2. McLellan 2
It was during our very first module that I began to form my research question. After
watching “In Sickness and in Wealth” I wanted to explore how disparities in wealth affect other
aspects of our health. Then one night at dinner my mother commented on a syphilis outbreak in
South Dakota that had reached the reservation and it clicked. In South Dakota individuals of a
lower socioeconomic status have increased rates of sexually transmitted infections (STIs) due to
limited access to healthcare services as well as limited use of barrier contraceptives that stems
from a lack of community education.
The Centers for Disease Control (CDC) include chlamydia, gonorrhea, viral hepatitis,
genital herpes, HIV/AIDS, human papillomavirus, syphilis, trichomoniasis, chancroid,
lymphogranuloma venereum, pubic lice, and scabies in their list of STDs (“Sexually Transmitted
Diseases (STDs)”). Both chlamydia and gonorrhea can persist without symptoms, and if left
untreated these infections may lead to pelvic inflammatory disease and infertility (“Sexually
Transmitted Diseases in South Dakota – 2013” 2). The CDC recommends six different strategies
for decreasing the risk of contracting an STD. These include abstinence, vaccination (against
HPV and Hepatitis B), mutual monogamy, reduced number of sexual partners, condoms, and
frequent STD testing (“Sexually Transmitted Diseases (STDs)”).
The South Dakota Department of Health (SDDH) reports STD data alongside other
“reportable diseases” such as Malaria, Pertussis, and Rocky Mountain spotted fever. As you take
in the chart reporting numbers from 2003 to 2012, the largest numbers that catch your eye are
most likely an STI. For example in 2012 there were 3,924 Chlamydia trachomatis infections and
707 cases of Gonorrhea. Also reported in this list are the 4 cases of Lyme disease and the 32
cases of chicken pox, vastly different in number and type to the above STIs. There were also 29
cases of HIV/AIDS, 53 cases of Hepatitis B, and 21 reported syphilis infections (“2012 Yearly
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Infectious Disease Summary” 108). From the data presented on this web site I calculated that in
2012, these five sexually transmitted infections made up 73% of the 54 different types of
reportable disease that the Department of Health tracks.
More specifically, Pennington County, where Rapid City is located, had 647 cases of
Chlamydia, 183 cases of Gonorrhea, 7 cases of Hepatitis B, and HIV/AIDS was not reported.
Unfortunately, the SDDH does not take socioeconomic status into account when collecting this
data, but they do consider race. In South Dakota, 1,537 of the 3,924 cases of Chlamydia and 476
of the 707 cases of Gonorrhea were among American Indians (“2012 Yearly Infectious Disease
Summary” 110). The United States Census Bureau states that American Indians and Alaskan
Natives make up 8.9% of South Dakota’s population (“South Dakota”). This is in stark contrast
to the approximately 43% of sexually transmitted infections they face. Planned Parenthood
Minnesota, North Dakota, South Dakota also analyzed the SDDH’s data reaching very similar
conclusions, including quickly rising rates and a large disparity between American Indians and
those that identify as Caucasian (“Sexually Transmitted Diseases in South Dakota – 2013” 1).
The first interviews I conducted were at the Rapid City office of the South Dakota
Department of Health. It was located in a strip mall between a drugstore and a casino. The lobby
was full of children’s toys and housed copious bulletin boards with posters about vaccinations,
STI testing, car seat safety, and so much more. The people I waited with were from all walks of
life, but due to their well-worn clothes, work boots, and blue or pink collars, I would not have
classified them as upper class.
I had an appointment with Shay, an R.N. and a Disease Intervention Specialist. After our
interview she introduced me to her peer Summer, who also is a Disease Intervention Specialist.
The main task of her job surrounding STIs is receiving reports from clinics around the area of
4. McLellan 4
new diagnoses, contacting the individual to set up an appointment, and then engaging in
counseling and partner elicitation. She also talked about community education they engage in
such as some small presentations, one on one counseling, and the development and mailing of
information sheets. The main task of this position is to limit the spread of infectious disease, but
South Dakota has seen a steady rise in sexually transmitted infections since the installment of
disease intervention specialists (“Sexually Transmitted Diseases in South Dakota – 2013” 3).
When I asked Shay if she sees any differences in STI rates among the different
communities they are responsible for, she replied, “Pine Ridge is about 90% of our STI
business.” Summer also stated that American Indians are part of their “heavy workload.”
The story of American Indians is wrought with genocide, war, disease, and other horrific
atrocities. The state of South Dakota has seven reservations, and one of the most notable is Pine
Ridge Indian Reservation. The best depiction of poverty on Pine Ridge, besides visiting yourself,
is an NPR interview with accompanying photos by photographer Aaron Huey. The statistics are
also staggering. On Pine Ridge Indian Reservation the unemployment rate is 80-90%, the per
capita income is around $4,000, the cervical cancer rates are five times higher than those of the
United States, and life expectancy is the lowest in the United States (“Pine Ridge Indian
Reservation”).
While Pine Ridge Indian Reservation is outside of my community focus, I have become
aware of why this significantly influences STI rates in Rapid City. The reservation is an hour and
a half drive away and Rapid City is the largest metropolis on the western half of South Dakota.
This allows for significant travel to visit family, shop, and go out on the town. When talking
about a serious syphilis outbreak on Pine Ridge currently, Shay said it is only a matter of time
before it gets here. We cannot rely on a 90 minute distance to stop the spread of this infection.
5. McLellan 5
Furthermore when Shay’s partner elicitation reveals an individual living on Pine Ridge she has to
report to the FBI, and she has no idea what steps are taken for the contact and treatment of those
individuals.
Both Shay and Summer gave two reasons for the high rates of STIs among our American
Indian population. Shay noted the lack of education and the high rates of sexual abuse on the
reservation. Summer discussed “cultural reasons” such as parties that are held for the purpose of
multiple sexual encounters where protection is not used. Another reason was poor access to
health care, especially on the reservation. Summer talked about how difficult it may be for
individuals to get to Indian Health Services on the reservation, the 3-4 hour wait times once they
arrive, and then a patient may be tested but not necessarily receive treatment that day. This
means they would have to repeat the process a couple of days after. “It is an amazing chore.”
Shay and Summer also talked at length about the lack of sexual education in Rapid City.
One main point was that we cannot continue to rely on parents to educate their children because
they are often not aware of their children’s behavior, they most likely do not have accurate
information themselves, and it obviously is not working. Shay said she is not surprised when a
15-year-old does not understand their new diagnosis of a gonorrhea infection, but she is when the
individuals are 30 or 40. “They just don’t know.” Summer recognized that people are not aware
of the many infections at risk and they are not aware of the prevalence in our community.
Both women proposed some possible solutions to the problem. One of the more
interesting points Shay made was about the power of school nurses. She recognized that their job
is starting to fall by the way side but there is an enormous opportunity for their role in sexual
education and counseling in the public school system. Summer expressed her frustration with the
wait time between testing, diagnosis, and treatment. She said doctors often know what the
6. McLellan 6
diagnosis will be during the patient’s appointment. This wait time allows for more sexual
encounters and the further spread of infection.
My time at the South Dakota Department of Health was the most enlightening of my
project. I could read the passion in these women’s eyes as they expressed their frustrations with
our community. These women deal with the aftermath and cleanup of sexual infections. It was
clear to me that they were itching to educate; they were excited to talk to someone before the fact
that was interested in what they had to say. I left the office with an article for further reading and
24 condoms of various flavors.
The second interview I conducted was with Mary Beth McLellan, R.N., B.S.N. She is the
director of clinical operations at the Family Medicine Residency Clinic (FMRC), has engaged in
sexual education at the middle school level, and is my mother. We met in her office after hours
to discuss this topic that she is extremely passionate about.
FMRC’s patient base is 60% Medicaid recipients, half of which are American Indian.
The other 40% are those with private insurance or are hospital employees (McLellan). Mary
Beth estimated that 90% of her positive STI tests are from Medicaid patients. It was unclear if
this was because of their lower socioeconomic status, or because a majority of her patients not
receiving Medicaid are health care professionals or their family.
When asked why she sees a higher rate among poorer populations, Mary Beth simply
stated a lack of education and access to services. The point about access struck me as interesting
coming from a medical professional whose responsibility is to provide those services. Mary Beth
included distance travelled, availability of transportation, financial status, work hours conflicting
with clinic hours, and the reliability of communication methods as reasons for this deficit. “A
patient’s cell phone can be working the day they make an appointment, but their service can be
7. McLellan 7
cancelled because of their inability to pay the phone bill before they receive a diagnosis
(McLellan.)”
Mary Beth also discussed ways they are attempting to improve treatment for patients.
First of all they try to provide cost-effective treatment options. Antibiotics for curable infections
such as Chlamydia and Gonorrhea range from $4.00 to $30.00; the Department of Health
provides treatment for those that cannot afford it. They also have begun the use of “partner
packs” which is antibiotics for a patient’s sexual partner. This limits the reoccurrence of these
infections and the time it would take to test, diagnose and treat a second patient.
Mary Beth educated as a guest speaker for middle school sexual education programs.
These middle schools included South, North, and East which are located in the predominantly
middle and lower class neighborhoods of Rapid City. The clinic developed this as part of their
resident physician education. This program included a slideshow that showcased images of many
different sexual transmitted infections. Mary Beth recognized that the focus of her program was
to educate about STIs, but she was mandated by the school district to only discuss abstinence as
a student’s option for healthy behavior. It was extremely clear that this conflicted with her
personal beliefs. She stated, “Human nature tells us that adolescents will experiment with sexual
activity. If we educated them about the use of barrier [contraceptive] methods we would be so far
ahead it would be unbelievable.”
I am personally a product of South Middle School and went through their health program.
In order to better explore the education provided I contacted my teacher Corinne Foley who
continues to teach physical education and health at South. Sexual education is only incorporated
into the 8th
grade health classes which are taught conjointly with physical education. Corinne,
who commonly goes by Corky, described her health class as focusing on how to make healthy
8. McLellan 8
choices (including diet and exercise) and how to avoid risky behaviors. These include “tobacco,
alcohol, other drugs, sexual activity, and bullying (Foley).” This means that sexual education is
only a section of her nine week program that also shares time with dodge ball, sports, and weight
training.
Corinne also talked about the guidelines and curriculum she is given for the class. She
recognizes that health education is mandated by the school district, but how it is delivered is up
to individual schools. The major guideline that stuck out to me was that the Rapid City Area
School District is abstinence based. Corrine mentioned that she does discuss “safe sex” but also
the risks that accompany it. However she made many comments that I believe may alter the
delivery of this information. Corkey stated,
My personal belief is to teach abstinence as the best guarantee for STI prevention as well
as emotional freedom from fear and regret. I want to help students understand that this is
a choice that is possible and guard their hearts emotionally until they are much older and
ideally married. We discuss healthy relationships and how to look for men and women of
integrity and value (Folley).
This personal belief alludes to many biases including sex being emotionally harmful and that it
does not align with integrity or value. She did not support these statements with psychological
evidence, but I do believe they allude to deeper cultural norms in our community that may tie to
the predominant Christian religion.
Corky and I also discussed the need for further education in our school district. She
recognized that this is the last formal, sexual education provided. I called Central High School,
where North, South, and East middle schools feed, to verify this information. The receptionists
that received by call stated that they did not know, did not know who I could contact to find out,
and overall seemed fairly uninterested. Then I talked to a current high school student Kyle Shay
who will be junior at Central. In his sophomore level biology class there was one lecture about
9. McLellan 9
what STIs are, but there was no information provided about how they can be prevented. Corky
discussed that teachers she knows at the high school level do not see sexual health really fitting
into their curriculum. However she also recognizes that some of her former students tell her they
need a refresher course in high school. This is not surprising because in the state of South Dakota
47% of high school students have reported some form of sexual activity (“Sexually Transmitted
Diseases in South Dakota – 2013” 3). Corky identified the home and parenting for the root of our
STI problem. She discussed that parents are not aware of their children’s behavior, offer birth
control at an early age, but do not discuss the consequences of an STI.
I next contacted my primary care doctor Ruth Thatcher, M.D. She is a faculty physician
at FMRC. I attempted to set up a shadowing experience with her, but due to her fears of
confidentiality breech and the comfort of her patients, we made a compromise. Ruth advanced
my well woman exam by three weeks so I could observe her and her nursing staff during an
appropriate appointment. After the usual height, weight, and blood pressure measurements were
taken, she asked me a series of questions. These included how many sexual partners I have had,
if I use barrier contraceptives, and if I have been exposed to anything that I know of. Then
ensued a pelvic exam where specimens were taken to test for chlamydia and gonorrhea. She
asked if I had any questions or if anything else was bothering me and then I was sent home. This
appointment was on a Thursday and I did not receive my results until the following Tuesday.
In the course of this experience I learned specifically about my privilege. In order for this
appointment to be successful I had to have a cell phone to set up the appointment and receive
results, afford the gas to transport myself 20 minutes to the clinic, have the knowledge base to
ask relevant questions, time off from work, and health insurance to help pay for the appointment.
It is true that my physician was not judgmental, I felt safe and trusted her, and the overall
10. McLellan 10
experience was fairly painless. However if any of the above factors had not been met, I likely
would not have been able to be tested.
A few days before this appointment I also interviewed Ruth in their resident physician
library. The best adjective to describe this woman would be granola. Dr. Thatcher is extremely
down to earth, very understanding, and also prefers to be called Ruth by her more frequent
patients. She provided very different information than her peer Mary Beth. Ruth said that she
personally hadn’t noticed any different rates of STI infections that correlate with differences in
socioeconomic status. She also recognized that sexually transmitted infections are a problem for
our community, but she takes a different approach to her explanation. “People live together, have
sex, and pass stuff around.” She discussed that sexually transmitted infections carry a stigma in
our society, but that sex is completely natural. Her perspective reminded me of the evolutionary
medicine we discussed in module 2, specifically the Randolph Nesse interview. Ruth’s ability to
understand STIs as relationship between humans and microbes that has developed over time
allows her to remove judgment from the equation. We also discussed access to barrier
contraceptives. The most interesting point she made was that many of her patients are not
extremely resourceful; patients may not take the time to locate options for free condoms or ask
questions about their use.
In order to improve STI rates, Ruth discussed a study FMRC is conducting. She told me
that women are tested annually for gonorrhea and chlamydia and pregnant women are
additionally tested for HIV/AIDs and syphilis. Ruth recognized that women are tested frequently
because many are seeking birth control. Men do not have birth control medications available to
them and do not become pregnant. I was not very surprised to find out that men do not usually
come in for STI testing unless they are symptomatic and severely symptomatic. Therefor FMRC
11. McLellan 11
is going to allow free testing for young men during a study with hopes to eventually develop a
policy for annual testing.
I next attempted to set up an interview with the mid-level providers at Community Health
Clinic that conduct STI testing and family planning. This is one of the main providers for
individuals on Medicaid and of a lower socioeconomic status. However their limited work
schedule did not allow for an appropriate time to meet. They are often out of the clinic early on
week days, they do not work any Fridays, and their receptionist informed me that they do not
work during the Sturgis Motor Cycle Rally. This provided me with a clear perspective about how
difficult it may be to access health care if federally run clinics are your only option.
I also attempted to set up an interview at Rapid City’s Planned Parenthood clinic. Due to
the enormous volume of class related phone call they receive I was directed to their “Got
Homework?” website page. Here I found an interview request form, wrote a series of questions,
and submitted it. The woman who replied is Emily, the Operations and Administrative Associate
with the Education & Outreach Department at Planned Parenthood Minnesota, North Dakota,
South Dakota. She recognized that she could not provide the specific perspective I was looking
for and recommended I contact my Rapid City Planned Parenthood Clinic. I had come full circle.
However she did provide some data and interesting points I had not yet discovered.
Emily provided that 40.1% of the Rapid City Planned Parenthood’s patients in 2013 were
at or below the federal poverty line. Furthermore 54.3% of their patients had full or partial
subsidy to pay for their appointment. This demonstrates that patients of a lower socioeconomic
status have an increased need for sexual healthcare. However the clinic is only open 15 hours a
week, spread between 4 days a week (“Rapid City Clinic-Rapid City, SD”). Furthermore Emily
discussed that Planned Parenthood educates patients based on the care that they are seeking, such
12. McLellan 12
a birth control, family planning, and STI screening. However they do not engage in community
education outside of their Rapid City clinic currently.
It is clear that the limited sexual education in public schools affects the entire community,
not just those of a lower socioeconomic status. This limits the understanding of contraceptives
and the severe risk of STI infection. However for individuals that have sufficient health
insurance, access to quality healthcare, and frequently visit their doctors’ offices sexually
transmitted infections are not as severe. Policies such as annual testing and treatment options will
diagnose and clear many infections. However among those of lower socioeconomic status the
limited access to healthcare increases the time an individual may be infected, increasing their
risk of more serious health complications and the spread of infection to others. This is why we
see higher rates of STIs among poor populations and specifically American Indians.
The first suggestion that Planned Parenthood makes to improve the situation in South
Dakota is to mandate HIV and STD education in public schools including information about
abstinence and contraceptives. They also recommend that South Dakota increase funding for
clinical diagnosis and treatment of these infections (“Sexually Transmitted Diseases in South
Dakota – 2013” 3). I also support the multiple solutions proposed by my community
stakeholders including the use of school nurses as sexual health educators, limiting the time
between testing and treatment, and the annual screening of men for STIs. Furthermore, South
Dakota would benefit from research that is able to critically dissect how social and cultural
factors influence disease disparities based on social inequalities, as we discussed in Paul
Farmer’s article “Social Inequalities and Emerging Infectious Diseases.” With increased
education, improvements in healthcare, and amplified funding South Dakota may begin to see
the first decrease in STIs and level the sexual health disparities.
13. McLellan 13
Bibliography
“2012 Yearly Infectious Disease Summary.” Infectious Disease Surveillance. South Dakota
Department of Health, 2012. Web. 23 July 2014.
Emily. “Re: Student Interview Request.” Message to the author. 29 July 2014. Email.
Folley, Corrine. “Re: Anthropology Project.” Message to the author. 25 July 2014. Email.
McLellan, Mary Beth. Personal Interview. 24 July 2014.
“Pine Ridge Indian Reservation.” Re-Member. HODGEInteractive, 2014. Web. 5 August 2014.
“Rapid City Clinic-Rapid City, SD.” Planned Parenthood. Planned Parenthood, 2014. Web. 1
August 2014.
Shay. Personal Interview. 24 July 2014.
Shay, Noah. Personal Interview. 5 August 2014.
“Sexually Transmitted Diseases (STDs).” Centers for Disease Control and Prevention.
USA.gov, 2014. Web. 5 August 2014.
“Sexually Transmitted Diseases in South Dakota – 2013.” Planned Parenthood. Planned
Parenthood Minnesota, North Dakota, South Dakota, 2013. Web. 30 July 2014.
“South Dakota.” State and County Quick Facts. United States Census Bureau, n.d. Web. 23 July
2014.
Summer. Personal Interview. 24 July 2014.
Thatcher, Ruth. Personal Interview. 31 July 2014.
