Native American Healthcare Series (Lee Newspapers)
"PEOPLE DIE LIKE THAT" Part I in a series entitled "Gone Too Soon", by Nora Mabie, Missoulian, January 16, 2024. (Part II, click here) (Part III, click here)
CROW RESERVATION — When doctors in Billings told Ursula Rides Horse-Russell she had Stage 2 breast cancer, her mind went blank. She had buried her 34-year-old son two days earlier.
She couldn't remember who came to the funeral or who sent condolences. Navigating a new and scary diagnosis felt impossible.
Doctors surgically removed her cancer but told Ursula she'd have to travel to Billings several times a week for chemotherapy — 50 miles each way.
For Ursula and her husband Barry, Ursula's care presented a logistical nightmare.
To drive from their home in Hardin to doctors in Billings, Ursula and Barry would need a reliable vehicle and money for food, gas and possibly a hotel — none of which they had.
And Ursula and Barry's children have health issues of their own. Like many grandparents in tribal communities, they raise their three grandchildren full-time. That means they'd also have to find trustworthy care for the kids when traveling for Ursula's appointments.
Moving to Billings could make things easier, but how would they find affordable housing and good schools for the kids? And could they leave their community behind?
At 63, Ursula is three years older than the average age at which Indigenous women die in her county. When she learned her diagnosis, she knew she'd have to fight more than just the cancer to survive.
"I knew I had to live for my grandchildren," she said. "We're the only parents they know."
Ursula, who is Crow, is one of thousands of Indigenous people in Montana who face serious barriers accessing the health care they need to live.
Native Americans have the lowest life expectancy of any racial or ethnic group in the U.S. In Montana, where Native Americans comprise 6.7% of the population, Indigenous people die a generation younger than their white neighbors.
Experts say inadequate care, food deserts, discrimination at the doctor's office, harmful U.S. policies, poverty and rurality are among the factors contributing to the crisis. And while tribal leaders have raised the issue for years, they say improving health outcomes is not a priority among state and federal leaders.
Indian Health Service, the federal agency responsible for providing health care to federally recognized tribes, is chronically underfunded and doesn't administer specialty care. So, depending on where one lives on the reservation, a person may have to travel hours for things like cancer treatment, behavioral health services or even to deliver a baby.
In a place where almost 30% of people live below the poverty level — more than twice that of Montana and the U.S — traveling for health care comes at significant cost. There's gas money, vehicle maintenance, child care, time off work.
Rurality isn't the only issue — Native Americans in Montana die, on average, 17 years younger than the state's white rural residents. A deep-seated mistrust of the Indian Health Service means community members may avoid getting the care they need. And while Indigenous people are more likely to die from heart disease, cancer, diabetes, liver disease, stroke and suicide than their white neighbors in Montana, they must rely on an overburdened, underfunded system of care.
Despite these challenges, however, community members fight for solutions to help each other survive.
'Gas is very precious': Distance to care No. 1 challenge
The most significant barrier community members face in accessing care is transportation, according to LeeAnn Bruised Head, director of the Crow Tribal Health Department.
"We live in poverty here," she said. "A lot of people don't own cars, and if they do, gas is very precious."
While several programs offer transportation or financial assistance, they don't come close to meeting community needs. Some organizations distribute gas cards to help people get to appointments. Tribal transit takes people to Billings in the mornings and evenings. And while the tribe can provide limited financial support to members, members must first submit their medical records to people in leadership. In a close-knit community where rumors spread fast, some are hesitant to share their medical records for privacy reasons.
Tribal transit didn't run at convenient times for Ursula's appointments. And she didn't feel comfortable giving the tribe her records, so Barry drove her to most appointments.
"I'm mad at the tribe," Ursula said, adding that she felt like she had to jump through hoops to get the support she needed. "We do everything ourselves, and we're doing the best we can."
It didn't take long for their frequent trips from Hardin to Billings to become precarious.
When it snowed, Ursula made Barry promise to drive slow, sometimes making their trips take twice as long. They often brought their grandchildren in tow, but with school and homework, that was difficult, too. With winter temperatures reaching 20 below zero and slick roads, sometimes Ursula and Barry would get stuck in Billings and have to pay for a hotel.
Other times, Ursula couldn't get to her appointments at all.
In October — six months after her diagnosis — Ursula, Barry and their three grandchildren secured affordable housing in Billings and made the move. Though she's glad to be closer to care, Ursula said moving was hard on her family.
"We don't hardly know anybody here," she said. "We keep to ourselves. The only ones we know are our doctors, nurses and pharmacy people."
While she and Barry drained their savings on countless trips to Billings, uprooted their family and left their community to live closer to doctors, they count themselves lucky.
They both know that if they hadn't been able to travel in the first place, doctors may not have found the cancer in time to safely remove it.
"A lot of people die like that," Ursula said.
'You'll die': IHS wields bad reputation
Prior to her cancer diagnosis, Ursula regularly made the 50-mile-drive to a hospital in Billings for her persistent chest pain.
While chest pain can be urgent, she didn't even consider going to the Indian Health Service (IHS) facility 15 miles away because she, like many community members, doesn't trust the federal agency.
Sidney "Chip" Fitzpatrick, who lives on the Crow Reservation, said growing up, his grandfather would tell him not to go to IHS.
"He said, 'They'll get you sick, and then you'll die,'" Fitzpatrick recalled, adding he avoided IHS for more than 20 years until a knee injury forced him to go.
Tribal leaders have urged members of Congress to increase IHS funding, improve services and enhance staffing for decades to little avail. Frustration is so high that one Montana tribe recently called for the removal of several IHS state and national leaders. Past unethical health abuses at IHS also have far-reaching consequences. A recent federal report cited the forced sterilization of Indigenous women as yet another reason why people remain skeptical of the agency.
It doesn't help that other policy decisions undermine this unique system of care. The unwinding of Medicaid has disproportionately hurt Native Americans nationwide, and a recent sober-living fraud scheme took advantage of Indigenous people in Montana. Last month, the state health department quietly eliminated the tribal relations manager position, sparking outrage among tribal leaders who said improving health outcomes just isn't a priority in the state.
'We accept no for an answer': Cultural differences in care
Tribal health professionals and community members say providers at IHS, an agency established specifically for tribes, need more training on culturally sensitive care.
For cultural reasons, Indigenous people may avoid eye contact with medical providers, which can be misinterpreted as a sign of disinterest. And community members say advocating for themselves in the medical space can feel uncomfortable.
Anna Whiting Sorrell, a citizen of the Confederated Salish and Kootenai Tribes, previously served as director of the Montana Department of Health and Human Services. She was also the IHS Billings Area director and an administrator for the tribal health department on the Flathead Indian Reservation.
When she worked for the state, Whiting Sorrell watched as non-Native families fought insurance companies, sometimes appealing to the governor's office until their issue was resolved.
"I was like, 'Wow. People do that?'" Whiting Sorrell recalled. She suspects self-advocacy doesn't come easily for Indigenous families, in part, due to historical trauma.
"We accept 'no' for an answer," she explained. "It's a belief prevalent in our tribal communities because we've been told 'no' to health care through IHS and other systems."
'An uphill battle': The unique problems with IHS
In its last budget report, IHS said it would need nearly $50 billion to be sufficiently funded. The Biden administration last year allocated $9.3 billion to the agency — $40 billion short of the request but still the largest investment in IHS to date.
Because IHS doesn't provide most specialty services, patients get referred to bigger hospitals, and IHS will usually cover the cost of care.
But that system can be unreliable, as community members know the agency can run out of money. IHS's funding is renewed at the start of each fiscal year in October, so patients have a better chance of getting a referral at the beginning of the year rather than at the end.
The agency also struggles to attract and retain doctors, nurses and behavioral health clinicians — problems that are exacerbated by a lack of housing and employment opportunities on the reservation.
And despite incentives that repay student loan debt in exchange for working at IHS, Levi Black Eagle, secretary of the Crow Tribe, said community members see non-Native medical professionals leave time and again.
"Say you have an outsider who comes in and wants to make a difference in this community," said Black Eagle. "They get here and it's an uphill battle. They have all these things working against them, and they're going to leave."
With limited staff at IHS, community members often see a revolving door of providers and face long wait times to schedule appointments.
Tribal health employees said in November that if someone wanted to receive behavioral health services or counseling, they'd have to wait between six months and one year to get in the door. Without someone to talk to, community members say too many people turn to drugs and alcohol to self-medicate. In 2020, 70% of Crow middle school students reported drinking alcohol before age 13, and chronic liver disease was the second-leading cause of death for Crow community members ages 18 to 54 from 2015 to 2019.
Lisa Daychild, who works at the Lodge Grass School District, lost two brothers and one sister — all in their 40s. Two died of addiction and one from suicide. She often wonders whether more resources, behavioral health or otherwise, could've saved them.
"I always think about that," she said, shaking her head.
'Someone they trust': Seeking out solutions
Caught in a web of government bureaucracy and red tape, Crow residents say solutions are most effective when they come from within the community. When it comes to insufficient staffing at IHS, those community members want to see more pathways for Native Americans to pursue careers in medicine. Little Big Horn College on the reservation offers a pre-nursing program, but students must leave the community to earn more advanced medical degrees.
Black Eagle, the tribal secretary, said that while non-Native providers often leave after a few months or years, community members, who have established support systems, are more likely to stay.
Tribal leaders say it's imperative all medical and nursing students receive education specifically on providing health care to Indigenous people. "Culturally sensitive care" refers to the idea that people of different backgrounds may face unique barriers in accessing Western health care systems.
Practicing this kind of care can look different in different contexts. It can mean doctors make space for Indigenous patients and their families to smudge. It can mean a provider understands that it's not uncommon for Indigenous patients' family members to attend appointments and do most of the talking.
Misty Wilkie, associate professor at the University of Minnesota School of Nursing, helped develop a virtual Ojibwe patient module to educate medical students on cultural differences. While this is a step in the right direction, she said increasing Indigenous faculty and enhancing programs for Native students is a must.
Because Native Americans face high rates of historical and ongoing trauma, Bruised Head, from Crow Tribal Health, said trauma-informed care is another crucial piece to the puzzle. Where culturally sensitive care acknowledges a patient's unique identity, trauma-informed care ad dresses a patient's entire life experience to provide quality care.
When done right, Bruised Head said trauma-informed care can promote healing and disrupt intergenerational cycles of psychological distress.
Crow community members say grocery stores, walking paths and health education outreach in schools would greatly improve health outcomes on the reservation as well.
Responding to a legacy of mistrust, Alma McCormick — executive director of Messengers for Health, a nonprofit that provides health education outreach on the reservation — said community members are more likely to listen to each other when it comes to important health decisions. It's why she goes door-todoor encouraging others to go to appointments.
"Our people need someone to reach out to them," she said. "Someone they know. Someone they trust. Someone that loves them and cares about them. That's the key."
Fitzpatrick, the man who once avoided IHS for 20 years, now does education outreach for Messengers for Health.
Fitzpatrick's cousin, who worked as a mechanic, died in his garage at 60. His uncle died on his doorstep. Another uncle died of a heart attack and another man close to him took his own life.
"They should have never died, but they did," Fitzpatrick reflected. "I was just thinking, they had to have had some pain. But they're so proud, they don't go to the hospital. When I hear that, I say, 'I better go get my blood pressure checked and get a colonoscopy.'"
And he tells others to do the same.
CROW RESERVATION:
BY THE NUMBERS
■ 55.8 – Average age at death for Native Americans on Crow Reservation (20032019).
■ 75.5 – Average age at death for white Montanans (2003-2019).
■ $51,250 – Median household income on Crow Reservation.
■ $66,341 – Median household income in Montana.
■ 1 : 3,340 – Ratio of mental health providers to people seeking care on reservation.
■ 1 : 300 – Ratio of mental health providers to people in Montana.
NATIONAL CONTEXT
■ Native Americans live 5.5 years less than the general U.S. population.
■ In some states, Native Americans die 20 years sooner than non-Natives.
■ Native Americans are 3.2 times more likely to die from diabetes than non-Natives.
■ Native Americans are 4.6 times more likely to die from chronic liver disease than non-Natives.
■ The Indian Health Service is responsible for providing health care to tribes.
■ 1 Dentist for every 1,645 people in the U.S.
■ 1 Dentist for every 9,259 Native Americans served by IHS.
■ 1 Dentist for every 9,259 Native Americans served by IHS.
ABOUT THE SERIES
Native Americans die a generation younger than their white neighbors in Montana. With support from the USC Annenberg Center for Health Journalism's 2023 National Fellowship, Lee Montana newspapers spent six months reporting on the factors that contribute to a lower life expectancy and what could help close the gap.
Today – A look at barriers to health care on the Crow Reservation.
Jan. 23 – How premature and preventable deaths affect residents of the Fort Peck Reservation.
Jan. 30 – How one woman works toward change on the Fort Belknap Reservation.
WHAT WENT INTO THIS PROJECT?
■ 3,105 Miles traveled in Montana alone
■ 6 Months of reporting
■ 72 Interviews
■ 71 Survey responses
■ 113 Facebook conversations
■ 296 Indigenous people in Montana provided insight
■ $6,575 Dollars spent
Nora Mabie reported this story while participating in the USC Annenberg Center for Health Journalism's 2023 National Fellowship which provided training, mentoring, and funding to support this project.
Part II "'You Don't Want to be Part of This Club': In Fort Peck, death has become part of life", by Nora Mabie, Missoulian and Billings Gazette, February 23, 2024.
WOLF POINT — Two weeks after burying her grandmother in the fall of 2020, Jen Medicine Cloud’s brother and sister were both hospitalized with COVID.
Jen’s sister was at the Mayo Clinic in Minnesota, and her brother, Scobey Baker, was at a hospital in Billings. She remembers when he called her crying the night before he was put on a ventilator.
“He was so scared,” she said through tears.
As an older brother, Scobey had always been Jen’s protector. While he’d struggled with alcoholism for decades, he’d been sober for the last two years. For his family, his sobriety felt like a gift.
Scobey died a few weeks later at 44 years old, leaving behind his 10-year-old son. After watching her brother fight to get sober, Jen said his death felt like “a cruel joke.”
“We got our brother back, and then he was just gone,” she said.
Native Americans have the lowest life expectancy of any racial or ethnic group in the U.S. In Montana, where Native Americans comprise 6.7% of the population, Indigenous people die a generation younger than their white neighbors.
Pre-COVID data reveals that, nationally, Native Americans die, on average, at age 71.8. In Montana, Native Americans die, on average, at 61. And on the Fort Peck Reservation, Natives typically die at 52.7.
Indigenous people in Montana are more likely to die from heart disease, cancer, unintended injury, diabetes, cirrhosis, respiratory disease, stroke, suicide, kidney disease and the flu than white residents. And when COVID came to Montana in 2020, Indigenous people were 11.6 times more likely to die from the virus than their white neighbors.
Experts say inadequate care, food deserts, discrimination at the doctor’s office, poverty and rurality are among the factors contributing to the crisis. And while tribal leaders have raised the issue for years, they say improving health outcomes simply isn’t a priority among state and federal leaders.
Located in the northeast corner of Montana and home to about 10,100 people, the Fort Peck Reservation stretches 110 miles long and 40 miles wide. There — where 26 could be considered middle-aged — a barrage of premature, preventable deaths tear at the living.
Schools and tribal offices close for funerals. On birthdays and graduations, people include visits to loved ones’ gravesites in their celebrations. Even as residents drive through the reservation on Highway 2, death dominates the landscape. Billboards warn of heart attack, suicide, alcohol, drug use.
Indigenous parents are dying in their 40s. Grandparents, who assume guardianship of their grandchildren, are dying in their 50s and 60s, leaving too many children and teenagers to grow up unsupported.
But some don’t get to grow up, dying young from car crashes, violence, addiction or suicide.
The cycle of premature death weathers and isolates Indigenous parents and grandparents on the Fort Peck Reservation. It disrupts the health, education and careers of young people, who, in the absence of accessible mental and behavioral health services, may turn to drugs or alcohol to cope.
Experts say these deaths steal from the workforce, contribute to homelessness, perpetuate violence and reinforce economic insecurity.
‘Take me!’: Premature death hurts families
On the same day as Scobey’s funeral service just down the road in Wolf Point, Frances Weeks was washing dishes and looking out her kitchen window when she saw her 28-year-old son, Cody, run by. She didn’t see the person chasing him.
Frances heard a gunshot. Then an ambulance siren.
She rushed to the hospital and found Cody laying in a bed. Her mind jumped to the days when he’d leap out to scare her in the hallways of her house.
“Let him be messing with me now,” she thought.
But then it hit her. Her son — who had been invited to four different proms, who had cheered his basketball teammates on when he was injured, who kept everyone’s secrets, who wanted to one day work with autistic children — was dead.
Frances fell to her knees on the cold hospital floor and screamed.
“Take me!” she yelled through tears. “Please!”
In 2017, homicide was the fourth-leading cause of death for Native American men ages 20 to 44. And from 2011-15, Native Americans in Montana were more than four times as likely to die from homicide than white Montanans.
Frances is 5-foot-7 and slender. Her copper hair has streaks of gray, she wears big, cat-eye glasses, and everyone calls her auntie or grandma. When Cody died, she stayed busy. She gathered community members to call for justice in his killing. She planned a funeral. She scrambled to arrange care for Cody’s three children.
She didn’t realize at the time that Cody’s sudden death put her other children at risk, too.
Annie Belcourt, Native American Studies chair at University of Montana, told Lee newspapers in July that violence, and the trauma and stress associated with it, can have far-reaching consequences, affecting someone’s health and quality of life.
“People who experience trauma may struggle with coping strategies,” she continued. “Maladaptive things may help them functionally avoid thinking about it. It could be substance abuse, gambling or working a ton to help you avoid thinking or feeling a complicated trauma response.”
Cody’s death rolled like a wave through the community and crashed on his younger brother Quentin.
Quentin, a strapping football star and Homecoming king at Chemawa Indian School in Oregon, returned to the Fort Peck Reservation when a close friend died by suicide.
Frances said Quentin used alcohol to cope with loss, drinking nearly every day in the wake of his brother’s death.
Soon, Quentin’s liver and kidneys began to fail. Frances took him to a hospital on the reservation and tried to help him detox. While the reservation has a recovery center, it does not provide inpatient services and struggles to meet a high demand of needs. Quentin was flown to a hospital in Billings, where Frances said his condition briefly improved. But by that time, it was too late.
"It was so hard for him to understand that there was no coming back from this," she said.
In April, Quentin died at 26 of liver and kidney failure. On the reservation, the death rate for chronic liver failure or cirrhosis is seven times higher than that in Montana.
‘We ... needed help now’: Mental health resources in short supply
In July, eight months after Jen’s grandmother and brother died of COVID, her world was again shattered when her father and 12-year-old nephew were killed in a car accident.
Jen had raised her nephew, Scobey John Baker (son of her late brother Scobey Baker), since he was an infant.
After the deaths of her brother and grandmother, Jen and her family avoided cultural events and stopped powwow dancing, as is customary in some Indigenous cultures.
As the one-year anniversary of their deaths approached, Jen prepared to hold a “wiping of the tears” ceremony, which is meant to bring people out of mourning. After the ceremony, she and her children would be able to dance again.
But Jen didn’t get to return to dancing that year. Scobey John’s sudden death nearly destroyed her. From a young age, it had always seemed like Scobey John was destined to be a leader. As a child, he would tie strings around his stuffed animals, and, like a puppet master, he’d have the animals mimic sundances.
Scobey John joked often — one time giving out "Indian names" to white girls on the playground — and he cared deeply for others, once found praying for his classmates when he was 8 years old.
His life, too, had been touched by death. His mother died of cirrhosis at 25, and his father, Scobey Sr., died of COVID when Scobey John was 11.
Kai Teague, who was adopted into the Medicine Cloud family, said when Scobey John died, the whole family felt hopeless.
“It sounds bad, but you don't get to just die,” Teague said. “I’m pretty sure that as a collective, if we could’ve, we probably all would’ve just gone.”
Jen’s daughter was suicidal after her brother’s sudden death and decided to leave college in North Dakota to move home and be with family.
“I was scared,” Jen recalled. “(We’d) go to sleep and pray that she was OK. And we’d make sure she was breathing the next morning. That’s scary.”
Phoebe Blount, who helped launch a crisis helpline on the reservation, said it's not uncommon for family members to experience suicidal ideation — or to turn to drugs and alcohol — after experiencing trauma and loss.
“It’s that hopelessness,” she said. “And it’s normalized. … Because it happens so much, (it becomes) just part of the consequences of life.”
For many on the reservation, getting help isn’t easy. And when people spend significant time and energy surmounting barriers to access health care, experts say they may not have the capacity to work or to contribute to the community.
As the country promotes a national suicide hotline — reachable at 988 — tribal members in Montana say they face barriers in using the service. As of now, when people on the Fort Peck Reservation call 988, someone 350 miles away in Great Falls will likely answer. But whoever answers may not necessarily understand the unique challenges of living in the Fort Peck community or what it’s like being Native American in Montana.
It’s one reason why the Fort Peck Tribes launched a new crisis helpline on the reservation. Now, when people call 406-653-2000, a fellow community member will be on the other end. Experts say bridging the cultural gap can make all the difference.
At the time, Jen didn’t anticipate the far-reaching consequences of a traumatic family event. Vicki Bisbee, former counselor at Southside Elementary School in Wolf Point and the 2019 Montana Counselor of the Year, has seen firsthand how premature death and subsequent trauma and grief can disrupt education for young people.
If a student on the reservation lost a parent, Bisbee said they may move 300 miles south to Billings to live with another relative. And if that relative died, the student may move back to the reservation to live with someone else.
This kind of disruption can be especially difficult for school-aged youth, Bisbee said, adding that traumatic events, like the premature death of a family member, can contribute to chronic absenteeism. At the high school level, Bisbee said about 10 students drop out each year.
“So that’s 40 kids over four years,” she reasoned. “And where do they go? Usually the streets or drugs. And they don't work. … We’ve noticed that people living on the streets are getting younger and younger.”
Fortunately, Jen’s daughter didn’t fall through the cracks.
Because Jen had health insurance through her job, she took her daughter to Northeast Montana Health Services, a hospital on the reservation. Teletherapy felt like a godsend. Now, Jen’s daughter is substitute teaching and working toward a bachelor’s degree.
Jen fears her daughter may have faced a different outcome if she hadn’t been able to access appropriate mental health services. About one-third of Fort Peck Reservation residents do not have health insurance. “(Indian Health Service) is so overwhelmed with people,” Jen said. “We couldn’t wait … (my daughter) needed help now.”
‘You don’t want to be part of this club': The resounding pain of loss
Nine months after Quentin’s death, Frances continues to raise her 7-year-old grandson, who she’s cared for since infancy. She’s weathered by grief and by persistent back pain from her decades in tribal law enforcement.
After Scobey John and Jen’s father were killed, Jen returned to work teaching first graders. While the children brought her solace, Jen felt hollow. She wonders whether she should’ve been teaching at all while she grieved.
Frances raised money to travel for back surgery, but with limited mobility, she can’t bring food to people experiencing homelessness or take her grandson to the park like she used to. Jen tracks her loved ones’ locations on her phone. She must know where everyone is at all times, fearing something bad will happen to them.
At 55, Frances is 3 1/2 years younger than the average age at which Native women die on her reservation. At 44, Jen is the same age her brother was when he died. The idea of death haunts her. She’s afraid she’ll die while her kids still need her. She doesn’t know whether she’ll be able to survive another loss in the family.
Scobey John’s powwow bustle hangs above Jen’s mantle in her house. Six blocks away, Frances keeps Cody and Quentin’s belongings in a room of her house. Their old clothes, trophies, photos and poster boards are piled so high that they barricade the door shut.
“You don’t really move on,” Frances said. “For me, it’s been eye-opening to know that everybody feels the same way. Everybody has that hurt, but you don’t want to be part of this club.”
Part III "Filling the Gaps in a Broken System" by Nora Mabie, Missoulian and Billings Gazette, January 30, 2024
FORT BELKNAP RESERVATION — Less than 200 feet from her driveway on a morning in August, the retired cop car Tescha Hawley drives for work began to slow. Hundreds of people waited on the other end.
"Oh no," she said. "No, no, no."
She pulled into a neighbor's driveway just as the 1988 Crown Victoria died.
"I don't have time for sh— to break down," Hawley said, hitting her hand against the steering wheel. "I have too much to do!"
Life expectancy is Hawley's mission. Herself a cancer survivor, she knows death comes too soon for Indigenous people in America and even sooner for people on the Fort Belknap Reservation in north-central Montana where she lives.
Frustrated by a health care system that consistently fails Indigenous people and elected officials who don't seem to prioritize the issue, individuals like Hawley often work to fill gaps in the system. While her mission isn't easy, Hawley knows her efforts save lives.
That's why on this particular summer morning, Hawley planned to distribute tens of thousands of pounds of fresh produce to her community. It's why she drives people to medical appointments and hands out gas cards. It's why she helps community members navigate a complex medical system and encourages them to seek preventive care. And why she launched her nonprofit, Day Eagle Hope Project, which recently received national recognition.
Native Americans have the lowest life expectancy of any racial or ethnic group in the U.S. And in Montana, where Native Americans comprise 6.7% of the population, Indigenous people die a generation younger than their white neighbors.
Experts say inadequate care, food deserts, discrimination at the doctor's office, oppressive policies, poverty and rurality are among the factors contributing to the crisis. And while tribal leaders have raised the issue for years, they say improving health outcomes simply isn't a priority among state and federal leaders.
From 2018 to 2022, white Montanans died on average at 78, and Native Americans in the state typically died 17 years sooner at 61. On the Fort Belknap Reservation, the gap widens. The most recent county health assessment reveals that on the reservation, Native men die, on average, at 56. In the same county, white men typically live 27 years longer.
Hawley — like others who do this work in tribal communities statewide — is up against intense barriers. She doesn't have a proper food storage facility or a central distribution point. Hawley has no full-time staff. And the people who help her often don't have reliable vehicles.
Limited resources mean Hawley constantly scrambles for funding. Political dynamics bring further complications. And, of course, Hawley must also grapple with her own health issues.
Hawley is the first to admit that individual efforts aren't enough to fix a broken system of care. She alone cannot ensure the federal Indian Health Service is adequately funded. She can't help that some of the closest medical services are hundreds of miles away. She can't change the fact that almost one-third of families on the reservation live below poverty level or that most towns on the reservation have a convenience store — not a grocery store.
"I'm just a gap filler," she said. "But sometimes it feels like I am the filler."
In the driver's seat of the retired cop car, Hawley took a deep breath and sighed as her phone pinged with Facebook messages from community members: "Where is the food distribution going to be? When does it start? Is food distribution today?"
The car was the least of her problems.
Hawley had scrambled to move her food distribution site after one tribal building was condemned for black mold. And she'd recently heard that tribal housing employees, who usually haul food on large trailers, were unavailable.
Hawley, who is Aaniiih, has wavy blonde hair, big brown eyes and isn't afraid to speak her mind. Sitting in her stalled car on the side of the highway, she had to find a different way to distribute 26,000 pounds of fresh produce across the 1,000-square-mile reservation.
She grabbed her phone and opened Facebook.
In a place where there's no local newspaper, where cell service is limited and where there aren't many areas for community members to convene, Facebook — which requires low bandwidth and is accessible to elders — is a vital tool of communication.
"Good morning," Hawley typed in a post. "We will be delayed this a.m."
'Twenty-six should not be middle-age': IHS struggles to provide quality care
Indian Health Service (IHS) is responsible for providing health care to federally recognized tribes
.
While tribal members statewide criticize the agency for being understaffed and underfunded, agency leaders say IHS faces unique challenges in providing care.
Jessica Windy Boy, former CEO of the Fort Belknap IHS facility, knows firsthand that barriers to care can mean the difference between life and early death on the reservation. Her uncle, a rancher, died at 56 of diabetes.
"There's tons of 80and 90-year-olds in Montana — just not here on the reservation," she said. "Twenty-six should not be middle-age." The two hardest things to do in government, according to Windy Boy, are hire someone and buy something.
IHS facilities everywhere face severe staffing shortages. In August, 42 of the roughly 200 positions at the Fort Belknap IHS unit were vacant, which, at the time, was the best vacancy rate of all seven IHS facilities in Montana.
Because the IHS doesn't provide most specialty services, people must often drive 200 miles each way to Billings, 160 miles to Great Falls or 50 miles to Havre for things like cancer treatment, a CT scan or dialysis.
The IHS has a van, but it can only comfortably transport three people at a time — limiting its effectiveness.
Of the seven IHS facilities on reservations in Montana, Windy Boy said the Fort Belknap IHS unit is the only one that runs ambulance services.
But transport can also be dangerous. The Fort Belknap IHS does not have a blood bank. Ambulance drivers — who can log thousands of miles a week on unlit, rural roads — often work overtime and face high rates of burnout. Plus, there's the deer problem. Windy Boy said EMS drivers hit so many deer that one seemingly invincible ambulance earned the nickname "Deer Slayer."
An IHS bus would help more people access care. In August, Windy Boy wasn't optimistic that resource need would be met. IHS funding is appropriated through Congress, and money for each facility is limited.
"I can't depend on money from IHS if I want to grow a program or service," she explained. "I have to find that through a third party. No other hospital has to think about how to fund EMS."
'Why are we living like this?': Resources are limited
After abandoning her car on the side of the road, Hawley jumped in her personal truck back at her house. On a food distribution day, she could easily log more than 100 miles just driving on the reservation alone, so she typically tries to avoid putting miles on her own vehicle.
Today, however, she had no choice.
Arriving at the community center, Hawley watched as her friend Trisha Blackcrow — a short woman with long brown hair — used a forklift to hoist pallets of food boxes, stacking them like Tetris blocks into the beds of pickup trucks.
With the original food distribution building condemned, the tribes' community center was Hawley's best option. One major problem, though, is that the building doesn't have heating or cooling. In the August heat with no walk-in refrigeration, Hawley figured she had 24 hours before the lettuce would wilt and the celery would soften.
"Why are we living like this?" she shouted to no one in particular. "There's no damn reason!"
Once they were loaded with boxes of food, truck drivers headed out to towns on the reservation, where there are about three people per square mile. One traveled 25 miles east to Dodson, another 35 miles south to Hays and a third 40 miles southeast to Lodge Pole. Another driver took a truckload of produce to the Rocky Boy Reservation, 70 miles west of Fort Belknap.
In Hays, cars pulled up every few minutes to get boxes filled with lettuce, celery, cauliflower and onions.
A grandmother thanked the group, saying she relies on Hawley's food distribution to feed salads to her grandchildren. A man in a tank top leaned out of his powder blue minivan and shouted, "I love you guys!"
Hawley yelled as a red SUV sped past blaring music.
"Hey!" she shouted. "Get over here!"
The car's wheels screeched as the driver spun a U-turn and pulled up. Inside, four young men smiled and joked with each other as Hawley loaded a box in their trunk.
"You can grind that cauliflower up and make rice, you know!" she told them as she closed the trunk door.
While there are a handful of convenience stores on the reservation, residents often must travel to an Albertsons grocery store just outside the reservation for healthy food. Depending on where one lives on the reservation, a trip to that store could be 40 miles each way. In a place where the median household income is $46,250 — about $20,000 less than Montana's statewide median and about $28,000 less than the national figure — not everyone has a reliable vehicle or money for gas or for produce, which is typically more expensive than food at a convenience store.
Lack of access to healthy foods, experts say, contributes to poorer health outcomes. Nationally, Native Americans are 3.2 times more likely to die from diabetes than non-Natives. In Montana, where most reservations are considered food deserts, Natives are 4.5 times more likely to die from diabetes than their white neighbors.
Hawley knows she could be more effective if she had more resources. She wants a centrally located building, with a covered loading dock, heating, cooling and walk-in refrigeration for adequate food storage. Reliable vehicles and paid employees would improve food distribution efforts. If Hawley had a bus, she could also transport people to medical appointments across the state. And if she had a reliable car herself, maybe she wouldn't have been late on this August morning.
Hawley disburses more than $20,000 twice a month to buy and ship produce to her community. She doesn't get paid for her nonprofit work, and it's not her fulltime job. To make ends meet, she serves as a mental health therapist at Harlem Public Schools, earning $42,000 a year. Hawley typically submits grant applications for her nonprofit on nights and weekends, sometimes staying up until 2 a.m., and she takes time off work to distribute food across the reservation.
'Do it yourself': Cracks in the system
While the Fort Belknap Aaniiih and Nakoda Tribes provide financial assistance to members seeking medical care, leaders say the support drains tribal resources.
Mark Azure, former tribal president, said while the tribe budgets for medical assistance, it's impossible to predict how many people will get sick in a given month, so budgets often fluctuate in unpredictable ways. Tribal officials said the tribes distribute between $60,000 and $90,000 each month to help members pay for gas, food and hotels to get to medical appointments.
Azure said budgeting can be especially burdensome for rural tribes, like the Aaniiih and Nakoda. At a conference with tribal leaders nationwide, Azure remembers people spoke of things like a tribally-run golf course in Las Vegas, an offshore drilling site in the Gulf of Mexico or a big hotel or casino — all of which earn outside revenue for tribal communities.
Even small tribes can have big revenue streams. Take the Shakopee Mdewakanton Sioux in Minnesota. Profiting largely from casinos and resorts that attract thousands of people each year, the tribal community of 779 people has a net worth of more than $2 billion.
But tribes on the Fort Belknap Reservation — which is home to less than 3,500 people in rural Montana — don't have the same opportunities.
"There aren't a lot of people here," Azure said. "The demographics are small. So, I don't know how you could build a huge casino. It's not, 'If you build it, they will come.' You can build it, but that doesn't mean they're coming."
As community members from different tribal programs helped load and unload boxes of produce, Hawley noticed a group that wasn't there — the tribal council.
Hawley isn't afraid to voice her frustration, but being outspoken, she said, comes at a price in the small, tight-knit tribal community.
When asked about the council's apparent lack of support, President Jeffrey Stiffarm said Hawley would need a majority vote to get more resources, and, "If we put it to a vote, I don't think she'd get her way."
"It's not (that people are) against what she's doing," he elaborated. "It's how she approaches (council members) to get it done. She's very upfront. She's very, maybe sometimes, too pushy for them. (But) I do my best to try to help her accomplish the things she's trying to get done."
Hawley knows this is her reality. "If you want to get things done here," she said, "you have to do it yourself."
'I pray someone would step up': Future uncertain
Hawley knows more than anyone that it's important to stay on top of her own health. But she resents the fact that she must leave her community — and the hundreds of residents who depend on her — to get the care she needs.
While Hawley is cancer-free, she sees a doctor in Billings to ensure her own nutrition levels are stable.
Once food distribution was complete and after Hawley had visited with several cancer patients, after she had counseled students at school and coordinated concessions for the next sports game (advocating for healthy options), Hawley would have to pack a suitcase, and her aunt would drive her three hours to Billings. Together, they'd stay the night in Hawley's niece's basement apartment on a pullout couch and drive home the next day.
At 52, Hawley is nine years younger than the average age at which Native Americans die in Montana.
If she were to die tomorrow, Hawley knows it would be nearly impossible to find someone to fill her unpaid position. She invests almost as much time in her volunteer work as she does her fulltime, paid job.
"I pray that someone would step up," she said. "(But) I know that would be difficult. I had to get a paying job just to feed my own children. (It's) difficult managing two full-time jobs."
'I reached out to Tescha': Assistance saves lives
Before leaving town, Hawley pulled into the Kwik Stop gas station to fuel one more truckload of food.
A mug of coffee balanced haphazardly in one cup holder, and a plate of half-eaten strawberries wobbled on her dashboard.
"Need some gas?" Bret Kuntz, a cashier at the Kwik Stop, asked Hawley as she walked in the convenience store.
Kuntz, who's been working at the Kwik Stop for two years, knows firsthand the power of Hawley's work.
Six months earlier, Kuntz, 54, was diagnosed with colon cancer. He took time off work to travel 50 miles each way to Havre for treatment. When he got surgery, he had to take four months off work to recover. He drained his savings in trips to and from appointments.
"I reached out to Tescha," he said. "She helped me out with gas cards and anything financial that I needed. That was a real godsend."
Kuntz's surgery was successful, and his trips to Havre have become less frequent. He prides himself on knowing almost everyone in the small community and is relieved to be back at the Kwik Stop where he enjoys chatting with people as they come and go.
"(Without Hawley), I don't know exactly what I would've done," he said. "I would've found a way, probably, but I just don't know."
Nora Mabie reported this story while participating in the USC Annenberg Center for Health Journalism's 2023 national Fellowship, which provided training, mentoring, and funding to support this project.