[Senate Hearing 108-164]
[From the U.S. Government Printing Office]




                                                        S. Hrg. 108-164

   RURAL HEALTH CARE FACILITY ON THE FORT BERTHOLD INDIAN RESERVATION

=======================================================================

                                HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                                   ON

                                S. 1146

  TO IMPLEMENT THE RECOMMENDATIONS OF THE GARRISON UNIT JOINT TRIBAL 
ADVISORY COMMITTEE BY PROVIDING AUTHORIZATION FOR THE CONSTRUCTION OF A 
 RURAL HEALTH FACILITY ON THE FORT BERTHOLD INDIAN RESERVATION, NORTH 
                                 DAKOTA

                               __________

                             JUNE 11, 2003
                             WASHINGTON, DC



87-959              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512�091800  
Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001


                      COMMITTEE ON INDIAN AFFAIRS

              BEN NIGHTHORSE CAMPBELL, Colorado, Chairman

                DANIEL K. INOUYE, Hawaii, Vice Chairman

JOHN McCAIN, Arizona,                KENT CONRAD, North Dakota
PETE V. DOMENICI, New Mexico         HARRY REID, Nevada
CRAIG THOMAS, Wyoming                DANIEL K. AKAKA, Hawaii
ORRIN G. HATCH, Utah                 BYRON L. DORGAN, North Dakota
JAMES M. INHOFE, Oklahoma            TIM JOHNSON, South Dakota
GORDON SMITH, Oregon                 MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska

         Paul Moorehead, Majority Staff Director/Chief Counsel

        Patricia M. Zell, Minority Staff Director/Chief Counsel

                                  (ii)

  
                            C O N T E N T S

                              ----------                              
                                                                   Page
S. 1146, text of.................................................     2
Statements:
    Baker, Frederick, chairman, Mandan Hidatsa and Arikara Nation 
      Elders Organization, New Town, ND..........................    14
    Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, 
      chairman, Committee on Indian Affairs......................     1
    Conrad, Hon. Kent, U.S. Senator from North Dakota............     6
    Dorgan, Hon. Byron L., U.S. Senator from North Dakota........     8
    Hall, Tex G., chairman, Mandan Hidatsa and Arikara Nation, 
      New Town, ND...............................................     9

                                Appendix

Prepared statements:
    Baker, Frederick.............................................    25
    Hall, Tex G..................................................    17

 
   RURAL HEALTH CARE FACILITY ON THE FORT BERTHOLD INDIAN RESERVATION

                              ----------                              


                        WEDNESDAY, JUNE 11, 2003


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The committee met, pursuant to other business, at 10:48 
a.m. in room SR-485, Russell Senate Office Building, Hon. Ben 
Nighthorse Campbell (chairman of the committee) presiding.
    Present: Senators Campbell, Conrad, and Dorgan.

 STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM 
        COLORADO, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

    The Chairman. We will now proceed to the hearing on S. 
1146, the bill to authorize the construction of the health 
facility at the Fort Berthold Reservation.
    [Text of S. 1146 follows]
      
      

  


      
      

  


      
      

  


      
      

  


    The Chairman. If Tex Hall and Fred Baker would please take 
a seat. We do not have a lot of time before we have to go vote. 
Senator Conrad is going to chair this part of this morning's 
meeting. I want to tell you, though, I am very proud to be able 
to cosponsor this legislation with both of your Senators. I 
think it is really needed. Let me just make a short statement.
    The story of the confiscation of the lands to build the 
Garrison and Oahe' Dams in North Dakota during the 1940's 
remains one of the most disheartening episodes in United States 
history. The Department of the Interior, through the Garrison 
Unit Joint Tribal Advisory Committee, finally issued a report 
in 1986 detailing the extent of financial and infrastructure 
damage suffered by the Three Affiliated Tribes of the Fort 
Berthold Reservation. Among the recommendations in that report 
was the replacement of the hospital destroyed when the dams 
were built. Yet, to date, after all these years, it has not 
been acted upon.
    Chairman Hall, you are very well known to this committee as 
you are not only a leader in your tribe, but with the National 
Congress of American Indians. We are delighted to have you 
here. Before I turn the gavel over to Senator Conrad though, I 
would like to tell you something else not related to this 
hearing. I am sorry to inform you that our Indian section for 
the energy bill that you and I worked on for the last almost 2 
years collapsed yesterday. I am very sorry to tell you that. 
But it just seemed to me that there were less people around 
here really interested in trying to create some jobs for 
Indians than I thought there was going to be. Even though NCAI 
supported it, CERT supported it, the USET supported it, 2 dozen 
individual tribes sent letters of support, even the U.S. 
Chamber of Commerce supports it, we simply did not have the 
votes I think, and I am just sorry to have to tell you that. 
But rather than taking a chance of losing it on a vote, they 
are going to work on the bill this week and bring it back up I 
understand in July. And if we can do a little more bridge 
building, hopefully by July I might be able to reintroduce it. 
But I just wanted to pass that on to you.
    Mr. Hall. Thank you.
    The Chairman. With that, Senator Conrad, if you would like 
to chair, I would appreciate you doing that.

 STATEMENT OF HON. KENT CONRAD, U.S. SENATOR FROM NORTH DAKOTA

    Senator Conrad [presiding]. Thank you so much, Chairman 
Campbell. Thank you personally for allowing us to go forward 
with this hearing. We appreciate it very much. And special 
thanks, too, to your staff who have just been superb to work 
with. We appreciate that as well. And, of course, our thanks to 
Senator Inouye and his staff for their assistance in scheduling 
this hearing. We appreciate it very much.
    I am pleased to welcome Chairman Tex Hall and Fred Baker, 
chairman of the Mandan Hidatsa and Arikara Elders Organization, 
to present testimony.
    It was 50 years ago today President Eisenhower dedicated 
the Garrison Dam in North Dakota--50 years ago today. For the 
Three Affiliated Tribes of Fort Berthold, it closed a bitter 
chapter of its history that forever changed its people and 
their way of life. In 1948, Interior Secretary Krug signed a 
contract to purchase more than 150,000 acres from the tribe for 
the construction of the Dam and reservoir to provide flood 
protection to downstream communities. George Gillette, who was 
then the chairman of the Three Affiliated Tribes, quite 
eloquently and in simple terms summarized its impact on the 
tribe and its future. He said:

    We will sign this contract with a heavy heart. With a few 
scratches of the pen, we will sell the best part of our 
reservation. Right now the future does not look too good for 
us.

    And there is the picture of the signing. Chairman Gillette 
has his head in his hands and you can see that he is very 
emotional at what he knows will be real hardship for his tribe. 
And I am told that the fourth gentleman from the right in that 
picture is the grandfather of Chairman Hall, the very 
distinguished, handsome looking man standing right over the 
shoulder of Secretary Krug.
    So 1 year later, 325 families, 80 percent of the tribal 
membership, were forcibly relocated, one-quarter of the 
reservation's land base was destroyed, 94 percent of the 
agricultural land of these farmers and ranchers was inundated. 
The remainder of the reservation was segmented into five 
waterbound areas. In addition to the loss of land, the Three 
Affiliated Tribes lost vital infrastructure--bridges, homes, 
schools, roads. The tribal headquarters at the community of 
Elbowoods was completely flooded. The tribe also lost its 
hospital. Here you will see a picture of the Elbowoods Hospital 
before it was flooded. At the time of the flooding, the Federal 
Government made a number of commitments to the tribe, one of 
which was a commitment to replace this hospital. That was 50 
years ago.
    Now 36 years after the land was taken then Interior 
Secretary Donald Hodell signed a charter creating the Garrison 
Unit Joint Tribal Advisory Committee. This committee was 
charged with examining the effects of the Dam's construction 
and the making of recommendations for compensation. In its 
final report, the committee found quite clearly the Three 
Affiliated Tribes were entitled to financial compensation and 
the replacement of lost infrastructure. The committee noted 
that the replacement of the health facility is ``an emergency 
need that should be pursued immediately.''
    So, 50 years ago a promise was made; 14 years ago it was 
recommitted to by Congress and the Administration at the time.
    In testimony before this committee, C. Emerson Murry, 
former chairman of the Joint Tribal Advisory Committee, noted 
that many promises were made by the Government to force the 
tribe to sell their land, yet many of these promises were never 
fulfilled. He said:

    Many assurances were given, expressly or by implication, by 
various Federal officials that the problems anticipated by the 
Indians would be remedied. The assurances raised expectations 
which in many instances were never fulfilled, and in other 
cases were only partially fulfilled.

    In 1992, with the leadership and assistance of this 
committee, we were able to act on some of the recommendations 
of the Joint Tribal Advisory Committee by passing the Three 
Affiliated Tribes and Standing Rock Sioux Equitable 
Compensation Act. However, at the time, due to budget 
limitations, we were not able to fulfill the commitments on 
infrastructure replacement. The Indian Affairs Committee, under 
the leadership of Senator Inouye, in its report on the act, 
specifically noted that:

    Every effort should be made by the Administration and 
Congress to provide additional Federal funding for these 
infrastructure priorities, taking into account the JTAC deemed 
several of these infrastructure needs to be urgent and critical 
more than five years before.

    More than 10 years later, many of these infrastructure 
priorities still have not been met.
    Without a doubt, the Three Affiliated Tribes paid the 
highest price for the construction of the Dam. It destroyed 
communities, it uprooted families, and it disrupted the tribe's 
way of life; 50 years later, the after shocks of the Dam's 
construction are still being felt. The time has come to right 
these wrongs.
    This is a recent headline, June 8, from the Fargo Forum, 
Fargo, ND, the headline ``A Flood of Tears: Five Decades Later, 
Tribes Still Recovering From Dam Losses.''
    I am especially pleased that Senator Dorgan has joined me 
in introducing the Three Affiliated Tribes Health Facility 
Compensation Act, to authorize a $20-million health facility 
for the tribe. The tribe was clearly promised a hospital to 
replace the one that was destroyed. However, Chairman Hall and 
I and Senator Dorgan recognize that a full service hospital is 
not financially feasible today. The facility we are authorizing 
is designed to provide extended hours of care to meet the 
emergency medical needs of those on the reservation on evenings 
and on weekends. It also includes a cancer screening unit and 
expanded dialysis services, all of which are critical elements 
to tackling the conditions afflicting many on the reservation. 
We believe that this facility will greatly enhance health care 
services to thousands on the reservation and provide access to 
the care they have lacked for many years.
    The history on this matter is crystal clear. A commitment 
was made to the tribe that must be kept. We should insist, as a 
matter of fairness, and more as a matter of law, that this 
promise be kept by the Federal Government.
    I look forward to the hearing today. I again thank the 
chairman for his willingness to convene this hearing, and to 
our Ranking Member, our vice chairman, Senator Inouye, for his 
assistance as well.
    I would now turn to my colleague, Senator Dorgan, for his 
opening statement.

  STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH 
                             DAKOTA

    Senator Dorgan. Once again because of the time, Senator 
Conrad, I think I will just be very brief. We have an 11:15 
vote. I want to make sure that Chairman Hall and Mr. Baker have 
time to make their presentations. I think it is important to 
say a couple of things. Within the last 2 weeks I toured the 
Minne Tohe clinic once again. I fully understand that this is 
not an acceptable level of service for the need that exists.
    There are a couple of things to point out with respect to 
the bill that we have introduced. Almost certainly, we should 
be able to get this authorization bill enacted into law. That 
is different than being able to fund a facility. Funding a 
facility is going to be very, very difficult for a number of 
reasons. First, there is a priority list. At this point, the 
project is not on it. Second, the President's fiscal policy 
increases defense funding, increases homeland security funding, 
decreases revenue, and shrinks almost everything else. It does 
not add up and the funding is going to be dramatically short in 
virtually every single area. So, passing an authorization bill 
is something that we must do. We owe it to the Three Affiliated 
Tribes. Getting the funding is going to be quite a significant 
challenge.
    It is important I think to emphasize, as Senator Conrad has 
just emphasized, that we are not talking with this 
authorization bill about funding a ``hospital'' in the 
traditional sense where you have acute care beds for long-term 
stays and so on. We are talking about building a facility that 
will dramatically improve the capability for clinic treatment 
and emergency treatment in the region. That is something that 
is desperately needed, is owed the tribe, and we would not be 
at this point to talk about it were it not for the persistence 
of Chairman Hall and Mr. Baker. Your sheer persistence I think 
is very admirable. I hope one day we will be able to go to a 
ribbon-cutting and open a facility that all of us can be proud 
of that really does meet the health care needs at the Three 
Affiliated Tribes and begins to keep the promise that was made 
so long ago to the Three Affiliated Tribes.
    Mr. Chairman, thank you.
    Senator Conrad. Let me just say before we begin, Dr. Grim, 
you and your family are excused. We appreciate very much your 
being here. We look forward to supporting your confirmation. We 
look forward to working with you. If you have other 
obligations, please know that you are free to leave the hearing 
room. We appreciate your participation here today.
    Chairman Hall, welcome. Thank you for being here. Please 
proceed with your testimony.

STATEMENT OF TEX G. HALL, CHAIRMAN, MANDAN HIDATSA AND ARIKARA 
  NATION, NEW TOWN, ND, ACCOMPANIED BY FRED BAKER, CHAIRMAN, 
     MANDAN HIDATSA AND ARIKARA NATION ELDERS ORGANIZATION

    Mr. Hall. Dosha! [Hello] Thank you, Mr. Chairman, Senator 
Conrad, Senator Dorgan, members of the committee, and staff. 
Just briefly, it brings up real sad memories to see the 
pictures that were put up. When I was young, when I was 5 years 
old my grandfather and my father, he was on the tribal council, 
we went around to community meetings, 1958, 1960. They told me 
to pay attention, do not play around like 5-year-olds would do, 
pay attention because some day you may have to go to Congress 
and help lobby and replace this facility.
    It is 50 years to the day, June 11, 1953, since the 
dedication of the Garrison Dam. It is not a day to celebrate 
for our people. It is a sad day, really. But it is also a day 
to reflect on the promises made and the promises not kept. I 
looked at Dr. Grim's testimony, and he did a real fine job of 
answering the questions, but I see he is from the Cherokee 
Nation and they had a sad chapter in their history; the Trail 
of Tears happened to his people. A University of North Dakota 
study, a professor wrote a study about my people and he equated 
the Garrison Dam forced removal and dislocation of my people to 
the same as the 1830 Trail of Tears, that happened in 1953. So 
it really is with great sadness that I look at the pictures. 
And as I come before the committee today 50 years later, we are 
still taking about the difficulties that it could be to get 
this funding that is needed.
    But as my grandparents and my father had indicated, you 
have to continue this. We will continue to work with you, 
Senator Dorgan, Senator Conrad, to make this a reality. So we 
appreciate very much your efforts to sponsor S. 1146, which is 
entitled, The Three Affiliated Tribes Equitable Compensation 
Act, by authorizing a new comprehensive rural health care 
facility to replace what the United States destroyed in 1953 by 
the flooding of our homelands.
    This is an unfulfilled promise, a promise the U.S. 
Government made to my people to replace the Elbowoods Hospital, 
a 28-bed hospital that was destroyed 58 years ago by the flood 
waters. This unfulfilled promise is truly a black mark on the 
credibility and the decency of the United States, particularly 
of the Army Corps of Engineers, particularly when the United 
States over the past 50 years earned billions of dollars from 
this hydro-electrical dam. This health care facility 
constitutes an equitable and moral lien on the Dam. And after 
50 years, I believe it is time that we look for the funding to 
pay for this.
    This was a wonderful hospital, as Fred Baker will testify 
later on his testimony. Actually, he was born in that hospital. 
And over the past 50 years, while waiting for the United States 
to keep its promise, too many of my people have died on the 
roadways. My father passed away 2 years ago when he had a heart 
attack after we were dancing in May 2000 at a memorial. I had 
to pick him up in my arms and put him into a van, and he is a 
big man, and put him into a van and drive 35 miles away to 
Watford City. I saw my mother pass away of stomach cancer 
because our facility did not have the diagnostic treatment to 
treat her. And then last year, to literally save a man's life 
who was bleeding because of a horseback accident, because we do 
not have 911 or we do not have an ambulatory facility and after 
hours to treat on Saturday. So, for whatever reason, in my role 
I have also been asked to play doctor, which I do not care to 
play because I am not a doctor. I am an example of many of our 
people who have to do that, literally get in a car and take 
your relative, your sister, your brother, your mother, father, 
and drive 90 miles an hour if you can to get to that facility.
    The after hours, people get sick after 5 or on weekends. It 
is just a tragedy for my people. So the small, inadequate 
facility that we have is just not able to reach our needs. Our 
clinic today, which is right here, the Mini-Tohe, is actually 
8,100 square feet. Elbowoods was a 35,000-square foot facility. 
And as was mentioned, my grandfather was vice chairman at the 
time of the signing in 1948 when Chairman Gillette is weeping 
in the picture. And the cessation of the tribal lands broke 
many of our hearts. Tony Mandan, and elder, yesterday, when we 
had a diabetes workshop, said:

    I blame the diabetes on the Dam. I blame the cancer on the 
Dam. Because we have never been replaced with the facilities 
that we need.

    And so it is ironic we are coming back 50 years to the day 
to try to have the Government of the United States fulfill its 
promise, particularly the Army Corps of Engineers, which had a 
duty to replace the hospital and did not. I am very 
appreciative of both of our Senators, Senator Conrad and 
Senator Dorgan, for their efforts today. We hope we do not have 
to tell our grandchildren 50 years from now that we are still 
working on this.
    And as Senator Dorgan mentioned, we have been told it is 
going to be difficult to get S. 1146 appropriated because IHS 
has a priority list that must be followed. But our legislation 
is a compensation; it would not put us in the priority list, it 
would be a compensation that would create a fund, special 
appropriation funds. This is an entitlement versus the priority 
list is based on need. So we looked the criteria of the new 
facilities management criteria on the IHS and it does not take 
into consideration the high disease factors, and it does not 
take into consideration the isolation and rural geographic 
factor. So while our existing facility is grossly inadequate 
and desperately needs to be replaced, our claim on the United 
States involves something more compelling than just need. It is 
compensation legislation; paying for the cost of building the 
Garrison Dam, just as our Equitable Compensation Act provided 
compensation for the land that was taken from us.
    So to quote Senator Conrad, this facility is owed to us as 
a matter of fairness, and more as a matter of law. And as a 
result, it cannot be placed in the same category as the IHS 
priority list. In fact, to make this clear, one of our 
suggestions is that S. 1146 be amended so it is entitled ``The 
Health Care Facility Compensation Fund.'' So that it creates a 
fund by that name in the Interior Department for the deposit of 
the $20 million that would be appropriated for the health 
facility.
    I do not know how much time I have, Mr. Chairman. I am 
trying to be as brief as possible. If you need me to just close 
it, I will do that.
    Senator Conrad. Why not take another 5 minutes to just 
conclude your testimony, and then we would turn to Mr. Baker. 
The problem we are up against is there is a vote at 11:15.
    Mr. Hall. Okay.
    Senator Conrad. We can probably go till 11:25 or perhaps 
even stretch it a little beyond that.
    Mr. Hall. Okay. I will be as quick as I can. The chart that 
is right here is actually our wellness center that is closed. 
It has got a sign that says ``Do Not Enter,'' and that building 
is called M-14 and that is because of mold. I know both 
Senators Conrad and Dorgan are very much aware of the mold 
problems that exist on all of our reservations in North Dakota 
and in Indian country. This is an old quarters unit that we had 
to turn into office space. We had 11 quarters, now we only have 
8 because of the use of M-19 and we had to shut it down. So now 
instead of 11, there is only 8 quarters. And the wellness 
center staff, most of the diabetes staff are now inside Mini-
Tohe. So, Senator Dorgan, when you went there you probably saw 
the traffic jam of people having to share a desk. So that is 
the urgent need for a facility as well, because of the mold 
situation.
    The 1986 JTAC Report, it was a huge study and I will not 
get into the whole detail of it, but it was a tremendous study 
that deemed the replacement of our health facility is urgent 
and critical and an emergency need that should be pursued. And 
that was in 1986. And this Committee, in a 1991 report, noted 
that the JTAC found tribes at Fort Berthold are entitled to 
replacement of infrastructure lost by the creation of the 
Garrison Dam and Lake Sakakawea. The JTAC findings identified 
health care facilities as the number one priority. And 
recognizing the limitations currently imposed by the Budget 
Enforcement Act, the committee nevertheless believes that every 
effort should be made by the Administration and Congress to 
provide additional Federal funding through annual 
appropriations for these infrastructure.
    And so, despite all of this, here we are again. The IHS 
redesign of the priority list has been ongoing for the last 10 
years. And as I mentioned, I have seen the draft and the draft 
is not good for our tribe and I think Aberdeen tribes because 
of the disease factor, it does not give enough weight, and 
because of the isolation factor, it does not give enough 
weight. So we feel if we get on the priority list we are going 
to sit here again for a long, long time. There has got to be a 
different way. But, again, we feel this is not based on the 
need of the priority list, this is an entitlement because of 
the flooding.
    Also, in working with IHS, we have actually talked to Dr. 
Grim on a conference call on S. 1146 and talked to Dr. Peters, 
the Aberdeen Area acting director, and our service unit 
director Carol Parker, so we are working in consultation with 
them. Dr. Peters advised us that there will have to be 
additional funds amended to authorize $6.6 million for 
staffing, because there will be a need for an increase for 
staffing, $2 million for maintenance, and $2 million for the 
design, and then eventually new quarters.
    The Elbowoods Hospital was 1928 to 1953, a 35,000-square 
foot, 28-bed hospital. From 1953 to 1968, we had no facility at 
all. That was based on a recommendation by our trustee, the 
Bureau of Indian Affairs. The Bureau of Indian Affairs has 
never advocated for our people, and said that for the Three 
Affiliated Tribe's health care they can go to off reservation 
health care providers that were over 160 miles away. So for 15 
years we did not even have a facility at all. We all went to a 
facility in New Town, but we know, in the southern end of our 
reservation, Twin Buttes is 120 miles away.
    The new facility will be a 66,000 square foot. But even 
though the IHS, in collaboration with Dr. Peters, as I 
mentioned, their recommendations for our user population, just 
under 6,000 user population, is 107,000 square foot at a $30-
million cost. But we knew that was going to be very difficult 
and we have agreed to work on this 66,000 square foot facility. 
But the key thing is it will be open after hours. It will be 
available to do the emergencies that we had talked about.
    I just wanted to point out that this is the sign that our 
membership, all of our people, have to go see. And if you are 
non-Indian, good luck. You do not even get to go through that. 
But this is right on the front door. Our clinic hours are 
Monday, Tuesday, Thursday, and Friday, 8 to 5, on Wednesday 
they must have something going on in the morning so it does not 
open until 10:30. So you will see huge lines. And for 
emergencies after hours or on weekends, if you are West of the 
river, you have got to dial this number. There is no 911 on the 
whole western half of the reservation. That is where I live and 
that is where my parents lived. If you are in Montreal County, 
East of the river, you can get 911 services.
    What this does not show as well is that, a true story, a 
gentleman that is younger than myself, his name is James Hunts 
Long, who is diabetic, he stepped on a nail. He knew he had to 
go to the hospital. It was a Saturday. Obviously, as this sign 
says, this facility is closed. He went to Watford City and 
convinced the hospital in Watford City that he needed to be 
treated. They treated him. He came back on Monday and wanted to 
get the bill paid, and guess what IHS said? That is not a 
priority one. So a little later on one of James' brothers, same 
thing, a diabetic, steps on a nail and tells James, ``Drive me 
to the hospital in Watford City, just like you did.'' James 
said, ``No, the IHS is not going to pay for it.'' So you know 
what he did? He stayed home. The point being that many people, 
including diabetics, stay home.
    There are people on Fort Berthold that do not get treated 
because of these unpaid medical bills that both Senator Conrad 
and Senator Dorgan were talking about. I think that is illegal 
to change the status of priority one because you run out of 
money. But that is the fact of the matter. We have done that 
research right at Mini-Tohe service unit in IHS. The fact of 
the matter is we have a young tribal member, she needs a kidney 
transplant but before she can get a kidney transplant she has 
to get her old bill taken care of, it was a $30,000-bill. She 
was approved to get it and, because they ran out of money for 
the next fiscal year, they said it is not priority one, you owe 
that $30,000. She had to declare bankruptcy in order to save 
her house and her car. So that is where she is at. Now she can 
go and start looking at a kidney transplant.
    So, that is the fact of the matter. That is a day to day 
thing that our people have to see, have to go through. The main 
thing is a facility has to be emergency ambulatory and it has 
to be after hours. We have a new bridge, we have a new refinery 
that is going to be built, we have even more dangerous 
construction work, and we have a lot of non-Native people that 
cannot use this facility as well.
    So in closing, we know the budgets are tight. But the need 
for immediate health care facility replacement is the most 
urgent need on Fort Berthold, and we will do everything we can 
to assist you, Mr. Chairman, and Senator Dorgan, in this effort 
so we can finally close this sad chapter in my people's 
history. Thank you very much. I appreciate the opportunity.
    [Prepared statement of Mr. Hall appears in appendix.]
    Senator Conrad. Thank you for that excellent testimony, 
Chairman Hall. I have just been going through your extended 
testimony and it really is excellent and will be of great help 
to the committee.
    Mr. Baker, welcome. It is good to have you here. Please 
proceed with your testimony.

 STATEMENT OF FRED BAKER, CHAIRMAN, MANDAN HIDATSA AND ARIKARA 
            NATION ELDERS ORGANIZATION, NEW TOWN, ND

    Mr. Baker. Thank you. Mr. Chairman and members of the 
committee, I think talking to Senator Conrad and Senator Dorgan 
is kind of like preaching to the choir. You guys have an 
understanding of the problem and have been supportive, and we 
appreciate that very, very much. I think in the interest of 
time, I will kind of try to summarize what I was going to say 
here. But other than to say that I am a Paotsa/Mandan, one of 
the few remaining Hidatsa speakers, I was born at that 
hospital. Coincidentally, my grandfather was also in the 
picture with my Uncle Jim Hall. He is the seventh guy. You can 
see his head and his ear back there. Anyway, that is my 
grandfather, also named James.
    I think three major disasters involving the Three 
Affiliated Tribes over the years. One was, obviously, a 
smallpox epidemic of 1781 which reduced the Mandan Tribe from 
13 villages, each capable of raising about 200 warriors, down 
to only 2 villages. And this happened just almost within a 
blink of an eye, within 1 year's time. Smallpox totally 
devastated that tribe. The tribe, at one time we were the 
kingpins in that area and we controlled all the fur trade, all 
the trade period. We raised crops, we were farmers, very 
successful in our area. And that drastically reduced us.
    The second major disaster was the smallpox epidemic of 
1837, which reduced not only our tribe but many of our 
neighbors as well, but especially it had a really tough effect 
on especially the Mandan and the Hidatsa. It reduced us down at 
one point, I remember my grandfather saying that there were 
only about 50 able-bodied men left after the smallpox epidemic 
of 1837.
    The third disaster was the Garrison Dam. And we are still 
recovering from that one.
    The Elbowoods Hospital was a place where we went for health 
care. The thing about the hospital there was that we were 
familiar with people that worked there, our relatives worked 
there, our friends worked there, and it was kind of like a 
place where we were welcomed and we felt comfortable. When the 
Garrison Dam came through and our hospital was closed, we were 
forced to go to a totally different environment with people we 
did not know, procedures or situations that we did not 
understand. It was almost like going to a foreign place. A lot 
of times we were not very welcome in the areas surrounding the 
Fort Berthold Reservation. So, as a result, a lot of our elders 
especially just refused to go. They just kind of stayed home 
and toughed it out until their life ended from whatever disease 
they had.
    I think the Mini-Tohe clinic, I spent 9 years there as 
service unit director, I am a retired Federal employee having 
spent 17 years as a service unit director. I spent my last 9 
years there. It is also kind of the same thing. There is a 
certain amount of I would call it familiarity or whatever you 
want to call it, but people always were comfortable. I remember 
many a time talking to folks in the Hidatsa because they did 
not quite understand what the doctor said to them or what the 
situation was, or how sick am I, or some of those kind of 
things. So I would get a chance to visit with those folks in 
our Hidatsa language, and I think that was kind of a 
familiarity that people viewed as a positive healing tool as 
well.
    The problem with that clinic, and we have said this over 
and over, is that it is inadequate no matter what we do. There 
are only so many exam rooms and only so many things you can do 
with patient flow. I spent many, many, many hours trying to 
figure out how to make the patient flow go faster so that we 
could get more people in to see the doctors and get people out 
in a reasonable time. Now, it takes literally days, sometimes 
weeks. I am a diabetic and I go back for periodic checkups and 
sometimes when I make an appointment it is two weeks down the 
road before I can get to see a doctor. And that is pretty much 
par for the course. So that is a real problem.
    The other problem that results from that is that when 
people come in, sometimes if we have a person who is a lot 
sicker or if there is an emergency that comes into the clinic, 
then everything backs up. Recently, my aunt was a patient, came 
to see the doctor, and she sat there for 2 hours waiting beyond 
her appointment, she was very ill. So she decided that she was 
going to go home. She was just too sick to sit there any 
longer. So she started to walk outside, she collapsed and ended 
up spending several days in the hospital at Minot after a very 
terrifying ambulance ride. So these things happen in that 
place. And again, it is like talking to the choir, you two 
gentlemen understand that situation.
    That in summary is some of the things I was going to say. 
The other thing is that the new building would not only meet 
our basic needs but also would allow us to receive a lot of the 
procedures or the specialty care kinds of things that now we 
have to go 70 to 150 miles to receive. Ambulatory care surgery, 
for instance, I think we could build a facility that would be 
capable of doing ambulatory surgery. And if that were the case, 
then people could get their surgery procedure there and go 
home. Now if we have to get ambulatory care, then we are 
looking forward to 150 mile drive or a 70 mile drive back to 
Fort Berthold. So I think those things would not only save 
money but would also make it a little easier for our patients.
    I think I will stop at that point. I appreciate the 
opportunity to be here.
    [Prepared statement of Mr. Baker appears in appendix.]
    Senator Conrad. Thank you so much for being here. Let me 
just say that your full statement will be made part of the 
record.
    I think this has been an excellent hearing. It could not 
have gotten started in a better way than to have Chairman 
Campbell indicate that he will cosponsor this legislation with 
us. I think we will enjoy broad support. I think this hearing 
has laid the case very clearly. The promise was made, the 
promise was not kept. The promise was repeated in the JTAC 
Commission that was under the Reagan administration. This is a 
long time ago. They said it was urgent, urgent that the promise 
be kept. That was repeated in the followup report that has been 
made by the Congress of the United States. And this committee 
has made clear that this was a priority and that it was owed to 
the people of the Fort Berthold Nation. So I think with that 
record we have an opportunity to convince our colleagues.
    What Senator Dorgan has said here is also true; and that 
is, it will be very difficult to get the appropriated funds 
because of the cuts that are occurring. The need, as we heard 
from the previous testimony, far exceeds the available 
resources. But my own judgement is this is a priority. This is 
a circumstance in which a promise was made to convince people 
to leave their land and to sign a contract. They kept their end 
of the bargain, the promises that were made to them have not 
been kept. And that is a shameful circumstance for this Federal 
Government and it absolutely requires a response.
    Senator Dorgan.
    Senator Dorgan. Thank you very much. People from Indian 
country are probably too familiar with broken promises for 
literally centuries. In the last couple of hundred years, 
treaties and so many other promises have been made and not 
kept. I agree with Senator Conrad that this is one that needs 
to be kept and is a priority.
    I think, Chairman Hall and Mr. Baker, you have well made 
the case today and we will have full statements as a part of 
the record. And the support of the chairman of this committee 
is going to be very important in terms of getting the 
authorization bill passed, which is, of course, the first step 
in this process.
    Senator Conrad and I are very familiar with your tribe, 
with the leadership both of you have provided on these many 
issues, and we look forward to working with you.
    I regret that we have to abbreviate this hearing just a bit 
because of the vote, but that is the way the U.S. Senate works 
sometimes. But I think we have been able to have a pretty good 
opportunity to hear a full statement from both of you about the 
urgency of this, and we deeply appreciate your coming to 
Washington to make it.
    Senator Conrad. Chairman Hall.
    Mr. Hall. Just 10 seconds. Senators Conrad and Dorgan, I 
want to thank you again for your support, and Patricia, I want 
to thank you and Senator Inouye in his efforts, and all the 
staffs including both of the Senators' staff, they have worked 
very hard with us. I feel very confident and comfortable about 
the testimony because of the research and the collaboration 
that was done with all of your people and our people and also 
Indian Health Service. So everybody was included in drafting 
the testimony. So thank you for the opportunity.
    Senator Conrad. We appreciate that. And with that, we will 
adjourn the hearing. Thank you.
    [Whereupon, at 11:30 a.m., the committee was adjourned, to 
reconvene at the call of the Chair.]


=======================================================================


                            A P P E N D I X

                              ----------                              


              Additional Material Submitted for the Record

=======================================================================


Prepared Statement of Tex G. Hall, Chairman, Mandan Hidatsa and Arikara 
                                 Nation

    Dosha! [Hello] Mr. Chairman, members of the committee. Thank you 
for this opportunity to testify on behalf of S. 1146, which would amend 
the Three Affiliated Tribe's Equitable Compensation Act by authorizing 
a new comprehensive rural health care facility to replace the hospital 
the United States destroyed when the Garrison Dam flooded our homeland.
    It is ironic that today's hearing is being held on the 50th 
anniversary of the dedication of the Garrison Dam by President 
Eisenhower, June 11, 1953. Yet it must be a tainted celebration, 
because, after 50 years, the United States still has not fully paid for 
it, even while earning billions from the power generated by the Dam, 
The Dam destroyed the 28 bed Elbowoods Hospital that served the Mandan, 
Hidatsa and Arikara tribal members. Fifty years ago, the United States, 
in order to persuade my people to vote in favor of the dam and to give 
up 156,000 acres of our best lands, made a solemn commitment to replace 
the hospital. Once it received that reluctantly given consent from our 
people, the United States proceeded to abandon its commitment, while 
reaping all of the monetary and other benefits from the Dam. This 
health care facility constitutes an equitable if not a legal lien on 
Dam. After 50 years, it is time to pay for the United States to pay its 
debt.
    Over the past 50 years, while waiting for the United States to keep 
its promise, too many of my people have died because they got sick 
after 5 pm or on weekends when the small and inadequate ``replacement'' 
clinic is closed; too many have died from traffic accidents because 
they did not reach an off-reservation health facility in time, too many 
of my people have died because the existing 8,100 square foot clinic 
cannot provide anything close to adequate health care. Yet over the 
same 50 years, the United States has earned hundreds of millions of 
dollars in revenue from the power generated by the Dam such that it is 
in our mind a dam that has been paid for with the blood of my people. 
It is far past time for Congress to quickly enact S. 1146 and then 
quickly appropriate the $20 million called for in the bill so this 
dishonest and dishonorable chapter in our Government's history will 
come to an end.
    We have been told that the budget is tight such that it will be 
difficult to obtain $20 million in appropriations. We have been told 
that IHS has a priority list that must be followed. But our request is 
not part of the priority list appropriations process and it would be 
wrong to treat it in the same category. While we desperately need a new 
facility, our claim on the United States involves something more 
compelling than just need. To boil it down to its essence:

   50 years ago the United States destroyed our hospital;
   50 years ago the United States promised to replace the 
        facility it destroyed;
   50 years later that promise has not been kept.
   For 50 years, my people have been dying because that promise 
        has not been kept.
   After 50 years, it is time for the United States to keep its 
        promise.

    My grandfather, James Hall, was present during the signing of the 
contract between the United States and the Three Affiliated Tribes. He 
was the tribal vice chairman at the time of the signing and went on to 
serve as tribal chairman from 1958 to 1960. He is the second to the 
left of George Gillette, the tribal chairman at the time who is the man 
weeping in the picture. The cessation of the tribe's lands broke many 
hearts. Everyone within the tribe knew that life would never be the 
same. When I was 5, my grandfather told me about the flooding and 
explained to me that the government never replaced the tribe's hospital 
or schools. He told me to pay attention to what he was telling me 
because some day I may have to ask the Government to replace the 
hospital it took from us. Today I am fulfilling my grandfather's 
prophecy and I am asking you to do the correct thing and fulfill the 
Government's moral and legal obligation to my tribe.

I. The Legal and Moral Obligation of the United States To Provide Us 
    With an Adequate Health Care Facility is Fully Documented and 
    Undisputed

    Over the past 50 years, numerous Congressional and executive branch 
reports and hearings have documented that the United States made an 
unequivocal commitment to replace the health facility that was 
destroyed, that my tribe is legally entitled to such a facility, and 
that my people have been dying because of the United States' failure to 
keep this promise. As a result, there is no doubt that such an 
obligation exists, as the citations below demonstrate:

       The 1986 JTAC Report confirmed that the Army Corps of 
        Engineers [COE] had made this promise to the tribe. ``The 
        [Elbowoods] hospital, like the rest of Elbowoods, was flooded 
        after the dam was completed. The COE had promised to construct 
        a new hospital...''
       The 1986 JTAC Report concluded that the tribes are entitled 
        to the replacement of infrastructure destroyed by the Federal 
        action;...The replacement of a primary care in-patient health 
        facility and outpatient services is deemed to be urgent and 
        critical.
        The JTAC Report found that the tribe had the highest death 
        rates for diabetes, alcoholism and cardiovascular disease in 
        the Aberdeen Area and concluded that ``the high death rates are 
        due in part to the available health facilities''.
        The JTAC Report recommended that, to meet the United States' 
        obligation to the tribe, it construct; ``a primary care in-
        patient facility and out-patient services to meet the special 
        health care needs of the Tribe. This is an emergency need that 
        should be pursued immediately.'' The JTAC Report recommended a 
        25-bed, 35,155 square foot hospital at a cost of $4,688,000, 
        plus annual staffing and maintenance costs of $5 million.
        The Senate Committee on Indian Affairs, in its 1991 Report 
        accompanying the Equitable Compensation Act bill (Report 102-
        250), stated:

    ``The committee notes that the JTAC found the tribes at Ft. 
Berthold are entitled to replacement of infrastructure lost by the 
creation of the Garrison Dam and Lake Sakakawea. The JTAC findings 
identified health care facilities, a bridge, school facilities, and 
adequate secondary and access roads as replacement infrastructure. 
Recognizing the limitations currently imposed by the Budget Enforcement 
Act, the committee nevertheless believes that every effort should be 
made by the administration and the Congress to provide additional 
Federal funding through annual appropriations for these infrastructure 
priorities, taking into account that the JTAC deemed several of these 
infrastructure replacement needs to be urgent and critical more than 5 
years ago.'' (p. 6)

        At a hearing of this committee on August 30, 2001 held on the 
        Ft. Berthold Reservation, Senator Conrad stated: ``This Tribe 
        was also promised health facilities, specifically a hospital. 
        That promise has not been kept....[W]e should insist as a 
        matter of fairness and, more, as a matter of law [that this 
        promise] be kept by the Federal Government.''

    Despite the urgent pleas to Congress by the JTAC Report in 1986 and 
by this Committee in 1991 to fund the construction of a new facility 
out of annual appropriations, no action was ever taken to do so. 
Because the Indian Health Service facilities' priority list has been 
closed to new applicants for over ten years, our Tribe has not and will 
not be able to obtain the promised facility through the normal Indian 
Health Service construction appropriations process for many years to 
come. As a result, the only way Congress can keep the United States' 
commitment is through enactment of S. 1146, followed by the immediate 
appropriations of the $20 million called for in that bill. (As 
discussed below, according to Indian Health Service, the bill will need 
to be amended to add $6.6 million for staffing and $2 million for 
maintenance and operation of the new facility.) While I recognize that 
the budget is tight, I have difficulty explaining to my people why the 
United States can find hundreds of millions of dollars to pour into the 
rebuilding of foreign countries but can find no money to keep its 50 
year old commitment to rebuild our homeland.

II. Description of the Elbowoods Hospital That Was Destroyed By the 
    Flooding and the Effect the Flooding Has Had On Our Reservation.

    The Elbowoods Hospital was a 28-bed, 35,000 square foot facility 
with six basonettes. In the 1 year period between June 1, 1947 and May 
31, 1948, 460 patients were admitted to this hospital and 3,921 were 
treated as outpatients. Two apartment buildings provided living 
quarters for the doctors and nurses that served the hospital. The 
Reservation had eight Reservation communities and the furthest 
Reservation community, Sanish, was approximately 60 miles from the 
Elbowoods Hospital.
    The United States never replaced the Elbowoods Hospital. The tribe 
has gone without a comparable hospital for the past 50 years. As set 
out at length in this testimony, a combination of the absence of an 
adequate facility, the stress caused by the dislocation, the dispersal 
of our population to remote and barren uplands, and the change in our 
lifestyle, all caused by the flooding of the best part of our 
reservation, has caused the health of the tribe's members to suffered 
tremendously since.
    The Elbowoods Hospital was located within the 156,000 acres of the 
Reservation's prime river bottomland that was flooded in 1953--what our 
people called the ``heart of our reservation''. Three hundred twenty-
five families were forced to evacuate these lands. Garrison Dam flooded 
one- quarter of the reservation's landbase and 94 percent of this land 
was prime agricultural land. When the Garrison Dam was completed, the 
reservation was fragmented and the reservation communities became 
distant from one another as a result of the newly formed Lake 
Sakakawea. The farthest tribal community from New Town is Twin Buttes 
which is 120 miles away. The distance of the other reservation 
communities from New Town are as follows: Mandaree--30 miles; 
Parshall--20 miles; and Whiteshield--60 miles.
    The dispersal of our people has increased traffic accidents because 
tribal members have to drive long distances on bad roads because the 
United States failed to keep its promise to build new roads to these 
outlying communities. At the sametime, the increased distances from New 
Town have made it more difficult for emergency services to reach 
injured persons. As discussed below, these factors have led to too many 
unnecessary deaths of people lying by the side of the road waiting for 
an ambulance to arrive.
    The destruction of our close-knit social and cultural society by 
the dispersal of our population to the remote communities has 
contributed to alcoholism, depression, suicide, and violence. The 
flooding also changed our diet and work habits. When most of the 
population lived in the rich bottomlands, virtually every family had a 
farm that included a garden and livestock, which enabled most of the 
families to be economically self-sufficient. When we were forced out to 
the barren uplands, where the soil cannot be farmed, families became 
dependent on commodity foods, which are high in fat and starch, 
contributing to diabetes. Families also had no way to support 
themselves, contributing to alcoholism, suicides, and family violence.
    The destruction of the Elbowoods Hospital also left us without any 
health facility at all for the first 15 years, and then with a tiny and 
inadequate clinic for the past 35 years. When Elbowoods had to shut 
down in 1953 because of the flooding, the Corps of Engineers promised 
the tribe that it would construct a new hospital. However, our trustee, 
the BIA, in its infinite wisdom, recommended that our tribal members 
utilize hospital care in cities and towns adjacent to our reservation 
because it thought it would be easier to travel to other cities and 
towns than to come to a centralized hospital on our reservation. (See 
page 20 of the JTAC Report.) Many tribal members opposed the BIA's 
recommendation at the time, but we lacked the power to challenge the 
BIA's position, which reflected the Federal Government's termination 
policy at that time. As a result, from 1953 when the Elbowoods Hospital 
was destroyed, until 1968, when our present small clinic was built, 
there was no Federal health care available on our reservations. Tribal 
members had to go to private non-Indian health facilities. Because of 
the cultural and transportation barriers to the use of these non-Indian 
facilities, many, tribal members were unable to obtain adequate health 
care and there were no preventative programs being provided. It was 
during this 15-year period that the health status of our people began 
its precipitous decline.
    (In contrast, the Cheyenne River Sioux Tribe, which was also 
promised a new facility when its reservation was flooded in 1949, but 
was not subject to BIA interference, had such a facility built for it 
by the Corps of Army Engineers out of COE's appropriations. Since then 
it was replaced by a newer facility and then upgraded again.)
    In sum, the flooding of 456,000 acres of our best land was a 
catastrophe for our people's health in so many different ways. But the 
ultimate indignity and unconscionable action by the Federal Government 
was its failure to at least keep its promise to replace the health 
facility it destroyed in order to enrich itself from the Dam and to 
benefit all of the downstream populations.

III. The Gross Inadequacies of the Existing 8-5, Five Days a Week 
    Clinic

    In 1968, 15 years after Elbowoods was destroyed, the Government 
finally built a health care facility on our reservation. But instead of 
giving us a facility that was even remotely comparable to the Elbowoods 
hospital, it gave us a tiny, understaffed, underequipped 8 am to 5 pm 
clinic that was inadequate when it was built and that has so 
deteriorated over 35 years that today it is also a safety and medical 
disaster area. It is only 8,100 square feet, compared to Elbowoods 
which was over 35,000 square feet. A report by Dr. Robert Marsland, 
Retired Assistant Surgeon General, USPHS/IHS documented the shocking 
and unacceptable deficiencies in our present health clinic and found 
that these deficiencies were at least partially responsible for this 
unacceptable health epidemic on our reservation.
    Two sentences in his report starkly summarize his findings: ``The 
current IHS facility and service is inadequate, poorly staffed in 
numbers, poorly funded and unable to provide more than minimal 
community and primary health care. While the facility is staffed with 
competent and dedicated employees and officers, the lack of an adequate 
facility and budget compromises their ability to provide quality 
care.'' A grossly deficient facility that is less than one-quarter the 
size of the facility that was destroyed is not the kind of health 
facility the Mandan Hidatsa and Arikara people ever imagined they would 
end up with when they gave up 155,000 acres of land in return for a 
solemn commitment from the United States to replace the Elbowoods 
Hospital. Given the diabetes, cancer, and other epidemics that are 
killing our people, the present facility's ability to address these 
problems has been likened to ``trying to put out a forest fire with a 
garden hose''.
    The clinic is staffed by only 3 doctors, 2 nurse practitioners, and 
3 nurses. In addition to working at the clinic, this small team spends 
1 or 2 days a week at the mini-clinics the tribe has built with its own 
funds out in the remote reservation communities. (Twin Butte is open 1 
day a week and Mandaree and White Shields are open 2 days a week. We 
are unable to open the new facility the tribe built at Parshall because 
IHS says it does not have the money for staff or operations.) As 
highlighted by Dr. Marsland's report, this dedicated but understaffed 
team is trying to provide health care in a facility that is deficient 
in more ways than one can count. Quoting directly from that report:
    ``According to the IHS Level of Need Funding Report, Ft. Berthold 
Service Unit has a level of Need Funding of 45 percent, or less half 
the amount needed to provide an adequate level of health care.'' Ft. 
Berthold's level is even lower than the average for the severely 
underfunded Aberdeen Area, which averages a level of Need Funding of 54 
percent.
    ``The existing Minni-Tohe Health Center located in New Town, 
constructed in 1968 and comprising 8,100 square feet, is old, too small 
and poorly designed to meet the health service needs of the service 
population.''
    ``Rooms are small and without organization for efficient patient 
flow. There are too few examination rooms, the six rooms available are 
small, minimally equipped and some lack privacy.... All parts of the 
facility are chopped up and so congested that there are potential 
safety, privacy and HIPPA problems throughout. Additions to the 
original building and changes to accommodate expanded services have 
resulted in very poor ventilation, with heating and coolingproblems.'' 
(Dr. Marsland also points out that the lack of ventilation forces the 
physicians to leave the exam room doors open, so the patients have no 
privacy, putting the facility in violation of the HIPPA Federal privacy 
requirements.)
    ``Work space for all departments and services, except for pharmacy, 
which is minimally acceptable, are totally inadequate and fraught with 
safety, overcrowding, and numerous maintenance problems. The laboratory 
space is extremely small, crowded with equipment, poorly ventilated, 
with no room for desk space for lab and radiology personnel, yet the 
lab scored 100 percent on the accreditation survey. Credit must go to 
the dedicated staff to obtain such high results from such a difficult 
and demoralizing workspace.''
    ``Building settling has produced cracks and separations in several 
areas. The floor under the Medical Records space was not properly 
reinforced to sustain weight of medical record storage units and files 
so the floor is sagging.''
    ``N-19, the building that was to be used as a Wellness Center [a 
building adjacent to the clinic] is so badly affected by black mold 
that it must be removed. Lead and asbestos were discovered in planning 
for removal of the building. Black mold has also been discovered in the 
quarters' units necessitating extensive repair and renovation of these 
buildings.''
    IHS is planning to spend over $1 million to renovate the existing 
facilities and quarters. But even when finished with that expenditure, 
the facilities will still require over $1 million to correct the 
deficiencies needed to bring the facilities into compliance with JCHAO, 
OSHA, and State safety standards. Funds to do this have not yet been 
identified. But even if IHS spent the full $2 million, we would still 
have a clinic that is too small and open only from 8 to 5, so our 
people would continue to die because of the United State's failure to 
keep its 50-year old promise. Further, there is no room for expansion, 
because the site of the existing health care facility is land-locked by 
the new bridge. As a result, it has no room to grow even if funds were 
available for an addition to the existing clinic.
    In an effort to compensate for the inadequacies of the facility, 
the Tribe has contracted the employment of medical personnel and each 
year contributes $700,000 of its own funds to supplement the 
professionals' salaries, in order to provide them financial incentives 
to stay longer than 2 years and to work hard. This is apparently 
succeeding since Dr. Marsland repeatedly noted how the ``competent and 
dedicated employees'' try to overcome the deficiencies in their 
facilities.

IV. Our Health Problems, Intensified by the Flooding and the Inadequate 
    Clinic, Have Created A Health Crisis of Epidemic Proportions

    Our health problems are at epidemic proportions, especially in 
areas such as accidental injuries, cancer, heart disease, and diabetes 
related health problems. In addition to destroying our hospital, the 
flooding of our reservation has added to our health problems. Numerous 
studies have concluded that stress and dislocations of the kind that my 
people suffered as a result of the flooding cause serious health 
problems. We have seen our health problems on our reservation grow 
geometrically since 1953. When this increase is placed on top of the 
health problems suffered generally by Indian people throughout the 
country, and is coupled with our inadequate 8 to 5 clinic, it has 
produced a health epidemic on our reservation, while we have been 
denied the weapons we were promised and we need to effectively combat 
it.
    Our diabetes rate is more than 14 times the national average; 576 
tribal members, approximately 10 percent of our on-reservation 
population, are known diabetics. Many others likely have yet to be 
diagnosed. Of those diagnosed, 20 percent are under 18 years of age. 
Our children are now being diagnosed at an alarming rate with juvenile 
diabetes. When we tested our Head-Start children, 20 percent were found 
to be predisposed to diabetes. This means they may suffer with diabetes 
their entire lives. Our dialysis center presently serves 37 patients 
diagnosed with ``end-stage renal disease''. As the name implies, these 
are people whose diabetes has affected their kidney functions so 
severely that their blood must be cleaned (dialyzed) not through their 
kidneys, but through special machines at our dialysis center. Of the 
576 members suffering from diabetes, over 300 are between 40 and 60 
years of age. Many of them will be needing dialysis and other intensive 
treatment in the coming years, making the need for an adequate diabetes 
care center even more pressing. In addition, this center needs to be 
housed in an adequate health care facility that can serve the needs of 
patients who may suffer complications while receiving dialysis 
services.
    I recently declared a ``War on Diabetes'' that will involve a 
variety of innovative preventative and medical initiatives, including 
an Internet screening program in conjunction with Georgetown University 
that has been funded through the Defense Appropriations Act with much 
appreciated assistance from Senators Conrad and Inouye. However, our 
existing facility lacks the space to house any preventive health care 
activities, much less the efforts needed to carry out and win this war.
    Our cancer rates are up to seven times the national average 
depending on the kind of cancer. Many of these are forms of cancer that 
need screening to be detected early enough for treatment. The clinic 
lacks the equipment and the space for equipment to conduct mammograms, 
putting additional pressure on the inadequate CHS dollars. My mother 
died of stomach cancer, not diagnosed early enough, because there had 
been no screening program instituted for the disease at our local IHS 
facility.
    Heart disease, the third leading cause of mortality, is four times 
the national average. The tribe's Casino is located just across the 
highway from the center. We have had seven people die there from heart 
attacks in the past 18 months because they were unfortunate enough to 
have suffered the heart attack after 5 pm. One of the persons that died 
was a mother of a fellow councilman who watched helplessly as his 
mother died in his arms. His mother and the others that suffered heart 
attacks may have been saved if we would have had a 24-hour healthcare 
facility on our reservation.
    We have just begun construction of the new Four Bears Bridge and, 
in 1 year, will begin construction of a new refinery. Together they 
will involve hundreds of workers involved in dangerous construction 
tasks. The construction work on these projects will not stop at 5 pm or 
be limited to weekdays. Our present clinic and the hours it is open are 
totally inadequate to handle the existing workload, much less the 
increased workload these construction projects will contribute.

V. Absence of a 24-hour Facility Combined with Inadequate Ambulance 
    Services are Causing Too Many Unnecessary Deaths

    As indicated throughout this testimony, one of our most serious 
concerns is that the existing clinic is only open from 8 am-5 pm and 
only on weekdays. A tribal member who gets sick or injured in the 
evening or on weekends or holidays must be transported to an off-
reservation hospital. The three off-reservation hospitals are all at 
least 85 miles from New Town and further from the outlying communities. 
Minot is 85 miles, Williston is 90 miles and Bismarck is 160 miles. 
(The nearby off-reservation facilities in Stanly and Warford city are 
only ``critical access facilities'', capable of just performing triage 
and then transferring the patient to these other distant hospitals.) 
There is no Medivac or other air transport available. The IHS ambulance 
is used only to transport patients from the clinic to the off-
reservation hospitals. It is not equipped or staffed for emergency 
medical services.
    Even when the clinic is open, it is too small to handle serious 
automobile and other injuries. We have a high accident rate on our 
reservation, largely attributable to the flooding because our community 
went from a compact one in which most people lived in a 60-mile stretch 
along the Missouri River, to one that is spread out over a wide and 
remote upland territory. People must travel dangerous roads, many of 
which are gravel or dirt, because the COE failed to build the roads it 
promised to connect the new upland communities. All of these factors 
increase the critical importance of adequate EMT and ambulance 
services. However, Dr. Marsland concluded that the ambulance service 
for doing so is totally inadequate.
    The combination of the remote and dangerous roads, the long 
distance from health facilities, the absence of basic ambulance 
services, and an 8 am-5 pm clinic, have combined to cause far too many 
accident victims to become unnecessary fatalities because medical 
treatment was not provided in a timely manner. All of these problems 
are attributed to the flooding and the Government's failure to keep its 
promise to provide a new health facility.
    Dr. Marsland's report effectively summarizes the ambulance 
situation:

        The Ft. Berthold Reservation and Minni-Tohe health Center are 
        medically isolated. The nearest secondary/tertiary health 
        facility is located in Minot--85-100 miles away from various 
        reservation communities. Only one of the four ambulance or 
        Emergency Medical Services that serve the different parts of 
        the Reservation are certified for ACLS stabilization and 
        transport. Currently there is no way to effectively use that 
        ``golden hour'' of time from the moment a life threatening 
        event occurs to stabilize and transport a patient from the 
        scene of the event, whether home, highway or health center, and 
        transport to a certified facility and provide the advanced 
        cardiac and life support necessary to prevent death or 
        catastrophic results.

    To try to reduce the number of deaths, the tribe spends 
approximately $113,000 a year to pay for ambulance services, which are 
provided by three off-reservation communities and the city of New Town. 
But because of the distances, difficulty in finding the victim(s) in 
the remote countryside, and boundary disputes among these four 
ambulance services, they often take too long to arrive and three out of 
four of them lack the sophisticated equipment needed to utilize that 
"golden hour" Dr. Marsland referred to. Also, there are areas of our 
reservation that have no service at all because they are outside of the 
"territory" of the various ambulance services. The entire west side of 
our reservation does not even have 911 service, as can be seen from the 
sign on the clinic advising people what to do for service when the 
clinic is closed. As a result of all of these factors, most of which 
are directly attributable to the Dam and the Government's failure to 
keep its commitment, far too many of my people have died because they 
picked the ``wrong'' time and place to get sick or injured.

VI. The Unfulfilled Promise has a Devastating Effect on Our Contract 
    Health Services Program, On Our People's Credit and On Off-
    Reservation Providers

    The inadequate existing facility also has a devastating effect on 
our contract care (CHS) program. Because the facility can handle such a 
limited range of medical procedures and services, an inordinate amount 
of medical services has to be referred to off-reservation providers. 
Dr. Marsland found that the CHS funds ``...are insufficient to meet 
even Priority I needs for protection of life and limb throughout a 12-
month period. The service unit usually depletes its CHS funds sometime 
from May-July.'' Many services that others in this country take for 
granted are never funded because of the, inadequate CHS budget at Ft. 
Berthold.
    The extraordinary dependency on the CHS dollars because of the 
inadequate facility has also unfairly ruined the credit rating of 
hundreds of tribal families. This in turn has undermined the tribe's 
efforts to promote mortgage-financed housing because these families are 
treated as uncredit-worthy by the mortgage financiers. Yet the fault 
lies with the Indian Health Service. Even though the Service Unit knows 
it will run out of CHS funds before the end of the year (and it is 
prohibited from paying bills incurred in one fiscal year with funds 
appropriated in the next year) the Indian Health Service has instructed 
the Service Unit to never deny any tribal member CHS services on the 
grounds that there is no money. So if a tribal member needs a Priority 
I procedure, the Service Unit approves it. But, if, when the bill for 
that procedure is received by IHS, the CHS funds for that year have 
been exhausted, IHS, in a maneuver that is immoral and probably 
illegal, simply declares after the fact, that the procedure is now not 
a Priority I procedure, such that IHS has no legal obligation to pay 
the bill. Responsibility for the bill now falls, after the fact, on the 
tribal member. Thus a tribal member who walks into the CHS provider 
having been told that IHS would cover the costs of the procedure, can 
learn weeks later that he is personally and legally responsible for 
thousands of dollars in medical bills. If the tribal member cannot 
afford to pay this unanticipated bill (which is the usual case), his 
credit rating is destroyed and he is ineligible for mortgaged financed 
housing, car loans, etc., through no fault of his own. One family 
facing a $30,000-medical bill because of this IHS practice, was forced 
to declare bankruptcy to keep the CHS provider from seizing all of the 
family's assets.
    The absence of a 24-hour facility and the resulting reliance on CHS 
dollars, also creates financial problems for the off-reservation health 
facilities. In the situations described above, most tribal members 
cannot afford to pay these medical bills even if they were willing to 
let IHS off the hook. As a result, the off-reservation facilities are 
never fully compensated for the CHS care they provided. This raises the 
cost of health care to the off-reservation population.

    VII. A Description of the New Facility

    The $20 million authorized by S. 1146 would pay for the 
construction of a 66,000-square foot facility, located on 66 acres of 
land donated by the tribe, set overlooking Lake Sakakawea. This is a 
bare bones facility. Based on IHS data, a facility for a user 
population the size of Ft. Berthold (a population of 5826 in 2002 and 
expected to grow to 7436 in 2010)) should be 107,000 square foot, with 
$3.5 million for design, $9.7 million for 140 new staff, $13 million 
for O&M, and $21 million for 75 new housing quarters for the new staff. 
When the Tribe submitted the $20 million cost to Congress, it was just 
for construction and was not intended to include these other costs, 
which we have been told must be authorized, and then specifically 
appropriated in the first year of operation. If that is done, IHS will 
include them in its base budget in future years. If that is not done, 
there will not be funding to staff or maintain the new facility. We 
therefore request that S. 1146 be amended to provide for the additional 
staff ($6.6 million), O&M ($2 million), and design ($2 million) that 
IHS would include in any 66,000 square foot facility.
    The $20 million also does not include funds for new quarters for 
the additional staff needed for the new facility. Yet, some of the 
existing quarters were converted to use for medical purposes and others 
cannot be occupied because of black mold. Unless new quarters are 
provided, it will be virtually impossible for the Tribe to recruit the 
additional providers that will be needed to staff the new facility. The 
Tribe requests an opportunity to visit with the Committee at some time 
in the future to discuss this need for staff housing.
    We have been planning our new facility for almost 15 years, ever 
since the JTAC Report acknowledged our right to such a facility. While 
we were promised a new hospital to replace Elbowoods, the Tribe has 
agreed to compromise on a 24-hour outpatient facility. We have had 
numerous community meetings and have consulted other tribes and various 
health experts. The result is a facility plan that was designed 
specifically to address the health problems that are killing our 
people, based on the successful model of a comprehensive rural health 
care facility.
    The facility will provide 24 hour, 7 day a week outpatient and 
emergency room services. It will have an expanded kidney dialysis unit, 
since diabetes on the Reservation is 14 times the national average and 
is the leading cause of death. It will have a cancer screening unit 
because our Reservation has a cancer rate seven times the national 
average and cancer is the second leading cause of death. It will have a 
telemetry unit for testing persons with heart problems, since heart 
disease is the third leading cause of death. It will also have an 
Intenet-based health information technology resource center, to be 
developed with the cooperation of the Georgetown University Medical 
Center, that will enable the medical staff to monitor diabetes patients 
in their homes and will provide the staff with information on the best 
practices available on diabetes and cancer treatment, particularly, in 
regard to diet and lifestyle of the patients.
    It will provide 10 ``swing beds'' for patients who need skilled 
nursing care but do not belong in a hospital, such as for 
rehabilitation and alcoholism. These beds, the numbers for which were 
based on analysis of existing utilization, will produce significant 
savings in IHS Contract Health Services dollars that are now spent 
putting patients in expensive hospital beds, not because they need to 
be in a hospital but because there are no alternatives. These beds will 
also enable patients to recover at a facility that is close to home, 
rather than in an off-reservation hospital that may require a 2- to 4-
hour drive, one way, for family members seeking to visit.
    Finally, the budget includes funding for fully equipped ambulances 
that will serve the remote communities. The Tribe will provide the 
facilities to house the ambulances. The staffing includes EMS personnel 
in each segment. The budget also includes funds for a helipad. All of 
these are designed to reduce the unnecessary deaths caused by the 
dispersed communities caused by the dam.

Conclusion

    The United States has a legal and moral obligation to enact S. 1146 
and to provide the appropriations called for in the bill. The Tribe's 
request does not interfere with or override the IHS health facility 
priority list or the appropriations process for that list. The tribe is 
not simply seeking a new facility because its existing one is 
deficient. It is owed that facility because the United States destroyed 
its old hospital and promised to replace it. As Senator Conrad stated 
at the August 30, 2001, hearing the tribe is morally and legally 
entitled to this facility. To make this distinction clear, the Tribe 
requests that Congress consider revising S. 1146 so that it creates the 
``Equitable Compensation Health Care Facility Settlement Fund'' in the 
Office of Special Trustee, and that it provide that the $20 million for 
construction of the new facility, when appropriated, be placed in this 
fund. The Tribe would then use the funds to build the new facility. 
This takes the appropriations out of the priority list category and 
makes it clear to all that the appropriations are being provided in 
settlement of an obligation of the United States. There are precedents 
for this. For example, the Northern Cheyenne Water Settlement Act 
created a similar Fund for the construction of a darn, with the dollars 
appropriated, pursuant to settlement, directly into that Fund.
    While appropriations are always difficult, the Garrison Dam has 
created enormous economic opportunities for those downstream who will 
forever be spared devastating floods, produces generous amounts of 
cheap electricity, provides recreational opportunities that now benefit 
all of the upper Great Plains, and is an enormous reservoir of water to 
meet the needs of North Dakota's residents, farms, and industries. In 
particular, the Dam has enabled WAPA to earn significant profits, which 
it pays over into the United States Treasury. While reaping these 
profits, the United States has not paid the full costs of generating 
that power since it has failed to provide us with the replacement 
health facility that is one of those costs. We view those profits as 
being earned on the backs of our people. It is time for the United 
States to fully pay the cost of the facility it has been benefiting 
from for 50 years.
    Congress has recognized the connection between a Federal Power 
Authority's profits and the Government's obligations to meet its 
commitments to Indian tribes. The Colville Tribe had a claim against 
the United States and the Bonneville Power Authority for under-
compensating the tribe for the land taken for the construction of Grand 
Coulee Dam. The tribe and BPA worked out a settlement that is actually 
being paid for by BPA out of its revenues, thereby eliminating the need 
to obtain an appropriation from Congress. While that model may not be 
an acceptable approach here, it makes the point that there is a direct 
relationship between the revenues earned by the Power Authorities and 
the obligations and commitments made by the United States in order to 
obtain the land needed to earn those revenues.
    In conclusion, on this the 50th anniversary of the dedication of 
the Garrison Dam this Congress, led by this Committee, must move 
forward aggressively to enact S. 1146 and then to appropriate the 
funds--as a matter of fairness, as a matter of conscience, and as a 
proof that a great nation keeps its promises. Thank you for this 
opportunity to testify.
                                 ______
                                 

 Prepared Statement of Frederick Baker, Chairman, Mandan, Hidatsa and 
                      Arickara Elders Organization

    My name is Frederick Baker. I chair the Mandan, Hidatsa, and 
Arickara Elders Organization, which is a duly sanctioned organization 
of the three affiliated tribes. Our responsibility is to provide 
services to, advocate for, and provide leadership to those enrolled 
members of our tribe who are sixty years and older. I am a retired 
Federal employee, with seventeen years as a service unit director for 
the Indian Health Service, including nine years at the Ft. Berthold 
Service Unit.
    I was raised as a Hidatsa Mandan and I am one of the few remaining 
Hidatsa speakers. I was born prior to the construction of the Garrison 
Dam, and have clear memories of life before our homelands were flooded. 
In fact, I was born in the Elbowoods Hospital, and spent the first two 
weeks of my life there, (although my memories of those two weeks are a 
little fuzzy).
    The Elbowoods Hospital was the place where we went for health care. 
People came from all corners of the reservation in their horse drawn 
wagons or sleighs, depending on the time of year, to seek medical care. 
We came to Elbowoods because that was our hospital. chances are that 
one of our close relatives or one of our good friends worked there. The 
staff knew our ways, and made us feel comfortable and welcome.
    With the advent of the Garrison Dam, our hospital at Elbowoods was 
closed, and we were forced to seek care at hospitals where we knew no 
one, everything was strange and different, and sometimes we were not 
treated very well. as a result, many of us, especially our elders 
refused to seek medical care and many died at home, rather than seek 
care at such a foreign place.
    Today, many of us elders still hesitate to seek care away from the 
reservation. we look at the mini-tohe clinic as our own; we see our 
relatives and our friends working there, and feel assured that we will 
be better understood. I remember that as the service unit director, I 
spoke to patients, sometimes in the hidatsa language in an effort to 
help people better understand their health condition. Although we 
depend on our clinic for our health care, it is woefully inadequate. 
Our population has grown, and will continue to grow at a fast pace. 
While other communities are closing their schools because of declining 
rural populations, we are building on to our schools to meet the 
growth.
    As previously stated, we have outgrown our mini-tohe health center 
building both in size, and technology. There are insufficient numbers 
of exam rooms, hence patients have to wait long periods of time to get 
appointments, and if an emergency type patient presents during clinic 
hours, the patients that do have appointments, have to wait sometimes 
as long as two hours beyond their appointment times to be seen. We have 
had elders who have left because of a long wait only to collapse 
outside the clinic and require an ambulance ride to the nearest 
emergency room which is 70 miles away.
    Our clinic is only open from 8 am to 5 pm, Monday thru Friday. If 
we get sick and require care outside of these hours, then we have to go 
at least seventy miles to seek medical care. We are always feuding with 
the Indian Health Service because they will only pay for what they 
consider is an emergency. If we present at a non-IHS facility, theirs 
will only authorize payment for what they consider an emergency. If our 
situation does not fall within their definition of an emergency, then 
we are stuck with the bill. Many of us have had our credit ruined 
because we sought medical care at an outside facility during non-clinic 
hours, for what we thought was an emergency, only to have the IHS deny 
payment, and we, not having the resources to pay the bill, end up at 
the hands of a bill collector.
    We desperately need a building that is adequate to meet not only 
our basic needs for medical care, but that can provide us with twenty-
four hour emergency service, and specialty clinics including ambulatory 
surgery. In all, these specialty care services will save money because 
they will allow more patients to receive services early enough to 
prevent costly urgent and emergent procedures further down the road. I 
recall an occasion when, as a service unit director, I had neither the 
resources available at the clinic, nor the contract health care dollars 
to pay for a diagnostic procedure that would have cost about 500 
dollars. Six months later, this same patient had to have a life-saving 
procedure that cost the Indian Health Service 65,000 dollars. This 
procedure and its subsequent costs could have been avoided, had we had 
the proper resources at the clinic to make the diagnosis.
    A new clinic, equipped with today's technology, and the necessary 
staff, will bring our level of care to a more reasonable level and 
closer to the level of health care that all other Americans enjoy. 
Further, it will fulfill the promise of replacing our hospital at 
Elbowoods.
    Thank you for your interest in our healthcare and for supporting 
our desperate need for a new clinic.