Alaska hospitals make wrenching decisions as they begin to ration care
Rural areas across the United States are in crisis as Covid-19 overwhelms some hospitals, but the situation is especially dire in Alaska, which has the highest US rate of Covid cases and recently turned to emergency measures to allow the rationing of healthcare at 20 medical centers across the state.
Alaska’s health system, stretched by enormous distances and limited resources, was precarious before the pandemic hit, and now remote communities are worried they will have nowhere to send their sickest patients.
One in 84 people in Alaska was diagnosed with Covid-19 in the last week of September alone. On Monday, the state reported 2,290 cases and one death over the course of three days. Less than two-thirds of eligible Alaskans are fully vaccinated, and the entire state is on high alert for significant spread of the coronavirus.
The surge comes as Alaskan leaders and communities are sharply divided on issues like masks and vaccinations, and health workers are burned out and bullied.
On Kodiak Island in southern Alaska, doctors are spending entire shifts searching for beds in other states so patients can receive the care they need. Providence Kodiak Island Medical Center is implementing crisis of care standards, and the nearest major hospitals in Anchorage have been filled to overflowing for weeks.
“We have medevaced people all the way to Seattle, and some of our providers have reported that it has taken them literally 12, 18, 24 hours of phone calls to find a place that will accept one of our patients,” said Carol Austerman, chief executive officer of Kodiak Community Health Center.
This spike has been “devastating”, she told the Guardian, and it’s not easing yet. Her worst fear would be “to lose a patient because we can’t find a place to send them”.
In Anchorage, Alaska’s largest city, one doctor had to choose between several patients vying for the same open bed in the intensive care unit, including the resident of a rural community who would have flown in for emergency surgery. After careful deliberation, the medical team decided one of the other patients would be more likely to survive – and the rural resident died.
Alaska relies on a tenuous network of small community clinics, mid-level regional centers, and larger hospitals in major cities. But when those hospitals fill up, the entire network begins to fold. Rural residents are worried not just about a lack of care for Covid but also about surgeries, cancer treatments, accidents and other health emergencies.
On Friday, the Republican senator Lisa Murkowski spoke on the Senate floor about a loved one who recently sought emergency care at a hospital in Fairbanks. There were no ICU beds available in Fairbanks or anywhere else in the state, she said, and if he needed that level of care, he would be flown thousands of miles away to Seattle or Portland.
“When your hospitals are full, you just can’t put them in an ambulance and take them to another town,” Murkowski said. And the person was seeking care unrelated to Covid. “That’s the squeeze,” she said. “That’s the pressure that it puts on the rest of your system.”
Alaska is geographically bigger than California, Montana and Texas combined. Facing vast distances, Alaskans travel on average about 150 miles each way to get medical care. And unlike most other states, Alaska is much more limited in its ability to transfer patients to other hospitals. Seattle and Portland, for example, are facing their own surges.
Remote villages also have to deal with the vagaries of weather and long-distance travel. “We have really struggled, off and on throughout the pandemic, with being able to get people out,” Austerman said. Kodiak is only accessible by ferry or plane, and Covid-positive patients travel by medevac. A weather delay “throws a whole ’nother stick in the fire,” she said. The transfers happen only when they find a bed in a bigger facility in the first place – a dimming prospect.
Early in the pandemic, Alaska reacted swiftly, closing down remote regions and taking precautions, especially in villages where the legacy of the devastating 1918 flu pandemic still lingers. Alaska was initially a leader in distributing vaccines, despite its vast and remote geography. Yet that progress faltered in the face of growing political opposition.
Governor Mike Dunleavy, a Republican, has resisted measures like mandating masks or encouraging vaccination, saying those are measures best left up to local jurisdictions. Local meetings have grown hostile, with one Anchorage resident recently comparing mask mandates to the Holocaust – a comparison endorsed by the city’s mayor, Dave Bronson, who walked back his comments only after an outcry.
Murkowski called meetings like these “horrible, horrible altercations” and the comparison to the Holocaust “shocking”.
“It is neighbor against neighbor,” she said of the divisions in Alaska.
Health workers, once exalted as heroes, are now being spit upon and mocked at public meetings, and one health center was recently vandalized. It’s getting harder to know exactly how many Covid patients in Alaska hospitals are vaccinated, because some grow angry or violent when health workers ask their status, Dr Anne Zink, Alaska’s chief medical officer, told the Guardian in September.
Now, Alaska is reaching the point health workers have dreaded and worked hard to avoid: a disintegrating health system. “We’ve always known that healthcare capacity would be and continues to be one of the greatest limitations in Alaska’s response to Covid,” Zink said. Alaska has “incredibly limited resources and an unprecedented number of people who are needing particularly ICU-level care in our state.”
It’s not just a lack of beds and resources. “Staffing in Alaska is just horrific,” Austerman said. “We are so low on medical staff right now. No one is applying.” Some nurses have taken high-paying travel contracts to work in other cities, she said, leaving remote areas with a critical shortage of staff.
Austerman hopes the triage announcement will relieve some of the pressure on hospitals, as the state brings in about 500 health workers to deal with the crush of patients.
But that’s a short-term solution for hospitals, Austerman said, and it won’t help remote health centers like hers. “The clinics are not included in that announcement,” she said. “We’re not getting any of those people.”
Health officials and workers are still holding out hope that more Alaskans, in both rural and urban areas, will understand the crisis facing the entire state and choose to get vaccinated in order to relieve pressure on the crumbling system.
“Vaccinations are hopefully going to make a huge difference,” Austerman said. In Kodiak, about 60% of those eligible have gotten shots, which is similar to rates in the rest of Alaska. “That 40% that’s left is really devastating everybody else.”