Woeful Health Facilities Putting Indians at Risk

A nurse midwife pulled a limp and blue Tyler Bryant Tipton into the world at a Native American hospital that wasn’t ready for him.

The midwife used a suction cup device to help pull Tyler out of his mother, tugging so hard that the cup popped off twice and she fell back against the wall. Once Tyler was delivered, nurses and doctors couldn’t find an infant-sized breathing mask. A worker sent to find one came back with an adult-sized mask.

Tyler has cerebral palsy, which a medical expert hired by the Tipton family concluded was caused by a string of mistakes at his 1997 birth. If the midwife had called a doctor to perform a Caesarean section, Tyler probably would not have had brain damage, Dr. John R. Marshall concluded.

The government has since paid the family $5.3 million.

“It makes you wonder why nothing’s been done,” said Tyler’s mother, Misty Tipton. “They’re just damaging babies. It seems like they would do something about it.”

An Associated Press analysis of court and government records and interviews with outside experts, agency officials and patients found problems like the Tiptons’ at facilities run by the Indian Health Service, the federal agency that provides health care for American Indians.

Although Indians get more services than uninsured Americans, IHS care has been called substandard by federal judges and is usually less comprehensive than what privately insured Americans get.

IHS officials acknowledge the shortcomings, but say their agency has helped Indians make dramatic health gains in recent decades.

“We’re way underfunded,” said Dr. Craig Vanderwagen, the agency’s chief medical officer. “But we do well with what we have.”

What the IHS has is a budget of $2.9 billion this year, although not all that budget goes for patient care.

While Americans average $3,800 each in health care per year, the IHS provides about $1,300 per person.

The IHS really needs about $15 billion a year to adequately serve Indian health needs, said Dr. Michael Trujillo, the agency’s head.

AP examined hundreds of government documents, interviewed dozens of people in 13 states and visited Indian communities in New Mexico, Oklahoma and South Dakota. Among the findings:

* At least 21 of the more than 900 doctors who have worked for the IHS in the last six years have been punished by state medical boards, AP checks of disciplinary records found. The medical boards, which are independent of the IHS, punished the doctors for administrative, ethical or competence problems including chronic drug abuse, negligence involving patient deaths and sexual misconduct with patients. About 2.6% of the IHS doctors had been sanctioned--more than four times the average for the federal government and the highest of any federal agency that employs doctors.

* Since 1997, 16 of the 49 IHS hospitals have been cited as among the worst in the nation for at least one quality criterion by the Joint Commission on Accreditation of Healthcare Organizations. That means hospitals did not meet the minimum standards in one or more areas set by JCAHO, which sets national quality standards for hospitals. For example, the rating agency cited the Phoenix Indian Hospital in 1999 for not meeting any of its standards in the care of patients during operations. Less than 1% of hospitals nationwide ranked that poorly.

Vanderwagen, IHS’ chief medical officer, said the problems went well beyond mere record-keeping. “It was a host of other issues working at quality,” he said. “How do we know we’re getting the quality we want if we’re not putting it down?”

* Patients or relatives filed 342 formal malpractice complaints against the IHS from January 1997 through Sept. 30, 2000, according to records released under the Freedom of Information Act. That’s more than one complaint for every three doctors. Although most claims were denied, the agency has paid at least $23.6 million in malpractice settlements and judgments in the last four years. No federal agency tracks malpractice claims against private-sector doctors and hospitals.

IHS officials say the number of malpractice complaints is low for a system its size.

“We do have our failures, like anybody does,” Vanderwagen said. “And, interestingly, most of those are system failures as opposed to individual-practitioner failures. . . . And each one of those failures is a lesson, and we share those with the providers in the field.”

* The diagnosis was wrong for one in five patients listed in IHS computer files as diabetic or infected with common diseases, according to a study of 1996 and 1997 data by researcher Kelly Gonzales of the Northwest Portland Area Indian Health Board.

* Due to a lack of money, IHS rations specialty care. That means patients in some areas are forced to do without some treatments and tests, such as mammograms or gall bladder surgery.

“You can be suffering with gall bladder attacks, in a lot of pain, but if it’s not life-threatening [the response is], ‘I’m sorry, you’re going to have to put up with that pain,’ ” said Deanna Bauman, health director for the Oneida Nation of Wisconsin.

The government has promised to provide health care to American Indians in treaties and laws dating to colonial times.

IHS was created in 1955 to meet that obligation. It provides health care to more than 1.5 million Indians, or about 60% of the Americans who identify themselves solely as Indian.

Even the agency’s harshest critics say IHS has many talented and dedicated caregivers and has helped Indians make dramatic health gains in recent decades.

Indian infant death rates have dropped by more than half since the early 1970s, to a rate of 8.9 per 1,000 births. That’s still far higher than the national average of 7.2 infant deaths per 1,000 births, however.

Indian children are vaccinated at higher rates than the general population, but Indians are still plagued by serious health problems.

A 1998 IHS study found that Indians are 7.4 times more likely to die from alcoholism, five times more likely to die from tuberculosis, four times more likely to die from diabetes and nearly twice as likely to die from suicide or homicide than the general population.

The strain on IHS is only increasing as the Indian population booms. The number of Indians living in areas served by IHS facilities jumped 27.6% between 1990 and 2001.

The agency’s problems have real-life consequences.

Patients allege that some IHS facilities are so dirty they are dangerous. Renee Knepp sued the Albuquerque Indian Hospital because her 6-year-old son cut his finger on a scalpel he found in the waiting room in 1998. Government lawyers acknowledged the boy found the scalpel but denied IHS wrongdoing.

Both sides moved to dismiss the lawsuit earlier this year.

Patients with life-threatening conditions have been sent home. In New Mexico, lawsuits have accused IHS workers of sending home four patients who later died of heart attacks or infections.

Blaise Magooshboy Jr., a baby boy, died on the Mescalero Apache reservation in 1998. When his parents brought Blaise to an IHS hospital emergency room, a nurse told them he had chicken pox and sent them home, according to the family’s lawsuit.

When the boy’s mother and grandmother brought him back two days later, the lawsuit said, he waited hours to get treatment, then stopped breathing as workers were drawing blood for tests. Attempts to revive him failed. He died of septic shock, his system overwhelmed by the chicken pox.

Lawyers defending IHS said Blaise’s mother took him home from the first hospital visit before a doctor could see the boy. The government denied malpractice.

The family settled the lawsuit out of court in December. The terms weren’t disclosed.

These days, the Tiptons measure Tyler’s achievements in smaller steps than parents of other 4-year-olds. His head often lolls to one side. His hands are curled and clumsy, his arms and legs loose and shaky.

But he can smile. He can laugh. He can make friends at school.

The Tiptons sued IHS after they heard from other parents at Children’s Hospital of Oklahoma that other children had been injured at birth at Carl Albert Indian Hospital. The Tiptons said they didn’t know about any problems with IHS before Tyler’s birth.

“When we went to the hospital, we figured, they’re the professionals, it was their job,” Misty Tipton said. “We put our trust in them.”

In 1999, JCAHO cited the 53-bed Carl Albert hospital for lapses in medication use, staff training and assessments, record-keeping and infection control.

After a follow-up visit in March 2000, JCAHO investigators still gave Carl Albert the lowest possible rating for assessing staff competence and screening incoming patients.

Hospital spokeswoman Kelley Allison declined comment.

IHS, without admitting wrongdoing, settled the Tipton case last year. Most of the $5.3 million will pay for Tyler’s medical care for the rest of his life.

“The federal government is the one having to foot the bill for all of this,” said Tyler’s father, Jeff Tipton, a Choctaw tribal member. “For what they spent they could have hired them some excellent doctors.”

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On the Net:

Additional photos, interviews and data from the project are available at the Associated Press’ Web site: wire.ap.org

IHS: www.ihs.gov

National Indian Health Board: www.nihb.org