The challenge of providing health care in Alaska

Think that you have problems with your health care?

Many of us complain about the medical care that we receive, whether it’s long waits to get an appointment, high copays, the small amount of time spent with the doctor, insurance hassles and more.

Many of these are real and problematic, but ironically, a lot of us are still the lucky ones. Those of us who live in, or near, cities with populations in the hundreds of thousands have access to a plethora of primary care doctors, specialists, imaging centers, surgery centers, hospitals, urgent care centers and other medical necessities.

But think about those who don’t have that luxury; people living in small towns where there isn’t that much choice, and there aren’t that many specialists.

A colleague of mine practices obstetrics and gynecology in a small Texas town. He’s the only Ob-Gyn for 60 miles. There are two primary care doctors in town, and the nearest hospital is about 35 miles away (imagine that ambulance ride, when minutes count — in fact, there might not be an ambulance, read on). That’s it. No specialists, no urgent care centers, one pharmacy, no lab, no X-ray or imaging center.

Sometimes he’s delivered babies, urgently, in his office when there wasn’t time to get mom to the hospital. At other times, he’s done (unplanned) home deliveries when patients were so far along that they couldn’t wait for transport in their husbands’ trucks (no EMTs or ambulances near by). Wherever he goes, he carries an emergency OG-Gyn pack of sterile instruments and other supplies in his car.

Another colleague works two weeks per month as an emergency room doctor in a small town in Alaska. They have a small hospital, a few inpatient beds, a tiny ER, one operation room. The hospital has a lab and x-ray department. Nothing fancy, no CT on MRI, no PET scans. There’s one general surgeon in the town, three primary care docs, and the two ER doctors who each work 12 hour shifts for 14 day stretches. The ER doctors and primary care doctors get to do the deliveries.

Hyder, Alaska. Population: 87. (Via Shutterstock)

Hyder, Alaska. Population: 87. (Via Shutterstock)

Now, there are some specialists — most of whom are in the local “metropolis” about 100 miles away. So that’s not too bad, right? Unless you mind driving 200 miles round trip to visit your therapist each week. But even that drive you could manage, if you had to. Except there are no reads to the nearby metropolis. They have a few streets in the town itself, but other than that, they rely on ships to go down the river to the nearest town.

Or dogsleds. Or helicopters. Or small planes.

So going to the specialist gets to be a bit of a challenge. Especially in the winter, when the river and bay freeze up, and the snow falls. When that happens, it’s either small plane, dogsled or helicopter (for emergencies) as the means of transport. Unless the weather gets bad, then those modes of transport might also be grounded. (And this is Alaska in winter, so the weather does get bad, at times, very bad.)

When the weather does get bad, sometimes for days or weeks at a time, those in town, stay in town. Sometimes, if something happens to one of the people there that can’t be treated locally — like a heart attack, which in a big city would be treated with a quick trip to the cardiac catheterization lab for a stent placement — the patient takes his chances with the available treatments. Sometimes, if that treatment isn’t enough, he dies.

Sound grim? It can be. My colleague says that their ER loses a few patients every winter who could probably have been saved if they had specialists, a larger hospital, support staff, and reliable transportation. But the people in town have it good compared to some others.

Many native Alaskans live in remote villages that may be miles outside of town. When winter hits, they may be totally snowbound in the village for months. Here the only means of routine transport in the winter is dogsled, or snowmobile (called “snow machine” in Alaska), and/or helicopters for emergencies only. Each village has a “health aide“; someone who has been given some basic training in first aid: how to do some parts of a physical exam, some familiarity with medicines and other aspects of basic health care. Oh, and they deliver babies, too. Kind of a mini-medic plus.

Barrow, Alaska. Population: 4,000. (Via Shutterstock)

Barrow, Alaska. Population: 4,000. (Via Shutterstock)

The ER stays in touch with these villages by radio. If one of the villagers becomes ill, he goes to the health aide. She (almost all are women) gets his history, does a brief exam and contacts the ER. She gives the ER the data she’s collected, and she and the ER doctor work to further examine and diagnose the patient. If he can be treated in the village, he is. If not, a helicopter gets sent, weather permitting. And that assumes the helicopters aren’t tied up rescuing others. If he’s in bad enough shape, the helicopter will take him directly to the local metropolis’ hospital.

Of course, “metropolis” is a relative term in Alaska. The largest city is Anchorage, with about 300,000 residents. The next largest is Fairbanks, with 31,000.  Then Juneau, and then it gets a lot smaller from there:

Alaska's top cities, via Wikipedia.

Alaska’s top cities, via Wikipedia.

If the patient isn’t in too bad a shape, he comes to the town’s ER where he gets treated. That’s the ideal when the situation isn’t critical, and the weather isn’t too bad. But among the villages over the course of a year, some people die just because they are where they are and the needed help isn’t. People have died because of massive bleeding, heart attacks, strokes, and accidents. They died because of inclement weather, or just the fact that they were just too sick to survive the long trip. Some undoubtedly could have been saved had they lived closer to a city.

None of this is to say that those of us in the lower 48 don’t face our own serious health care problems. But it is interesting to look at how others live, and realize that in some ways, with all the problems we face with health care “down” here, a lot of us actually have it relatively good.

Assuming we can afford it.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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  • Buford

    Alaska socialized its oil revenues to the extent that every citizen gets a $1000-ish cash payout annually, but it can’t figure out how to effectively provide health care for those same citizens…?!?!?!

    This is Amerika in a nutshell, folks.

  • Hue-Man

    It’s funny that you would choose Hyder, AK, as the example. The nearest medical facility is only 3.3 miles away:

    “Stewart Health Centre provides out patient services, including public
    health, pre- and post-natal infant and child care and walk in emergency
    services. There are regular scheduled day and afternoon shifts as well
    as a physician on-call. The centre provides emergency room services and a
    doctor’s clinic.” http://careers.northernhealth.ca/Communities/NorthwestRegion/Stewart.aspx

    Although I haven’t been Hyderized, I spent my college summers working in Northern B.C. and came to understand that the 300 km drive to Terrace for its 3 surgery suites and first world health care is part of choosing the northern lifestyle (assuming the road isn’t closed by avalanches in the winter). Part of B.C.’s approach is to charge a flat $80 for an ambulance or air ambulance/helicopter for medical emergencies, far less than cost or the fees charged to visitors to the province – $2,746/hour for helicopter or $7 per statute mile for airplane. http://www.bcas.ca/about-us/fees/

  • Kenneth Brown

    Rural healthcare has always been a challenge, there are companies such as medsys2 that provide doctors, therapists and home health nurses a electronic medical records system for less than $300 per care giver that allows them to work in remote locations without internet connection. They can transmit notes, medication profiles, medical history whenever a connection is available. This type of system should be deployed in each village to that when an emergency occurs the patient’s medical history can be obtained easily. I learned about the system at http://www.medsys2.com. They have a mission to make healthcare information technology affordable.

  • docsterx

    You might want to try contacting their general internal medicine clinic or family medicine clinic. Sometimes the clinics have openings and can take new patients faster than doctors in private practice. If he needs some form of specialty treatment (cardiac, orthopedics, etc.) they often have clinics for that, too.

  • Tatts

    What you describe in this article is also true of many popular vacation spots in the US. Many such places have no federally designated trauma center nearby (within a distance that is quick enough for someone who needs trauma treatment): Key West, Russian River, Vail, Yellowstone, Grand Canyon, Jackson Hole, etc., And the local hospitals in many vacation areas may be similar to the ones in Alaska.

    Here’s more: http://www.traumamaps.org/Trauma.aspx

  • Swami_Binkinanda

    I live in the big city of Anchorage now, but have lived in Fairbanks and North Pole as well and spent some time in rural Alaska. There are definitely some service provision issues here but there is also a lot of innovation in terms of telemedicine, EMT training, AED placements and so on. But yes, you could die here in sight of a road and not be found for years if ever. http://www.alaskadispatch.com/article/20140602/human-remains-discovered-crew-battling-kenai-peninsula-wildfire
    http://www.alaskadispatch.com/slideshow/photos-1952-military-plane-crash-salvage-colony-glacier

  • judybrowni

    Republican states, mostly.

    Republican voters in very rural areas, mostly.

    Too bad their politicians don’t find it necessary to serve their medical needs.

  • Elijah Shalis

    I am just grateful that my boyfriend was approved for the expanded Medicaid in Michigan recently. Now the trick is finding a good doctor that accepts new patients. Which I will be calling U of M every day for the next two weeks until their new patient calendar opens. He is out of work right now but is in college.

  • lynchie

    Same conditions exist in the lower 48. Living in the country has its negatives and access to immediate health care is one of them. We are blessed with a great life flight system here in North Western Pa. but to me the advantages to rural living far outweigh living in the city. Everyone makes choices and as I have grown older winter is no longer something I look forward to, but I got myself a good 4 wheel drive truck, put in a pellet stove rather than dealing with cutting, splitting, piling and bring wood in the house but I have no interest in moving to warmer climes.

  • http://www.americablog.com/ Naja pallida

    Even with all those challenges to providing health care, the life expectancy in Alaska is still higher than pretty much all the southern states. So what’s the excuse for states like Louisiana, Mississippi, Georgia, Alabama, etc? When you choose to live in a rural area, there are some personal risks that go along with it, but there’s no reason for the generalized poor availability of care in many US counties, other than the fact that it’s simply not profitable.

    Extremely remote areas are a challenge even for socialized medical systems. Canada’s territories, and even northern Manitoba, Ontario and Quebec all have a significantly lower life expectancy, even lower than Alaska. But when many places are only easily accessible for less than half the year, and don’t have a nurse or doctor living there, much less an actual medical clinic, even an otherwise non-life threatening injury can easily become one.

  • The_Fixer

    When I was much younger and “invincible”, I always thought “Who would want to live in a city?”

    Now that I am older and cognizant of the fact that I am not invulnerable, I completely understand why anyone would want to live in the city. Now I think “Who would want to live in the wilderness?” This post cites one very good reason why I have changed my thinking 180 degrees.

  • Abby

    That’s why we let them share the oil profits, life can be both difficult and impossible, but if you go to college or end up in a nursing home, the state pays.

  • Indigo

    Those are pioneer choices. I respect them, I don’t admire them.

  • emjayay

    Well, I guess if you decide to be a rugged moose shootin yearly oil revenue check gettin pioneer out in the snow in the middle of nowhere there are certain compromises you have to accept, like not living near the Mayo Clinic.

    From extensive research, and by that I mean watching every episode of Call the Midwife, the standard of birthin babies in 50’s England under National Health was having it at your home with a couple of nurses attending. Ambulance to the hospital available of course, where they had a fraction of the tech and interventions available that they do now. Apparently they also had personal prenatal care and classes available to everyone.

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