communities and the legal basis for the establishment of the Indian Health Service. Did you know all that when you went to the cemetery?
That was all O.J. I didn’t know about Chief Spotted Tail, I didn’t know about the treaty, and so I didn’t know about the history, and O.J., I think, was aware that he was a guide for me, and he very deliberately showed me around and pointed things out. He was really great, and I think he was very savvy about being available and talking and being up-front and frank, and knowing that he would be in the story as a character.
“My goal was to absorb anything that I could because I knew I just had this one shot—there’s no way I was coming back through South Dakota before I wrote the story.”
You open the story by introducing Kathy Boyd and describing the cardiac emergency that she suffered. That opening sets readers up to appreciate the gravity and the personal cost of the federal government’s neglect of tribal health. How did you learn about Kathy Boyd?
Learning about Kathy Boyd was really just blind luck. I didn’t actually learn about her until very late in my reporting. I had been speaking to [Evelyn] Espinoza, the tribe’s health director, several times by that point. Everybody I spoke to, generally I would ask them, “Do you know anybody who has had a bad experience with the system whose story I might include as a for-instance—an example of something that went wrong?” And like our fourth or fifth conversation, Evie said, “Oh, you know, my mother-in-law went through this and she was one of the cases that was mentioned in the reports.”
Then I asked, would she be willing to talk to a reporter? And surprisingly, she said yes. And then Kathy was very willing to share her memory of the experience with me. Her story was really powerful and it was so representative of the problems that had come up so many times before. her case was so helpful to the story was that it wasn’t just the family claiming she had a bad experience—which a reasonable person would agree seems bad—but the inspectors from CMS had also ratified that assessment, pointing to her case in the report as an example of what was going wrong.
And on top of that, it’s so rare that you have so much detail of a person’s case. I’d read her case, I was familiar with the information, I just didn’t know it was her. So I guess it was just happenstance that the person who had been flagged in this agency report, I was able to reach her.
Was all of this after you went home from South Dakota?
Yes. All of my reporting with Kathy was on the phone, and she literally had no cell service, so I had to call her on her drive back from work in the evenings. We’d talk for a while as she drove back home, and then as she got close I would have to wrap up or she’d just go dark. We spoke several times about what she remembered. I also talked to her husband and to Evie, [both of whom] had been there that evening, and I was able to piece together a reconstruction of what happened.
Did you know right away that Boyd’s story would be your lede?
Initially, actually, it wasn’t that elaborate at all. In my first draft, it was sort of a quick illustration of what she went through, and then I very quickly went into the investigative reports. I think I had sort of woven in the time stamps and details from the records, just alluding to them initially not in any systematic way. Ginny read the story and encouraged me to kind of slow it down, so it registered as sort of a tick-tock. And she had this idea to break Kathy’s story in half and present half of it in the beginning and present half of it [about her now waiting for a referral to a pulmonary specialist] at the end, which I thought was really effective in terms of reminding the reader that this is an ongoing problem.
Your tour of Rosebud Hospital, again with Semans, paints a pretty dreary picture of what the place is like—especially of the severe understaffing there, and what that means for patients. Those details give readers a visceral context for the later discussions of the lawsuit and the investigations of the place and the Indian Health Service’s handling of complaints. How did you approach your reporting at the hospital?
My goal was to absorb anything that I could because I knew I just had this one shot—there’s no way I was coming back through South Dakota before I wrote the story. So I had one phone that was recording, I had one phone taking photographs, and I tried to write down anything I saw, with the [idea] that a physical tour of the hospital was going to be a key part of the story. You need to be there to understand why this is important and why these are questions that people are even raising—the fact that it’s rural, the fact that there are so few people in this huge plot of land, and it seems so forgotten.
I also needed [O.J.] there because I was pretty sure they would kick me out of the facility if I didn’t have somebody with me from the tribal health board saying that I was there as their guest. So I was glad that he was able to be there, and it also made sense for him to point out the things that he’d told me on the phone so I could both see it for myself and also present it in the story later.
What was the hardest aspect of reporting this story?
One challenge was that at the time, I was new to reporting on federal agencies and I wasn’t aware of how reticent they could be in engaging with reporters’ questions. So I tried very hard to have the agency respond to very specific questions and very specific queries that the community had—either to acknowledge that they exist or to say if they were working to improve them. I always got these on-background responses that almost never addressed the question. There’d just be paragraphs of background info that almost didn’t acknowledge the question at all. I have since realized that this is not perhaps surprising for an agency, but at the time for me it was somewhat frustrating.
Did you push back?
There was a lot of pushback. I had multiple phone calls with the press lead on background—or off the record, depending on what she wanted—about why it was important that their side be presented in the story. We went off-record [or] on background only if she insisted. I tried very hard to keep everything on-record, arguing that otherwise we would not be able to add any of it to the story.
I made every effort to request specific answers to questions, and I made multiple requests by email for them. Before the story published, I also sent them a detailed list of every fact pertaining to the IHS that was presented in the story, in bullet point form, to allow them to correct any numerical inaccuracies or vocabulary errors, but also to [let them] have their say if they chose to.
What worried you the most when you were working on this story?
I was worried that I was reporting on a community that I was not a member of. I was worried that I was hearing these stories of hurt and neglect and outrage, but I also didn’t want to present the community as victims—I wanted their activism and their engagement with the problem to be really clear.