Tuesday, May 28, 2013

Two stories highlight spatiality's challenge to service delivery in Alaska

NPR reported this morning on the federal government's efforts to track down veterans in remote northwestern Alaska, the same day that the New York Times reported on the challenges presented by rural and remote spatiality to deliver medical services in that region, but in an area to the south, in the Bethel and Kuskokwim Delta area.

Kirk Johnson's story for the Times, headlined, "Health Care is Spread Thin in Alaska's Vast Frontier,"  focuses on the spatial and climate challenges faced by the Yukon-Kuskokwim Health Corporation, which serves 28,000 residents, most of them Alaska natives.
[H]ere in the state’s far west end, spread out over an area the size of Oregon that has almost no roads. People can travel by boat or snow machine at certain times of the year, but not right now: the Kuskokwim River, which wends through Bethel to the Bering Sea, is choked with unstable melting ice in late May, magnifying the isolation that defines everything in what may be America’s emptiest corner. 
* * * 
The 56 tribes in the region voted in the mid-1990s to bundle their health care money from the federal government to finance the hospital. Grants supplement the work. 
But the one thing that shapes every care decision, from the routine to the catastrophic, is the map. Triage in medical decisions, logistics and money is all filtered through an equation of time and distance on a vast and mostly untracked land.
Not only is this story about the challenges of spatial isolation and the struggle to achieve economies of scale, it tells of how the health corporation trains local residents, called community health aides, to assist with triage and to provide care.  At a time when California is debating whether to permit nurse practitioners to practice alone--in part because of the dramatic need in rural areas and other underserved communities--I was struck by the description of these health aides, who have far less training than a nurse practitioner.  They are part of a "uniquely Alaskan" system that dates to a 1950 tuberculosis outbreak, in which aides were trained to dispense medicine:
[I]n sessions here at the hospital, ... 150 ... aides, mostly women, learn medical skills that include trauma response, pregnancy testing and vaccination, all based on a book that they call their bible, which walks them through a kind of algorithm of step-by-step questions leading to treatment protocols.
Lack of anonymity can be an added stressor for these aides.
In a tiny village, every patient is without exception also an acquaintance or a relative.
One aide is quoted:  
It’s really tough to work on someone you know.
Lack of anonymity and spatial isolation also play roles in Quil Lawrence's story for NPR.  Lawrence reports from Wales, Alaska, population 150.  It is the westernmost population cluster in mainland Alaska, and is farther north than Bethel, part of the Nome Census Area.  The headline is "Searching for Veterans on Alaska's Remote Edges," and this is the story of the Dept. of Veterans Affairs outreach efforts to those entitled to benefits, but who may not know that.  Amazingly, the Department does not have a master list of those who served.  That means someone from the VA has to go find them.  It's a task that tests the limits of the federal government's commitment to these folks and their communities.  

This vignette in particular is the story of the VA's assistant secretary for Public and Intergovernmental Affairs, Tommy Sowers. He has traveled many hours from Washington, DC, to near the Bering Strait to find veterans and inform them of their rights.  Lawrence reports:  
Sowers visited Alaska recently to look at what challenges rural veterans face in getting benefits, but it turns out that just finding them can be a challenge. 
Twenty-two million Americans served in the military, but the vast majority are from the Vietnam and Korea generations. They're getting older now, and many live in rural, sometimes remote areas. Alaska has the highest number of veterans per capita in the country — native Alaskans and other vets who got posted up here and never left.
Ron Huffman, a tribal veterans representative who volunteers as a liaison between the VA and local veterans, is an example of the latter phenomenon. The military brought Huffman, a Virginian, to Alaska in 1963, and he married an Alaska native woman and stayed.

But this is a story not only about the literal spatial challenge of finding vets, it is also one of a frontier culture of self-reliance.  Huffman states:
Most of these vets, they've never applied for any type of entitlement whatsoever. ... And a lot of them are at the age now that they're suffering with some pretty severe-type ailments. It would be very beneficial for them to try to get connected with [the VA]. 
Indeed, Huffman knows about the ethos of self-reiance.  Though Huffman now lives in Nome, he and his wife visit her native village each summer, where they catch enough salmon to get them through a winter.

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