Alaska Tribal Health System - A Model for Rural Healthcare

Join us in learning from Dr. Nora Nagaruk about the ingenuity of the Alaska Tribal Health System and the ways it rises to the challenges of rural healthcare in a culturally integrated manner.

We dedicate this episode to the families and communities impacted by the crash of Bering Air flight #445 on February 6, 2025, in which 10 people died about 30 miles outside Nome, Alaska. A community health aide from a nearby village participated in the search and rescue efforts. We honor community health aides' sacrifices to go above and beyond to help loved ones and strangers in times like these. May the spirit of their compassion reach those still grieving.

Learning Objectives

1. Understand the rural Alaska environment and culture, which are the foundation of the Alaska Tribal Health System (ATHS) (“What is a village?”).
2. Describe the need for, and the power of, the role of ATHS Community Health Aide.
3. Appreciate the changes in healthcare outcomes since the ATHS Community Health Aide Program was initiated.

Credits
Guest: Dr. Nora Nagaruk
Co-Hosts: Dr. Marianne Parshley, Dr. Molly Southworth
Executive Producer: Dr. Tammy Lin
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman
Senior Producer: Dr. DJ Gaines
Managing Producer: Joanna Jain
Production Assistants: Clara Baek, Ann Truong
Website/Art Design: Ann Truong
Music: Chris Dingman https://www.chrisdingman.com

Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com

Transcript

[00:00] Dr. Marianne Parshley: Welcome to the DEI Shift, a podcast focusing on shifting the way we think about and talk about diversity, equity, inclusion, and medicine. I'm Marianne Parshley, a general internal medicine physician in primary care with a geriatric focus in Portland, Oregon. I serve as a Regent of the American College of Physicians and Vice Chair of the Global Engagement Committee, and I'm a past governor of the Oregon chapter of ACP and a healthcare advocacy enthusiast.

I also love commuting and traveling by bike and on foot at a human pace with my gradually increasing family. Today we're excited to bring you an episode featuring two amazing people. One is our guest co-host, Molly Southworth. Dr. Southworth is an endocrinologist in Anchorage, Alaska. And the other is Dr. Nora Nagaruk from Nome, Alaska. And on The DEI Shift, we like to use first names. Is that okay with both of you?

[01:04] Dr. Nora Nagaruk: Yes, that’s fine.

[01:06] Marianne: Alright, I’m going to turn this over to Molly.

[01:10] Dr. Molly Southworth: Thank you Marianne, and thank you to the California Southern Region III ACP Chapter for developing this wonderful podcast. It's a real pleasure to be here. My name is Molly Southworth. I'm an internist and endocrinologist, and I've spent most of my career working in the Alaska Tribal Healthcare system, which we'll be talking about today. I have also taught medical students for many years in what's known as the WWAMI Program. For those who are not familiar with WWAMI, it stands for Wyoming, Washington, Alaska, Montana, and Idaho, which are the states that collaborate with University of Washington in their regional medical education program. I grew up in Northern Minnesota, then I attended Oberlin College and Conservatory of Music. I went to Case Western Reserve University School of Medicine in Cleveland. I did my internal medicine residency and endocrinology fellowship at University of Washington before migrating to Alaska with a couple of side trips on the way. I spent my first year in Alaska in the northernmost community, which in those days was called Barrow. Now it goes by the name Utqiagvik. I had also done medical student rotation in the community of Kotzebue, which is 13 miles north of the Arctic Circle. And in both of those remote communities, I was so impressed with how effective the community health aide program was at providing primary care with elevation of care as needed to the highest level at the Alaska Native Medical Center in Anchorage. I ended up spending most of my career actually in the tribal system. I would love to introduce Nora. She is my good friend and colleague and it so happens we're sitting together right now today in Anchorage. She is a general practice physician who lives in Nome, Alaska. Nora grew up in Unalakleet, which is a village of approximately 700 people located on the west coast of Alaska, south of Nome. I first met Nora when I was on the admissions committee for University of Washington School of Medicine. She came to us as a senior from University of Oklahoma with a 4.0 average and a really impressive application. Since it's customary in Alaska Native cultures to refer to one's family background and heritage, as part of an introduction, I'd like to mention that Nora's mother is of Norwegian and German descent, and her father was Iñupiaq and Russian. Nora's father unfortunately died when she was a young child, and her mother, who had four children, remained in Unalakleet. Her mother remarried and Nora's stepfather became a teacher, which was really helpful in drawing the family out of financial poverty. Nora has said to me that, in spite of not having much financial means when they were young children, she remembers her life being so rich because of strong community support, the vast skies, clean air, and an ocean and tundra providing subsistence foods for the community, which is so reflective of the Alaska Native way of life. Nora chose the Alaska Family Practice Residency program after medical school, and her plan was to return to serve her people in Western Alaska. She asked me to share that her training was interrupted at the end of her R-2 year by a diagnosis of leukemia, which required extensive periods of time in Seattle for treatment. Following those intensive treatments, Nora returned to medical work as a physician and she spent more than eight years as a community health aide trainer in Nome, also seeing patients in the juvenile detention center as a physician. Her work was interrupted a second time for another diagnosis of cancer in 2019, once again requiring many absences from home for treatment. But now, since 2022, Nora has been seeing patients at the state corrections facility in Nome, following in the footsteps of Dr. Robert Lawrence, who is our new Chief Medical Officer for the state of Alaska. When I visited Nora in Nome last spring, at the time of the Iditarod finish, I was so impressed with how many activities Nora was involved in. She's also very involved with a large extended family and with her church, and she's active in hunting, fishing, and gathering, all consistent with the traditional Alaska native lifestyle. Thank you so much, Nora, for joining us.

[05:40] Nora: Thank you, Molly, for that introduction. I'm excited to be here. I am Iñupiat, and I would like to attempt to introduce myself in our language. Our people have had some challenges in keeping our language alive, and so there's an effort to revitalize our language. Nora Nagaruk speaks Iñupiat, her native language. That was a lot of syllables, but all I said was, my name is "Ayu" and I'm from Unalakleet, "Ayu" is my native name. From what I understand, I was named when I was two years old because I used to play in fishing nets. An elderly lady who was known for her fishing in the winter through the River Ice. Her name was Ayu and she had passed away, so they called me Ayu growing up.

[06:20] Molly: Thank you for sharing all of that, and it kind of brought us into our next section, which we call “Be the Change” . We ask each of you, in particular you, Nora, how did you start your journey to doing the work that you're doing now in medicine? 

[06:35] Nora: Well, right before my 14th birthday, I was about 10 miles up the Unalakleet River—actually it's the North River, which comes off of the Unalakleet River at a Bible camp. It was our first night there. My best friend and I finally got put into the same cabin. I was so excited because they always separated us. We were playing a game on the Rocky Beach there, and my hip broke. I had had this benign bone cyst growing in the neck of my femur, which is the thigh bone, and it had eaten the bone away to where it was just like an eggshell. We had a big plastic trash can, 50 gallon trash can in the center, and we all linked arms in a circle, and everyone had to try to pull each other to the center. If you touch the center, you're kicked out. So the circle got smaller and smaller. I'm a 13-year-old and I was so determined to not get hit by the trash can. And so I dodged it the first time. And then the second time I stuck my leg out and then it just broke. But they didn't know it was my hip. We thought it was my knee. So I was put on a piece of plywood brought to one of the cabins and the camp nurse was looking at me. This camp ispretty isolated, just like our villages, and there's no phones there, especially, this was back in 1989. We did have radios though. VHF was a very common way to communicate back then between villages, so they radioed down to town and just to let the community health aide, which we'll be talking a lot about, know and were notified to be ready to accept me. I was put into a boat with the camp director and we boated down on the plywood, so I'm looking up at the sky, boated down the river. He hit a log and it jostled me. I remember that being so painful. We didn't have any type of ambulance, so the village public safety officers had a pickup truck and they met us at the beach landing. They put me in the back of the pickup truck and then drove me to the clinic. The health aide was there and she examined me and called the doctor on call in Nome. The doctor said we need to have the patient come to Nome for an x-ray, of course. And so we waited for an airplane to come from Nome. We got to Nome at like two in the morning, and then I got admitted to the hospital there. They did the x-ray. It was definitely fractured and it looked pathologic. So the next step was to see an orthopedic surgeon. Back then, they didn't have dedicated medevac planes to transport patients to Anchorage, the tertiary care center, and that's where the orthopedic surgeons were. So they put me into an Alaska Airlines commercial flight. I had to use up, I think it was six to nine seats because I was in a stretcher at that point, and transport me down to Anchorage. I had surgery and was in the hospital for four weeks in traction in bed. I had a lot of time to think in the hospital. I was starting to think about, you know, what do I wanna do with my life and what do I wanna be when I grow up? So I got exposed to medicine through that experience. I do have to say I had really good high school math and science teachers. My high school math teacher was also the senior class advisor. I was still trying to decide, “Can I go into medicine? I don't think I can. It seems so daunting. ” But he says, “You can be a doctor. You should be a doctor. ” Sometimes it just takes that person believing in you to take that next step forward. And so that's when I started to take it seriously. So I chose family practice and I am so happy to have been able to come back to my region and my people. Even though it's completely different than what I was originally planning with my cancer diagnoses and experiences, I'm still able to serve my people the way I'm doing now. So that's kind of my journey into medicine.

[10:15] Marianne: Nora, you know, it sounds to me like the village is sort of the center of life. You wanted to come back to your village, which is why you chose not to go into orthopedics and to go more in family and general medicine. Can you explain to our listeners what you mean by village and why that connection is there?

[10:34] Nora: Yes. So we divide Alaska into two different parts geographically, the road system and rural Alaska. So the road system is the big cities; Anchorage and Fairbanks are connected by a highway. And then further south there's some other larger towns that are connected by a highway system. So the villages are off of the road system, meaning we have to fly.You have to fly to these villages. That's the only way we can get in and out. With some exceptions, there are some villages that have some roads that connect to each other, but it's very, very rare to have a road that you can drive from a village to a larger town. I'll speak from my experience of Western Alaska, but in general, most of the rural villages have a hub where you can fly from the small village to the larger town and then fly on to Anchorage or Fairbanks. Nome would be an example of a hub as far as population goes. The smallest village would be in the hundreds, and then the largest would be close to a thousand. The villages are federally recognized tribes. I'm not an expert on the native tribal land history, but instead of the United States government dividing Alaska into reservations like they did in the lower 48, they took a different approach. In 1971, there was the Alaska Native Claims Settlement Act that was signed. That exchange, I think, was like 44 million acres to the Alaska native people. Alaska is divided into regions based on the hub areas I described. Each region developed their own corporation and we received a set amount of lands, and so we have regional corporations. There's about 12 of them in Alaska, and then within each regional corporation, there are village corporations. So there's a Uklakleet native corporation, and we're under the Bering Straits Native Corporation. The Bering Straits Native Corporation has control of the subsurface rights, I believe, and then the native corporations have land around their village. If you were born before 1971, everyone got an allotment, a Native allotment, meaning they got their own land that they could build a cabin on, usually right outside of the villages. And our villages are isolated. When I think of a village, they often have irregularly shaped roads that are gravel and dusty. There's not a lot of cars or trucks, but if you do see them, they'd be pickup trucks. There's a lot of four-wheelers, or ATVs; we call them four-wheelers. Those are really helpful vehicles to get out into the country to hunt and fish. In the village, there's a lot of snow machines in the wintertime. There's ice on the ocean, there's ice on the rivers. It's cold, it's snowy, it's dark. And people get by, get around, with snow machines—that's our term for snowmobiles. And then sometimes small planes. The planes that are flown are very small. They seat anywhere from six to twelve people, twin engines, and they fly between the villages and the hub.We do have jet service, like from Nome to Anchorage. We've got two flights every day fromAnchorage on a jet.

[13:43] Molly: Maybe, Marianne, I could interject that the Alaska Tribal Health System coversapproximately 180 villages. So we have 180 community clinics, each one staffed by a healthaide. And there are 25 sub-regional centers, which are larger than the tiny clinics.And six regional hospitals—one is in Nome, where Nora got transferred with her broken hip.Another one is in Barrow, one is in Kotzebue, and so forth. The tertiary referral hospital is in Anchorage, on the campus of the Alaska Native Medical Center. So all of the people in those 180 villages see a health aide.Or sometimes nowadays, they see a PA. If they have, let's say, a broken hip, they get sent to Anchorage pretty quickly. I mean, that all happened within 24 to 36 hours, however much time it took to get the airplane going—but it's quite efficient. You know, we don't have to check with insurance or get pre-approval and so on and so forth.It's a really wonderful system for efficiently getting people the care they need. And on the other hand, if they're out in their village and really what they need is an update on their vaccinations, or maybe a Pap smear or other screening tests, those things can generally be done right in the community clinic by the health aide. Sometimes there might be a nurse practitioner, a PA, or a visiting physician involved. But a lot of it can be done right at home, and they therefore don't have to travel. It's quite an efficient system and very economical. It's quite an economical way to deliver comprehensive care to people who live in remote places.

[15:21] Marianne: I wonder if you've got a village that's 500 people, everybody must know each other. Do people come in from outside to become community health workers, or are they recruited from the village itself?

[15:34] Nora: For the most part, the health aides are local—they're from their own village. Every now and then, we get someone who is not from Alaska, or just not from the region. Sometimes it's a spouse who becomes a health aide. There was another student I taught—she was a midwife in Pennsylvania and had moved to Nome because she had friends who had moved there, and she was just adventurous. So she'd heard about the health aide program, signed up, applied, got accepted, and trained. Then she was sent to Little Diomede, which is a teeny-tiny village on a rock, basically an island that's three and a half miles from Russia, near Big Diomede Island. That village is only accessible by helicopter. But for the most part, it's local. Usually, it's women. It's challenging because everybody knows everybody in a village, and a lot of people are related. So you're having to treat your own family members. You’re having to treat your maybe ex-boyfriend, or a person you don’t like, or someone you’ve had an argument with. So it’s very challenging for a community health aide to do their job in that setting.

[16:39] Marianne: How did the community health aide program start and grow?

[16:43] Nora: It started in the 1950s. There was a tuberculosis epidemic, and the public health nurses were tasked with going out and delivering medication to people in the villages where these outbreaks were happening. But there just weren’t enough nurses. So the nurses started to train local people to give out and distribute the medications. That was the start of the health aide program—it began from that. It’s grown from just delivering medications to doing what a health aide does now, which is a lot more.

[17:16] Molly: It was finally recognized by Congress in 1968.

[17:20] Marianne: How did Congress recognize the program? Did they fund it?

[17:24] Molly: They officially recognized it in 1968, and I believe the health aide program has been funded by IHS, the tribal entities, and the State of Alaska. As you know, the IHS is responsible for the health and healthcare of American Indian and Alaska Native people, which came about through the U.S. Constitution and subsequent documents, and even court cases, in a fairly short period of time. After that, healthcare outcomes began to improve dramatically in Alaska among Alaska Native people. I jotted down one example: over a 10-year period, between 1976 and 1985, neonatal mortality rates fell from 10.8 per thousand down to 6.7 per thousand. At that time, the rate in the U.S. overall was 7 per thousand. So we started out much higher and fell to even maybe a little below the national rate, right when the Community Health Aide Program got off the ground. In 1994, the Alaska Tribal Health System underwent something called "compacting" , an agreement between the U.S. government, IHS, and the Alaska Tribal System, which allowed Native people here to manage their healthcare themselves. So, I hope I explained that accurately. It's a very complicated transition that happened, but the Alaska Tribal Health System, or ATHS, as we know it now, has evolved over the past 30 years and is now managed by the people themselves, rather than by IHS—which is quite different from many other areas of the country.

[19:07] Marianne: In 1994, did you live through the transformation where the Alaska Tribal Health System became the managers and owners of the healthcare system up there? I'm just wondering if you lived through that period and if you saw a transformation of how care was delivered.

[19:24] Nora: I remember it happening, I think I was probably a sophomore in college. I didn’t quite understand what was going on, but I knew it was something very significant. And I think it changed, in a positive way, how healthcare was delivered by giving the regional health corporations the power to manage, disperse, and use funding in the ways they needed to. Each region has its own differences, because we’re such a large state. I mean, the North Slope versus Southeast Alaska—that’s rainforest down there, and we’ve got frozen tundra and darkness up here. So they’re going to have different ways of managing healthcare, just because of geography.

[20:03] Molly: Also, different cultures and different languages, different approaches, different kinds of foods, different lifestyles.

[20:09] Nora: How they divided them up was basically based on how the Native corporation regions were organized. In our region, the Bering Strait Native Corporation, we're called the Norton Sound Health Corporation, and it includes all the villages that fall under the Bering Strait Native Corporation. I'm not sure how that was originally decided, but it seemed natural.It created some trust, or helped create trust, with the patients, knowing that it wasn’t somebody in Washington, D.C. making the call. It was someone local, or at least more local, making decisions about how healthcare is delivered.

[20:37] Molly: One example that I’m especially familiar with, because I was here in Anchorage by that time, is Southcentral Foundation, which is the organization responsible for care in the Anchorage Bowl, a fairly large area. They developed something called the Nuka System, where they hold frequent listening sessions. They ask people, “What do you need? What do you want from healthcare?” and so forth. Then they implement programs to try to meet those needs. They have twice received what's known as the Malcolm Baldrige Award. It’s a really very impressive program. And Nome, where Nora works, would be another example. I know less about exactly how it works there, but she might be able to tell us a little bit about the health aide training.

[21:23] Marianne: I’d be personally interested in knowing how culture impacts the delivery of care. It sounds like there are a number of languages and cultures intermixed. Maybe starting with where you are, Nora?

[21:34] Nora: Yeah, so when I try to explain what a health aide is, I like to clarify: it's not a certified medical assistant, and it’s not a home healthcare worker. The Community Health Aide Practitioner has a lot of different roles all wrapped into one, and I think it’s one of the most difficult jobs out there. They’re the doctor, the nurse, the pharmacist, the paramedic, the social worker, the case manager, sometimes even the mortician, for patients who come to them in the village. They're the first person patients see when they’re sick. They come to the clinic and see the health aide, and the health aide takes care of them. It’s not a program where you have to pay tuition to get your health aide training. You’re hired and then trained—you’re paid during your training, which is a critical piece. I don’t think many people from the village would go and pay out of pocket to be trained as a health aide. Now, how do they do that? And how is it legal for them to give out medications, especially when many of the health aides only have a high school education? The reason they can do this is that they follow a manual that’s been written by physicians, physician assistants, and nurse practitioners, with input and edits from health aides themselves. We train the health aides on how to use this manual and how to use it safely. The manual starts off with introductory questions like: Why are you here?—the chief complaint. Why did you come in? It includes a brief history of symptoms, allergies, past medical history, and then the book is divided by body systems. So, if someone comes in with, let’s say, a sore throat, they’ll go to the respiratory section and start asking questions listed under "sore throat. " We teach them how to ask those questions and how to explore the answers. Once they get through the history, there’s an exam section, just lines from head to toe, on what to do for the physical exam. And so we teach the health aides how to do these exams. We're training them to listen to the heart and lungs, look in the ears, and perform an abdominal exam. In the manual, they go through the exam and then come to an assessment chart that includes a column for history findings, exam findings, and the assessment that matches those findings. They come up with anassessment based on what they see in that chart.Each assessment has a corresponding plan. There's also an emergency manual included.There’s always a section that says: if the patient has this, this, and this—these are red flags—and this is an emergency; go to the emergency section. There are also other red flagsthat indicate something isn’t an emergency, but it's very important and should be reported to a doctor.If you have standing orders signed by a doctor, you can then proceed with the plan without needing to call the doctor. There's an entire manual on patient education that they go through with the patient during follow-up, like when they need to come back. It's very thorough, but it doesn’t cover complex assessments. It focuses on common assessments like otitis media and strep throat. There are also sections on prenatal care and well-child care. As a health aide progresses through their training, there are four sessions they complete. If the timing works out just right, it can take about two years to reach the practitioner level. There are four levels of a health aide. They come in for four weeks at a time to the training center, and it's very intense. We’re teaching them basic anatomy, basic physiology, what these assessments are, and how to perform the exams. They also have lab skills to learn. So we teach them how to do finger sticks for hemoglobin, strep throat swabs, and at least basic point-of-care tests. We also teach them about medications and how to calculate dosages. Usually, the book calculates it for them, but sometimes they need to double-check the math. After completing the four weeks at the training center, they’re sent back home to complete their field training requirement. That’s usually overseen by a supervisor, either in the clinic or sometimes by a trainer who can travel to supervise them in person. There’s a whole checklist of skills that have to be signed off, like exam skills, point-of-care tests, just to make sure they know how to do everything properly. Once they finish their field training, they can move on to the next level of training. They do take call. In our region, health aides usually begin taking call after completing Session Two. That’s where it can become very challenging, because being on call means you have to stay in the village. It’s especially hard during subsistence time in the summer and fall, when everyone else is out berry picking or fishing—they have to stay close to the phone. So being on call is very challenging for a health aide, and it can lead to a lot of burnout, which is a real issue for them. Level Three covers more well-child care and women’s healthcare topics. Session Four focuses on chronic care, like checking in with someone about their hypertension or diabetes. Those visits are often reported to the doctor. “Reporting” means they can either call the on-call doctor right away if they need to talk to someone, or they can send their visit electronically to the on-call doctor.It used to be called “radio traffic” because, back then, we used VHF radios. Anyone could listen in on the doctor’s radio traffic with the health aide. But now, it’s done through either the telephone or the electronic health record. It’s a pretty extensive job for someone with just a high school education. It’s a very important role. They are also the first line for emergency calls, trauma or medical emergencies. And that is incredibly difficult, because there’s a lot of trauma in the villages. Accidents happen—hunting accidents, gunshot wounds—because people use guns to hunt. And what’s especially traumatic sometimes is suicide. The suicide rate among Alaska Native people is very high, about triple the U.S. general population. So health aides get called to scenes where someone has been hurt or may have taken their own life, and it’s just incredibly traumatic. So it really is a very difficult job, doing all of that. And they’re amazing people.

[27:23] Marianne: Is there a system for supporting them in dealing with that trauma?

[27:29] Nora: Yes, we have a Behavioral Health Services department at our hospital, and it’s improved a lot over the last 10 to 15 years. There’s a team that can respond when a health aide needs debriefing or critical incident stress management. They’re remote, though, and sometimes you can’t be there in person with someone because they’re in a different town, there’s a blizzard, and you can’t fly in, or the next flight out isn’t until the next day. It can be very challenging to provide that kind of support. We use a lot of telemedicine. The Native healthcare system has used telemedicine, especially for ENT, for many years. We have the capability to do video calls, and the new clinics being built in our villages include a small emergency room with a camera that can be turned on during emergencies. That way, the doctor can be there, somewhat live, to help guide the health aide through what needs to happen. That’s been a great resource, though internet connectivity isn’t always reliable in rural Alaska.

[28:31] Marianne: Oh wow. This is fascinating. I am learning so much just listening.

[28:36] Molly: I happened to know a couple of the physicians who put together the very first Community Health Aide Manual, I think it was in the early eighties. The manual is very specific. Just to give an example: if a baby has a temperature over 101°F and isn’t feeding, you must call the doctor. It’s very clear. Whereas if their temperature is 99°F, they’re playful, they’re eating, they have good skin turgor and moist mucous membranes, then you can give them Tylenol and check on them again the next day. So there are very specific directives for the health aide, which is incredibly helpful. We affectionately call it the CHAM—Community Health Aide Manual. And it has evolved over the years now.

[29:17] Nora: Now it’s on a tablet. Before it became electronic, it used to be three separate books. There was the main manual that you used to guide a visit, the medicine handbook, and a small emergency pamphlet that you could pull out during an emergency.

[29:29] Marianne: You know, I’m even thinking of a kid’s rodeo that I got to see that was like 60 miles from the nearest clinic, and one of the kids got injured. It reminded me of your story. They broke a bone, they were loaded into a pickup truck on a piece of wood, and they had to go 60miles. It’s not 500, but it was still over dirt roads. Having a community health aide to help—that would be awesome.

[29:52] Nora: Yeah, talk about the health aide as being the eyes and ears and hands for the doctor.

[29:56] Marianne: Especially now that we have telehealth that actually works. And it sounds like you guys were pioneering that way before the rest of the world was, which is amazing.

[30:06] Nora: Even our travel is paid for, from the village to the regional hospitals, and then on to Anchorage. I still have to come to Anchorage to see my oncologist, and I don’t have to worry about, “How am I going to pay for that airline ticket?” Right now, airline travel is so expensive. In our region, after COVID, two airlines went out of business. Now we just have one airline in our region that services the Nome area and the Kotzebue area, and it costs about $585 to travel round trip from Nome to Unalakleet, which is only 150 miles. That’s almost $600 for one person, round trip. And then from Anchorage to Nome, round trip, that varies based on the season. So Iditarod time is going to be a lot more expensive, and summer is more expensive too, but it can run about $630 round trip. When I went through my breast cancer treatments, I had to travel in every week to get an infusion. That adds up. I can’t imagine how people get through cancer recovery with that added stress of the finances. So I just wanted to highlight that element of our care here, that we are very fortunate not to have to worry about that. Anything else, Molly?

[31:20] Molly: Oh, no, I was just thinking about the fact that, really, the cost of all that insurance was paid by the Indigenous people when they gave their land to the U.S. government, and the U.S. government promised to provide healthcare. If you actually look at the numbers, the amount of money that goes to the IHS for healthcare is less, much less, per person than for other federal programs. Fortunately, in Alaska, the tribal system has been able to find other sources of funding, at least in some cases. The other thing I was going to mention is that I was a co-author, so I guess I should say that. I don’t know if that’s a conflict of interest, but ACP does have a policy paper on supporting the health and well-being of Indigenous communities. The first author, Josh Serchen, did such a beautiful job writing it. And for those in our audience who are especially interested in Indigenous health, they might find that paper of interest. It was published in the Annals of Internal Medicine a couple of years ago.

[32:23] Marianne: Thanks for mentioning that. And I am so grateful, so grateful for the story, so grateful for the education I've received, and I want to thank you very much.

[32:34] Molly: Thank you so much, Maryanne, for inviting us, and thank you to Nora for coming. It’s just so gratifying to see one of my former students who has become such a great physician in rural Alaska, and so resilient through all of her own health challenges. It’s really a pleasure to participate in your program. Thank you so much.

[32:56] Marianne: Now we’re going to invite everyone listening, all our listeners, to continue the discussion online. We’d love to hear your stories related to this topic, your questions, the specific barriers and challenges you’ve faced, what you’ve learned, and how you’re applying it. We have additional resources and a transcript of this discussion available online. Please get in touch with us. We’re also on social media: on Twitter (I won’t call it X), Instagram, and several other platforms. So let’s stay in touch. Thank you.

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