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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