Healthcare at the Top of the World: Long Appointments and Deep Awareness Bolster Health in Alaskan Villages

The Alaska island of Little Diomede is in the Bering Strait, less than 2.5 miles from Russian territory. It’s home to a community of about 80, most of them Inupiat people practicing a traditional lifestyle, including subsistence hunting and fishing. There are no roads, and most buildings sit on stilts to accommodate the rocky terrain.  

There’s a scheduled helicopter flight once a week to the mainland for people who need transport, and supplies flown into the island are usually hand-carried wherever they’re needed. The families who live there feel a strong connection to place, community, and tradition, said Megan Mackiernan, a physician assistant and chief quality officer at Norton Sound Health Corporation, a tribally owned, nonprofit healthcare organization. 

“Families really value their kids having that experience of growing up on the island,” MacKiernan explained. “We take that ‘It takes a village’ thing very strongly.” 

There’s also a clinic located in the village of Diomede – one of 15 village clinics operated by the Norton Sound Health Corporation, which serves rural communities throughout the Norton Sound and Bering Strait region.

That clinic’s story has been key to the organization’s close partnership with Direct Relief, according to Mackiernan. 

In September 2022, when the Little Diomede clinic was newly built, a helicopter dropped off a large shipping container filled with equipment and supplies Norton Sound had purchased for its facility: machines for monitoring vital signs, exam tables, a pharmacy dispensing unit. When a typhoon barreled across Alaska’s western coastline, the container tumbled around the island’s coast, damaging and destroying the contents.  

Norton Sound had received a $50,000 Direct Relief emergency grant a couple of years earlier, at the height of the Covid-19 pandemic. When the clinic’s supplies were destroyed, Mackiernan recalled, a colleague suggested, “Why don’t you reach out to those Direct Relief people?” 

Direct Relief provided a second emergency grant, this time of $160,000, to cover the cost of getting replacements for the destroyed supplies shipped to the village.“We were able to have all that stuff and get that clinic functional,” Mackiernan said. 

Today, the two organizations work closely together. Direct Relief supports Norton Sound’s care with shipments of sterile water, liquid IV and oral rehydration supplies, epinephrine, naloxone, and over-the-counter medicines and supplies – over $494,000 in total material aid.  

In an area where running water, medicines, and even food are expensive – supplies are generally brought in by plane or barge – Mackiernan says the ongoing support is invaluable: “Norton Sound really loves Direct Relief.” 

Today, Norton Sound operates not only 15 village clinics but a regional critical-access hospital, located in the town of Nome (population about 3,600), and a nursing home for Alaska Native elders. About 85% of the organization’s patients are Inupiat, Central Yup’ik, and Siberian Yupik, and about two-thirds of them live below the poverty line. Mackiernan said other patients include recent immigrants – such as teachers who come from Korea or the Philippines to teach in local schools. 

“We get very experienced teachers,” she said. Many of them work in small villages and even live at the schools where they teach because of the area’s acute housing shortage.  

Norton Sound providers deliver babies, treat injuries, clean teeth, test hearing, offer physical therapy, and care for chronic diseases. And caring for the area’s patient population, which has particular medical needs, requires a nuanced understanding of traditional diets, culture, and daily life. 

The population has a high percentage of patients with CPT1A, a gene that, in its Arctic variation, affects fatty acid metabolism. While medical attempts to manage the gene often lead to obesity, Mackiernan said, “the traditional native diet is really just the best thing.” 

The organization’s patient population also has high rates of TB, cancer, and serious mental health conditions such as major depressive disorder and schizophrenia. Norton Sound provides full-time inpatient and outpatient psychiatric services to meet mental health needs. 

Five communities in the region don’t have piped running water, and a single shower is expensive at the local washeterias – a place where residents can access showers and laundry, Mackiernan explained. Norton Sound works with village communities to make washeteria facilities more accessible. Patients can receive free passes for coming to a wellness visit or screening for colon cancer. 

“Our goal is to make this a wellness center,” she said. “Cleanliness is such an important part of health, but when a shower costs $10, when are you going to have a shower?”  

Awareness and time are key to healthcare in the area. Mackiernan explained that a typical visit lasts at least an hour, and developing trust and rapport are key to working in partnership with patients, who frequently rely on subsistence hunting and gathering to feed their families and can be cautious about communicating with newcomers.  

“Life here does not operate at the same pace it does elsewhere,” Mackiernan said. “You come in and you sit down. You don’t touch the patient, you just sit down…Having that first conversation with your ears open, that’s going to be where you learn important things about the patient.” 

Louisa Albright, a physician assistant at the Unalakleet clinic, said she’s learned to look to her patients for nonverbal communication, like facial expressions, movement in the shoulders or arms, or just a growing quietness to indicate how the conversation is going. Her husband and children are Alaska Natives, she explained, and she first learned the importance of nonverbal communication in her husband’s family.  

“It’s important no matter where you are, to be aware of people’s expectations and their backgrounds, and what they’re trying to accomplish,” she said.  

Unusually for a provider, Albright does immunizations, blood draws, and home visits. She cares, on a daily basis, both for chronic conditions and for patients whose needs are so acute she often needs to contemplate an emergency transfer.  

“You have to know sick versus not sick: Do I need to transfer this patient emergently?” she explained. “We really do everything from birth to death. We take complete care of the patients.” 

Helping patients manage chronic conditions means understanding their values and cultures. If a provider knows that eggs are still out of stock at the grocery store – they’d been out for five days when Albright spoke to Direct Relief – they’ll be a better resource for patients working to manage nutrition and finances. Foraging for berries, a traditional practice, can provide essential vitamins, exercise, and mental health benefits together. Working with a tribal healer in Albright’s village has helped Albright understand her patients’ perspectives. 

“People here tend to not want to be on medication…I try to be really sensitive to that,” she said. “If people can eat a traditional diet, I always encourage that.” 

Norton Sound also works to fill gaps in food availability – for example, providing fresh produce to patients either at cost, or for free after a patient has a blood sugar or cholesterol check.  

Mackiernan said new providers, often from schools in higher-resource settings with large populations, need guidance to work well with Norton Sound’s patients. “You need to think about what life looks like for that family, you need to offer something doable,” she said. Pushing people to purchase supplements or produce that are expensive or unavailable won’t help – it will just dishearten them. 

Vast, sweeping changes in the region’s history have deeply affected patients and communities. “Some communities are less than 150 years from contact” with Western culture, Mackiernan noted. Disease outbreaks, such as the 1918 influenza pandemic or the COVID-19 pandemic, have taken a huge toll. Many still experience the devastating legacy of forced enrollment and assimilation in the United States’ residential schools for Native children. Melting permafrost destabilizes life in traditional communities and jeopardizes hunting – a serious loss in communities where a moose can provide months’ worth of food for a family. 

Norton Sound actively partners with regional tribes to enhance community health by employing local professionals such as community health aides, dental health aide therapists, and behavioral health aides. These workers, well known and trusted in local villages, encourage patients to visit the clinic and take advantage of available services. Tribal representation is invaluable in guiding the direction of healthcare in the region, ensuring that it effectively meets the needs of the community.

For Albright, living and working in a primarily Alaska Native community of about 600, her familiarity in the community where she works bolsters the care she provides.  

“I think people automatically put back their chips and pop” when they see her in the grocery store, she laughed. But knowing her patients outside the clinic helps her. If there’s an injury on the school basketball court when Albright is there with her kids, she’ll jump up to treat it – knowing community members will look after her kids while she’s working.  

“My kids go to school with these people, I see their families in the community,” she said. “People share a lot.”