In the emergency room of the Rosebud Indian Health Service Hospital, suicide attempts by drug overdose are seen nearly nightly. Alcohol-related car accident injuries fill many of the small hospital’s beds, competing for space with tuberculosis, pneumonia and liver and kidney failure. Diabetes is common, leading to loss of life and limb.

The physical complications of poverty, joblessness and epidemic rates of alcoholism, diabetes and depression spill over into the wards here at the only hospital on the Rosebud Reservation, which has a population of 13,000 and stretches across 1,970 square miles of South Dakota prairie. Life is short, violence high and health care lacking in Todd County, the second poorest county in the nation.

“There are three ‘spiritual’ paths here: Native Lakota, Christian or alcoholism,” says Rick Emery, a physician assistant here for the past 13 years. He’s hunkered down in command central, a small office in the ER, awaiting the arrival of an assault victim. It’s late March — spring break for the local schools. Drug- and alcohol-related cases are up. The staff morale, down.

“Bath salts, meth, Sudafed, anything that’s cheap,” Emery says. His hair is gray, his kind face weathered. “It’s worse when school’s out, when kids on the reservation have nothing to do. We get young people, 17, 18 years old, coming in with chest pains.” Sometimes they’re drug-induced, sometimes not. The night before, a 16-year-old came in with a severe anxiety attack. The night before that, a 25-year-old male who had hanged himself arrived too late to save.

Cursed with some of the highest suicide rates in the country, tribal leaders declared a state of emergency here back in 2007 making headlines in The New York Times. But today, six years later, not much has changed. Across the United States, American Indian and Alaska Native youth ages 15 to 24 are still committing suicide at rates three times the national average of 13 per 100,000 people for their age group, according to the U.S. surgeon general. On the Great Plains, the suicide rate for Native Americans is 10 times the national average. Unemployment hovers at 80 percent, and the life expectancy for males is in the upper 40s, about 30 years lower than the U.S. average.