The Department of Pediatric Hospital Medicine at the Alaska Native Medical Center (ANMC) in Anchorage, Alaska has served the Alaska Native community since 1999. Our group works with the community to provide broad-spectrum pediatric tertiary care. The group includes 15 pediatric hospitalists and four pediatric nurse practitioners, with a combined total of 15 full-time equivalents (11.75 MD and 3.25 NP). We cover a 19-bed inpatient pediatric unit (including intermediate care patients and post-operative pediatric surgery patients) and a 12-bed level 2b NICU.
Equally important to the care we provide is our respect for the cultures and traditions of the Alaska Native people we serve. As a result of historical trauma to indigenous people in the U.S., some patients and families distrust the medical system. Our group at ANMC strives to provide culturally sensitive and relevant care, ensuring that patients and their families feel comfortable, are involved in the process, and understand what’s happening every step of the way. We’re committed to the hospital’s mission of providing the highest quality health services for all Alaska Native people.
Caring for patients
We provide consultative services in pediatric trauma care and other subspecialty services at ANMC, including consultations with the ANMCED practitioners. We cover newborn care, including circumcisions, in family birthing services where there are about 1,600 deliveries per year. We also attend high-risk deliveries. We provide phone consultative services to clinic, hospital, and emergency department practitioners caring for Alaska Native patients throughout rural Alaska, including those transporting children from rural areas of the state into Anchorage for both urgent and routine concerns.
About 1,600 babies are delivered each year at ANNMC, Dr. Elliott and her team are there to assist. Credit: Alaska Native Medical Center
We run hospital-based sedation and infusion clinics. We also maintain pediatric field clinics in rural Alaskan regions, working with primary care practitioners who lack regular in-person access to pediatricians to provide non-urgent consultations and continuity of pediatric care for children with complex medical needs. We’re supported by a separately organized pediatric critical care group at ANMC. This care group is available 24/7 and enables us to care for higher acuity patients whom we might otherwise need to refer to outside hospitals.
In addition to our clinical duties, we participate in a wide range of hospital-based committees. We’re active members of local, state, and national professional organizations and we’re involved in quality improvement and research projects. Our team also engages in many aspects of health care practitioner education within Alaska, including community health aide, physician assistant, nurse practitioner, medical student, and resident education.
A look at ANMC’s history
In 1975 the Indian Self-Determination and Education Assistance Act allowed tribes to choose to self-govern, including management of health care. Alaska Native-owned and operated health care organizations have taken over all contracts from the Indian Health Service (IHS) and are now responsible for all health care delivery to Alaska Native people.1,2 The Alaska Native Medical Center is the flagship tertiary hospital for all Alaska Native people and was built in 1997, replacing the Alaska Native Service Hospital, which had served Alaska Native people since 1953.
In 1999, the management of ANMC was transferred from IHS to shared ownership and management by the Alaska Native Tribal Health Consortium (ANTHC) and Southcentral Foundation (SCF).
ANTHC is a nonprofit tribal health organization governed by representatives from all of the tribal health organizations in Alaska. It provides comprehensive health care services, wellness programs, disease research and prevention, rural provider training, and rural water and sanitation systems to Alaska Native people across the state.2
SCF is a nonprofit Alaska Native-owned and operated health care organization serving Alaska Native people living in Anchorage, the largest city, and other south-central Alaska communities.
The Alaska Tribal Health System (ATHS) is a voluntary affiliation of 35 Alaska tribes and tribal organizations providing health services for the more than 177,000 Alaska Native and American Indian people residing in the state. The ATHS is a network of 171 village clinics, 27 regional clinics, six hospitals, and a tertiary care medical center.
Geographic challenges
These facilities are in the most remote settings across a service area comprised of 20% of the landmass of the entire U.S.2,3 Alaska is 570,640 square miles in size, which is more than the next three largest states of California, Texas, and Montana combined.4 The 2020 census determined that Alaska Native people are 21.9% of the total population of Alaska (this number includes those people who identify as Alaska Native alone or in combination with another race).5 Of those Alaska Native people in Alaska, 50,221 are under 18 years of age.5
The ATHS is organized into tribal health regions, which are further subdivided into tribal health organizations (THOs). The THOs manage health care for Alaska Native people living in communities within their geographic area. The ATHS is often described as a hub-and-spoke model, where care within each THO starts in a person’s small community.
Each small community has a clinic staffed primarily by community health aides/practitioners (CHA/Ps), working in collaboration with practitioners at subregional and regional health care facilities (larger clinics or hospitals). If escalation of care is needed, the patient is referred to a subregional or regional center. Some regional health care facilities have established pediatrics groups, though most are staffed primarily by family medicine physicians. If a higher level of care is required, the patient is transferred outside of the THO, typically to ANMC in Anchorage. Some subspecialty care is not available in Anchorage, and in these cases, people are referred to facilities in the lower 48.
The majority of small rural communities in Alaska (more than 80%)2 don’t have access to roads so when escalation of care from a small community to a regional center or from a regional center to Anchorage is needed (for both urgent and routine care), people access that care via plane. These isolated communities rely entirely on air transport to the nearest inpatient medical facility. As more than half the population served through the ATHS lives in rural and remote locations2 and 50% of Alaska Native people 19 years of age and younger live in a community off the road system,6 air transportation is, by necessity, the primary means of travel to access health services.
The average Alaska rural community has 350 residents, limiting the level of health care available locally. Distance and weather make air travel unreliable and expensive. To receive basic medical care, a patient may fly in multiple aircraft, for as many as 1,100 miles. For comparison, the distance from many communities to the nearest medical facility is equivalent to the distance from New York to Chicago.2
Why we do it
With this background in mind, picture a 4-month-old infant with two days of high fevers who’s described by the community health aide as irritable and whose mother described two minutes of shaking at home, during and after which her baby was not responsive.
Think of a 2-month-old infant brought to the community clinic because he’s been sweaty when he eats and seems to have no energy for the last couple of weeks. In the clinic, the community health aides/practitioner hears a loud murmur not reported in the birth record.
Imagine a 15-month-old who had a cold two weeks ago, and now presents to the clinic with trouble breathing and fatigue, and whose lung sounds are not consistent with bronchiolitis or pneumonia.
Envision a pregnant woman at 32 weeks of gestation who walks into the community clinic and reports that her water broke and she’s having regular contractions.
These patients’ journeys to definitive care take them across a vast state often affected by harsh and unpredictable weather. They’ll travel from a small rural community clinic through their regional centers and likely to ANMC via two medevac flights, all while receiving excellent pediatric care in a system carefully designed to serve even the most rural Alaskan children.
As pediatric hospitalists in this unique health care system, our practice of wide-ranging pediatric hospital care, supported by our appreciation of health care, traditions, and culture in the Alaska Native community, provides us with a deep understanding of medicine as practiced here that allows us to provide thoughtful and high-quality care to the infants, children, and young adults we serve. Our work also guides us in further developing programs tailored to this community as it grows and changes with time.
Dr. Elliott is a pediatric hospitalist who has practiced community pediatric hospital medicine at ANMC for the last seven years.
Dr. Hirschfeld has been a pediatric hospitalist at ANMC for the past 16 years and is also the medical director of maternal child health services at ANMC.
Dr. Ogena has been a pediatric hospitalist at ANMC since 2005 but initially came to rural Alaska in 2004 to work as a locum tenens physician at the Yukon Kuskokwim Health Corporation in Bethel, Ala. She is the current medical director for inpatient pediatrics at ANMC and serves as the Alaska chapter president of the American Academy of Pediatrics.
References
- University of Alaska Anchorage, Alaska Pacific University. Do Alaska Native People get free medical care? And other frequently asked questions about Alaska Native issues and cultures. In: Roderick L, editor. Subsistence And Relationship To Land, Waters, And Wildlife. Anchorage, AK: University of Alaska Anchorage & Alaska Pacific University; 2008.
- Data and information provided by Alaska Native Tribal Health Consortium, Anchorage, AK.
- Alaska Native Health Board. Alaska Tribal Health System. Available at: www.anhb.org/tribal-resources/alaska-tribal-health-system/. Accessed 9/14/21.
- US Census Bureau 2020. Selected Population Profiles in the United States. Available at: data.census.gov/cedsci/. Accessed on 9/14/21.
- US Census Bureau 2020. Race and Ethnicity in the United States. Available at: www.census.gov/library/visualizations/interactive/race-and-ethnicity-in-the-united-state-2010-and-2020-census.html. Accessed on 9/14/21.
- Data provided by the Alaska Native Epidemiology Center, Anchorage, AK.