Roger Gollub, a model for leadership in public health

Dr. Roger Gollub and his beloved golden retriever, Sophie, at the famous Balto  statue in downtown Anchorage.
Dr. Roger Gollub and his beloved golden retriever, Sophie, at the famous Balto statue in downtown Anchorage.

Five years ago today, on a cold Alaska night, I was awoken by a strange phone call left on my answering machine saying something had happened to my Anchorage friend, Dr. Roger Gollub. Confused, I called the emergency room at the Maniilaq Health Center in Kotzebue, a remote bush city in the Northwest Arctic Borough, 26 miles north of the Arctic Circle on the Chukchi Sea. Roger had flown there a day earlier on assignment—I was with him the night before. I could not believe what I heard. The medical personnel told me, with great difficulty, that one of county’s finest pediatricians and public health caregivers had died from injuries sustained on a trail just outside of town that night.

Dr. Roger Gollub, a career pediatrician with the U.S.  Public Health Service’s Indian Health Service, never returned home from his short visit to care for patients in this mostly Native community. He, along with a coworker, were mushing on a shared-use trail in subzero weather, under Alaska’s majestic starry skies, when they were run over by a snowmachine. The driver had a criminal background and was under the influence of drugs and booze. It was about a senseless a crime as I could have ever imagined, and more brutal because of the injuries Roger and his coworker sustained. (Note, Roger’s colleague survived, but only after heroic procedures and months of recovery, all costing more than any non-wealthy person can afford.)

After a bitter scream of disbelief upon hearing the news, I caught myself and thought, what would Roger do. I then spring into action for the next 24 turbulent hours, and the years beyond. In fact, my response to Roger’s tragic passing continues to this day. I would never have gone back to graduate school and earned my MPH in 2012 had I not been inspired by Roger’s amazing life’s work. He remains the finest man I have ever known.

Roger Gollub's good friend and champion in so many uncountable ways, Gunnar Knapp, stands by spot where Roger was taken. Thanks, Gunnar, for sharing this with all of us who cared about Roger.
Roger Gollub’s good friend and champion in so many uncountable ways, Gunnar Knapp, stands by the spot where Roger was taken on Nov. 19, 2008. Thanks, Gunnar, for sharing this with all of us who cared about Roger.

Roger had just retired from a distinguished career, which included an epidemiological residence with the U.S. Centers for Disease Control and path-breaking work with Native American and Alaskan Native communities (details here). He was still working under contract serving his many patients, and thinking about an active life ahead, including research, time with his wife and two daughters, projects with the Anchorage Amateur Radio Club, and travels he long delayed. Roger’s death forever changed my life, but also in a good way. From that time on I vowed to work even harder at showing the type of leadership that Roger demonstrated throughout his life.

Though he was only 5’6”, Roger towered above his peers as a professional, and particularly as an exemplary caregiver who understood his young Native American and Alaskan Native patients and their families. He was named physician of the year by the national health agency he dedicated his life too. He had legions of fans across the U.S. Public Health Service who held him in the highest of regards.

At Roger Gollub's "Celebration of Life," hundreds of well-wishers offered condolences and happy memories of one of Alaska's finest doctors ever (December 2008).
At Roger Gollub’s “Celebration of Life,” hundreds of well-wishers offered condolences and happy memories of one of Alaska’s finest doctors ever (December 2008).

I saw hardened, even stoic and cantankerous men who knew him through his ham radio activities openly weep when trying to make sense of his death. (Roger was an advanced ham, who knew Morse code, and who brought amazing life into the local club.) I saw more than 500 mostly Alaskan Natives give him the highest honors normally bestowed only to revered elders. I heard dozens of stories describing how Roger helped and even saved their very sick children, all while preventing costly medical waste within a sometimes-inefficient bureaucratic health delivery system. That alone is amazing, and Roger never expressed cynicism about that system that often thwarted him and his seasoned colleagues.

This letter, published in the Anchorage Daily News shortly after his death, captured a sentiment that lit up the blog coverage of his passing, with comments pouring in nationwide: “I am sure I’m not the only one who feels a great loss with the recent passing of Dr. Roger Gollub. He was truly a man with a servant’s heart and had a tremendous impact on my family. As a pediatrician at the Alaska Native Medical Center, he has shown pure dedication to the Native community and loved each and every patient. He had a place in my heart and my children’s. Once, my daughter had to see another doctor while he was on vacation, and cried for her doctor to come back. The world will never see another with the same compassion, dedication, intellect, integrity and valor as he. I was privileged to know this man for six years and he will never be forgotten in my children’s heart and mine. Linda Tomaganuk Anchorage.”

On the darkest of days, Roger still managed to smile. He always took phone calls from worried parents–at home, in his car, on his walks, wherever. How many doctors take house calls, or personal calls, ever? That was Roger. That was the kind of leader he was. He breathed it. He lived it.

Roger demonstrated to me examples of the leadership that I admire most:

Emotional Intelligence: Roger demonstrated this trait that most researchers say is the best predictor of leadership. He never appeared flustered. His coworkers described his ability to bring chaotic situations under control, in hospital wards or during infectious disease outbreaks, with a calm, deliberative, thorough, and positive manner. It proved contagious, and he earned trust and credibility among his peers.

Understanding of and Respect from his Peers: Abraham Lincoln, America’s greatest politician, was infamous for his empathy and his ability to understand his friends and opponents, which helped him articulate decisions and policy choices that always seemed perfectly suited for the difficult challenges ahead. He knew where the audience was, and where he needed them to go. Roger was celebrated in the Indian Health Service for his true commitment to community based participatory research, for which he earned the deepest respect from his Native American medical professionals. Mention Roger to anyone who has worked in this community, and you will quickly learn of Roger’s deep and genuine appreciation for the community he served during his lifetime. I met a former career pediatrician in the Indian Health Service last spring and mentioned Roger’s name, and was greeted by the most contagious grin I had seen in months. One University of Washington School of Public Health faculty member, who specializes in the field of community based participatory research and who knew Roger in New Mexico, said unequivocally, “Roger was the real deal.”

Leading by Example: Dorris Kearns Goodwin’s portrayal of Lincoln’s wartime cabinet, his famous “team of rivals,” highlights Lincoln’s eventual winning over of Democrat Edward Stanton. Before the Civil War, the former Ohio attorney had ridiculed and mocked the then lesser-known Illinois lawyer as a “long-armed ape” during a legal case during which Stanton shunned Lincoln’s work. Lincoln did not hold a grudge, and he then sought out Stanton to run the War Department during the Civil War, because he had the right qualities to master a complex organization. Stanton later become Lincoln’s strongest ally. Lincoln’s ability to put aside personal grudges and genuinely collaborate even with his political rivals was not an act. It was genuine.

Roger treated everyone he interacted with, even those who did not return the courtesy, with respect. I never once heard him utter a bitter word or even cynical comments, even when I expected them. I have met few people who have demonstrated this trait. Roger had a work ethic paralleled by few. He put in 12-hour days and longer, never compromised his duties as a father or husband, and excelled at nearly anything he tried to do—medicine, engineering, ham radio communications, running, parenting, research, epidemiology, research. Roger adopted practices seeing patients that saved taxpayers tens of thousands of dollars, which his peers steadfastly noted at his funeral. He never sought glory, though during his life he was gaining a national reputation he could never even imagine.

That tiny little guy you see in the front row, in the middle, is team captain Roger Gollub (University City Senior High School Track Team, 1973).
The small guy in the front row, in the middle, is team captain Roger Gollub (University City Senior High School Track Team, 1973).

Roger  particularly demonstrated this talent at University City High School, where he ran track and cross country. I attended the same high school, though ten years after Roger. Roger was the smallest man on an interracial track team, which was comprised of very large young men who towered over Roger. Racial tensions were real here, but so were the strong bonds. I know this school, and I can assure you this is a serious alpha dog environment and not for the faint of heart, particularly among young, competitive men. Roger’s peers voted him captain of the track team, because he pushed the bar farther and competed harder and ran faster than all of them. In short, he inspired them to do better. He never asked for that title. He earned it. He made his team a genuine competitor at the state level. Roger carried that excellence to Yale where he competed for the Yale track team as well. (Roger’s own running hero was Olympian Edwin Moses.)

Moral Vision and Visionary: Roger’s values were nurtured in his Jewish, middle-class upbringing in a diverse community, University City, Mo., which we both called home. (I lived next door to Roger, but only briefly overlapped when I was younger, as he was 10 years older.) It was an often-hard place to learn about racial differences, but also a great place to dream big about pursing a path that made a difference. Roger knew exactly who he was and what he wanted. He graduated class valedictorian in 1973, and never forgot his roots. His vision was, as his friends said, a mix of Mighty Mouse heroism mixed with the Star Trek prime directive to do no harm–and yes, these describe his actions and values as a doctor working cross-culturally.

At Roger Gollub's celebration of life, his family assembled assorted "tools of the trade" he used to care for sick kids, and of course the famous lobster hat.
At Roger Gollub’s celebration of life, his family assembled assorted “tools of the trade” he used to care for sick kids, and of course the famous lobster hat.

I never once saw Roger lose faith in others or in the inherent goodness of people. His service to patients, the core mission of the U.S. Public Health Service, and purposes far bigger than himself can be seen in every personal and professional choice he ever made. He demonstrated and articulated a clear, humane vision for health care, community, family, race relations, and society that he blazed intensely everyday, inspiring dozens if not hundreds by his example.

Don’t be fooled by that doctor you see in this picture with a goofy grin, and a lobster hat and Elmo toys. That was a master professional’s slight of hand to get nervous kids comfortable and the most conniving of change agent’s subversive and effective strategy to reform a health care system that has long forgotten how to put compassion ahead of egos and profits.

I have yet to meet anyone in the field of public health and public service who embodied all of the leadership traits Roger seemed to have in spades. Sometimes we just get dealt the right hand and can say, damn, I was lucky I had a chance to work with or know such a gifted, natural leader. Thanks, Roger!

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The crowded, congested, contested road: unsafe at nearly every speed

Seattle traffic
Seattle traffic is among the worst in the nation, and it can be downright deadly, according to those who track road-related fatalities.

Every day that I drive to work, I am literally putting my life on the line. I commute roughly 80 miles daily, round trip, from Seattle to Tacoma, navigating one of the most harrowing urban traffic corridors in the Untied States, on Interstate 5 and two state highways. (My story why I am commuting this way will be for another day, but there are good reasons.)

Routinely, erratic drivers dangerously pass me, putting our lives at risk, in order to gain a few extra minutes by speeding. I have seen many accidents, some fatal, on this route over the years, and I am glad that I have my will and living will in proper order in case a truck jack-knifes near me in the rain—and yes I’ve seen that happen twice before on the freeway system around Seattle.

Seattle Road Kill 2001-2009
How deadly are roads in the Puget Sound–take a look at the roadkill on this data map showing types of mortality by form of transportation for 2001-2009.

Judging by this map, we get a fair share of road kill in the metro area I call home.

The Centers for Disease Control and Prevention (CDC) put the number of road deaths annually in my home state at nearly 500 (2009). Nationally, in 2012, the United States reported that 34,080 people died in motor vehicle traffic crashes in 2012, a 5.3% jump over 2011. This ranks as 10th leading cause of death in the United States, if one pulls this form of death from all accidental deaths, in which it is grouped by the CDC epidemiologists.

So by all counts, getting in one’s car (or on one’s bike or in a bus or other form of transportation) and hitting the road can be deadly business in my country, especially given the proliferation of mobile-device users and drunk drivers.

In 2011, cell phone use in the good ole’ U.S.A. was a contributing factor in more than 3,300 deaths and for the previous year, in 387,000 motor vehicle injuries. These are very sobering numbers, and I actually expected there would be more given that I have seen far too many texters during peak travel times in vehicles moving 70 mph. Normally I move over a lane or lay on my horn to snap them out of it.

But this is nothing compared to the perils that passengers and drivers experience globally. According to the World Health Organization (WHO), road accidents claimed 1.2 million lives globally in 2011, ranking as the No. 10 cause of death, on a list that has some pretty nasty company, including respiratory infections (3.5 million), tuberculosis (1.3 million), and the big killer of children ages 0-5 years, diarrhea (2.5 million).

The Institute for Health Metrics produced this data table showing how road deaths globally compared to other causes of death (it's No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap
The Institute for Health Metrics produced this data table showing how road injury globally compares to other burdens of disease (it is No. 10); go to: http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-heatmap

A typical story that one sees with mind-numbing frequency overseas are bus collisions with motorcycles and motor scooters. This November 2012 story, 19-yr-olds crushed to death by bus, notes two aspiring young men were run over by an errant bus driver and dragged 40 feet in Chandigarh, India; the driver then fled the scene. Both of the men’s heads were crushed by the bus’s wheels.

I saw no less than three similar road maulings on the island of Java in 2009, when I visited Indonesia. That island, one of the most densely populated locations in the world, is overwhelmed with low-income and middle-income residents on  scooters competing for space with trucks and army of loosely and unregulated van taxis and buses.

Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation's infamously unsafe and crowded roads.
Indonesians who use these highly efficient and inexpensive 100-125cc motor scooters are frequently killed on the island nation’s infamously unsafe and crowded roads.

Road accidents alone in Indonesia account for more than 48,000 deaths annually, the 9th leading cause of death in the world’s largest Muslim nation.

The United States Department of State offers this stern warning to would-be American visitors to Indonesia–a country I really loved by the way: “Air, ferry, and road accidents resulting in fatalities, injuries, and significant damage are common. … While all forms of transportation are ostensibly regulated in Indonesia, oversight is spotty, equipment tends to be less well maintained than that operated in the United States, amenities do not typically meet Western standards, and rescue/emergency response is notably lacking.”

During my two-week visit in 2009 to the island nation, I rode about a dozen different buses and equally as many microbuses, not to mention the country’s crash-prone domestic air carriers once, their local train service (also unsafe at times), and the far less safe inter-island ferry services. I saw about a half dozen crashes from my bus window, most fatal and usually with motor cycle riders as victims, and from my hotel room I heard one multi-vehicle crash in the middle of the night that clearly claimed many lives. I learned the next day it was between a bus and truck. The bus was totaled.

Roads can really kill you overseas, and so can planes, boats, and trains too

Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.
Buses like these are cheap in Indonesia, but your life can be as some locals would say, insha-Allah, or at the mercy of God.

The writer Carl Hoffman, author of the book The Lunatic Express: Discovering the World… via Its Most Dangerous Buses, Boats, Trains, and Planes, documents the horrendous conditions of ferries, public transportation, trains, planes, and other forms of transport. The book’s online promotion notes that it offers a “harrowing and insightful look at the world as it is, a planet full of hundreds of millions of people, mostly poor, on the move and seeking their fortunes.”

Anyone who has travelled in developing or “middle-income” countries (like, say, Chile or Turkey) knows their life is literally in the hands of drivers who may have no proper training, in busses with no proper maintenance or even reliable brakes. Worse, the drivers of buses and microbuses in countries from Uganda to India to Mexico may trust their fate to Allah, Saint Christopher, the Virgin Mary, or Krishna. Those who have travelled in such places know this to be true, by the many religious deities dangling at the front of public transportation by the drivers’ seats.

Worse, the drivers will often play chicken with their competitors by speeding into oncoming traffic at high speeds while passing other vehicles or simply to “have fun.” I swear I thought I would die on many occasions in: Mexico, Guatemala, Nepal, Peru, Uganda, Indonesia, Egypt, Turkey, Chile, Argentina, India, and other places that I’d rather forget just now.

accident or more by Birn
When is an accident really an accident, or when it is linked to larger systems issues? This analysis is provided by Anne-Emmanuelle Birn in her description of the social determinants of health (SDOH).

Three separate times, after I lived through the near mishap, I swore I would never, ever take a bus again in a developing nation. Yet I threw caution to the wind, as I needed to get around, and I could not afford to get around any other way. Not seeing the country I was visiting was not an option.

Is it really  “just an accident” or something more?

Anne-Emmanuelle Birn, international health professor at the University of Toronto, and co-author of the widely used global health tome called Textbook of International Health, points out the deeper connections that road-related deaths have to poverty and social inequity in undeveloped and middle-income countries. Birn writes that road traffic accidents are the second-leading cause of death for children between 5 and 14 years of age globally, and that poor and working classes are disproportionately affected in most countries. In high- income countries, most of those killed are drivers and passengers, whereas in low- and middle-income countries pedestrians, cyclists, and public transport passengers make up nine out of every 10 road-related deaths.

In Haiti, for instance, the word for local transport is molue (“moving morgue”) and in southern Nigeria locals say danfo (“flying coffins”).

Duncan Green, an Oxfam policy adviser and development blogger, recently wrote an article asking when road traffic injuries would finally be recognized as a priority by the international development community.

In fact a major report released in June 2013 by the Overseas Development Institute, the United Kingdom’s leading development think tank, notes that transportation is not recognized as a human right like access to water, yet it still is a fundamental factor for many to achieve basic human rights. Well-run transportation systems, for people and for goods and services, promote benefits, while unsafe and weak transportation systems harm the most vulnerable citizens.

Given the debate emerging now for future sustainable development post-2015, the deadline set for the Millennium Development Goals, road safety may finally find a way into the broader public health, development, and environment agenda, as a way to tackle this clearly documented major global killer. Perhaps the threat may finally be treated as the international epidemic that is is, globally or closer to home in the United Sates. For me, this includes the roads in the Puget Sound where I spend more than two hours daily to and from my public health job.

Two milestones put the Oglala Sioux back on the global stage

This 2002 file photo by the Denver Post shows alcohol being sold in Whiteclay, Neb., adjacent to the Pine Ridge Reservation.

October was a huge month for the Oglala Sioux Tribe of South Dakota. The Lakotan band made the national spotlight, perhaps in ways not seen since the historic and bloody siege at Wounded Knee in 1973.

On Oct. 1, 2012, the tribe lost a $500 million lawsuit it filed against a group of multinational beer manufacturers and four stores in neighboring Nebraska that the tribe claimed were liable for bootlegging and the widespread destruction of alcoholism that has plagued the Pine Ridge Reservation for decades. The 3.5 million-acre reservation, about the size of Connecticut, is officially dry. However, 5 million 12-ounce beers were sold in 2010 at the Nebraskan stores immediately adjacent to Pine Ridge. That means about 13,000 cans a day were purchased for consumption at a reservation with just 45,000 residents—a simply staggering figure.

The litigation represents a legal and public health strategy that seeks to hold the companies and retailers/distributors culpable for downstream effects of the health hazard for a legal drug, in this case, alcohol. It also demonstrates the tribe’s proven ability to use symbolic and media tactics that capture global interest, in order to highlight glaring, historic, and shocking injustices that are not tolerated elsewhere in the United States. I actually first heard about this story not from U.S. news sources, but while listening to the BBC World Service in February this year.

Oglala Sioux tribal attorney Tom White holds a press conference after filing the tribe’s lawsuit in Lincoln, Neb.

The second major but not disconnected story last month was the death on Oct. 22, 2012, of famous Oglala Sioux activist Russell Means, a major figure in the American Indian Movement (AIM). The so-called “radical” group galvanized Native Americans and many tribes in the early 1970s by first occupying Alcatraz Island in 1969. The New York Times, in a fit of what can best be called sanctimonious arrogance and historic ignorance, was dismissive of Means’ lasting significance to Native activism of the 20th and 21st century.

The obituary/editorial referenced Mean’s alleged proclivity to guns and brawls. However, the editorial noted Means galvanized global attention of the plight of Native Americans during the  siege at Wounded Knee, at the height of the Vietnam War and amidst President Nixon’s growing Watergate scandal. The Gray Lady begrudgingly states in its judgmental obituary: “Pine Ridge and other reservations have not escaped plagues of poverty and alcohol. Governmental neglect remains a scandal.” Today, Shannon County, S.D., where the reservation is located, is the nation’s third poorest, where more than half of all residents live in poverty.

Oglala Sioux tribal member Russell Means died on Oct. 22, 2012.

By comparison, the Oglala Sioux Tribe, which itself was divided violently before and after the 71-day siege at Wounded Knee, immediately proclaimed Means’ birthday (June 26) as Russell Means Day on the Pine Ridge Reservation. The tribe acknowledges his contributions to helping improve his impoverished tribe’s status. A web site paying tribute to Means’ lasting role to Native Americans called him the most important Native American since Sitting Bull and Crazy Horse.

Means seemed to capture the Oglala’s Sioux defiance and resilience. National Geographic’s August 2012 profile of that resilience  highlighted 60-year-old activist Alex White Plume.  He summed up the injustices brought upon his people by the federal government and others. The tribe is one of seven Sioux bands whose once far-ranging ancestral lands of the Northern Plains and Inner Mountain West were literally taken by the expanding U.S. nation in the mid- and late 1800s. “They tried extermination, they tried assimilation, they broke every single treaty they ever made with us. They took away our horses. They outlawed our language. Our ceremonies were forbidden.”

The most egregious crime was the U.S. Calvary’s massacre in 1890 at Wounded Knee of 146 Sioux members, of whom 44 were women and 18 children. The mass murder was a fearful reaction to the Ghost Dance that was sweeping the Sioux people, a deeply spiritual religious revival that promised a rebirth and paradise on earth. Another 200 Native Americans were killed in related incidents shortly after.

Nearly a century later, starting in February 1973, the AIM movement again focused the attention of the globe on the impoverished Pine Ridge Reservation in what became known as the siege at Wounded Knee.

About 200 AIM members occupied the site of the Wounded Knee massacre. They protested broken treaties and the corrupt tribal governance of then tribal head Dick Wilson. At the time, the tribal government ran its own private militia called Guardians of the Oglala Nation, or GOONS, who were made infamous in the 1992 film Thunder Heart, which was based loosely on the Pine Ridge incidents. The GOONS, National Guard troops, and FBI agents surrounded the activists.

During the siege, 130,000 rounds were fired, two FBA agents were killed, and 1,200 arrests had been made. Ian Frazier, who writes about the incident in his 2000 travelogue and profile of the Oglala Sioux called On the Rez, interviewed Le War Lance, a participant in the siege. Le claims to have snuck in out of the siege 18 times and to have observed the presence of U.S. military forces (82nd Airborne), armored personnel carriers, and helicopter and reconnaissance flights. (A summary of the FBI’s files is here.)

The problems at Pine Ridge did not end with the siege. AIM activists and their sympathizers note that between March 1, 1973, and March 1, 1976, the murder rate on the Pine Ridge Reservation was more than 17 times the national average. Activists attempting to free Leonard Peltier, who was sentenced to life in prison for the killing of two FBI agents during the siege, have counted 61 unsolved homicides during that time. Some of those killings are now being re-investigated.

While AIM may not have created lasting change on the Pine Ridge Reservation, it did demonstrate what Frazier called a real flair “for the defiant gesture in the face of authority.” Frazier says that, along with AIM’s strong historic self-identity, made it both conservative and radical all at once. That same flair and sense of historic injustice is clearly visible in the unsuccessful lawsuit that was brought in February 2012 by the Oglala Sioux in Nebraska’s U.S. district court.

The suit alleged that one in four children born on the reservation has fetal alcohol syndrome or fetal alcohol spectrum disorder. The tribe’s average life expectancy ranges from 45 and 52 years, shorter than anywhere else in the Northern Hemisphere outside for Haiti. By comparison, the average life expectancy in the United States is 77.5 years. The suit sought rewards to cover cost of health care, social services, law enforcement, and child rehabilitation that it claims are caused by chronic alcoholism on the reservation. “The devastating and horrible effects of alcohol on the (Oglala Sioux Tribe) and the Lakota people cannot be overstated,” the lawsuit stated.

In terms of negative health outcomes, Native Americans and Alaskan Natives (AI/AN) fare much poorer than their fellow countrymen by all standard public health measures. The Centers for Disease Control and Prevention (CDC) notes that “rural and urban AI/AN alike experience greater poverty, lower levels of education, and poorer housing conditions than does the general U.S. population.” And, of course, such conditions lead to a range of health issues, including the alcoholism and the despair prevalent on the Pine Ridge Reservation.

The CDC, while trying to present unfiltered data, bizarrely and disparagingly states, “Geographic isolation, economic factors, and suspicion toward traditional spiritual beliefs are some of the reasons why health among AI/ANs is poorer than other groups.” Remarkably, the CDC summary of health data, at least in this source, does not account for the systemic and historic racism, political persecution, coordinated and clearly documented efforts to destroy Native American cultures and languages, and economic exploitation as potential contributors to current health disparities. While the top two killers of AI/NA are heart disease and cancer (both greatly influenced by the social determinants of health), the No. 3 killer is “unintentional injuries,” which can include car accidents, and the No. 8 killer is suicides. For those not familiar with the social determinants of health, these two types of deaths are easier to link to the deep socioeconomic disparities experienced throughout Indian country.

Today, Pine Ridge is the only reservation in South Dakota that bans alcohol. The booze is supplied by nearby Whiteclay, Neb., population 12. For its part, the state of Nebraska split hairs and postured it could do nothing to ban alcohol sales that tribal leaders alleged were tantamount to genocide. The Denver Post reported that Nebraska’s  Attorney General, Jon Bruning, said he “despised” Whiteclay’s beer sellers, “but feared shutting down Whiteclay would cause patrons to travel to other Nebraska towns.” Such statements almost defy logic and demonstrate that state’s leaders still willfully ignore staggering data  that show the state has a legal and moral obligation to solve a public health crisis originating inside its state borders.

The major beer makers singled out by the lawsuit were Anheuser-Busch, Molson Coors Brewing Company, MIllerCoors LLC, and Pabst Brewing Company. Given the historic settlement by 46 states attorney generals against tobacco manufacturers in 1998, it is all but certain that these titans of American suds have mapped out a legal strategy to stem all future efforts to hold them liable for downstream impacts of alcohol consumption. Fetal alcohol syndrome and DUI-related fatalities are two of the more well-known and symbolically rich health impacts of alcohol that capture the media’s interest and harness the public’s collective disgust with the harmful impacts of the drug.

Tribal leaders are now discussing whether to legalize the sale of alcohol on the reservation. A previous effort failed in 2004. Though the tribe lost, the lawsuit may spark future public-health framed legal challenges to the sellers and manufacturers of alcoholic beverages. It should be noted that trial attorneys repeatedly failed over 50 years to hold tobacco companies liable for the deaths and illnesses of former cigarette smokers. That does not mean other tribes and trial attorneys will not continue to explore legal challenges to the commercial reality of alcohol “on the rez.”

As for the continuing omnipresence of alcohol on the Pine Ridge Reservation, or any of the other more than 560 reservations in the United States, that is nearly certain. The socioeconomic conditions that have made reservations fertile ground for America’s No. 1 drug of choice remain unchanged. As the most famous contemporary Native American writer, Sherman Alexie, writes, “Well, I mean, I’m an alcoholic, that’s what, you know, my family is filled with alcoholics. My tribe is filled with alcoholics. The whole race is filled with alcoholics. For those Indians who try to pretend it’s a stereotype, they’re in deep, deep denial.“