Health on the Map: Contemplating Health Crises with South Dakota's Secretary of Health

Mount Marty University President Marc Long recently joined the Secretary of Health for South Dakota, Melissa Magstadt, for Health on the Map, a podcast that explores rural health care in the United States. She was appointed to this position by Governor Kristi Noem in 2022 and previously served as a member of the South Dakota House of Representatives from 2011–2015. She served as a family nurse practitioner for more than 25 years, mostly in northeast South Dakota. And before that, she was a staff nurse, education coordinator and an emergency department nurse. Madstadt holds degrees from Huron University, South Dakota State University and Mount Marty University. 

This conversation has been taken from the original podcast and edited for length and clarity. 

President Marc Long: Why did you decide to become a nurse?

Melissa Magstadt: This is sort of interesting. Back in fifth grade, Huron McKinley School [we had] a career day. They [the teachers] wanted us to pick something that we'd want to be when we got older, and me and my best friend decided that we wanted to be nurses. So, my mom took us down to the thrift store and got us a couple of old nursing uniforms, and we wore it to school that day. And she and I both went on to become nurses. So, you know what, never underestimate those little fifth, and sixth grade, or fourth grade exposures to potential careers; that could be the root right there.

So one of the things we're doing at Mount Marty University is really focusing a lot on rural health, and I know that's obviously your background of being the Secretary of Health for South Dakota. I'm sure you spent a lot of time thinking about those issues. What are the one or two most challenging public health issues in our state? And I guess another way of asking that is, what do you spend your time thinking about as secretary?

So things that I spend my time thinking about, and actually, our executive team was having this conversation probably a couple months ago that really sort of summed it up. We said, “What is going to be the next public health challenge? What will be the next crisis? I mean, we're on the backside of the COVID piece of it, but what's the next public health crisis?” And we all came up with this and finally settled on the word complexity.

And it’s not necessarily that the illnesses are more complex, but the environments and where people live, getting access to care, [and their] social determinants of health, which is basically where people live, work and lay down their head at night [are]. Do they have access to healthy foods? Do they have access to things that shore up healthy lifestyles? And then, do they have access to care when they need it? So, you know, it's not that the illnesses are more complex but the environments that people live and work, play and lay their heads down at night are sometimes the bigger challenge to get health care delivered to those people rather than even just the complexity of an illness.

And speaking about complexity, you know our state is increasingly complex. Sioux Falls is one of the fastest growing cities in the country. Rapid City is growing at a pretty fast clip. Of course we know the challenges—health challenges—that the reservations have, and much of the rest of the state is declining in population. How do you and your staff sort of work with providers and health systems throughout the state to ensure that the quality of access to care remains during this time of change?

That’s a great question. I think the first thing that we look at and try to do this—well, and if I were to say [is] if you're going to your health care provider, nurse practitioner [or] whoever you're going to, they're gonna check a set of vital signs on you, right? They're gonna check your temperature, they're gonna check your blood pressure, and it's gonna be just a little bit of an indicator of how you're doing in that moment in time. Well, we do the same thing for the population. We check the vital signs, the temperature of the population, and we do that with health outcomes: that data. So, we have pivoted to become very data–centric so that we're no longer making decisions by gut instinct or what we think or what we assume works this way, but really focusing on having clean, clear data. Not only are we taking in and making sure that it's accurate and true, but we're disseminating that out to the population, and the partners, and the health systems, and Indian health services and tribal leaders, and rural communities in ways that they can use as well—whether that's for program planning, or community planning, or grant asking for communities. We carry a lot of data and … we've got to make that data very transparent and in the hands of the people who need it. 

So, the first thing we start with is the data piece. Every community and every area has a different set of temperature that's taken, and that outcome really helps us drive what areas do we need to focus on, what do we need to lift up, and what interventions need to be done for this area—but maybe this area over here needs something completely different. And so assessing this with good data that is relevant down to the county level so that you can actually make very good programming and interventions that meet the needs of those various communities. 

Sixty-four out of sixty-six of our communities are considered rural, but some of our areas are even to the point of frontier. I chuckle at some of the interstate conversations that I'm in with the health officers from other states, and they talk about the struggles of delivering health care in rural entities. I say, “Think about taking it to frontier areas.” That's a whole other level of health care access and not only health care access delivered to the folks, but them being able to reach either specialty services or primary services or even the services of delivering babies. In some of our places, it's 60, 90 minutes, two hours, for areas to deliver babies. … Put that in the context of that access to care. Babies still get delivered and born, and moms still get pregnant in very frontier areas. So delivering that care is going to look very different than it does even in Sioux Falls.

Yeah. I'm sure your colleagues around the country don't fully appreciate, for instance, a colleague from New Jersey or Maryland isn't going to fully appreciate some of the challenges that you have in some of these frontier communities and counties. So I would imagine that that communication, going back to that that conversation we had earlier about complexity between the local providers and the state is critical.

That’s to your point. We have 356, or something, employees in the Department of Health. There's 905,000 people who live in South Dakota. Three hundred and fifty-six people working in the Department of Health cannot possibly impact the whole public health of the entire state. So, our reliance on people with the same sort of heart for delivering health care to the people of South Dakota, we partner [and] link arms with those people who have that same sort of mindset. And I said, “Anyone wants to get in the boat and row with me? I am totally inviting them on board.” So those partnership pieces are critical to us. Shoring up what our traditional partners are, shoring up what our non-traditional partners have, we've discovered [that] to be really critical this past year. 

We spend a lot of time at Mount Marty talking about advanced practice nursing. I don't know if you know this or not, Mount Marty has the second largest graduate nursing program in the state. And so we think about—you know, we love physicians and love what they're doing, [but] there aren't enough of them in our rural communities. So we really try and educate and train nurse practitioners at the highest level because in many cases nurse practitioners and physician assistants are going to be those primary care providers in rural areas.  You’re a nurse practitioner yourself, how do you think the roles of nurses, both the RN level and the APRN level, have changed in the last few years? And what do you think the future of nursing practice is like? 

What’s really sort of interesting is that, what's the new practice look like? It actually kind of looks like the old practice. There was a time when it was nurses and advanced practice nurses. You think back to Mary Breckinridge in Kentucky, right? She was one of the first nurse midwives who developed the frontier nursing services in Kentucky and went into the Appalachian Mountains and started helping deliver babies up in those mountains. Dropped the maternal and infant mortality rate significantly happened in Alabama with a Margaret Smith, and she, out of the 3000 babies that she delivered, did not lose one mother out of 3000. So I think, honestly, as we're evolving back into getting nurses out into the frontier and rural areas and putting them into those communities is actually to return to the way health care used to be. 

Going into the communities, being connected right in the neighborhoods, there's a lot of even moving into home visiting nurses, right? So we have this program called Bright Start, and it is in every county in this state. [These nurses come] right into the home and helping establish those first thousand days of life from pregnancy/conception all the way to two years old, which is the first thousand days of life. And having nurses who are right into the home with those families makes a massive impact. 

So for me, using the army of health care providers to the top of their licensure and getting them into the places where health care access is a struggle is a key intervention for health care right now. But like I said, this is not a new idea. This is an old idea, just redone.

So some recent research shows that nationwide residents in rural areas are more likely to die from diabetes than those in urban or suburban areas, which I actually thought was tragic yet fascinating at the same time. And that's one of the reasons we at Mount Marty have established our graduate program in endocrinology for nurse practitioners, only the second one in the nation. How can we as a society, as a state, get a handle on diabetes?

Sure, that's a great question. Diabetes is one of the, I think, best examples of the partnership that happens between health care providers and the patient themselves, because diabetes is one of those types of illnesses that is really dependent on what the patient is doing day in and day out and the community and the environment they live in. 

So let's just take that and take it down the road just a little bit by going to a community where someone is struggling with diabetes. And all they have, and nothing against the C-stores, is a C-store for access to food. And C-stores are not set up to have fresh produce. So now you have pre-packaged foods as your only access point. You're talking to a patient about their diet and sort of healthy eating, but their access to healthy foods is going to be a massive barrier for them to do well in diabetes care. So, then it becomes even the next step for the health care provider, whether it's nurse practitioners, nurses or whatever, to start looking at where the person lives and spends all their time. If we're not thinking about our patients outside of the exam room or outside of the hospital bed and sending them back into this environment, we're going to be personally frustrated that patients aren't doing as well as we'd like them to. 

Our patients are going to be personally frustrated because they want to be healthy too. And if you have tons of barriers to get over with and your outcomes are not changing for the better, so much discouragement and frustration and all that can be a part of it. And diabetes, I think, probably is one of the biggest examples of the health care patient partnership that needs to be in lockstep, because you're only going to see that patient once every 15 minutes every three months, right? You check their blood level, redo their prescriptions, whatever they need, but it really behooves health care to now get in with the patient in the world that they're living in, in the environment that they work and sleep and play and go to school in, and be enmeshed into that environment if you're going to actually have healthy outcomes when it comes to diabetes care and basically all chronic illness.

Let's stay in the behavioral health sort of sphere here and talk a little bit about mental health and that relationship to physical health in our communities. Most school and higher education administrators say they spend a lot of time working with kids on behavioral health issues. I sometimes wonder if school counselors have any time to work with college planning because they're dealing with the behavioral health issues from the counseling side in their schools. I certainly see it in higher education too, the mental health challenges with young people. But I also then see and talk to a lot of churches who have programs working with older adults and loneliness. So it seems like throughout society we have some issues with mental health challenges. How can communities and organizations work to improve those outcomes?

I think one of the best things that we've started doing is considering that mental health is health care; it is the same thing. When I went to school a bazillion years ago, there was the health care part and then there was almost the siloed mental health/emotional health type piece. And the perspective of bringing it all back together to being the patient is the biological, physical part, the mental, emotional and spiritual part that all of us are, and then we stop separating them out. And to your point on that whole piece of mental health data, we gather a lot of data in the Department of Health, and suicide would be the number one reason that we lose young people. But the highest number of suicides that we have in our state are the working adult and the 50 to 60 year old. It is a forgotten population that I think probably in that generation—I was in that generation—we didn't talk about, didn't normalize the conversations around mental health/emotional health struggles.

I appreciate that the schools and colleges are just normalizing that. So it's normal for young people to consider that mental health, tending to self-care and reaching out when you're struggling is being wired in as part of the normal, which I absolutely appreciate has been happening in this generation. But in my generation, we didn't talk about that. And so one of the precursors to a higher risk for suicide we have found in our data is a diagnosis of a chronic illness. So just as we were talking about diabetes, right? So as we're handing out the diagnosis that we do day in and day out: you have diabetes, you have heart disease, you have high cholesterol; we hand these diagnosis out from one patient to the next. Do we really consider what it means for the patient to receive that particular diagnosis? If we can start handing out diagnoses with the thought about what is received on the other end, just an awareness. It is something to take note of. 

So what are you most proud of? You've talked a lot about what the South Dakota Department of Health is doing, sort of how communities are responding. What are you most proud of during your year and a half as Secretary of Health?

I think what has probably excited me the most over this last year is shoring up the amount of data we get and the amount of data we share with others. We need to share our story. We need to find those who are rowing the boat with us. We need to partner with the people who need this information and be generous with that information to whoever is interested and can be a part of the solution. 

I think we've become much better at taking that data and putting it into action. We gather a lot of data, but we weren't necessarily making our decisions based on it. If this population is struggling, for instance, we have the first compilation that we have ever done—we call it the American Indian Data Book—which is South Dakota data and the comparisons between two populations that are the predominant populations in South Dakota. That data has never been compiled until this year. 

Well, we're certainly very thankful that you came on and shared some of this information with us. I've learned a lot today. Is there anything else that you want to cover during our time together?

Well, currently we're in a rural health care assessment analysis. So we're taking a few months here to do an environmental scan of the current state of health care accessibility. We're hoping to have that report put out with the analysis but also some grant funding opportunities when it's all said and done to help us bend the trajectory of rural health care delivery.

It's one of those things that there's no easy answer, but health care is kind of in a period of a little bit of pain and suffering right now. It's got a bit of an angst to it, but also the flip side of it is, that's when innovation happens. Creative things happen because of angst. That's when the fun starts. 

I love health care right now, because right now creative is the game and the innovative is the key. So, I think it's a fantastic time to be in health care. You're going to do some innovative, creative things that weren't thought of 10, 15 and 20 years ago. 

Great. Thanks so much for your time today. I've loved connecting with you. Pleasure to meet you as well, and you have a good rest of your day.

Health on the Map is a production of Mount Marty University Nursing and is available for streaming on Spotify, Apple Podcasts, and YouTube. To learn more about Mount Marty, South Dakota's Catholic University, visit mountmarty.edu/nursing.

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ABOUT MOUNT MARTY UNIVERSITY

Founded in 1936 by the Benedictine Sisters of Sacred Heart Monastery, Mount Marty University is South Dakota's only Catholic institution of higher education. Located along the bluffs of the Missouri River in Yankton, with additional locations in Watertown and Sioux Falls, Mount Marty offers undergraduate and graduate degrees focusing on student and alumni success in high-demand fields such as health sciences, education, criminal justice, business, accounting, and more. A community of learners in the Benedictine tradition, Mount Marty emphasizes academic excellence and develops well-rounded students with intellectual competence, professional and personal skills and moral, spiritual and social values. To learn more, visit mountmarty.edu.