Difficult delivery: Alaska's rural health care system copes with numerous obstacles.

• Author: Richardson, Jeffrey
• Position: Rural Health Care Report

Despite unforgiving geography, cruel climate and financial austerity, rural health care in Alaska has made dramatic headway against lethal diseases. Epidemics of infectious diseases virtually have been wiped out; life expectancy is up; infant mortality is down. One state health official says the improvement is the most miraculous of any population in the world.

Key to these successes are a dedicated corps of community health aides, supported by specialists in regional and urban medical facilities; advanced telecommunications; and strong, coherent political advocacy.

But despite these triumphs, the struggle to provide adequate health care to more than 65,000 Alaska Natives and nearly 60,000 non-Natives residing in rural areas is beset by several crises. Some experts worry that the system may be threatened by burgeoning new pressures.

Alaska Natives still experience higher rates of infant mortality and some of the highest rates of Sudden Infant Death Syndrome in the nation. Tuberculosis and other infectious diseases have been replaced by injuries -- many related to alcohol abuse -- as the leading cause of death among Alaska Natives. Cancer and heart disease death rates are climbing in the Native population as well.

In addition to new or recurrent health problems such as AIDS, alcoholism, hepatitis and deteriorating village water systems, Alaska's rural health care network will sooner or later have to face some of the same issues confronting health care delivery in the rest of the country.

"I feel we're providing better care than poor people living in inner city Chicago are receiving. I feel this state ought to be really proud that health care measures are as good as they are," says Richard Mandsager, a physician and director of the Alaska Native Medical Center in Anchorage.

"But I feel the community health aid system could be a house of cards that could come tumbling down with one malpractice case. I don't have a clue how we would provide care in rural Alaska if that were to happen. I fear it has incredible ramifications."

Mandsager also is concerned about recruiting doctors to fill rural positions. Government incentives, such as paying a medical student's $100,000 med school tuition in exchange for four years of service in poor areas, have dwindled or disappeared, in part because of a misperception that the supply of rural-bound doctors was plentiful. Also, the number of doctors reneging on the deal is rising, as many are lured to more lucrative positions or choose exotic specialties over basic family practice.

"Recruitment is a serious issue for the future," Mandsager warns. "Alaska is a tough sell when there's no job for the spouse and it's a small community and the cost of living is high. The cost of living in Nome is a whole lot different than the cost of living in Minneapolis."

Dealing with Differences. There are many reasons for the chronic discrepancies between the health care provided to rural and urban Alaskans, and they are tightly interwoven. The high cost of delivery to remote areas, many of which are marked by high levels of persistent poverty, is exacerbated by declining government aid. Furthermore, health among Alaska Natives has been a barometer...