Editor's note: This story is the second one in a two-story series.

HURON — The patchwork nature of the rural and reservation health care system in South Dakota sometimes requires innovation, compassion and a healthy dose of teamwork to keep people healthy.

That played out recently in Huron when an immigrant family on a work visa arrived in this east-central South Dakota city without money, insurance or English skills. The family from Myanmar had a 2-year-old son with leukemia.

They were introduced to Leonard Wonnenberg, a physician assistant who provides primary care to patients of all incomes and backgrounds at the James Valley Community Health Center operated by Horizon Health.

Like most clinics in small cities and towns across the state, the Horizon clinic does not have specialists to provide high-level medical treatment. Furthermore, the family spoke only a Karenic language, so Wonnenberg enlisted an interpreter from a local church to help communicate, then found a volunteer willing to drive the family two hours to Sanford Children's Specialty Clinic in Sioux Falls.

Once there, the boy received treatment and medications that have put his cancer in remission.

"Now, he's doing well. He's thriving. He's just like any other ordinary kid," Wonnenberg said. "He's really cute and he talks a lot."

Tribal health mentor knows the ropes

Sara DeCoteau is seen as a health care hero to many people in Sisseton and within the Sisseton-Wahpeton Oyate (SWO) tribe on the Lake Traverse Indian Reservation in northeastern South Dakota. With 50 years of tribal and public health employment on her resume, it’s easy to understand why so many look up to her.

These days, DeCoteau, 70, runs the health program for the SWO tribe. DeCoteau said tribal residents have ready access to a strong medical network, with a local public hospital and combined offerings of the tribe and IHS. 

DeCoteau pointed to staff recruitment and retention as a major issue for SWO and IHS. She said transportation challenges, a lack of health literacy and limited service hours all create barriers to obtaining proper health care for tribal residents.

But no local issue can top the challenges created by the chronic underfunding of IHS and other government tribal health programs.

For services not offered by SWO or IHS, tribal members can obtain treatment outside the reservation through a “purchased-referred care” payment system, in which the federal government pays non-tribal providers for services.

While that system is working well now in Sisseton, DeCoteau said, there have been times where the referral funding has run out near the end of the fiscal year each summer.

“For years, and years, we used to say, 'Don’t get sick after June,’ because funding would evaporate by then, and only the highest priority cases would be considered for care,” she said. “It is so aggravating, so unfair to the American Indian people to be treated like that."

In late 2023, after a two-year effort, the tribe was finally able to launch its Asniyapi Field Health Clinic program, in which a nurse practitioner travels the region in a mobile clinic to provide a wide range of medical, behavioral health, addiction, education and pharmacy services to people in their communities and neighborhoods.

Personal experiences reveal gaps

A while back, DeCoteau needed cataract surgery on both eyes in Sioux Falls. When complications arose months later, DeCoteau had to go to Sioux Falls again, but a blizzard required her to travel a day early.

“That's rural health care,” she said. “You're at the mercy of the system and the weather, too.”

Wahleah Watson, who works in tribal health education in Sisseton, said she drove an hour to Watertown to give birth last year.

Watson said she received prenatal services through IHS and then made the drive to Watertown, hoping she had planned well and did not undergo any last-minute complications. When the Coteau des Prairies Health Care System in Sisseton ended its child delivery program on March 1, Watson said all pregnant women in the area will now be forced to make that drive for a hospital delivery.

"That's a huge barrier to our young mothers, and in general, it’s scary to get pregnant because we don’t have that medical facility here to give that care and deliver babies here," she said.

Rural hospital 'does what it can' within limits

Craig Kantos is CEO of the Coteau des Prairies health system in Sisseton.

The small hospital has a medical staff of eight, a lab, X-ray, MRI and CT machines, telehealth stations and a helipad for emergency transports.

Kantos said the hospital continually struggles to hire new medical staff when openings arise. The hospital could accommodate three more family physicians and five or six additional nurses if it was able to recruit them. 

Kantos said the hospital system faces regular challenges in balancing revenues and costs, especially since 70% of gross revenues come from sources, including Medicaid, Medicare and IHS, that do not cover the full cost of treatment.

“You do the best with what you have. But the staff here, they will bust their butts to save a life,” he said. 

'If we aren't here ... conditions can worsen'

With a caring demeanor, a commitment to helping others and a family history of living and working with minority populations, Wonnenburg might be the perfect person to work in family medicine in a place like Huron.

Huron is a small city in east-central South Dakota with a population of 14,000 that includes people from a wide diversity of backgrounds. The median household income in 2022 was $57,700, about $12,000 less than the state average.

“Some of these folks, they would rather spend their last $10 on groceries for their families rather than $10 on medicine for their health,” Wonnenberg said. 

Wonnenberg, who soon will leave the James Valley clinic to pursue a speciality in orthopedics, said his time working in Huron has solidified his belief in the critical role rural clinics and health care workers provide across South Dakota.

“It’s a safety net because if we aren't here, conditions can worsen and get out of control and it can end badly for patients,” he said.

This article was produced by South Dakota News Watch as a project for the USC Annenberg Center for Health Journalism’s 2023 Impact Fund for Reporting on Health Equity and Health Systems. News Watch, a nonpartisan, nonprofit news organization, is online at sdnewswatch.org, where readers can sign up for an email every few days to get stories as soon as they're published. Contact Bart Pfankuch at bart.pfankuch@sdnewswatch.org.