Alaska Tribal Health System: A Model for Rural Healthcare

The DEI Shift's mission is to create a podcast series on diversity, equity, and inclusion (D.E.I.) in medicine that sparks discussion and provides practice-changing data and stories for a physician, student, allied health professional, and health care leader audience. Listeners will be able to gain useful information to improve their practices and environments, to gain empathy, cultural competency, and humility, and to learn more about emerging D.E.I. concepts. The DEI Shift will discuss issues related to gender, race, sexuality, religion, ability, socioeconomics, and so much more.

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.

[00:00–01:19] Introduction of Co-Hosts and Episode Topic

• Dr. Marianne Parshley introduces The DEI Shift podcast and guest co-host Dr. Molly Southworth.
• Molly provides an overview of her background in internal medicine and endocrinology, her work in Alaska’s Tribal Health System (ATHS), and her commitment to rural healthcare.
• The episode will focus on healthcare delivery in rural Alaska, with special attention to the role of Community Health Aides and cultural context.

[01:20–05:39] Introducing Guest: Dr. Nora Nagaruk

• Molly introduces her longtime colleague, Dr. Nora Nagaruk, a family physician from Nome, Alaska, originally from Unalakleet.
• Nora shares her cultural heritage, including her Iñupiat and Russian roots, and the community-based upbringing that shaped her values.
• Her path to medicine included overcoming financial challenges, excelling in academics, and facing two cancer diagnoses during medical training and practice.
• Nora now provides care in Nome’s corrections facility and remains deeply involved in her community and traditional subsistence lifestyle.

[05:40–10:14] Journey Into Medicine and Cultural Identity

• Nora shares a formative story of how a broken hip at age 13 introduced her to healthcare delivery in remote Alaska, sparking her interest in medicine.
• She highlights the critical role of a local Community Health Aide during that emergency and reflects on how mentorship and encouragement helped her pursue a medical career.
• Despite detours due to illness, she found a fulfilling role serving her region as a family doctor.

[10:15–13:42] Life in Alaska Villages and the Role of Geography

• Nora explains the distinction between Alaska’s road system and rural “off-road” villages accessible only by air or boat.
• Villages typically have a few hundred to a thousand residents, and each belongs to a Native corporation created through the Alaska Native Claims Settlement Act of 1971.
• Life in the village includes gravel roads, four-wheelers, snow machines, and strong communal ties that shape healthcare delivery and access.

[13:43–15:33] Overview of the Alaska Tribal Health System (ATHS)

• Molly provides a structural overview of ATHS, which serves 180 villages with community clinics, 25 sub-regional centers, and 6 regional hospitals.
• The system efficiently coordinates care across vast distances and includes a tertiary referral center in Anchorage.
• Access is not limited by insurance barriers, and much care can be delivered locally by trained aides.

[15:34–17:15] Community Health Aide Program Origins and Growth

• Nora explains that the Community Health Aide Program began during a 1950s tuberculosis epidemic when public health nurses trained locals to administer medication.
• In 1968, Congress officially recognized the program, and it has since expanded into a cornerstone of rural healthcare.
• Funding comes from IHS, state, and tribal sources.

[17:16–20:36] Community-Managed Healthcare and Regional Autonomy

• In 1994, ATHS transitioned to tribal management, allowing local corporations to control healthcare funding and delivery.
• Nora shares how regional differences in geography and culture shape healthcare approaches, from the tundra of the North Slope to Southeast rainforest areas.
• The shift built trust and enabled tailored healthcare solutions aligned with each community’s needs.

[20:37–23:39] Cultural Competence and the Health Aide’s Role

• Nora emphasizes that health aides are often from the village they serve and wear many hats: provider, nurse, social worker, and more.
• Health aides are trained via a structured manual developed with clinical and community input and receive paid on-the-job training.
• Cultural familiarity and community relationships enhance trust but also present emotional challenges due to personal proximity to patients.

[23:40–28:30] Training Structure and Emotional Toll on Health Aides

• Health aides undergo four intensive training sessions over two years, with hands-on fieldwork and oversight.
• They use a manual-driven system to assess and treat common conditions and emergencies, sometimes with telemedicine support.
• Being on-call, managing trauma, and responding to suicides or violence creates risk of burnout, and behavioral health support is vital yet logistically difficult to deliver consistently.

[28:31–31:19] Innovations and Infrastructure Support

• Nora describes advanced telemedicine capabilities and newly designed clinics with integrated video support, improving emergency response in isolated villages.
• She shares how fully-funded travel to Anchorage or regional centers helps reduce barriers for patients needing advanced care, especially in high-cost and low-access environments like post-COVID rural Alaska.

[31:20–32:56] Closing Reflections and Policy Context

• Molly reflects on the historical promise of healthcare in exchange for land and how underfunding persists despite that agreement.
• She mentions the ACP policy paper on Indigenous health, which she co-authored, as a resource for further learning.
• The episode concludes with gratitude for Nora’s resilience, her community service, and the broader implications of culturally grounded, community-managed care.

Resources

Alaska sees the most dramatic increases in life expectancy in the nation, new study says

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2626194#google_vignette

From IHME, since it gives a great visual regarding IMPROVEMENT in life expectancy.  It can be accessed directly from this link: https://cdn.jamanetwork.com/ama/content_public/journal/intemed/936342/ioi170020f2.png

GBD US Health Disparities Collaborators. Life expectancy by county, race, and ethnicity in the USA, 2000-19: a systematic analysis of health disparities. Lancet. 2022 Jul 2;400(10345):25-38. doi: 10.1016/S0140-6736(22)00876-5. Epub 2022 Jun 16. PMID: 35717994; PMCID: PMC9256789.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9256789/

https://www.cdc.gov/nchs/pressroom/sosmap/life_expectancy/life_expectancy.htm

https://www.anhb.org/

The Alaska Native Health Board website. It is considered the “statewide voice on Alaska Native health issues,” and members of the Board represent the Alaska Native Regional health organizations around the state.

https://anmc.org The Alaska Native Medical Center website

https://www.anthc.org The Alaska Native Tribal Health Consortium website; the ANTHC provides tertiary care for all Alaska Natives around the state.

CHAP Alaska www.akchap.org The official website for CHAPs, which gives a nice overview and history of the Community Health Aide program (as well as for Behavioral and Dental Health Aides). It includes a map demonstrating the referral networks overlayed on the contiguous states, which helps the viewer appreciate the geography of the tribal health care system.

https://www.southcentralfoundation.com

These next 3 focus especially on SCF which is the organization responsible for primary care for those in the Anchorage Bowl.  SCF and ANTHC share responsibility for the Alaska Native Medical Center. SCF has been receiving lots of recognition for their groundbreaking work (2 Baldridge awards for primary care, in 2011 and 2017). 

https://scfnuka.com Southcentral Foundation Nuka System of Care website

Politico article by Joanne Silberner about Southcentral Foundation: “The Doctor Will Analyze You Now: A health center for native Alaskans brought mental and physical care under one roof, with impressive results. Why isn’t it more popular?” https://www.politico.com/agenda/story/2017/08/09/mental-illness-primary-care-000486/

Joanne Finnegan article about Politico article: Alaskan health center is model to integrate mental health into primary care | Fierce Healthcare

https://www.carnegiefoundation.org/blog/learning-from-healthcares-use-of-improvement-science

Dr. Don Berwick comparing health care strategies to education strategies

Medicaid: A Brief History of Publicly Financed Health Care in the United States

Josh Serchen, Dejaih Johnson, Katelan Cline, et al. Improving Health and Health Care in Rural Communities: A Position Paper From the American College of Physicians. Ann Intern Med.2025;178:701-704. [Epub 1 April 2025]. doi:10.7326/ANNALS-24-03577

Contributors

Marianne Parshley, MD, FACP – Co-Host

Molly Southworth, MD, MPH, MACP – Co-Host

Nora Nagaruk, MD - Guest

Pooja Jaeel, MD, ACP Member – Co- executive producer

Maggie Kozman, MD, ACP Member – Co-executive producer

Tammy Lin, MD, MPH, FACP – Executive Producer

DJ Gaines, MD, ACP Member – Senior Producer

Ann Truong – Production Assistant

Clara Baek – Production Assistant

Reviewers

Tiffany Leung, MD, MPH, FACP

Tammy Lin, MD, MPH, FACP

None of the contributors or reviewers for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All financial relationships have been mitigated.

Release Date: July 14, 2025

Expiration Date: July 13, 2028

Accreditation Statements

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the DEI Shift.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 0.5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to .5 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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