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In a rural small town, a group of locals steps up to support senior health
Don Fitterer, 81, sits for a portrait at his home in Glen Ullin, N.D., on May 23. Fitterer is a participant in the Western Morton County Aging in Community program, which connects older adults in the medically underserved area of western Morton County with a variety of resources that can improve their quality of life.
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GLEN ULLIN, N.D. — When small rural towns get smaller, the challenges for those who remain get bigger.
It’s especially true for older residents and those who care for them in this shrinking North Dakota town.
Adults age 65 and older make up a third of Glen Ullin’s roughly 700 residents. The town’s retired teachers, accountants and health care workers are making every effort to age at home, but one big obstacle for them is the ability to access medical care — without it, they are often forced to move to a larger city.
Rural health care has been facing a crisis for years. But in rural towns such as Glen Ullin, older adults are getting help to manage, thanks to the handful of community members working to fill the gaps.
A welcome sign stands alongside Highway 49, leading into Glen Ullin on May 24.
Tim Evans for NPR/
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Each person plays a separate role — from keeping lonely older adults company to springing into action when a health emergency arises. In rural towns experiencing a loss of people, jobs and resources, this network of support can make a big difference.
NPR visited some of them to see what obstacles they encounter when trying to make sure the community’s older adults have the care they need.
The program coordinator, a jack-of-all-trades
Kyla Sanders, the program coordinator for the Western Morton County Aging in Community program, helps program participant Leona Staiger, 94, set up a medical alert device at her home in Hebron, N.D., on May 23. Sanders wears many hats in her role.
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It typically starts with a concerned neighbor.
“They’ll say, ‘I haven’t seen him outside for six weeks,’ or something like that, and I’ll go tap on their door,” said Kyla Sanders, a coordinator for the Aging in Community program in western Morton County, where Glen Ullin is located.
It’s a pilot program at North Dakota State University Extension to support older people living alone in rural areas. The idea behind the initiative is that older adults living alone are at the greatest risk of struggling under the radar. They are also the most likely to move out of town to be closer to resources.
Sanders helps deliver meals to a resident at the Marian Manor senior apartments in Glen Ullin on May 23.
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There’s no catch-all term for the work Sanders does. A former nurse and lifelong farmer, Sanders has the official title “program coordinator,” but her list of responsibilities changes every day — from setting up internet at an older person’s home to leading a flower arrangement class for a group of seniors to helping an older adult apply for Medicaid.
She’s a firm believer that there are small, affordable ways to keep older people aging at home and that they don’t have to relocate to a large town or city to thrive.
Sanders helps deliver meals to residents at Marian Manor on May 23. She says there are small, affordable ways to help older adults age at home.
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There are about 150 older adults whom Sanders visits or talks with regularly on the phone. According to Sanders, more than half the program’s participants don’t have family members living nearby or able to help. She suspects even more seniors are living alone in the greater region, and she hopes to expand the program out to 200 miles — about five times more than the distance she typically travels now.
“I think it’s such a treasure to be able to have older adults stay in place and that it just can’t be overlooked,” she said.
Sanders helps Don Fitterer, 81, fill out a health directive for local EMTs at his home in Glen Ullin. According to Sanders, many of the Western Morton County Aging in Community program’s participants don’t have family members living nearby or able to help.
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The nurse practitioner, aka the primary care provider
Rhonda Schmidt’s official title is “nurse practitioner.” But like in many small rural communities, she’s Glen Ullin’s main primary care provider.
On a regular day, Schmidt sees somewhere between 15 and 20 patients. Her core staff is made up of two other people — a nurse’s aide and a receptionist. Another nurse practitioner fills in once a week. Together, they handle medication refills and acute infections. But the clinic could do so much more if it had the staff, Schmidt said.
A quiet downtown Glen Ullin is seen reflected in the window of the town’s pharmacy on May 24.
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For instance, X-ray tests can help identify pneumonia, a disease common in adults over 65. The clinic has the X-ray equipment but no technician to run the machine, according to Schmidt. A doctor from an affiliated hospital used to help fill that gap, but that is no longer the case.
CT scans are another service that’s limited at the clinic. Staff members who operated a mobile CT scanner used to visit once a week, according to Schmidt. Now, they come once a month.
A rainstorm skirts the horizon near Glen Ullin on May 25. Inclement weather and long travel distances to medical providers are barriers to health care access for older people in Glen Ullin and many parts of the rural United States.
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In North Dakota, only six out of 53 counties are considered to have enough health care workers, according to the Rural Health Information Hub.
Schmidt was born and raised in Glen Ullin. Of her four siblings, she’s the only one still in town, and she lives on the same dairy farm that she grew up on.
“I just feel it’s my job to make sure they get what they need,” she said of her patients. “If I can’t figure out how to see them, they’re going to have to drive or find a driver.”
The volunteer EMT crew
Glen Ullin Ambulance Service EMTs Wade Kottre (from left), Lori Kottre, Dwight Kuntz and Rita Wallin pose for a portrait on a county road in Glen Ullin on May 25. The ambulance service is staffed entirely by volunteers and provides an essential service for Glen Ullin and the surrounding area.
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Lori Kottre may work 9 to 5 as the office manager at Glen Ullin’s nursing home, but she serves around the clock as the town’s emergency responder.
“I have my pager on 24/7,” she said. “And if I’m gone from the office three or six hours a day, I make up my time here so that my job here isn’t neglected.”
Glen Ullin Ambulance Service EMT Dwight Kuntz, who has been on the crew for 48 years, drives the team’s vehicle through Glen Ullin on May 25.
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Son and mother Wade and Lori Kottre, both Glen Ullin Ambulance Service EMTs, are pictured in Glen Ullin. Many of the ambulance volunteers are older adults themselves and have been on EMT crews for decades, but some younger locals have stepped up to join the team in recent years.
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Kottre has worked as a volunteer EMT for nearly 30 years, alongside her son, daughter, daughter-in-law and five others. Like Kottre, all of them have day jobs. In the U.S., more than half of rural EMS agencies are staffed by volunteers, compared with 14% in urban areas.
The ambulance squad receives 120 to 150 calls a year — a majority of which involve older adults, Kottre said. This means that the calls the EMTs receive are almost always serious, such as cardiac arrest and strokes. But they are limited in how they can help.
The ambulance carries aspirin, EpiPens and medications to help treat chest pain and asthma. But with no paramedic on the squad, there is no one certified to insert an IV or place a breathing tube. In those cases, the EMT crew calls the ambulance service in Bismarck, North Dakota’s capital, to meet on the highway, typically about 17 miles out of town, and take over.
According to Kottre, the EMT crew wouldn’t be able to afford a paramedic. Many rural communities face that challenge as a result of a national paramedic shortage.
“They don’t stick around the small towns,” she said.
Still, Kottre tries to do the best with what she has.
“I feel more responsible for trying to take care of the patients as good I can, because we know all of them — we know all of their children, all of their grandchildren,” she said.
The priest making home visits
The Rev. Gary Benz offers Holy Communion to Marianne and Jim Schaaf, both in their 90s, at their home in Glen Ullin on May 24. Benz works to support homebound, often socially isolated older adults who are dealing with health concerns by offering them Communion and an opportunity to connect with someone each week.
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When he’s not at church, the Rev. Gary Benz spends his weekdays traveling to the homes of his aging parishioners who are too ill or weak to attend services. He makes about seven to nine trips a week. Initially, the purpose was to bring them Holy Communion, but he quickly learned that they needed something else — connection.
“They say, ‘Father, this illness or condition is weighing on me and it just takes away my joy,’ or ‘It gets lonely being alone here all day,’” he said. “Some of them have family and friends who come visit, which is good, but some, they’re the only person in their house.”
Benz poses for a portrait at the Sacred Heart Catholic Church in Glen Ullin on May 24.
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Rural towns are often celebrated for their tight-knit communities and close bonds between neighbors. But even in areas where that holds true — like Glen Ullin — they face unique barriers to social connection, like distance, neighbors moving away and few opportunities to gather. According to the University of Minnesota Rural Health Research Center, older adults in rural areas report being lonelier than their counterparts in urban areas.
Loneliness can have detrimental effects on physical health, including increased risk of heart disease, stroke and dementia, according to a report from the U.S. surgeon general.
Benz bids farewell to Viola Weinhardt, 94, at her home in Glen Ullin on May 24.
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Benz, who leads three congregations in neighboring counties, sees the need firsthand. It’s why home visits are important to him. On top of daily Mass and confessionals and leading the youth ministry, Benz rarely misses a home visit or room visits with nursing home residents.
“These people — it’s not just a euphemism — they become part of my family,” he said.
Benz greets parishioners after a Saturday afternoon Mass at the Sacred Heart Catholic Church on May 24. Benz leads three congregations in neighboring counties but says he rarely misses a home visit.
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This story was supported by the Pulitzer Center on Crisis Reporting.
For decades, immigrants who have followed the rules and have not broken the law have had hopes of earning a green card, a document that allows them to live legally in the United States and gain a path to citizenship.
But under new guidance issued by the Trump administration, immigrants can now be denied a green card for expressing political opinions, such as participating in pro-Palestinian campus protests, posting criticism of Israel on social media and desecrating the American flag, according to internal Department of Homeland Security training materials reviewed by The New York Times.
The documents, which have not been previously reported, show how expansively the Trump administration is carrying out a directive from last August to vet green card applicants for “anti-American” and “antisemitic” views.
The administration includes criticism of Israel as a potentially disqualifying factor, with the training materials citing as an example of questionable speech a social media post that declares, “Stop Israeli Terror in Palestine” and shows the Israeli flag crossed out.
The materials were distributed last month to immigration officers at U.S. Citizenship and Immigration Services, which is part of the Department of Homeland Security and handles applications for green cards and other forms of legal status.
They reflect how U.S.C.I.S. — long considered the gateway agency for legal migration — has rapidly transformed under President Trump into another cog in his administration’s deportation machine. The agency has worked to strip naturalized Americans of their citizenship and has hired armed federal agents to investigate immigration crimes.
The administration is also granting permanent legal residency to far fewer applicants. Green card approvals have fallen by more than half in recent months, according to a Times analysis of agency data.
“There is no room in America for aliens who espouse anti-American ideologies or support terrorist organizations,” Joseph Edlow, the agency’s director, told Congress in February.
Critics of Mr. Trump’s approach say the administration is seeking to restrict legitimate political speech, and has conflated opposition to Israeli government policies with antisemitism.
Basing green card decisions on “ideological screenings is fundamentally un-American and should have no place in a country built on the promise of free expression,” said Amanda Baran, a senior agency official under President Joseph R. Biden Jr.
Administration officials said they were defending American values.
“If you hate America, you have no business demanding to live in America,” said Zach Kahler, a spokesman for U.S.C.I.S.
Abigail Jackson, a White House spokeswoman, said the administration’s policies had “nothing to do with free speech” and were meant to protect “American institutions, the safety of citizens, national security and the freedoms of the United States.”
The administration has moved aggressively against immigrants for expressing political views that officials have deemed anti-American, making ideology a central part of its immigration vetting process. Secretary of State Marco Rubio has revoked the visas of pro-Palestinian student activists, including one who wrote a column criticizing her university’s response to pro-Palestinian demands.
The Department of Homeland Security has proposed reviewing the social media histories of tourists seeking to visit the United States.
Immigration officers have significant discretion in deciding whether to grant foreigners long-term permanent residence. They have long considered a variety of factors, including criminal records, national security threats, family ties to the United States and employment histories.
Ideology has also traditionally been one of those factors. In some cases, U.S. law forbids officers from granting green cards to people who have belonged to a Communist or other “totalitarian” political party, have promoted anarchy or have called for the overthrow of the U.S. government by “force or violence or other unconstitutional means.”
But in the past, immigration officers have focused on statements that could incite or encourage violence, given concerns about infringing on constitutionally protected speech, former U.S.C.I.S. officials said.
The new training materials reviewed by The Times guide immigration officers through the factors they should consider when ruling on green card applications. They discourage officers from granting green cards to people with a history of “endorsing, promoting or supporting anti-American views” or “antisemitic terrorism, ideologies or groups.”
Immigration officers have been told to weigh those factors as “overwhelmingly negative.”
The documents list support for “subversive” ideologies as among other factors that could lead to an application being rejected. As an example, the materials point to someone “holding a sign advocating overthrow of the U.S. government.”
In addition, the guidance describes the desecration of the American flag as a negative factor, citing Mr. Trump’s executive order last year directing the Justice Department to prosecute protesters who burn the flag. The Supreme Court has ruled that flag burning is a form of political expression protected by the First Amendment.
Immigration officers have also been told to scrutinize applicants who encourage antisemitism “through rhetorical or physical actions.” They were instructed to “focus particularly on aliens who engaged in on-campus anti-American and antisemitic activities” after the Hamas attacks against Israel in 2023, the documents show.
Further examples in the documents of conduct characterized as antisemitic include a social media post showing a map of Israel with the nation’s name crossed out and replaced with the word “Palestine.” Another illustrative post suggests that Israelis should “taste what people in Gaza are tasting.”
Immigration officers must elevate all cases involving “potential anti-American and/or antisemitic conduct or ideology” to their managers and to the agency’s general counsel’s office for review, according to the documents.
In recent months, the agency has also changed the way it refers to the employees who adjudicate green card applications, long known as “immigration services officers.” In job postings, it now calls them “homeland defenders.”
“Protect your homeland and defend your culture,” one posting says.
Steven Rich contributed reporting.
Additional work by Jana Tauschinski
Oil and gas tanker location and destination data are from Kpler. The map shows the latest position for vessels with an active AIS signal on April 19–20, filtered by minimum capacity thresholds: crude tankers of at least 50,000 deadweight tonnage (DWT); oil product tankers of at least 55,000 DWT; oil/chemical tankers of at least 40,000 DWT; LNG carriers of at least 150,000 cubic metres; and LPG carriers of at least 50,000 cubic metres. Net fossil fuel import data by country are based on Ember analysis of the IEA World Energy Balances 2023.
A 26-year-old man is facing two counts of first-degree murder in the deaths of two University of South Florida doctoral students who went missing last week, local authorities said Saturday.
The Hillsborough County Sheriff’s Office in Florida said that evidence presented to the state attorney’s office resulted in the charges against Hisham Abugharbieh, the roommate of Zamil Limon, one of the doctoral students.
Abugharbieh is accused of premediated murder with a weapon. He was arrested on Friday, the same day Limon was found dead.
The family of Nahida Bristy, the other doctoral student, told CBS News that police said she is also likely dead. That is based on the volume of blood discovered at Abugharbieh’s residence, which he shared with Limon.
“Police told us she is no longer with us,” Bristy’s brother, Zahid Prato, said early Saturday.
The family was told her body may never be found and police believe she may have been dismembered, according to Prato.
CBS News has reached out to police for more information.
Authorities said in a statement Saturday they were still searching for Bristy.
Limon’s remains were found on the Howard Franklin Bridge in Tampa Friday morning, Chief Deputy Joseph Maurer with the Hillsborough County Sheriff’s Office said. His cause of death was pending autopsy results.
Deputies with the sheriff’s office took Abugharbieh into custody on Friday after responding to a domestic violence call at a home in the Lake Forest Community, a neighborhood near USF’s Tampa campus, officials said. He also faces charges of domestic violence and evidence tampering, as well as a charge of failing to report a death to law enforcement.
Limon and Bristy, both 27, had last been seen in the Tampa area on April 16.
Limon was studying the use of AI in environmental science and was set to present his doctoral thesis this week, his family said. Bristy is studying chemical engineering.
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