Is Epidemic and an American Disgrace: Suicide in the Oglala Lakota Tribe

Suicide among the Oglala Lakota on the Pine Ridge Reservation is an alarmingly critical public health issue. The act of intentionally ending one's own life is the second leading cause of death among Native Americans aged 15–24, and the third leading cause among those aged 5–14 and 25–44 (Alcántara and Gone, 2007). This grim reality exists amidst rural systemic violence, illicit drug use, and poverty. The Lakota people reside in South Dakota, specifically in the northern Great Plains (oglalalakotanation.org, 2018). They are a subset of the Sioux nation, one of the original groups of indigenous people in North America.

Their name translates to "friends" (Weiser-Alexander, 2018).

Native Americans have the highest rate of suicide compared to any other group in the United States (Kightlinger, 2017). The current data reports 27.4 suicides per 100,000 males and 8.7 per 100,000 females. In South Dakota, the suicide rates among Native Americans have increased, even reaching an alarming rate, over 400% greater than the suicide rates among whites (Ibid). Please refer to Figure 1. The exact reasons for these increases are unclear (Rettner, 2018). Some theories suggest the disproportionate impact of the 2007 Financial Crisis due to economic fragility, increased disconnectedness, adoption of technology, and other factors. The indigenous Mohave people attribute the rise in suicides over time to 'excessive individualism' (Devereux, 1961).

The factors that increase suicide risks are even more evident in indigenous communities. Specifically, the Centers for Disease Control reported 44,965 completed suicides in 2013 in the United States, an unfortunate increase of nearly 30% from 1999 figures (Curtin, Warner, and Hedegaard, 2016; see also National Vital Statistics Reports, Deaths: Leading Causes for 2013, 2016). It is ranked as the tenth leading cause of death in the United States (Curtin, 2016). Comprehensive data on Native American suicides is challenging to find, primarily due to selection bias and the inaccurate publishing of relevant institutions. Unpublished estimates from Pine Ridge Hospital (Tizes, 2018) indicated higher rates of completed suicides than those reported by South Dakota. Interestingly, the suicide rate among Native Americans decreases after early adulthood, which is in stark contrast to the general population where rates increase with age (Suicide among racial/ethnic populations in the U.S.: American Indians/Alaska Natives, 2013).

To provide some context, the Pine Ridge Reservation spans 2.1 million acres (bia.gov, 2018). This area is nearly twenty times the size of Wales and three times the size of Rhode Island. Approximately 50,000 people reside here (Tizes, 2018). It is reported as the poorest area in the United States (HuffPost, 2018). The projected life expectancy for males is approximately 47 years, and females tend to live longer (Tizes, 2018). The housing is typically compact and poorly constructed, with an average of 17 people living in two or three-room residences (Friends of Pine Ridge Reservation, 2018). Less than 10% of the labor force is employed, half of the adults are diabetic, and the infant mortality rate

The median individual income at Pine Ridge is $4,000 per year (Strickland, 2016). Lakota-on-Lakota violence pervades the reservation culture (Tizes, 2018). Alcohol and marijuana are ubiquitous, as are amphetamines and cocaine. Almost no family escapes the effects of drunkenness or violence. Knives and baseball bats are the weapons of choice (ibid).

In the beginnings of modern America, the Lakota moved freely. They adopted the use of horses in a nomadic lifestyle by the 1700s (Ndstudies.gov, 2018). The troubled lives at Pine Ridge today resulted, at least in part, from persistent American colonial, expansionist, and racist policies over hundreds of years. As white Europeans migrated westwards to the Great Plains, they entered Sioux territory. Multiple treaties were signed, with most being broken by the United States. The Pine Ridge Reservation was shaped by systemic violence, war, and conflict.

As a public health concern, Lakota suicide can be examined through the Ecological Model of individual, relationship, community, and societal risk factors. Individual risk factors for suicide include prior psychiatric diseases or suicide attempts, domestic violence, child abuse, and substance abuse, including alcohol (Tizes, 2018). The use of controlled substances correlates positively with violence and suicide (McGinty, Choksy and Wintemute, 2016). Feelings of disconnectedness, hopelessness, and isolation increase the probability of suicide, as does the loss of a loved one. Individuals with high impulsivity often display higher suicide rates (Tizes, 2018).

On a relational and interpersonal level, a family history of suicide increases the risk of individual suicide. The suicides of people with whom one has a quasi-familial or close relationship also increases the rate of individual suicide (Tizes, 2018). A lack of problem-solving skills leads to unfavorable outcomes (cdc.gov, 2018). Despite the American Psychiatric Association's recommended ratio of 1:10,000 psychiatrists to populace (Liptzin, 1979), there are no psychiatrists at Pine Ridge, where lethal methods are all too accessible.

Communities are substantially defined by their cultural norms. At Pine Ridge, the negative effects of subjugation, child alienation, broken economies, and forced assimilation are widespread. Lakota-on-Lakota crime, murder, rape, drug abuse, and low educational achievement shape the reservation culture (Tizes, 2018). Cultural beliefs about the acceptability of suicide affect its rates (Phillips and Luth, 2018). The Lakota people describe death using living terms such as “walk on” (Mendoza, 2017), which creates another layer of complexity for suicide prevention.

At a societal level, the Pine Ridge Reservation is controlled by the United States Government. The Oglala Lakota Tribal Council exercises elements of sovereignty, including resource distribution and law implementation. Nonetheless, the primary determinant of reservation life is poverty, which is closely connected with suicide rates (Kerr et al., 2017).

Lakota suicide can also be examined using the Health Equity Assessment Tool. Answering the question of what inequalities exist in relation to suicide is easy. Inequalities present at Pine Ridge compared to American norms encompass nearly every attribute, including endemic poor health, inadequate housing, remote rural location, poverty, systemic violence, substance abuse, and poor mental health infrastructure. Inequality is not limited to completed deaths. Suicide attempts involve significant risk and pathology. Adjusted for population, the rate of reported suicide attempts in the Pine Ridge Hospital Emergency Room is more than double the national rate (Tizes, 2018).

The mechanism by which these inequalities were created and maintained is brute force. For the Sioux in particular, Red Cloud’s War ended with the Treaty of Laramie (1868). The tribe was granted the Black Hills in perpetuity (National Archives, 2018). Perpetuity only lasted a decade before systemic violence reemerged. Sioux Chief Sitting Bull attacked at Little Bighorn (1876), killing 300 American soldiers. In 1890, the United States killed some 300 Sioux women, men, and children at Wounded Knee (Eyewitnesstohistory.com, 2018). That infamously put an end to active Lakota resistance. Nevertheless, the confrontation between the Sioux and the United States over the Black Hills and western South Dakota has been constant. Centuries after these conflicts began, the US Supreme Court held that the Black Hills were improperly taken from the Sioux, and ordered compensation (United States v. Sioux Nation of Indians, [1980]). The Sioux have refused the money.

Along with the appropriation of Sioux lands, assimilation became domestic policy. For example, at the Carlisle Indian School, Col. Richard Pratt voiced the commonplace aspiration to “kill the Indian, save the man” (Sioux Nation Relief Fund, 2018). It is not an exaggeration to say that the United States engaged in deliberate and continuing attempts to eradicate indigenous culture.

Finally, identifying those most advantaged by existing inequalities is straightforward. At the start of the United States, political structures largely benefitted white male landowners, typically of European stock. The legal status of native tribes was established as “domestic dependent nations”, constituting part of the United States (Cherokee Nation v. Georgia, [1831]). During the decades that followed, many of the “domestic dependent nations,” under severe duress, signed over land to the United States, reserving some smaller part for themselves.

Pine Ridge today advantages the few businesses servicing the local population. Sales of alcohol in neighboring communities are high. The impoverished, ill-educated constituency pays extortionate prices for substandard goods. The poor do not have time for critical thinking and uphold the status quo. The general public, in wholesale acts of moral distancing, views the Indian poor as impaired or lazy (Gans, 1971).

Equally, the econometric problem of poverty is intrinsic to American-style capitalism. While capitalism produces sufficient goods and services to eliminate insufficiency better than other systems, it requires the existence of poverty as well as wealth. Income inequality is a feature of the system. Absolute poverty is not required. Lakota economic troubles are of a relativistic range. Supply and demand relationships do not solve equitable distributions of wealth.

The alternative to poverty-targeting for public stability is a competent universal wage. Poverty-targeted recipients have low importance and influence. Therefore, allocation programs have high exclusion errors and low-value transfers. Accordingly, poverty-targeting (such as Pine Ridge entitlement programs) benefits the wealthiest of American taxpayers, by avoiding the more expensive universal wage.

Expanding on the concept of importance and influence, a Health Needs Assessment Matrix offers further insights. Relevant stakeholders are individuals or organizations that have an interest in and hold influence over the issue of Lakota suicide. The process questions who is informed, who is concerned, and who has the capacity to do something about it. Stakeholders with high influence have the power to accomplish their goal(s). Conversely, stakeholders with low influence are disregarded with impunity. Those with low importance lack sufficient motivation to participate. Conversely, those who are seen as highly important are motivated and affected directly.

Following this framework, stakeholders with high importance and influence include family members, tribal leaders, businesses, alcohol retailers, and the very wealthy. As depicted in Figure 2, family members are opposed to suicide. Businesses, including alcohol retailers, aim to maximize profits without regard for risks, making them at best indifferent to the issue of suicide, and at worst promoters of the behavior. Very wealthy American citizens favor poverty-targeting to reduce their taxation and costs, effectively favoring suicide. Stakeholders with high importance but low influence include victims, teachers, EMS/hospital services, and local and tribal governments. These groups lack the resources needed to address the suicide epidemic. Meanwhile, stakeholders with low importance but high influence include general citizens, celebrities, elites, and the US Federal Government. These groups possess ample resources, yet lack genuine interest in remedying the situation. Finally, neighboring residents, media outlets, non-tribal organizations, and the poor hold both low importance and influence. These groups are neither interested in nor capable of effecting positive change.

The Oglala Lakota are committing suicide at alarmingly high rates, marking this as a public health crisis. The Ecological Model identifies several risk determinants, including individual, relationship, community, and societal risk factors across poverty, substance abuse, and systemic violence. The HEAT tool illustrates the nature of the problem, its origins, and associated incentives. The Importance/Influence Matrix identifies the relevant stakeholders. In order to achieve public health equity and reduce suicide rates, systemic socioeconomic obstacles must be addressed. Some evidence suggests that strengthening protective factors may be more beneficial than reducing risks (Borowsky et al., 1998; see also Freedenthal and Stiffman, 2004; Pappas, 2014). Suicide amongst the Lakota spreads like a contagious disease (Slutkin, 2013). Life experiences at Pine Ridge are shaped by the long arc of history, as well as issues of money and power. Simply existing as native and poor in 2018 America should not result in a death sentence.

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