Rural Alaska is getting Covid-19 vaccinations right. Here’s what the rest of the US can learn

Alaska’s public health structure was built for complications — its size and tendency for inclement weather require it. So when it came time to start vaccinating residents, the state didn’t have to build a robust public health system from scratch like some others, said Dr. Anne Zink, Alaska’s chief medical officer.

Zink credits the state’s success to its “hub-and-spoke” model of health care: The “hub” — Alaska’s Department of Health and Social Services — gives local health care providers, or the “spokes,” the resources they need. But because Alaska is such a varied state, it’s up to local providers on how to use those resources to best serve residents.

A localized approach to vaccination hasn’t worked everywhere, but it’s worked in Alaska, Zink said. The state distributes vaccines to different regions but doesn’t give directives, she said — it’s up to the communities to decide how to administer vaccines based on their needs.

“If you provide communities with the tools they need to protect themselves, they oftentimes are really able to do it,” she said.

Because so much power has been turned over to different regions of Alaska and the health care providers trusted in those areas, health care workers have been able to “meet people where they’re at,” Zink said: That means they’ll deliver vaccines by boat, dog sled, helicopters and small planes, or go door-to-door in small communities to vaccinate as many community members as possible.

“It’s really different across the state,” she said. “It’s highly reliant on local communities who know their system … way better than we (the state health department) do.”

It expanded the eligibility criteria

Expanding who’s eligible for a vaccine is another strategy that helps them vaccinate Alaska Natives and low-income residents who are disproportionately vulnerable to Covid-19.

In areas where the population is mostly Alaska natives, there’s a greater amount of people living in multigenerational housing. That qualifies young people who may live with an at-risk elderly person to get vaccinated, too, said Dr. Bob Onders, administrator of the Alaska Native Medical Center in Anchorage.

And since 25% of rural Alaska doesn’t have running water or sewage, which can heighten residents’ risk for respiratory illness, it didn’t make sense to exclude rural residents from the first round of vaccinations, Onders said.

“Having more vaccines and quicker eligibility for Alaska Native people at higher risk is starting to even out the risk of Covid, cases of Covid, hospitalizations and mortality,” he said.

Sovereign tribes received vaccines separate from the state

Tribal health systems had the option to receive vaccine doses through the state or through the Indian Health Service — Alaska’s tribal health system chose the latter. This option gives the tribes more independence in distributing the vaccines as well as a specialized allotment of vaccines that takes into account the remoteness of where the tribes are located, the rate of infection among the tribe and handing the reins to providers that Alaska Native communities already trust.

“Rather than a top-down mechanism, where someone from outside of Alaska or rural Alaska is dictating how things are going, it’s much more about giving them supplies,” Onders said.

The state gets its doses monthly

Alaska asked the federal government to be treated “like a territory instead of state,” so it would receive a monthly allocation of vaccines versus a weekly or biweekly lot. That made it easier to plan ahead and deliver vaccines “creatively,” Zink said.

It can be costly to transport vaccines to some remote reaches of Alaska — over $15,000 for one trip, in some cases, Zink said. To make vaccinations more cost-efficient, some areas that are less densely populated receive their entire vaccine allotment, which makes it possible to vaccinate entire communities in one go.

Alaska’s state health department also doesn’t have to handle vaccinations on its own. Alaska’s 229 sovereign tribes, the US Veterans Affairs Department and the US Department of Defense each have a separate federal allocation for vaccines, which means more vaccines are being distributed in Alaska at once.

The state has done this before

The massive movement of vaccines is fairly standard for Alaska.

“We’ve been doing redistribution of vaccines for years,” said Dr. Anne Zink, Alaska’s chief medical officer. “It was pretty easy for us to stand up our existing [public health] structure.”

Some areas of the state are so remote that items aren’t shipped directly there — rather, they’re shipped to centralized redistribution centers in population hubs throughout the state like Anchorage and Juneau. There, large allotments of vaccines can be stored and divided into the proper amount for the community they’re going to so no area gets more or less than they need, Zink said — something that wouldn’t be possible if vaccines were shipped directly throughout the state.

So when it came time to distribute Covid-19 vaccines, the state benefited from years of preparation.

What the rest of the US can learn

What works for Alaska won’t work in more populous states or states with more urban hubs, and certainly every state can’t get a monthly allocation of its doses, but some of its success could be replicated in other states.

Invest in protecting minority communities. Alaska expanded its eligibility for the first round of vaccines to include Alaska Natives and low-income residents of the state that are more vulnerable to Covid-19. While there’s still work to do to alleviate that disproportionate risk, Onders said so far, it’s working.

“If we want equitable outcomes, we have to disproportionately invest in communities at highest risk,” Onders said.

Alaska’s done that, Zink and Onders said, by trusting health care workers who live and work in the communities they serve to educate residents. Zink leads daily Zoom calls with Alaskans, and she holds Q&A sessions to address disinformation about the vaccine. In Alaska Native communities, that can look like calling on young residents to inform their elders.

Customize the approach. States that were lagging in vaccinations are catching up, Karmarck said, as they formalize an approach to vaccination that best fits their state. In Massachusetts, for example, large vaccination sites have opened up at Fenway Park and Gillette Stadium to accommodate more people and storage the vaccines require. It’s improved the state’s vaccination rates, she said.

That approach may work in a relatively small state like Massachusetts, but the opposite is true in a state like West Virginia, which led the US when vaccines first became available by entrusting local pharmacies to vaccinate residents of the more rural parts of the state, Karmarck said.