– When 6-month-old James Ladeaux got his second upper respiratory infection in a month, the doctor at the Sioux San Indian Health Service Hospital reassured his mother, Robyn Black Lance, that it was only a cold.

But 12 hours later James was struggling to breathe. Black Lance rushed her son back to the hospital in western South Dakota, where the doctors said they did not have the capacity to treat him and transferred him to a private hospital in Rapid City. There he was given a diagnosis of a life-threatening case of respiratory syncytial virus.

"They told me if I hadn't brought him back in, he would have died," Black Lance said, choking back tears.

James was lucky to have survived that day in April 2016. The problems at Sioux San, one of 24 hospitals nationwide run by the Indian Health Service, an arm of the Department of Health and Human Services, are pervasive: Five government investigations have found that patients have died at Sioux San from inadequate care, are often given wrong diagnoses and are treated by staff members who have not been screened for hepatitis and tuberculosis.

The troubles were so severe that Sioux San's emergency room and inpatient unit were shut down by the Indian Health Service and Congress in 2017. Only an urgent care clinic, often understaffed, remained open.

Sioux San is emblematic of the scale of the problems facing the Indian Health Service, which provides government medical care to 2.2 million of the nation's 3.7 million American Indians and Alaska Natives and is widely judged to provide substandard care.

But Sioux San is also part of a growing trend in which tribes have declared themselves fed up with the federal government's management of the health care system and are seizing control of troubled hospitals in the belief that they can do a better job of running them.

In mid-July, the Great Plains Tribal Chairmen's Health Board, a nonprofit organization that represents 18 tribal communities in South Dakota, North Dakota, Nebraska and Iowa, began running the Sioux San hospital's operations.

The change in management has allowed the tribal authority to develop a plan to reopen the inpatient hospital and the emergency room, recruit more qualified doctors and health care workers and upgrade equipment.

But it is an expensive and daunting proposition.

A New York Times analysis of government data found that a quarter of medical positions within the Indian Health Service — including doctors, dentists and nurses — are vacant. In some areas, the vacancy rate is as high as 50%.

In states with Indian Health Service hospitals, the death rates for preventable diseases — like alcohol-related illnesses, diabetes and liver disease — are three to five times higher for Indians, who largely rely on those hospitals, than for other races combined.

Federal government spending on health care for Indians lags that for almost any other population. In 2016, the federal government spent $8,602 per capita on health care for federal inmates compared with $2,843 per patient within the Indian Health Service.

Despite the challenges they face, tribes who choose to take control of their own health care systems have tended to see improvement in their hospitals, said Lynn Malerba, chief of the Mohegan Tribe and chairwoman of the Tribal Self Governance Advisory Committee, an advisory body to the Indian Health Service.

"I know tribes that do have been very successful at creating a really wonderful health system to the point where they are experiencing better health outcomes," she said. "Tribal citizens who receive their health care through a tribal program are much happier."

But some in Rapid City are not convinced that the management change will be successful. Among them is Charmaine White Face, 72, a member of the Oglala Sioux Tribe.

White Face thinks there should have been more planning and communication with the residents who primarily use the hospital before the change. But most concerning, she said, is the lack of money to achieve the health board's goals.

"In order to be successful … the tribes, or the native organization, has to have a lot of other resources, and the tribes here in the Great Plains do not," White Face said. "We are too poor here."