Muchas personas deciden interrumpir sus embarazos después de este diagnóstico, les dijo un asesor genético a Ann y a su esposo. Pero el consejero tenía más malas noticias: en dos días, la familia ya no tendría esa opción en su estado natal de Texas.

Una , vigente desde el 1 de septiembre de 2021, permite que cualquier persona demande a quienes ayuden a alguien a abortar en Texas después de seis semanas de gestación, y el estado ofrece una recompensa de $10,000 a los demandantes, si ganan. El asesor genético le dijo a Ann que ya no podía hablar con ella sobre terminar el embarazo por ese motivo.

“En ese momento pensé, ‘No importa; no vamos a renunciar a este embarazo’”, dijo Ann, quien pidió que solo se usara su segundo nombre por preocupaciones sobre la privacidad y las posibles repercusiones legales para sus proveedores médicos, su esposo o ella misma bajo el marco legal poco claro de Texas.

Se consideraba a sí misma pro-vida, y el diagnóstico aún necesitaba ser confirmado a través de una amniocentesis y una ecografía.

Pero después de leer sobre la afección, se dio cuenta de lo devastadora que podía ser. Si Juliet sobrevivía al nacimiento, lo que era estadísticamente improbable, la niña sería hospitalizada con frecuencia y podría necesitar inyecciones diarias de hormonas, a un costo de $60,000 anuales. Ann y su esposo comenzaron a preocuparse por cómo esto afectaría a sus otros tres hijos.

La gran mayoría de los abortos ocurren , y las personas que buscan abortar después de ese límite con frecuencia mencionan las barreras para acceder a la atención o el descubrimiento de una complicación médica.

Pero la ley de Texas ha prohibido prácticamente todos los abortos en el estado porque muchas mujeres ni siquiera saben que están embarazadas a las seis semanas. Ninguna prueba prenatal puede diagnosticar condiciones genéticas antes de las 11 semanas.

Situaciones como la de Ann pronto se repetirán en todo el país. El 24 de junio, la Corte Suprema de los Estados Unidos confirmó el estatuto de Mississippi que prohíbe el aborto después de las 15 semanas de embarazo, y anuló la decisión Roe vs. Wade de 1973 que garantiza el derecho al aborto.

Es probable que prohíban el aborto, según el Instituto Guttmacher, una organización de investigación que apoya el derecho al aborto.

Antes de la decisión de la corte, solo con límites de gestación para el aborto tenían exenciones para condiciones letales antes o durante el nacimiento. Ninguno permite exenciones para condiciones graves pero no letales. Sin tales exenciones, las personas que no pueden permitirse criar a un niño con una discapacidad ni viajar a una clínica fuera del estado podrían verse en una situación difícil.

Para las familias que acaban de enterarse de que es posible que su hijo no sobreviva al nacimiento o que tenga una condición debilitante, estos problemas legales agregan un trauma más a una decisión ya de por sí traumática.

Lauren Westerfield, consejera genética prenatal en Houston, dijo que la ley de Texas le ha impedido hacer su trabajo por completo. Cree que, por esa razón, muchos consejeros optarán por no practicar en Texas u otros estados donde el aborto ahora es ilegal, o pronto lo será, debido a las leyes que ha desencadenado la decisión de la Corte Suprema.

Cuando los pacientes preguntan sobre el procedimiento, “les digo: ‘Legalmente, en Texas, no tienes esa opción’”, dijo. “No tengo palabras para describir la mirada que aparece en sus rostros cuando escuchan eso”.

Muchas pacientes no tienen más remedio que llevar el embarazo a término. Westerfield estimó que, desde que se aprobó la ley estatal, al menos el 75% de sus pacientes que habrían interrumpido sus embarazos no han podido hacerlo.

Se sabe poco sobre los resultados para las personas que no pueden interrumpir un embarazo con anomalías genéticas. Pero un estudio que siguió a que fueron rechazadas de las clínicas de aborto porque habían superado los límites de gestación halló que tenían muchas más probabilidades de caer en la pobreza y tenían peor salud en general que aquellas que habían abortado.

A , experta en genética y especialista en ética del Sarah Lawrence College, le preocupa que las leyes restrictivas sobre el aborto signifique que los trastornos genéticos eventualmente ocurrirán de manera casi exclusiva entre las familias pobres, en particular porque los avances tecnológicos brindan mejores diagnósticos prenatales. Las personas más ricas podrían viajar a otros estados para abortar o someterse a procedimientos in vitro que descartan embriones con anomalías genéticas.

“En última instancia, creará una situación en la que una parte de la población diga: ‘Esto no me puede pasar a mí'”, dijo, y todos los demás que no pueden pagar ese privilegio se quedarán sin opciones.

El , genetista médico del Hospital General de Massachusetts y defensor de las personas con síndrome de Down, dijo que la falta de educación y conciencia sobre las condiciones genéticas ya es un problema para las personas que viven con estos trastornos, así como para los padres que deciden continuar con un embarazo. Dijo que los consejeros prenatales deben proporcionar a los futuros padres información precisa y actualizada sobre la realidad de esas condiciones para que puedan tomar decisiones informadas.

A medida que las pruebas prenatales se han vuelto más comunes, también lo han hecho las interrupciones selectivas de embarazos que involucran condiciones genéticas. Una revisión publicada de estudios sugiere que el con diagnóstico de síndrome de Down terminan en aborto.

Sin embargo, entre los opositores al aborto, interrumpir un embarazo después de un diagnóstico de este tipo se considera un acto de injusticia contra un grupo más débil. , presidente de Texas Right to Life, calificó estas situaciones de “trágicas”, pero agregó que “debemos tener mejores respuestas que ‘la única solución es provocar la muerte del niño’”.

Seago dijo que su organización apoya conocido como Preborn Non-Discrimination Act (Ley de No Discriminación Prenatal), que requeriría que los consejeros en genética informen a las pacientes sobre los servicios de cuidados paliativos prenatales y los grupos de apoyo para ayudarlas a llevar el embarazo a término. En este momento, dijo, “las únicas voces” que escuchan las embarazadas en las conversaciones médicas son a favor del aborto.

Para Ann de Texas, no había respuestas simples. Una semana después de los resultados de las pruebas iniciales, una amniocentesis y una ecografía para ver la anatomía de Juliet confirmaron lo peor: Juliet tenía una afección cardíaca grave, problemas musculares y otras complicaciones.

Ann se unió a grupos de apoyo para el síndrome de Turner y a leer sobre personas que vivían con el trastorno. Muchos, aprendió, mueren de problemas cardíacos entre los 20 y los 30 años. También vio un video de una niña pequeña con síndrome de Turner recibiendo su inyección diaria de hormonas. Gritaba de dolor.

Fue entonces cuando Ann decidió interrumpir el embarazo, temiendo por el dolor que Juliet habría experimentado todos los días. “Esta decisión es por amor”, dijo. “Es quitarles el dolor al experimentarlo uno mismo”.

Hizo una cita en una clínica en Colorado a fines de septiembre. Debido a que el embarazo tenía 19 semanas, el procedimiento sería complicado y costoso, y requeriría quedarse en Colorado por una semana.

Sabe que tuvo la suerte de tener la opción de viajar, cosa que muchas personas en su situación no podrían hacer. “Estaba realmente enojada, porque sentí que esto era algo que su médico y su hospital deberían haber hecho”, dijo.

Poco después de los resultados de la amniocentesis, comenzó a experimentar calambres severos. Pero no le dijo al obstetra que había estado viendo, preocupada de que la práctica enfrentara la opción de dejarla como paciente o ser demandada bajo la ley de Texas por instigar un aborto.

Seago dijo que la ley se aplica solo a los abortos realizados dentro de Texas; ayudar a alguien a obtener un aborto fuera del estado no sería un delito.

Aún así, a Hercher y a otros les preocupa que este tipo de miedo e incertidumbre pueda terminar perjudicando a las embarazadas. Aunque las leyes de Texas y la mayoría de los otros estados brindan exenciones para proteger la salud de la madre, no está claro cómo se interpretará esto en cada estado.

Ann tuvo su aborto el 28 de septiembre, un mes después de que el diagnóstico inicial convirtiera la alegría de la familia en una pesadilla. Antes de Juliet fuera cremada, la sostuvo en sus brazos.

En los últimos meses se ha unido a grupos de apoyo para madres que han interrumpido sus embarazos por motivos médicos. Además de brindar una comunidad amorosa y comprensiva, son las únicas personas que pueden comprender completamente la situación de su familia.

“En ningún momento se siente como una decisión”, dijo. “La decisión la ha tomado el diagnóstico”.

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Many people decide to terminate their pregnancies after this diagnosis, a genetic counselor told Ann and her husband. But the counselor had more bad news: In two days, the family would no longer have that option in their home state of Texas. , in effect as of Sept. 1, 2021, allows anyone to sue those who assist any person in getting an abortion in Texas after six weeks’ gestation — and the state provides a $10,000 bounty to plaintiffs if they win. The genetic counselor told Ann she could no longer discuss termination with her for this reason.

“At the time I thought, ‘It doesn’t matter; we’re not giving up on this pregnancy,’” said Ann, who asked that only her middle name be used out of concerns about privacy and potential legal repercussions for her medical providers, her husband, or herself under Texas’ unclear legal framework. She considered herself pro-life, and the diagnosis still needed to be confirmed through amniocentesis and ultrasound.

But after reading about the condition, she realized how devastating it could be. If Juliet survived birth, which was statistically unlikely, the child would be hospitalized frequently and might need daily hormone shots, costing $60,000 per year. Ann and her husband began to worry about how having this child would affect their three other children.

The , and people who seek abortions later than that frequently cite barriers to accessing care or discovery of a medical complication. But Texas’ law has effectively banned virtually all abortions in the state because many women don’t even know they are pregnant at six weeks. No prenatal tests can diagnose genetic conditions before 11 weeks.

Situations like Ann’s will soon happen across the country. The U.S. Supreme Court on June 24 upheld Mississippi’s statute that outlaws abortion after 15 weeks, and overturned the 1973 Roe v. Wade decision that guarantees the right to abortion. are likely to ban abortion, according to the Guttmacher Institute, a research organization that supports abortion rights.

Before the court’s decision, only with gestational limits on abortion have had exemptions for conditions lethal before or at birth. None allow exemptions for serious but nonlethal conditions. Without such exemptions, people who can neither afford to raise a child with a disability nor travel to a clinic out of state could be left in a difficult spot.

For families who’ve just learned their child may not survive birth or will have a debilitating condition, such legal issues add one more trauma to an already traumatic decision.

Lauren Westerfield, a prenatal genetic counselor in Houston, said the Texas law has made it impossible for her to fully do her job. She expects that, for that reason, many counselors will choose not to practice in Texas or other states where abortion is now illegal — or soon will be — because of trigger laws launched by the Supreme Court decision.

When patients ask about termination, “I tell them, ‘Legally, in Texas, you don’t have that option,’” she said. “I don’t have words to describe the look that comes over their face when they hear that.”

Many patients have no choice but to carry the pregnancy to term. Westerfield estimated at least 75% of her patients who would have terminated their pregnancies have been prevented by the state law since it passed.

Little is known about the outcomes for people unable to terminate a pregnancy with genetic anomalies. But a who were turned away from abortion clinics because they were past gestational limits found they were far more likely to fall into poverty and had worse overall health than those who had gotten abortions.

, a genetics expert and ethicist at Sarah Lawrence College, worries that restrictive abortion laws will mean genetic disorders will eventually occur almost exclusively among poor families, particularly as technological advances provide better prenatal diagnoses. Wealthier people could travel to other states for an abortion — or undergo in vitro procedures that screen out embryos with genetic anomalies.

“Ultimately, it will create a situation where one part of the population says, ‘This can’t happen to me,’” she said — and everyone else who cannot afford that privilege will be stuck without options.

Dr. , a medical geneticist at Massachusetts General Hospital and an advocate for people with Down syndrome, said lack of education and awareness about genetic conditions is already a problem for people living with these disorders, as well as for parents choosing whether to continue a pregnancy. Prenatal counselors, he said, should provide expectant parents with accurate, up-to-date information about the reality of those conditions so they can make informed decisions.

As prenatal testing has become more common, so too have selective terminations of pregnancies involving genetic conditions. A published review of studies suggests that with a diagnosis of Down syndrome end in abortion.

Among abortion opponents, however, terminating a pregnancy after such a diagnosis is seen as an act of injustice against a weaker party. , president of Texas Right to Life, called such situations “tragic” but added that “we have to have better answers than ‘the only solution is to cause the death of the child.’”

Seago said his organization supports a known as the Preborn Non-Discrimination Act, which would require genetic counselors to inform patients about prenatal palliative care services and support groups to help them carry the pregnancy to term. Right now, he said, “the only voices” that pregnant people hear in medical conversations are pro-abortion.

For Ann in Texas, there were no simple answers. A week after the initial test results, an amniocentesis and an ultrasound to see Juliet’s anatomy confirmed the worst: Juliet had a severe heart condition, muscular problems, and other complications.

Ann began joining Turner syndrome support groups and reading about people living with the disorder. Many, she learned, die from heart conditions in their 20s and 30s. She also saw a video of a little girl with Turner syndrome getting her daily hormone injection. The child was screaming in pain.

That was when Ann decided to end the pregnancy, fearing the pain Juliet would have experienced every day. “This decision is out of love,” she said. “It’s taking the pain away from them by experiencing it yourself.”

She made an appointment with a clinic in Colorado in late September. Because the pregnancy was 19 weeks along, the procedure would be complicated and expensive, requiring her to stay in Colorado for a week.

She knows she was fortunate to have the option to travel, which many people in her situation could not do. “I was really angry, because I felt like this was something that should be done by your doctor and your hospital,” she said.

Soon after the amniocentesis results, she began experiencing severe cramping. But she didn’t tell the obstetrician she’d been seeing, worried that the practice would face the choice of dropping her as a patient or being sued under Texas law for abetting an abortion.

Seago said the law applies only to abortions performed within Texas; helping someone obtain an abortion outside the state would not be a crime.

Still, Hercher and others worry that this kind of fear and uncertainty may end up hurting those who are pregnant. Although Texas’ and most other states’ laws provide exemptions to protect a mother’s health, it’s unclear how this will be interpreted in each state.

Ann had her abortion on Sept. 28 — a month after the initial diagnosis had turned the family’s joy into a nightmare. Before having Juliet cremated, she held her daughter.

In recent months, she has joined support groups for mothers who have terminated their pregnancies for medical reasons. Besides providing a loving and understanding community, they are the only people who can fully understand her family’s situation.

“At no point does it feel like a decision,” she said. “The diagnosis is a decision that’s been made for you.”

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After the attempt failed, she was arrested and taken to juvenile detention in Poplar, a remote town on the Missouri River a short drive from the North Dakota oil fields. She was put in a cell and kept under observation for several days until a mental health specialist was available to see her. Her only interaction was with the woman who brought food to her cell.

“I remember asking her if I could have a hug and she told me, ‘I’m sorry, I can’t do that,’” Vega recalled. “That was honestly one of the hardest things I ever went through in my life. I felt like I was being punished for being sad.”

Jailing people because of a mental health issue is illegal in Montana and every other state except New Hampshire. But Vega is a member of the Fort Peck Assiniboine and Sioux Tribes, a sovereign nation with its own laws. An 11-year-old tribal policy allows law enforcement to put members who threaten or attempt suicide in jail or juvenile detention to prevent another attempt.

Fort Peck’s tribal leaders say they approved the policy out of necessity because there were no mental health facilities equipped for short-term housing of people in mental crisis.

The covid pandemic has only exacerbated the crisis. In 2020, the tribes filed a record 62 aggravated disorderly conduct charges, the criminal charge they created in 2010 to allow law enforcement to book people they deemed a risk to themselves or others.

Stacie FourStar, chief judge of the Fort Peck Tribal Court, said this year has been even worse: The tribe is filing two to four charges per week. The policy has swept up people — particularly adolescents — with no criminal records and no experience with the criminal justice system, she said.

The judge fears it creates a perverse incentive not to call 911 or reach out for help when depression sets in. “They don’t want to go to jail,” FourStar said. “They just want somebody to talk to.”

Tribal officials and various mental health advocates have been trying to find an alternative for nearly a decade. But the reservation is still badly lacking in both secure psychiatric facilities and qualified mental health workers. Despite funding available for new positions, recruitment efforts have failed and there is still no viable alternative to keep people safe.

“Their hands are tied,” FourStar said, noting that if “personnel and facilities aren’t available, we’ll be putting people in an unsafe situation.”

Having experienced imprisonment herself as a teen, Vega is now part of a team of tribal members, state educators and policy experts looking for alternative solutions.

The group’s ideas include ensuring that a mental health specialist is the first point of contact for a person in crisis and setting up safe houses, said , the project’s leader.

In May, the group presented a plan to the Fort Peck Tribal Council, which has yet to act on its recommendations. A spokesperson for the Fort Peck Tribes said the tribes are looking into the policy but declined to comment further.

Yet tribal leaders say that unless they can attract mental health workers to remote northeastern Montana, the jailings will likely continue. “We can propose all we want,” said Jestin Dupree, a tribal legislator and chairman of the law and justice committee. “We’re not getting the doctors, the qualified people.”

The Fort Peck reservation, a windswept cluster of small towns surrounded by 2 million acres of rolling farmland, has a suicide rate the national average. Native American adolescents are twice as likely to die by suicide as their white peers.

The 2010 policy that put Vega in jail followed a cluster of more than 150 suicide attempts and the deaths of at least six teenagers. Overwhelmed by the crisis, Fort Peck’s tribal government created the “aggravated disorderly conduct” charge.

“It came from desperation,” said FourStar, who was chief tribal prosecutor at the time. “Families weren’t able to handle the needs of their loved ones and they didn’t want them to hurt themselves.”

People charged with aggravated disorderly conduct are held until they can undergo a mental health evaluation and attend a court hearing, where they may receive a court-ordered treatment plan. If they comply with the plans, the charge is dropped. They usually don’t end up with a public criminal record, but the court system can still track them.

Nontribal members are never put in jail, because the tribe lacks jurisdictional authority over them. Instead, a police officer ends up sitting with them in the hospital — sometimes for days — until they can be evaluated.

Not every suicide threat or attempt ends in an aggravated disorderly conduct charge. Ideally, a person in crisis is immediately evaluated by a mental health professional at the Indian Health Service or a telemedicine provider who can refer them to emergency care, if needed.

“Even though there’s difficulties in trying to get care for them, we still persevere,” said Sylvia Longknife, an IHS mental health specialist in Poplar. Longknife is IHS’ only mental health worker on the Fort Peck reservation since two other providers quit this year, meaning she can’t always immediately see somebody in crisis.

Longknife said she sees between two and five emergency cases a week. If the situation is deemed an emergency, the patient is referred to a facility four hours away in Billings. IHS doesn’t have its own transportation, so it either asks family members to drive the patient or requests transportation funds from the tribe.

If a suicide attempt occurs on a weekend, after hours or when a mental health worker is unavailable, police officers who respond may end up taking the person to a hospital for medical treatment, if necessary, and then to jail.

Lisa Dailey, executive director of the Treatment Advocacy Center, a national nonprofit that pushes for access to mental health treatment, said jailing people for attempting suicide criminalizes mental illness. “Prison or jail are the worst settings you can possibly be because you’re in a psychiatric crisis,” she said. Even if the care is good, she said, “being incarcerated is a traumatizing experience.”

have shown that the risk of self-harm in prison increases if someone has been held in solitary confinement or has previously attempted suicide.

The Fort Peck reservation isn’t the only jurisdiction where people can be jailed after a suicide attempt. In New Hampshire, : the men’s prison.

After the Fort Peck tribes approached Carpenter’s Native American politics class last year for ideas, he and his undergraduate students began consulting with tribal members and others in Montana and working to research potential alternatives to jail.

The Flathead tribe in western Montana, for instance, specifies that people should be held in the “least restrictive environment” possible to protect their well-being, short of a jail cell. Carpenter said this could take the form of a “safe house” that separates a person from weapons.

Other potential fixes include requiring that a mental health worker accompany police during interactions with a suicidal person to ensure that jail is the last resort, and creating a new “mental health code” that would treat suicidal people differently from those who pose a threat to others.

The state of Colorado put toward community-based health treatment in 2017, to jail people awaiting mental health evaluations who hadn’t been charged with a crime.

But places like reservations may have no choice. “With no resources, there’s very little you can do about any of those issues,” Dailey said.

The IHS office has sufficient funds to hire four more mental health workers for Fort Peck. “We’re definitely aggressively trying to fill empty vacancies,” said Steve Williamson, chief medical officer of the IHS’ Billings area office.

But the positions have been difficult to fill. IHS and other health providers in northeastern Montana struggle to attract candidates to live in a region 70 miles from the nearest Walmart, with few jobs or entertainment options for families.

FourStar said the tribes hope to use covid relief aid to improve behavioral health services so that suicide attempts can be treated as civil cases instead of criminal ones. “I think this will go somewhere, as long as we can get the manpower,” she said.

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Immense quantities of sediment choked the rivers that supply most of the state’s water. In western Colorado’s Glenwood Springs, the water became so murky that the town twice had to shut off the valves that pump water from nearby rivers to avoid overwhelming its filtration system. City managers sent alerts to the town’s 10,000 residents, telling them to minimize water use until the sediment moved downstream.

Wildfires and their lasting effects are becoming a way of life in the West as climate change and management practices cause fires to increase in number, intensity and acreage burned, while extending the length of the fire season. In “burn scars,” where fires decimated forest systems that held soil in place, an increase in droughts followed by heavy rainfall poses a different kind of threat to the water supplies that are essential to the health of communities.

“You know about it; it’s in the back of your head,” said Glenwood Springs resident Paula Stepp. “But until you face it, you don’t know how it’s going to impact your town.”

Dirty, turbid water and other contaminants that cause illness. But experts say turbid water from burn scars is unlikely to make it to people’s taps, because water utilities would catch it first.

Still, the cost to municipal utility systems — and the residents who pay for water — is immense. Rural small towns in particular face the choice between spending millions of dollars to try to filter turbid water or shutting off their intake and risking shortages in areas where water may already be scarce.

And as fires move closer to communities, burning synthetic materials from houses and other buildings can create toxic compounds that leach into water supplies, which is what happened in California

“When we put [fires] out, we become less aware of them,” said , of Oregon State University. But from a water perspective, “that’s when all the problems start.”

Montana’s capital city, Helena, gets its drinking water supply from the Upper Tenmile Creek watershed in a forest thick with trees killed by beetle infestations. City leaders worry a fire would quickly chew through that dry fuel and leave the watershed exposed to sediment contamination. , the fire threat remains and city leaders worry the resulting sediment would overwhelm the water treatment plant and shut down the primary water source for 40,000 people.

“If we had a fire up there, depending on where it is and how big it is, it could put the Tenmile plant out for a season or two,” Helena Public Works Director Ryan Leland said.

To protect against that happening, the city is in the early phases of designing a basin that can trap sediment before the water reaches the plant, Leland said. , which would give them another drinking water supply option if something happens to the Upper Tenmile watershed. Treated water from the Missouri River is the city’s current backup supply.

The Rocky Mountains and about 200 miles separate Glenwood Springs from Greeley, in northeastern Colorado. But the 2020 fire season caused similar problems in both cities, creating burn scars that later flooded, contaminating water sources.

So far this year, Greeley has had to shut off its intake from the Cache la Poudre River for 39 days because the water was contaminated with sediment, ash and organic matter. “Normally we would never turn it off,” said .

To cope, the city has been trading water with a nearby agricultural company that owns reservoirs used for irrigation. The swap gives the turbid water to farmers and redirects the reservoir water to Greeley. “If we didn’t have the trade in place, the cost [of buying water] would be astronomical,” Chambers said.

But Chambers admitted this system is a luxury that smaller towns may not enjoy. Greeley is 10 times the size of Glenwood Springs and has spent more than $40 million this year recovering from the Cameron Peak Fire — the largest fire in Colorado history, which burned for four months in 2020. Those costs may climb as rain continues, he said. Larger towns also tend to have better filtration systems that can handle more sediment, which clogs up filters and requires utilities to add chemicals to remove contaminants before the water is safe to drink.

While dry states like Colorado expect fires each year, recent blazes in wetter places like western Oregon have caught researchers off guard. Last September, of the state’s Cascade mountain range, leaving burn scars above rivers and reservoirs that supply much of the state’s water.

“We have to be very proactive,” said a research engineer with the U.S. Forest Service in Moscow, Idaho.

After a wildfire is extinguished, Robichaud’s agency and others send teams of specialists to evaluate the risks that erosion and ash pose to water supplies. Their data can help land managers decide whether to take actions like thinning forests above rivers, dredging contaminated reservoirs, covering the area with mulch or seeds to reduce erosion, or forming a plan for alternative water sources.

Even advance notice of a flood could help immensely, said Stepp, the Glenwood Springs resident. She is the executive director of the nonprofit , which recently worked with the U.S. Geological Survey to along Glenwood Canyon. These monitor weather upstream and notify downstream water users that a sediment-laden flood could be coming.

She said it is crucial for small communities in particular to partner with state and federal agencies. “Basically, we work with everybody,” she said.

Although debris flows can bring soil bacteria into water supplies, city utilities can disinfect them with chemicals like chlorine, said , a hydrologist at the University of Colorado-Boulder. But those disinfectants can themselves cause a problem: Organic matter from sediment can interact with these chemicals and create carcinogenic byproducts that are difficult and expensive to remove.

Another waterborne danger comes from chemical byproducts and heavy metals from burned structures. “Those would be potentially really problematic to treat,” Livneh said.

After the 2017 Tubbs and 2018 Camp fires that devastated the Northern California communities of Santa Rosa and Paradise, researchers examining the tap water of nearby homes found benzene and other carcinogens. Public health researcher at the Public Health Institute in Oakland, California, said the contamination likely came from plastic pipes that melted and leached chemicals into the water.

Smoke and ash from burned structures may also add toxic chemicals to water supplies. “The smoke from the fires is a truly nasty brew,” Solomon said.

California has been relatively lucky when it comes to sediment flow. The years-long drought in most of the state means burn scars remain intact — though a heavy rain could wash down years of debris.

It’s unclear how long burn scars continue to pose a landslide risk, said Bladon, the Oregon hydrologist. But parts of Alberta in the Canadian Rockies, for instance, continued to see extremely turbid water for a decade after a 2003 fire.

“My fear is we may not have seen the worst of it yet,” Solomon said.

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Jeff Denny’s lungs are damaged from the asbestos he breathed while participating in an Environmental Protection Agency-run cleanup of the asbestos contamination caused by the vermiculite mine that closed 30 years ago in this community in the Cabinet Mountains. Patricia Denny is afraid she will get asbestos-related disease as well, given how many residents of the town have become sick. Barbed fibers, a byproduct of vermiculite, attach to the lungs when breathed in.

At least 400 people exposed to Libby asbestos have died of asbestosis, mesothelioma or other lung diseases, and thousands more have been diagnosed with lung damage and diseases caused by asbestos, according to the Center for Asbestos Related Disease, the Libby clinic that diagnosed Jeff Denny.

“It is not the matter of if, it is when,” Patricia Denny said in an online message. “Once this barbed killer gets in ya it stays … and kills the area it penetrates.”

The company that operated the mine, W.R. Grace, filed for bankruptcy in 2001, as thousands of lawsuits poured in after the extent of the contamination became known. Since then, the Montana Supreme Court has held several other companies responsible as well, including the BNSF Railway, one of the nation’s largest rail companies. BNSF, owned by billionaire Warren Buffett’s Berkshire Hathaway, is liable for spreading asbestos amid the dust that blew off its cars while transporting vermiculite across the nation for use in insulation and other purposes, according to court rulings.

Now, the railroad is going after the local health clinic that opened to deal with the health crisis in 2000 and still screens dozens of people each month as new cases emerge. BNSF is suing the Center for Asbestos Related Disease in federal court.

The rail company alleges that the clinic is defrauding Medicare and grant agencies by overdiagnosing asbestos-related diseases and running unnecessary tests. BNSF also takes issue with CARD’s reliance on X-rays or CT scans to make its diagnoses, even if independent experts disagree with the clinic’s interpretations of the scans.

“CARD knowingly billed the federal government millions of taxpayer dollars for medically unnecessary radiographic studies and interpretations that they routinely disregarded,” BNSF spokesperson Lena Kent said in a statement.

In the suit, which was filed in 2019 but not made public until Feb. 18, BNSF asked the U.S. government to prosecute CARD for fraud. The government declined, leaving BNSF to sue the clinic itself under a federal whistleblower statute.

Kent said that the decision “was not taken lightly” and that BNSF “recognizes the extraordinary impact that Asbestos-Related Disease has had on the [Libby] community.”

CARD’s team is one of the few who study the health effects of Libby amphibole asbestos — the name of the needle-like mineral found only in Libby and a few other mines around the world. The clinic is also the leading provider of asbestos diagnostics and care in the 2,700-person town, where mesothelioma and asbestosis are rampant.

CARD and its lawyers see the lawsuit as a ploy to damage the clinic’s credibility and limit the railroad’s financial liability by casting doubt on the legitimacy of the clinic’s diagnoses. The attorney representing CARD, Tim Bechtold, said the lawsuit is taking the clinic’s time and resources away from patients. “All they want to do is hassle CARD,” he said. “It’s completely cynical.”

The EPA declared Libby a Superfund site in 2002 and spent more than $600 million on the cleanup,. W.R. Grace agreed to pay current and future asbestos victims’ medical costs and $250 million for the cleanup, and the company emerged from bankruptcy in 2014.

People in Libby are still being diagnosed with asbestos-related diseases today. Decades can pass between exposure and the development of symptoms, Anyone in Libby can qualify for Medicare if they develop lung disease, under a special part of the Affordable Care Act.

The crux of BNSF’s accusations is that many of CARD’s diagnoses of distinct lung diseases in Libby residents are fraudulent, largely due to their rarity and the difficulty that others have diagnosing them.

Researchers from CARD and Mount Sinai hospital in New York City have that CT scans from the lungs of people exposed to amphibole showed a distinct type of scar tissue called lamellar pleural thickening (LPT). CARD’s research suggests that this scar tissue thickens over time and makes it increasingly difficult for the patient to breathe.

But few, if any, cases of asbestos-associated LPT have been diagnosed outside of CARD. The clinic said that is because no one else knows to look for it. “The disease is different than typical [asbestos-related] disease so it does in fact take a trained eye to identify it,” CARD said in a statement. “If the [CT] reader did not know what he/she was looking for, then it would not be identified.”

Others see this as evidence that CARD is overdiagnosing patients with a condition that may not exist. “I was appalled by what goes on in Libby,” said Dr. Anthony Dal Nogare, a pulmonologist at who has testified for BNSF in prior lawsuits. “It’s like the emperor’s new clothes if it’s something only they can see and no one else can.”

Dal Nogare, who visits Libby frequently to see patients, said he never sees LPT on CT scans and rarely sees asbestos-related lung diseases in people who did not work in the mine. He pointed out that the smoking rates in Libby are high, which could account for the shortness of breath and other symptoms CARD’s patients experience.

CARD said it sends each of its CT scans to independent radiologists who can confirm the diagnosis of LPT. The clinic’s records indicate it finds abnormalities in 60% of scans, while the outside radiologists find them in only 35%. CARD’s administrative director, Tracy McNew, said the discrepancy occurs because the independent radiologists don’t receive any clinical information about patients or their symptoms, meaning they can’t learn how to see LPT and associate it with the disease.

“It’s just not an exact science,” said Bruce Alexander, an environmental epidemiologist at Colorado State University. Although something serious like mesothelioma would be obvious in a CT scan or X-ray, he said, trained radiologists can differ on how to interpret subtle signs like pleural thickening, which may be confused with fat on the lungs.

Dr. Paul Scanlon, a pulmonologist at the Mayo Clinic in Rochester, Minnesota, said most radiologists would read what CARD calls LPT as pleural plaques, which are difficult to mistake on a CT scan. Pleural plaques are an indication that someone has been exposed to asbestos but are not very harmful by themselves.

CARD declined to make its medical experts available to respond, citing the pending case.

“There’s legitimate scientific debate about what the implications of these exposures are, but it’s pretty clear people in these communities were adversely affected,” Alexander said. In 2012, he the lungs of Minneapolis residents who lived near a plant that processed Libby vermiculite. He found about 11% of the residents there had a type of pleural thickening or plaques but said the long-term health implications are unclear.

Other evidence suggests that the lungs of Libby’s residents are especially damaged, both those of people who worked in the mine and those who did not. In 2017, the CDC a study showing that residents were more than 100 times as likely to die of the lung disease asbestosis than the general population.

“Simply by living in Libby, they were exposed to asbestos at a high-enough concentration,” said paper author Samantha Naik, a former CDC epidemiologist who is now a private consultant. She said Libby represents a rare case in which an environmental chemical can be scientifically proven to cause a disease.

For her part, Patricia Denny is frustrated that BNSF and other companies have yet to be held fully accountable.

“They all made a huge profit, still are, while the people are dying,” she said.

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For employees of small businesses in Montana suddenly laid off during the covid-19 pandemic, maintaining health insurance coverage could be a struggle.

Employers with 20 or more workers offer a bridge insurance program made possible by a federal law known as the Consolidated Omnibus Budget Reconciliation Act, or COBRA. The law allows people who have left a job voluntarily or involuntarily to keep their former employer’s health insurance plan for 18 months by paying the premium that the employer used to cover.

But smaller Montana businesses employing fewer than 20 people are not required to offer such a program, potentially leaving people without continuing coverage if they are laid off. Now, would create a “mini-COBRA” law that would require any small business with a group health insurance plan to offer continuing coverage for up to 18 months at the employee’s expense starting in 2023.

Montana is one of only six states without a mini-COBRA program, despite the estimate that around Montanans work at businesses with 19 or fewer employees. Rep. Mark Thane (D-Missoula), the bill’s sponsor, said it was brought to his attention last year by a constituent who worked at such a business.

“The concern, I think, was exacerbated during the pandemic when people were in layoff status and lost access to group health insurance plans,” Thane said.

He added that the legislation would not cost Montana taxpayers anything — the premiums are paid by individuals — and that it would bring Montana in line with most other states. The measure, House Bill 378, passed the House 84-14 on March 2.

But when the bill reached the Senate, business and trade groups said they opposed the measure because of the additional paperwork it might mean for small mom-and-pop businesses.

“Why do we need to add more red tape and regulations to small businesses?” David Smith, executive director of the Montana Contractors Association, asked a Senate committee on Wednesday.

In response, Thane said he acknowledges the concerns, but added, “I don’t see it as an overwhelming paperwork burden.”

The opposition by business was enough for a Senate committee to shelve the measure, at least temporarily, though it could be revived later in the session. Committee chairman Steve Fitzpatrick (R-Great Falls) told lawmakers to “keep this one in your folder.”

Mini-COBRAs are not intended to be long-term health insurance plans. For one thing, they generally are expensive. On average, employees with job-based single coverage pay s (for family coverage, it averages 27%). Under COBRA or mini-COBRA, a former employee pays 100%, plus a 2% administrative fee that goes to their former employer. Montana’s bill is modeled on and provides 18 months of coverage at 102% of the premium and an additional 11 months at 150% of the premium.

Mini-COBRAs are unlikely to be widely used for another reason. The federal exchange created by the Affordable Care Act that sells individual insurance plans is a less expensive option that is better for most people, said , co-owner of a health insurance brokerage in Colorado who writes about health insurance. After all, job loss is among the conditions that qualify a person to buy an ACA exchange plan outside the open enrollment period.

Norris said COBRA might be a better option for patients who are in the middle of treatment, for instance, and don’t want to switch physicians. People who have already paid off most of their maximum out-of-pocket costs might also prefer to continue with the same plan rather than starting over at zero with a new plan. “That’s where COBRA and mini-COBRA are really attractive,” Norris said.

Thane added that people who were laid off during the pandemic but expect to be rehired within a few months might also choose a mini-COBRA to tide them over.

But because the new Montana law, if it passes, wouldn’t take effect until 2023, its usefulness in that scenario is likely to be minimal. It also won’t come soon enough for Montanans who work at businesses with fewer than 20 employees to take advantage of a provision in the recently passed $1.9 trillion covid relief bill that will pay for individuals’ COBRA and mini-COBRA premiums through September.

Still, Thane hoped that the plan will give more options to employees of small businesses. “Given the competitive labor market, it’s become increasingly important for small entities to offer benefit plans to hire and retain folks,” he said.

[Update: This article was revised at 1 p.m. ET on March 19, 2021, after the Montana Senate temporarily shelved the mini-COBRA legislation.]

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As her son lay in the intensive care unit with a tube in his tiny lungs, Jayci began imagining worst-case scenarios. She worried that if Griffin ended up needing a lung transplant, he might be refused because he has Down syndrome.

“It was terrifying knowing that they could deny him certain lifesaving services,” she said.

Denying organ transplants to people with intellectual and neurodevelopmental disabilities like Down syndrome or autism is common in the United States, even though it is illegal under the Americans with Disabilities Act.

According to , 44% of organ transplant centers said they would not add a child with some level of neurodevelopmental disability to the organ transplant list. Eighty-five percent might consider the disability as a factor in deciding whether to list the person.

After Griffin recovered, Jayci brought Montana lawmakers’ attention to the issue. Largely as a result of her campaigning, the state is considering a bill that would ban physicians from denying an organ transplant based solely on a patient’s disability. Last month, ” — passed the Montana Senate 50-0.

Although Montana has no transplant centers of its own, advocates hope this bill and others like it will draw attention to the issue and pressure physicians to examine why they are making certain decisions. Andrés Gallegos, chairman of the National Council on Disability, said he hopes such legislation will inspire “a change of heart so people understand that they are discriminating.”

If the bill passes the state House and is signed by the governor, Montana would become the to ban such discrimination. Seven other states and the have similar bills pending, although some experts doubt such laws will be enforceable enough to eliminate discrimination.

With more than nationwide, and average wait times extending for some organs, physicians have to frequently make heart-rending decisions about which patients are likely to benefit most.

According to a , many physicians and organ transplant centers worry that patients with intellectual or neurodevelopmental disabilities are more likely to have co-occurring conditions that would make a transplant dangerous, or that these patients’ quality of life is unlikely to improve with a transplant. Others believe that these patients may not be able to comply with post-transplant requirements, such as taking immunosuppressive drugs.

But the report, which scoured research papers and medical reports, found that none of these concerns is universally true. Rather, disabled patients can benefit as much as any other patient, according to the NCD, an independent federal agency.

“If a determination is made to not include a person on the list only because that individual has a disability, that’s blatant discrimination,” said Gallegos.

Many intellectually disabled patients and their families see this firsthand. When Joe Eitl was born in 1983 with a congenital heart defect, his mother, Peg, was told that Joe would never be a candidate for a new heart because of his Down syndrome. So, when his heart failed in 2019, eight hospitals refused to even consider a transplant for Joe, who lives with his mother in Philadelphia.

Peg Eitl conceded that Joe’s case was difficult, given he’d had prior reconstructive heart surgery that would complicate a transplant. She pleaded with transplant centers for more than a year and even considered suing them. Last October, Vanderbilt University agreed to perform the procedure. Joe came home Feb. 10 and is recovering.

“I think my greatest frustration was the value placed on someone with special needs,” Peg Eitl said. “It pains me that they’re discounted as being less than and not as worthy.”

Bioethicist of Stanford University, who authored the 2008 study on the extent of transplant discrimination, said people like Peg Eitl shouldn’t have to prove that Joe would benefit from a transplant. Because people with disabilities are a protected class in the United States, he said, “the burden is on people who want to discriminate.”

But that doesn’t appear to be the case in practice. In September, Magnus a follow-up survey of more than 300 transplant programs. Of these, 71% said they would automatically disqualify an adult with an IQ under 35, which is considered severe intellectual disability, while 12% would disqualify a child at that level. Only about 20% of the institutions had formal guidelines regarding child patients.

Magnus suspects these numbers are low given that some physicians may be unwilling to admit to discrimination. He has not yet studied whether new state laws have affected physicians’ likelihood to discriminate against disabled patients.

But Magnus doubts that laws like Montana’s bill will be enforceable. Part of determining any patient’s eligibility for a transplant, he said, is whether they or a caretaker can comply with post-transplant requirements such as remembering to take immunosuppressant drugs. If a person with a disability can’t meet these criteria, that person might not be a good candidate.

“All of these are terribly difficult judgments,” Magnus said.

Transplant surgeons need to maximize the limited supply of organs and ensure they survive in the patients who receive them. If they don’t, “it’s taking an organ from someone who could have benefited from it,” said Dr. Marwan Abouljoud, president of the American Society of Transplant Surgeons.

Abouljoud said institutions have differing standards for weighing the importance of an intellectual disability in a transplant decision. Ideally, he said, the committee that determines whether to list someone for a transplant will include social workers and behavioral psychologists, as well as program leadership, who can find ways to help the person comply.

On Feb. 12, the transplant surgeons’ society adopted a new supporting nondiscrimination and encouraging transplant centers to find ways to support these patients. “We will be urging states to adopt local policies on this,” Abouljoud said.

Sam Crane, legal director at the Autistic Self Advocacy Network, which has written model legislation adopted by several states, said that some bills — including Montana’s — address the concern about post-transplant care. They ban transplant centers from basing their decision solely on a person’s ability to carry out post-transplant requirements and require an investigation into sources of support to help the patient comply.

But Crane said physicians could still come up with a pretext to avoid adding a disabled person to the transplant list if they believe a person without a disability would benefit more from receiving an organ.

“It’s very difficult to prove discrimination in that sort of situation,” she said.

Although a similar nondiscrimination bill has been introduced in the U.S. House of Representatives, Crane said advocates prefer to focus on state laws. Organizations like the autism group have taken the position that the ADA and other federal laws already prohibit this kind of discrimination, making federal legislation unnecessary. Gallegos added that states can also enact stricter requirements than the federal government and fit them to their specific medical systems.

Under state laws, patients can appeal to local courts for an emergency injunction or restraining order. These hearings can be conducted quickly, allowing a judge to decide whether to compel an institution to add a person to the transplant list.

That speed is what Jayci Dalrymple hopes Griffin’s Law will achieve. “When you’re needing to stop discrimination, you’re racing the clock,” she said.

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“We can’t have ceremony without memorizing all of the songs, songs galore,” he said. “We’re not supposed to record them: We have to be there. And when that doesn’t happen in my grandchildren’s life, they may never catch up.”

Such ceremonial gatherings have been scarce over the past year as Native American communities like Wetsit’s isolate to protect their elders during the covid-19 pandemic. Reservations have been hit especially hard, with Native Americans nearly as white people. Wetsit, a tribal elder and former chair of the Fort Peck Assiniboine and Sioux Tribes, said his tribe lost one person a day on average to the disease during October and November.

The deaths are doubly devastating to Native communities when they strike elders, as they are seen as the keepers of tribal history and culture. Wetsit worries that the combination of deaths and lockdowns will permanently harm the tribe’s ability to share traditional knowledge and oral history.

“Our grandchildren will feel it in their generation,” he said. “It’s like taking a number of pages of their textbook and ripping it out and throwing it away.”

With that in mind, many Native people have found innovative ways throughout the pandemic to continue sharing their culture despite physical distancing restrictions. Social media groups have provided some remedies, in ways that may continue after the pandemic wanes.

“If there was ever a time where we could see how interconnected our world is, that time is now,” said Jeneda Benally, a musician and member of the Navajo tribe in Arizona.

One Facebook group, known as , has helped its Native members connect through sharing videos of drumming, dancing and other traditions. Since its founding in March, the group has accumulated more than 227,000 members and taken on a life of its own, with people sharing prayer requests, birthday celebrations and death announcements.

“We didn’t expect it to take off like it did,” said group co-founder Dan Simonds, an artist based in Bozeman, Montana, and a member of the Pequot tribe. “It showed how much something like this was needed.”

For group members who rarely leave their isolated reservations, the videos provide an opportunity to see other tribes’ homes and traditions for the first time. “Every tribe is different, like every European country,” Simonds said.

The group has provided a platform to talk about important issues. In January, organizers hosted a with a doctor, nurses and community representatives who could answer group members’ questions about covid vaccines. Skepticism about the safety of vaccination tends to be high among Native Americans, and more than 9,500 people viewed the event. “People are listening and learning,” Simonds said.

Simonds expects the group will continue after the pandemic ends, and he has created a nonprofit spinoff that plans to hold in-person powwows once it is safe. “This is one of the first times in history we have our own space by Natives where Natives can be heard,” he said.

Among other powwow events that have seen an online resurgence is the , an Ojibwe tradition usually performed by groups of women wearing skirts adorned with tinkling metal bells. Women from various tribes have been posting Instagram videos of themselves dancing alone at home.

, an Ojibwe historian at the University of Minnesota, is not surprised the dance has become so popular during the pandemic. “Most women and young girls are very aware that that is a healing tradition,” she said.

According to legend, jingle dress dancing arose during the 1918 flu pandemic when a father with a sick little girl dreamed of a healing dance and had the dresses made for four women in his tribe. The girl recovered and became one of the first jingle dress dancers.

Child said the jingle dress tradition resonates because it is supposed to heal both the body and the mind during a time when fear and grief are rampant. “Ojibwe have always been aware there’s this psychological aspect to disease,” she said.

But some traditions are more difficult to share online, particularly those that rely on oral stories told by elders. Internet access can be scarce on remote reservations, and many older people struggle to use technologies like video chat. “It’s hard enough for our communities and elders to transmit that information to the next generation, but trying to find a way to do that with social distancing in this era is especially hard,” said Clayson Benally, Jeneda’s brother.

Since the Benallys’ band, Sihasin, can’t tour during the pandemic, the siblings have been performing online. They are also making instructional of traditional Navajo practices such as shearing sheep and harvesting medicinal plants.

“This is my desperate attempt to ensure that our culture continues to exist,” said Jeneda Benally. “Even though we’re losing people, this knowledge still exists. I don’t want our people to sink into a depression.”

Some practices are too sacred to share online, she said. Tribal members must walk a fine line between keeping people engaged and revealing privileged information to outsiders at the risk of cultural appropriation. Certain rituals, symbols and stories are meant to be shared only orally — many tribes forbid members to even write them down.

“It’s tricky because we have to be very cautious,” said Clayson Benally. “Our ancestors would never have imagined we’re teaching our ways through these airwaves that exist.”

Many Indigenous languages are in danger of disappearing forever, as speakers tend to be elderly and in fragile health. The pandemic has accelerated the threat.

“It’s the equivalent of having jumped forward 10 years and lost speakers that would have been with us still but now are gone,” said Wilhelm Meya, CEO of the nonprofit (TLC).

Meya’s organization preserves Indigenous languages through recordings, dictionaries, dubbed movies and lessons — mostly developed by sending linguists to visit Native speakers around the world. After the pandemic began, TLC set up computer terminals in unused schools and community centers on reservations. While staffers control the desktops remotely, language speakers and their families can visit the stations alone and record words.

By setting up six such terminals on the Crow reservation in Montana, TLC completed a four-year effort to develop an app. Similar projects are underway with tribes in Wisconsin, Washington and other states.

Meya said the strategy worked so well that TLC will continue using it after the pandemic to record Native languages in remote areas like Alaska and Australia. The nonprofit plans to offer more online lessons: Being stuck at home has led to a surge of interest among Native people in learning their historical languages, he said.

To Wetsit, the knowledge that Native Americans’ culture and communities have persisted through centuries of adversity suggests they will survive this crisis.

“If you’ve had cultural teachings, they’ll help you remember that things will get better and it gives you hope,” he said. “I think that our people realize that our culture can be changed a little bit without great harm. There’s no wrong way to pray.”

[Correction: This article was updated at 1:30 p.m. ET on Feb. 9 to correct Wilhelm Meya’s affiliation.]

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Leslie, whose father is a member of the Fort Peck Assiniboine and Sioux Tribes, is one of at least two teenagers on the reservation who died by suicide this summer. A third teen’s death is under investigation, authorities said.

Leslie’s mother, Natalie Keiser, was standing beside the grave recently when she received a text with a photo of the headstone she had ordered.

She looked at her phone and then back at the grave of the girl who took her own life in September.

“I wish she would have reached out and let us know what was wrong,” she said.

In a typical year, Native American youth die by suicide of their white peers in the U.S. Mental health experts worry that the isolation and shutdowns caused by the COVID-19 pandemic could make things worse.

“It has put a really heavy spirit on them, being isolated and depressed and at home with nothing to do,” said Carrie Manning, a project coordinator at the Fort Peck Tribes’ Spotted Bull Recovery Resource Center.

It’s not clear what connection the pandemic has to the youth suicides on the Fort Peck reservation. Leslie had attempted suicide once before several years ago, but she had been in counseling and seemed to be feeling better, her mother said.

Keiser noted that Leslie’s therapist canceled her counseling sessions before the pandemic hit.

“Probably with the virus it would have been discontinued anyway,” Keiser said. “It seems like things that were important were kind of set to the wayside.”

Tribal members typically lean on one another in times of crisis, but this time is different. The reservation is a COVID hot spot. In remote Roosevelt County, which encompasses most of the reservation, more than 10% of the population has been infected with the coronavirus. The resulting social distancing has led tribal officials to worry the community will fail to see warning signs among at-risk youth.

So tribal officials are focusing their suicide prevention efforts on finding ways to help those kids remotely.

“Our people have been through hardships and they’re still here, and they’ll still be here after this one as well,” said Don Wetzel, tribal liaison for the Montana Office of Public Instruction and a member of the Blackfeet Nation. “I think if you want to look at resiliency in this country, you look at our Native Americans.”

Poverty, high rates of substance abuse, limited health care and crowded households elevate both physical and mental health risks for residents of reservations.

“It’s those conditions where things like suicide and pandemics like COVID are able to just decimate tribal people,” said Teresa Brockie, a public health researcher at Johns Hopkins University and a member of the White Clay Nation from Fort Belknap, Montana.

Montana has seen 231 suicides this year, with the highest rates occurring in rural counties. Those numbers aren’t much different from a typical year, said Karl Rosston, suicide prevention coordinator for the state’s Department of Public Health and Human Services. The state has had one of the highest suicide rates in the country each year for decades.

As physical distancing drags on, fatality numbers climb and the economic impacts of the pandemic start to take hold of families, Rosston said, and he expected to see more suicide attempts in December and January.

“We’re hoping we’re wrong in this, of course,” he said.

For rural teenagers, in particular, the isolation caused by school closures and curtailed or canceled sports seasons can tax their mental health.

“Peers are a huge factor for kids. If they’re cut off, they’re more at risk,” Rosston said.

Furthermore, teen suicides tend to cluster, especially in rural areas. the risk that a surviving loved one will follow suit, Rosston said.

On average, every person who dies by suicide has six survivors. “When talking about small tribal communities, that jumps to 25 to 30,” he said.

Maria Vega, a 22-year-old member of the Fort Peck Tribes, knows this kind of contagious grief. In 2015, after finding the body of a close friend who had died by suicide, Vega attempted suicide as well. She is now a youth representative for a state-run suicide prevention committee that organizes conferences and other events for young people.

Vega is a nursing student who lives six hours away from her family, making it difficult to travel home. She contracted COVID-19 in October and was forced to isolate, increasing her sense of removal from family. While isolated, Vega was able to attend therapy sessions through a telehealth system set up by her university.

“I really do think therapy is something that would help people while they’re alone,” she said.

But Vega points out that this is not an option for many people on rural reservations who don’t have computers or reliable internet access. The therapists who offer telehealth services have long waitlists.

Other prevention programs are having difficulties operating during the pandemic. Brockie, who studies health delivery in disadvantaged populations, has twice had to delay the launch of an experimental training program for Native parents of young children. She hopes the program will lower the risk of substance abuse and suicide by teaching resiliency and parenting skills.

At Fort Peck, the reservation’s mental health center has had to scale down its youth events that teach leadership skills and traditional practices like horseback riding and archery, as well as workshops on topics like coping with grief. The events, which Manning said usually draw 200 people or more, are intended to take teenagers’ minds away from depression and allow them to have conversations about suicide, a taboo topic in many Native cultures. The few events that can go forward are limited now to a handful of people at a time.

Tribes, rural states and other organizations running youth suicide intervention and prevention initiatives are struggling to sustain the same level of services. Using money from the federal CARES Act and other sources, Montana’s Office of Public Instruction ramped up online prevention training for teachers, while Rosston’s office has beefed up counseling resources people can access by phone.

On the national level, the Center for Native American Youth in Washington, D.C., hosts biweekly webinars for young people to talk about their hopes and concerns. Executive Director Nikki Pitre said that on average around 10,000 young people log in each week. In the CARES Act, the federal government allocated $425 million for mental health programs, $15 million of which was set aside for Native health organizations.

Pitre hopes the pandemic will bring attention to the historical inequities that led to lack of health care and resources on reservations, and how they enable the twin epidemics of COVID-19 and suicide.

“This pandemic has really opened up those wounds,” she said. “We’re clinging even more to the resiliency of culture.”

In Wolf Point, Natalie Keiser experienced that resiliency and support firsthand. The Fort Peck community has come together to pay for Leslie’s funeral.

“That’s a miracle in itself,” she said.

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