Q&A: Verné Boerner on the priorities of the Alaska Native Health Board post-pandemic

Verné Boerner is the President and CEO of the Alaska Native Health Board (ANHB). She leads the ANHB with over 25 years of experience in addressing health disparities in minority populations. The ANHB, established in 1968, is recognized as the statewide voice on Alaska Native health issues. The mission of the Alaska Native Health Board is to promote the spiritual, physical, mental, social and cultural well-being and pride of Alaska Native people.

In this Q&A, Boerner discussed the impacts of the pandemic on the Alaska Native community and the priorities of the ANHB as the world begins to re-open.

Sydney Kurle: How have the Alaska native tribes driven the success of the state’s vaccine rollout?

Verné Boerner: “That is really a very key question. It really starts with going back to tribal sovereignty. So there are 229 federally recognized tribes in Alaska, and they collectively self-determined to go 100% self governance. I don’t know if you know what that means. Those 229 tribes, collectively, have joined in a single compact negotiation with the federal government. And through that process, they have been able to establish a true system of care. So we have the Alaska tribal health system is one that follows a continuum of care from the local, regional hub and state levels. And they have been developing this over several decades, and relying on self determination and their sovereign status as tribes. That’s where it starts.

Alaska’s 229 tribes are spread across over 660,000 square acres of land and water mass across the state. And in many cases, they are the only access point to care in their communities. And because of that, they are a critical component of the Alaska public health system. As part of that we have, over the years, developed a relationship with the state — including an existing immunization program that we’re able to tap into and utilize. So we capitalize on the partnerships that were there, the infrastructure that was already built, and our ability to self determine. And all of those put together allowed us to define our priority populations, tap into existing logistical issues with ordering, transportation and administering. So those are all the factors that have come together to help doctor the success of our vaccine rollout in the state of Alaska.”

SK: Vaccine hesitancy has been a problem in minority populations in other parts of this country, especially with the COVID-19 vaccine. Why do you think the Alaska Native population seems to have had a different trend?

VB: “In many communities, they still reflect upon and feel the experience of the 1918 Spanish Flu pandemic. In some communities at that time, Alaska Natives accounted for 80% of the state’s deaths. Whole communities were devastated. We lost the entire adult populations in those communities. They were orphaned communities. This is a strong part of our collective memory. Then we’ve had similar experiences of being equally traumatized by a disparate impact from the H1N1 epidemic that occurred. And even with the COVID pandemic, our people represented 37% of the deaths, and were overrepresented in the amount of deaths and hospitalizations.

So we saw and felt it right away and had that experience from the 1918 flu pandemic and H1N1. And also knowing the risk factors, our communities, our health professionals and our community leaders recognized immediately and took immediate action to both close their borders, and restrict travel because they knew what it could and would mean to their communities if the disease was able to take hold in the communities themselves.”

SK: But what are some of the challenges to containing a pandemic in these rural villages?

VB: “We have a number of infrastructural challenges that we are still fighting for today. A major one is the challenge of a lack of water and sanitation systems in our communities. We have over 30 communities that have absolutely no water and sanitation systems at all. We have others that just completely depend upon a washateria for the whole community. We have health clinics that still have to utilize the honey bucket system, which is a 5-gallon bucket to use to go to the bathroom. So they use that to collect samples. And this is in a health setting. 

So the water and sanitation issue is a huge challenge. And it is definitely one that poses a threat to community health and public health overall in our communities. Another issue that we have is crowded housing. So we have a number of homes with multiple families living within those households. We also have multi-generational housing, so those who suffer higher risk of severe disease and death are living with family members that may not have as much of a risk but may pose a risk to the household if they bring in the disease. There’s no place to really quarantine or isolate in a crowded housing situation. And so those are some of the challenges. And even our health care facilities have challenges because they’re not able to provide the social distancing levels required or necessary to help stave off contagions.”

SK: How has the pandemic affected the mental and behavioral health of Alaska Natives, both in rural villages and urban areas?

VB: “We are still assessing that. There’s a great deal of anecdotal evidence with regards to the mental health impacts. If you’re looking at some indicators, such as suicide attempts in the first quarters of the pandemic, those numbers actually went down. However, they went down because we have some of the highest suicide rates in the nation and because 2019 was a particularly bad year [for suicides]. I don’t have exact numbers. But it’s my understanding that later quarters of 2020 those numbers actually went up again. So as an indicator, we do believe that is a definite issue. 

However, if you want to take a balanced approach the pandemic did allow for the declaration of public health emergencies to be allowed. We were also able to utilize telehealth. We saw telehealth appointments skyrocket across the state, and in some communities our Tribal Health Organizations saw telehealth use increase by 400%.. The vast majority of that increase was behavioral health appointments. We also saw a huge decrease in no-shows for that service. So it really facilitated the ability to meet the need, where the patients are, and also offered certain flexibilities. We could utilize audio-only to conduct these services, which was also critical. So to some degree, it increased access through telehealth. It decreased no-show appointments, folks didn’t have to worry about child care or transportation and a number of the other barriers to access to care. But we’re also still trying to assess the level of increase in substance use and the potential level of increase in domestic violence. And again, we are still looking for numbers on surges or increases in the number of suicides.”

SK: In the operating and mental health budget, are there any items that you feel are especially important or that you’re concerned about?

VB: “I think that’s a really great question. We are certainly hoping as we’re looking forward to continuing some of those flexibilities with regards to utilizing telehealth to address behavioral health issues. We’re looking at greater flexibilities for issues such as audio-only. But when you think about it, and you think about overall health, we need to get a little bit out-of-the-box. There’s a whole slew of issues that really go towards equity. It is impossible for a lot of folks to really understand the fact that you have a [health] clinic that utilizes a honey bucket to collect medical samples. That has a mental health component to it.  If you don’t have water and sanitation and easy access to being able to wash your clothes, that truly impacts health overall. But it does go back to the mental health impact of these equity issues. So we’re really hoping to be able to take a holistic and a partnering approach to some of those broader issues that all come together to help create the whole person and support wellness overall. 

In Alaska, some of the biggest challenges that we have with regards to mental health is the fact that we don’t have great access to step-up and step-down services. So we are not able to intervene earlier. In order to just have a health care response, an individual has to progress in their illness so far, which makes it much more difficult to actually have a better outcome. So we really do need more levels of care so that we can adjust the needs in the communities as they arise. In many cases, we have waiting lists for individuals seeking help that are months long. And if you cannot reach an individual who is suffering from substance use disorder, at the time when they’re ready, you’ve missed an incredible opportunity to address that. 

We also see a disparity in transportation for mental health needs. Alaska has 660,000 square miles of land that our communities are spread over. Eighty percent of our communities are not on roads. So 80% are effectively islands, and in order to get to higher levels of care, you have to fly or take a ferry or boat. And in order to access that care for mental health needs, there is a disparity of being able to travel out a patient to address those mental health needs. And so we’re looking and hoping to be able to build a certain level of parity for those needs, and increase access to care in that way. We’re trying to be innovative in the state of Alaska. They’re looking to implement the “Crisis Now” model that is basically starting in the urban areas. If we can reduce the pressure on the Alaska Psychiatric Institute, it sort of opens up the bottleneck and we’ll create better access to that facility from rural Alaska. But so there’s a domino benefit effect, not a direct one. But we are hoping to be able to, after getting the crisis-now model started, look for ways to implement and utilize the unique aspects of the Alaska tribal health system. One way is getting behavioral health aid therapists out in the communities and meeting the needs of individuals in their communities — as opposed to moving them out of their communities to larger hub areas to address their needs.”

SK: You touched on infrastructure a little bit, but do you anticipate any funding from the possible American Jobs Plan Act to be used to develop either public health infrastructure in rural Alaska or the road system?

VB: “So we certainly do see some needs, and we are identifying those needs. We see needs in having access to broadband. And we know that the infrastructure bill will be proposing resources and funds to bridge the digital divide. We certainly see a need to to build that out. In Anchorage, you have cell phone bills of around $40 a month with data plans that are actually quite rich, but to have that same sort of plan out in rural Alaska can cost as much as $400. It’s exceedingly expensive. And that cell data service is not even at rates and speeds that would be necessary or support many of the requirements for speeds for broadband as measured by the FCC. So there is a huge disparity in access to high speed internet  in rural Alaska.  There’s also a need for water and sanitation. There are still issues with regards to aging facilities. We have clinics that have Visqueen separating spaces because we are not able to adequately separate patients and protect them from contagious diseases such as COVID. So there’s certainly a need. 

Also Alaska is warming at twice the rate of the contiguous U.S. and we are greatly impacted by climate change. Many of our communities have to tug in thousands of gallons of fuel a year during the short shipping season when lakes and rivers are not frozen, Then they need to store that fuel throughout the year. If they run out, you actually have to fly fuel and bladders in planes, which is highly regulated as to how you can transport it and therefore an extremely expensive venture. Looking at alternative heating and energy sources is also important.

This interview has been edited for clarity and length.