Initially the death and suffering driven by the COVID-19 virus seemed far away from the Plains of South Dakota.

Like the news of wars and natural disasters from distant foreign places, it seemed like a big city problem where people live chock-a-block in high rises and ride densely packed mass transit.

“It was hard to fathom what people went through back in the spring,” says Angel Wilson, nurse practitioner at the Rosebud Hospital on the Rosebud Reservation. “I could read about it and say how horrifying it was for them, but it was still far away.”

Now, however, the virus has arrived on South Dakota’s eight reservations, in a state that in recent weeks routinely tops the list of COVID-19 hotspots. And it has hit hard, overwhelming hospitals and requiring some patients to be flown out of state, often with limited means for returning home.

Many Native patients also suffer underlying health conditions such as diabetes, high blood pressure and obesity.

“When people here get sick, they get really sick,” says Wilson, a citizen of the Rosebud Sioux Tribe. “The level of suffering is unlike anything we’ve ever seen before.”

Using the formal language of a medical professional, Wilson describes the challenges of caring for “high acuity” patients, or those with greater needs.

“We often have to send them to other facilities with more resources,” she says. Patient acuity is a parameter used in allocating nursing staff.

Wilson pauses her clinical assessment.

“I cry at work,” she says quietly.

Born and raised on the reservation, Wilson has worked at the Rosebud hospital for the bulk of her career. She knows most of its patients.

“If I don’t know them personally, I know their parents or family; emotionally, it’s been really hard,” she said.

Wilson recently attended the funeral of her adoptive mother, who died from COVID-19.

“She was 81, a powerful person who had a big impact on people, “always happy and praying for everybody,” she said.

“It feels like we are losing a lot of the older generation; they’re going so quickly, and a lot of our culture and language is going with them,” Wilson said.

“People are just so scared, you know? I think there’s a lot of depression right now.”

Across the country, Native Americans have been hit hardest by the virus. According to the Centers for Disease Control, they are five times more likely to be hospitalized from COVID-19 than Whites.

In South Dakota, Natives make up nearly 25 percent of statewide COVID-19 related hospitalizations despite being only about 9 percent of the population.

Realizing their citizens are at greater risk and have fewer health care resources, many tribal leaders in South Dakota have taken aggressive action to prevent spread of the virus, such as mandating masks, closing schools and government buildings and periodically enacting curfews, shutdowns and checkpoints on reservations roads.

Many Indian Health Service facilities effectively function in a constant state of crisis during normal circumstances. Chronically underfunded and overwhelmed, the agency falls far behind other federal health programs; Medicare is funded at about three times more per patient than the Indian Health Service.

Public health investigators on the Pine Ridge Reservation estimate that about two out of 10 people who test positive end up being hospitalized.

Most Indian Health Service facilities in South Dakota are unable to care for seriously ill COVID-19 patients, who must be transferred often by air, sometimes hundreds of miles to hospitals in other states.

“There don’t seem to be any beds in South Dakota at this point,” said Wilson.

“They’ve (Indian Health Service) actually done a good job of keeping patients here when they can, but we have limited resources as far as nursing staff,” she said. “A couple of weeks ago, we were begging for places to take patients.”

According to Ralph Young, emergency medical operations manager for the Rosebud Sioux Tribe, patients are being transferred to Nebraska, Montana and Colorado.

“Very ill patients are airlifted to facilities out of state,” Young said.

Patients who recover are then discharged from faraway hospitals.

“That’s when the trouble starts for us.”

“Most of our patients are poverty stricken; they don’t have any family or resources to help bring them back home, so EMS picks them up,” Young said.

The roundtrip drive to Billings, Montana, for instance, takes two days; drivers must stay overnight and then bring patients back to the reservation. Drivers must wear complete protective gear for the return trip, according to Young.

“We have no choice; what are we going to do, force them to walk home?”

“We’re overwhelmed; normally we’re staffed at only about 60 percent of what we should be; our workload during the pandemic has doubled and tripled,” Young said.

Since emergency medical operations is an existing program, it doesn’t qualify for CARES funding, though the Indian Health Service has helped with supplies and staff.

The job has taken a toll on workers.

“We’ve had about 12 staff either get the virus or have to quarantine because of exposure,” Young said.

“I just hope we can get a break when this is over.”

Unlike her parents who grew up during the Depression, Wilson notes that she has never experienced the level of pain and loss caused by the virus.

“We weren’t rich growing up, but I’ve never been through anything like this; I’m scared for my family.”

“But, we’re survivors, like our ancestors; Native people have come through a lot, and we’re going to get through this too.”

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Mary Annette Pember, a citizen of the Red Cliff Ojibwe tribe, is a national correspondent for Indian Country Today. Follow Pember on Twitter @mapember. Based in Cincinnati, Ohio. Pember loves film, books and jingle dress dancing.

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This article originally appeared on Indian Country Today LLC, a nonprofit, public media enterprise. ICT does not charge for subscriptions and tribal media (or any media, for that matter) can use the publication’s content for free. Contribute to the nonprofit Indian Country Today.

Note: The Associated Press contributed to ICT’s report.