It's 1.2 miles from Alcatraz—the world's most famous prison—to the shore. But to swim, it's even farther: sometimes an extra half-mile or more as the current pulls and pushes you from your course.

It takes incredible effort, and a lot of support, to make the swim. No matter how strong you are, how sure a swimmer, it's almost impossible to keep your head above the freezing, briny water as you crawl away from The Rock. As the cruel waves slash and recede, Alcatraz looms large on the horizon, an enduring and evocative symbol of misery, defiance, and turning points in history.

Participants in the PATHSTAR program, who make this arduous journey every year, know too well the feeling of being buffeted about by uncontrollable forces. As members of one of the most disadvantaged communities in America, they've spent their entire lives at the mercy of poverty and disease and discrimination.

Among the dizzying array of non-profit groups addressing such issues in this country, PATHSTAR is unique. Started by San Francisco pediatrician Nancy Iverson*, 77MD, the program offers Native American participants an intensive, weeklong training in health and fitness, culminating in a group swim from Alcatraz Island to the San Francisco shore. PATHSTAR seeks to offer participants hope—to teach them self-reliance and optimism alongside healthy habits. It aims to transform participants' lives and communities—spiritually, mentally, physically, and socially.

Iverson is a lanky, long-limbed blonde: the picture of health. Although she has personally swum to Alcatraz from the San Francisco shore more than 100 times, she actually came up with the idea for PATHSTAR while attempting another ambitious swim.

Iverson doesn't consider herself a great swimmer—she only began to take dips in the Bay to help with a chronic back problem—but she decided to try swimming from San Francisco's Bay Bridge to Ocean Beach on the city's western shore. Such a strenuous, potentially dangerous undertaking requires a lot of support from people in boats or on surfboards, ready to assist if the swimmer becomes exhausted, hypothermic, or gets a cramp.

At one point during that ten-mile Bay-to-Breakers event, Iverson remembers looking up at all the people who'd come out to help. "I was just so struck by—overcome, really—that these people were out there purely for my benefit," she remembers. "I still had to do the work—they couldn't do it for me—but they were all putting in their time and effort in order to see me succeed. I started thinking how seldom in life we really get to fully experience that, and how important it is."

"It sounds a bit grandiose, and please word it in a way that's not grandiose, but I was hoping that the program could help create heroes."
- Nancy Iverson

Iverson wanted to offer that experience to other people who don't have access to the same resources—or the advantages she's enjoyed. Specifically, she wanted to help the Lakota people of South Dakota's Pine Ridge Indian Reservation, one of this country's poorest areas, a place where hope, achievement, and support are as rare as a sea breeze and salt water.

Pine Ridge is located on infertile land in rural South Dakota, 80 miles from the nearest off-reservation city. Life is harsh here in a way most Americans might associate with a developing country.

Of the 40,000 or so people who live on the reservation, more than 85 percent are unemployed—there is no industry here. The average family makes only $3,700 a year. Such chronic, grinding poverty breeds a host of other social and health concerns: 63 percent of the population lives below the poverty line; only one out of three students will graduate from high school; and alcoholism plagues most reservation families.

By almost any measure, the Lakota people endure an unbelievably harsh existence. Child mortality rates are 300 percent higher than the national average. The life expectancy for a man on Pine Ridge is 48 years, while women can expect to reach about age 52. That's about 20 years less than the national average—lower than anywhere in the Western Hemisphere except for Haiti. Half of those people who do live beyond age 40 struggle with diabetes or heart disease.

"A long time ago, the Lakota used to be pretty active people, but then it just kind of faded away," says tribal member Lisa Waters-Kaulaity, who first made the Alcatraz swim with PATHSTAR in 2004, and again with her sister in 2005. "My sister, myself, the people that we were around, we were pretty lazy."

Waters-Kaulaity's self-comparison to historical tribal heroes like Chief Red Cloud and Crazy Horse—who were known, feared, and respected by neighboring tribes and American settlers for their ferocity, industriousness, and independence—isn't exactly fair. By the time she and her siblings were born, some 150 years after the Oglala Lakotas signed a peace treaty with the United States, tribal members had been subjected to more than a century of federal programs designed to eradicate their culture, history, and identity. They'd been living in hopeless poverty for generations, with few role models, success stories, or opportunities.

"There is this dispiritedness," Iverson says. "There's a certain lack of energy, and I wouldn't call it laziness at all. There are so many obstacles and so few successes."

Things most Americans would take for granted are simply missing from reservation life: apart from the lack of jobs and money, there is no public library and few opportunities for recreation outside of high school sports. Most people can't afford to buy healthy food at the reservation's single grocery store; even if they could, they probably wouldn't know how to cook healthy meals.

Nancy Iverson (back row, far right) celebrates with some of the Lakota Sioux tribe members who swam from Alcatraz in search of a better way of life.

"I still can't get my head around what's it like to live where everybody you see isn't working very much, is probably not finishing high school," Iverson says. "Whom do you believe in?"

That's the problem PATHSTAR hopes to address.

Interested in American Indian cultures ever since her South Dakota childhood, Iverson had started working at Pine Ridge for the Indian Health Service in 1994, making several short trips to work on the reservation over the next few years. After practicing rural medicine in Northern California, she was used to making do—working without support staff or the latest equipment. Still, what she found on the impoverished reservation was far bleaker than she could have imagined.

Ground down by poverty, young people grow up without much hope for the future. As Iverson explains, "There's almost a certain acceptance that things will go bad."

While many parents raising children on the reservation are eager to teach them healthier habits, young people on Pine Ridge tend to learn more pervasive lessons from the constant presence of lifestyle diseases like heart problems and diabetes, the availability of junk food, and the lack of healthy activities. Recalls Iverson, "The expectation never seemed to be—either from within the hospital and the medical staff or from without—that it made much difference what you did."

At the same time, though, Iverson saw determination in the face of obstacles, the strong sense of identity and culture that bound the Lakota people. She designed PATHSTAR to show them a different way, literally removing some tribal members from the hopelessness that blinded them to possibilities. She wanted to teach them what it felt like to be supported in their efforts.

Through a regimen designed to change their fitness and nutritional habits for life, participants are immersed in the PATHSTAR program even before they hit the water. They learn to cook healthy foods that they eat together at communal meals; they try a variety of workouts.

PATHSTAR is an acronym for Preservation of Authentic Traditions and Healing, and traditional ways are an important part of the program's philosophy, which includes "reclaiming the best of indigenous traditional practices, augmenting these with the cultivation of wholesome 'new traditions.'" In 2003, the night before he and Armando Black Bear left Pine Ridge for San Francisco to become the first-ever Lakota Alcatraz swimmers, Richard Iron Cloud led a traditional talking circle—giving participants a chance to connect with one another, to share their thoughts and feelings in a healing, supportive environment.

PATHSTAR is free, inclusive of room, board, equipment, training, and travel expenses. The only investment participants have to make is the willingness to challenge themselves like never before. That's no small commitment. When Waters-Kaulaity arrived in 2004, she was nearly overwhelmed by the experience. She'd heard about the program from a coworker whose husband had done the swim. As a tribal fitness center employee, Waters- Kaulaity thought she'd be just fine. But when she arrived in San Francisco around July 4 of that year, she realized just what she'd signed herself up for.

"It was dark, foggy, and the water was so murky. It didn't look fun at all," she says. "I was like 'Oh, my gosh, what did I do?'"

Waters-Kaulaity wasn't an experienced swimmer; she'd only been to the ocean once in her life, and there aren't many lakes near Pine Ridge. The first time she got into the Bay, she panicked. The salty water kept getting in her mouth so she could barely breathe. Iverson talked her through her fears, distracting her so she wouldn't think about it so much.

Although the swim to Alcatraz comprises the final challenge, the lessons of PATHSTAR aren't restricted to the success or failure of that single event. In fact, because favorable weather conditions are critical to the safety of swimmers, participants don't know until the scheduled swim day if they'll even be able to make an attempt. "There might be too much fog, too much wind," Iverson says. "So we work towards this goal, and the whole time we don't know if we're going to actually be able to try. It's a really huge lesson all the way along—the outcome of the swim doesn't determine the success of your participation."

Of course, actually making it in from Alcatraz is a feat to celebrate—and most participants do. Iverson is careful not to let that success color the entire experience, though. At the end of the program, all participants receive a certificate from the City of San Francisco, honoring them for going through the process. One year, when city hall staff sent out certificates congratulating participants on completing the Alcatraz swim, Iverson sent them right back, insisting that the documents honor the Lakota for participating in the program.

Even though everyone had completed the challenge that year, that wasn't the point. "The swim isn't where the real courage comes in," she explains. "It's the showing up—and the trying."

The transformational effects of PATHSTAR are clearly written in the lives of its more than three dozen alumni. One man, a former high school dropout, went back to school and is now enrolled in college classes. Another swimmer passes on valuable PATHSTAR lessons as a child care center worker and boys basketball coach on the reservation. A third alum, a radio DJ, has started his own garden, helped develop 13 community gardens throughout Pine Ridge, and does a weekly public radio show on growing and serving vegetables. Waters-Kaulaity continued her work in tribal fitness initiatives after PATHSTAR, becoming a correctional officer. She lives in Arizona now and is taking time off from work to raise her three-year-old son, Sebastian.

Iverson admits that these are "small changes, measured against this colossally bleak background."

But in a quiet and personal way, they're also monumental.

Even though it's been years since she placed her faith in Iverson and plunged into the freezing, intimidating Bay, Waters-Kaulaity absorbed lessons through PATHSTAR that are still an important part of her life. They're lessons she's passing along to her son every day, showing him a better way through healthy cooking and eating, along with regular exercise. What once was alien to her is now an important part of life.

"PATHSTAR made me realize how important it is to be healthier—especially with children, because they look up to everything that you do," she says. "Everything that PATHSTAR is about wasn't really shown to us, living on the reservation."

Slowly, that's changing.

Iverson has taken a break from her medical practice to focus solely on PATHSTAR. She's currently promoting a documentary she produced to help raise awareness and funds for the organization. She's already taken the film to a dozen film festivals in the United States and around the world, where it garnered several awards.

Still, she calls herself a realist: "I know we're not going to change everything in a week. We can only really build on our successes or failures. And if you have a long history of failure …."

She breaks off for a moment and then finishes her sentence: "Whereas if you have a history of success, you keep building on those successes."

One stroke at a time.