On a sunny June morning last year, more than 100 medical personnel from around the world are ferried by bus to the foothills of the Chugach Mountains on the outskirts of Anchorage, Alaska. They arrive at the medical campus of Southcentral Foundation (SCF), an Alaska Native tribal health organization. They have come from as far away as Singapore, South Africa, and Australia to learn about a revolutionary model of health reform. As the visitors disembark, smartphones in hand, a black bear and her two cubs emerge from the spruce forest surrounding the health facility. The family become instant social media celebrities.
The visitors enter the primary-care clinic to further pleasant surprises. Art representing the multiple cultural traditions of Alaska Native people adorns the common spaces. In the foyer, a wooden carving of an Inupiat spirit mask covers an entire wall like a blazing sun. Throughout the facility, cabinets feature carvings made of walrus ivory, woven baskets, and beadwork created by artists from across the state. The craftsmanship and beauty on display promote pride, dignity, and self-confidence among Native people, says the organization that runs the clinic, which in turn promotes better health.
SCF is a tribally owned and operated health-care organization that serves Alaska Native and American Indian people, historically a woefully underserved population that is widely dispersed across the largest state in the Union. Alaska is nearly one quarter as large as the lower 48 states combined, and more than 200 Native villages count as distinct tribal entities. Many communities fall far outside the road system and remain accessible only by air or boat. Even today, Alaska Native people sometimes travel well over 1,000 miles to receive care.
Nevertheless, SCF has accomplished what others have found impossible: dramatically better health outcomes while controlling costs. It has reduced health disparities for the Alaska Native community through an integrated care system, called the Nuka System of Care. This approach joins Western medicine with traditional Native practices that emphasize connections among mind, body, and spirit. It addresses physical disease along with such issues as substance abuse, depression, domestic violence, and cultural and social connectedness.
In an era of soaring health-care costs and demands for reform, SCF represents the possibilities of a system that emphasizes wellness over treatment of disease and community relationships over profit. Organizations of all kinds have found in its holistic understanding of health a model for improving outcomes while cutting costs. At the same time, its story represents the unique challenges and possibilities that emerge from providing care to underserved communities in which history affects physical health and wellness is bound up with social justice.
For the community that SCF serves, wellness requires a holistic approach. Its health issues are rooted in a brutal history. Epidemics brought by European settlers decimated indigenous communities, and losses of land, languages, traditional healing practices, and economic livelihood followed. Such ordeals, in turn, induced more illness. “Trauma is held in the body,” explains Dr. Allison Kelliher, an SCF physician who combines conventional medicine with traditional healing practices.
Medical research now confirms such connections between social trauma and illness. An often-cited 1998 study by Kaiser Permanente and the US Centers for Disease Control and Prevention documents the fact that adverse childhood experiences such as abuse and neglect play a major role in physical disease and mental illness, and can be transmitted across generations. The science of epigenetics suggests that our ancestors’ traumatic experiences are encoded in our genes and can contribute to the development of depression, diabetes, heart disease, and other illnesses. “Many present-day health disparities can be traced back through epigenetics to a ‘colonial health deficit,’ the result of colonization and its aftermath,” says Dr. Bonnie Duran, a professor in the School of Public Health at the University of Washington.
Throughout Native America, health statistics are dire. According to the Indian Health Service, American Indians and Alaska Natives die of alcohol-related causes at more than six times the rate of other Americans, and they are three times more likely to die of diabetes. On the Pine Ridge Indian Reservation in South Dakota, life expectancy—48 years for men and 52 for women—is the lowest of any place in the Western hemisphere except Haiti.
Alaska Native people have faced the same bleak circumstances. Between 2012 and 2015, their mortality rate was 58 percent higher than the rate for US whites, the Alaska Native Epidemiology Center reports, and Alaska Natives had significantly higher rates for nine of the 10 leading causes of death, especially alcohol abuse, suicide, unintentional injury, and chronic liver disease.
But as bad as these statistics for Alaskan Natives are, SCF’s work over the last three decades has made a significant difference. Hospitalizations and emergency room visits decreased by 36 percent between 2000 and 2015, with current rates of emergency visits in the lowest 10th percentile of the standard national benchmark. Since SCF opened in 1984, deaths due to cancer, heart disease, and cerebrovascular disease have dropped by 26 percent, 47 percent, and 59 percent, respectively. Infant mortality has also dropped by 58 percent. The list goes on. And all of this has been accomplished while controlling costs.
This success has garnered prestigious awards. In 2011, SCF became the first tribal organization to win the Malcolm Baldrige National Quality Award, the highest US presidential honor for performance excellence. SCF president and CEO Katherine Gottlieb is the first Alaskan ever to win the MacArthur “Genius” Grant, which recognized her role in health-care transformation.
Now SCF has become an international model of health-care reform. By adopting the Nuka System of Care, CareOregon, a managedcare plan in Portland, improved patient health while slashing $2.8 million from its annual budget. The Cherokee Nation and the US Department of Veterans Affairs are following suit. Harvard Medical School’s Center for Primary Care recently announced plans to transform its own system based on SCF’s integrated-care approach and sends its physicians to Anchorage for on-site training.
Born in Crisis
All of this remarkable success would beggar the belief of those present 33 years ago, when SCF opened its doors as a community health initiative to confront decades of neglect and the legacies of an ineffective federal bureaucracy. Throughout Alaska, health care was virtually nonexistent until the middle of the 20th century, when the federal government expanded its presence in the territory: It built a few hospitals for tuberculosis patients and established a community-based health-care system in rural Alaska, consisting mostly of rudimentary clinics. Itinerant public health nurses administered vaccines and treated illnesses, but few villages had permanent medical personnel.
During World War II, most of the hospitals closed as resources were redirected to the war effort. This was the height of the tuberculosis epidemic in Alaska, the latest in a series of epidemics that decimated the Native population. In the first half of the century, tuberculosis accounted for one third of all deaths of Alaska Native people, a rate 23 times higher than that for the general population.
Beyond the lack of basic medical care, Alaska Native people confronted other health risks. When Alaska became a state in 1959, most lived in rural villages without safe drinking water, sanitation, or electricty. The Parran Report, commissioned by the US Department of the Interior, placed infant mortality at more than 10 percent of all births and life expectancy at 46 years. Poverty, the legacy of two centuries of resource exploitation and economic exclusion, worsened the problems. In 1960, Alaska Native personal income was about 10 percent of that of the white population in the United States, with more than two thirds of households falling below the poverty line—a rate more than triple that of white Alaskans.
By the late 1960s, the situation of Alaska Native people had reached what the newly formed Alaska Federation of Natives (AFN) characterized as a crisis. Despite the expansion of health care by the federal government, health statistics remained grim. P overty persisted in the face of War on Poverty programs targeted to Alaska Native people, which provided government-built homes, governmentfunded food supplies, and support for education, especially in rural areas. In fact, a US congressional report found that Native individual and social well-being had declined with the growth of government programs. Solutions to these problems, AFN insisted, had to come from within the Native community itself.
The transition to self-determination that commenced in the 1960s was seeded from an unlikely source. In 1968, oil was discovered on Alaska’s North Slope at Prudhoe Bay, now the largest oil field in North America. AFN filed legal suit because transporting the oil south to the port of Valdez would require construction of a pipeline extending 800 miles across traditional Native territory. AFN argued that Native claims to those lands had to be settled first. The courts agreed.
The result was the largest indigenous land claims settlement in US history. The 1971 Alaska Native Claims Settlement Act (ANCSA) conveyed title to 44 million acres, about one ninth of the state, to new corporations held by Alaska Native people. Despite notable shortcomings, the settlement provided resources for community development, including health care. Four years later, the Indian Self-Determination and Education Assistance Act enabled communities to enter into compact agreements with the Indian Health Service (IHS) to take control of programs previously administered by the federal government.
IHS was founded in 1955 to address health issues in Indian country and build hospitals in areas with large Native populations, including Alaska. This government responsibility for health care came at a high price: Through treaties and other agreements, Native Americans relinquished land in exchange for health care. Nevertheless, IHS is chronically underfunded. The federal government spends far less on Native Americans than it does on any other group receiving public health care (through, for example, Medicare, Medicaid, or the Department of Veterans Affairs). Per capita funding for health care for federal prisoners is twice that for Native Americans.
“As a person who grew up on the East Coast, I was shocked by the absolute Third World feeling of Browning, Mont., of Aberdeen, N.D., of some of the places in the Southwest,” says Dr. Steve Tierney, an SCF medical director and physician. “I thought they’d have what I considered basic things. In some of those places, the health center was two double-wide trailers wired together.”
In the mid-1990s, Tierney came to work at the Indian Health Service hospital in Anchorage. In those days, Gottlieb recalls, “the hospital was terrible.” Gottlieb began her career as a health aide in the tribal community where she grew up. In 1987, she joined SCF as a receptionist and within four years became its CEO.
The dismal conditions at the old Alaska Native Medical Center in Anchorage motivated her efforts. “The entry was through the emergency room,” Gottlieb recalls. “People had to wait for many, many hours, all in a crowded room, babies crying, people coming in with everything from cardiac arrest to traumatic injuries to babies’ colds. The treatment was rude, the providers were rude, the staff was rude. If Native people could take it over, I knew that we could make change in the system.”
In the aftermath of the land claims settlement, Native organizations took control of all Native health care throughout the state. They gradually transformed the system completely, from the physical space to the model of care. SCF was founded in 1982 as a nonprofit subsidiary of a Native corporation established under the land claims agreement. It entered its first compact agreement with IHS and in 1984 began to provide limited services (dentistry, optometry, community health, and injury treatment).
At that time, SCF had an annual budget of $3 million and a handful of employees. Over the next decade, it expanded its programs to include substance abuse treatment, health screenings, and family support. In 1994, it converted a ward in the old hospital to a small family-practice clinic. For the first time, primary care was no longer administered through the emergency room.
The most dramatic changes came in the late 1990s, after SCF assumed ownership of the entire health-care-delivery system. In 1998, it took over a greatly expanded primary-care system, and the following year it partnered with the Alaska Native Tribal Health Consortium to assume management of the new Alaska Native Medical Center. Redesigned by Alaska Native people who worked with architects, the new hospital had opened in 1997 to serve the state’s 136,000 Alaska Native and American Indian people.
Now that Alaska Native people controlled the entire system, they could also redesign their system of care. “We fundamentally rethought how health care was delivered,” explains Michelle Tierney, vice president of organizational development and innovation at SCF. “You can’t just fix pieces; you have to change the entire paradigm.” These changes, remembers Dr. Steve Tierney, began with a series of questions: “What would you do if the CEO and 50 of her extended family—and, by the way, your board of directors as well—were your patients? What if we started treating people, not diseases?”
The answers came from the community. “We asked, what do people want?” Gottleib says. The organization conducted extensive interviews, surveys, and focus groups with community members and tribal leadership about the shortcomings of the old system and ideas for change. The Nuka System of Care emerged completely from community feedback.
The result is health care that anyone would envy. Integrated medical teams provide state-of-the-art treatment with a strong emphasis on prevention. The teams include a primary-care physician, a medical assistant, a nurse who coordinates care, an administrative assistant, and often a behavioral health consultant. They share access to dietitians, pharmacists, and specialists. There are no physician’s offices. Instead, teams work together in an open area to facilitate communication. Team effectiveness pivots on the integrated delivery system and personal relationships between providers and patients. Physicians’ pay is calibrated not to office visits but rather to team performance. Patients, who are called “customer-owners” to emphasize their responsibility for their own care, choose their own medical team and stay with them to ensure continuity of care.
Same-day appointments with a primary-care provider are guaranteed, and customer-owners can contact their team by phone or e-mail and expect quick responses. Team members handle routine matters, often by phone, so that physicians’ time and appointments are reserved for more complicated issues. Wait times for appointments rarely exceed a few minutes. In a single visit, a customer-owner might see a physician, consult with a dietitian, and then drop in on a parenting or workout class. The customer satisfaction rate is 96 percent.
Healthier Through Connectedness
But to address the health issues that afflict the Native community, SCF not only had to improve quality and access, but also had to change behavior. Today up to 85 percent of US health-care costs are related to chronic and nonemergency illnesses. “For chronic conditions, the patient and family are in control,” explains Dr. Doug Eby, vice president of medical services at SCF. “Modern medicine ignores this fact.”
With SCF’s model, the customer is in control and makes healthcare decisions with the advice and support of providers. “The main work of our system,” Eby continues, “is to influence what people do when they’re living their lives, day in and day out. The main goal is healthier living, healthier choices.” The key to such change is “trusting, accountable, long-term personal relationships” between providers and patients. “Native wisdom about how to influence change in behavior,” he insists, is “the best wisdom I’ve found anywhere in the world.”
Native wisdom is the understanding that social, cultural, and spiritual connectedness is integral to physical health. This vision influences the delivery of information as well as the nature of the programs. Treatment for substance abuse and domestic violence, among other problems, targets families and communities rather than individuals, and programs such as cancer treatment encourage traditional diets and traditional ways of gathering and preparing food, including their spiritual and social dimensions.
Today SCF has 2,000 employees and an annual operating budget of more than $320 million. About half of its income comes from third-party payments (private insurance, Medicare, and Medicaid), and the remainder comes from IHS (43 percent) and federal, state, and local grants (5 percent). Customer-owners do not pay out of pocket for services, even for copays. No eligible person is denied care, regardless of ability to pay, and the organization even covers travel expenses for those from remote areas who need treatment at its flagship site. Nearly half of the entire population of Alaska resides in Anchorage, but SCF serves a population across 108,000 square miles through telemedicine and partnerships with 51 village health clinics. Medical teams also travel to villages on a regular basis.
Whereas US health care typically aims to promote revenue generation, SCF focuses on controlling costs. “If you spend more money in primary care,” Michelle Tierney says, “you save in more expensive parts of the system.” Emphasis on prevention and integrated health-care delivery results in less demand for specialty care and fewer ER visits. Equally important is the understanding that physical health is bound to social and spiritual well-being. Wellness, in this model, comes from facilitating cultural connection and strengthening families and communities.
In addition to primary care, SCF offers a range of programs in the areas of complementary medicine, substance abuse, mental health, and home health. Two of its signature programs, the Traditional Healing Clinic and Family Wellness Warriors Initiative, illustrate how they use the connections among mind, body, and spirit to revitalize health.
Traditional Healing Referrals
“Traditional healing has been around for 10,000 years,” Dr. Ted Mala says. “It sustained our culture long before MRIs and CT scans. The technology was psychoneuroimmunology: the mind engaging the body through things that raised one’s spirit and built up the immunological system to sustain us through the most difficult of times.” Mala, now retired, was the first director of the Traditional Healing Clinic, the only such program in a facility that is accredited by the Joint Commission, the organization that accredits US health-care organizations. In response to community demand, the Traditional Healing Clinic opened its doors in 2001 and now has several tribal doctors on staff.
At SCF, traditional healing complements allopathic medicine, and tribal doctors hold the same status as medical doctors. Primarycare physicians provide referrals for traditional healing, just as they would for any other kind of specialized care. Each healer has an area of focus (such as pain management or musculoskeletal alignment) and uses techniques appropriate to that specialization. These might include touch therapy, massage, traditional approaches to counseling and conflict resolution, prayer, or ceremonial songs and dances. Tribal doctors use electronic medical records to chart treatments and progress for review by the primary-care provider.
Treatment begins with a lengthy conversation about culture and community. “We talk about who you are, where you are from, what do you know about your culture, who is your family,” Mala says. It is no surprise, then, that SCF’s Anchorage medical facility feels like a community center. Common areas (lobbies and hallways) have been designed as gathering spaces with seating in circular arrangements. People gather there not just to seek medical treatment but also to meet over coffee with friends and family who might be in town. Outside in the back, doctors and staff members maintain a garden for plants used in tribal medicine. Tribal doctors teach customerowners how to identify and use these plants at home.
The Traditional Healing Clinic appoints only Alaska Native healers who have strong cultural knowledge and relationships with their tribal communities. Each undergoes a lengthy apprenticeship; then a council of elders decides who will be appointed as a tribal doctor. The goals of traditional healing extend beyond treating illness by integrating wellness practices into the daily lives of customerowners, a focus on prevention that is gaining validation even in mainstream medicine.
Curing Intergenerational Grief
Traditional healers do not simply treat the immediate ailments of the patient; they also treat what the patient carries from her ancestors—the multigenerational trauma that endures from her history. The connections among trauma, physical health, and social wellbeing are at the center of SCF’s other signature program, the Family Wellness Warriors Initiative, a faith-based effort that incorporates Native spiritual practices into the healing process.
Sexual violence and child abuse are among the greatest challenges confronted by Native American communities. In Alaska, statistics are especially dire. More than three quarters of Alaska Native women experience physical assault during their lifetime. Alaska has the highest homicide rate for female victims of domestic violence and, for 25 of the last 32 years, the highest incidence of rape in the nation. About 80 percent of victims are Alaska Native women. Child sexual assault occurs in Alaska at six times the national average, and over half of substantiated cases involve Native children.
The Family Wellness Warriors Initiative is a training and education program that addresses domestic violence, child abuse, and child neglect within and beyond the Alaska Native community. Sandra Bohling is one of the program’s managers, and Polly Andrews and Marcel Bergeron are trainers. “Statistics can easily just be numbers,” Bergeron says, “but to us, these are faces, these are the people we work with, these are our family.” Such personal connections led Andrews to join the program. “Every single family around me had children who had experienced this,” says Andrews.
The reasons are hard to pin down, but they are inevitably tied up with history. Through the middle of the 20th century, epidemics left many children without parents and thus without models to emulate when they had their own children. The expansion of churches and mission schools brought other risks. Here and elsewhere, children were systematically abused in mission and boarding schools. A decade ago, the Catholic sex-abuse scandal erupted in Alaska, revealing that for decades the church had sent known pedophiles to isolated Native villages.
When asked about the reasons for the statistics, Bohling, Andrews, and Bergeron turn to this history. “When my grandmother was a baby, both of her parents died of whatever sicknesses were going on,” says Andrews. “Today she’s 83, and she still grieves, and she still cries, because she was an orphan.”
The sources of such grief, in their telling, extend beyond families to entire communities. “Thinking about the boarding schools,” Andrews continues, “I always thought, well, people grieve because they were taken away from the villages, their identities were taken away, and they were far from home. I didn’t understand what it meant for all the adults and the parents until an elder in my hometown said, ‘It got so quiet when all the children left.’”
“When people are stripped of their identity,” Bergeron adds, “they need to cope one way or another, so they turn to alcohol, drugs, whatever is available. And then generational trauma gets passed on, and in my opinion, that trauma multiplies when it goes unresolved.” Alcohol and drug abuse, statistics show, dramatically increase the incidence of violence and domestic abuse.
The Family Wellness Warriors Initiative opened in 1999 with the goal of ending domestic violence, child sexual abuse, and child neglect. In addition to raising awareness of these issues and their causes, the program relies on personal testimony as a strategy for healing. “We have been silent about what happened to us for so many years, for so many generations back,” Bohling explains. “People are getting to tell their story for the first time to people who hear them, removing the shame.”
Initial training takes place through conferences that require on-site lodging. Group leaders act as models for sharing personal stories and responding in ways that encourage healthy relationships, and then participants share their own stories in small groups. Participants must also confront how their past experiences shape their current interactions with others. Mental health clinicians provide individual counseling, and the program conducts followup studies one year after training.
The initiative has been enormously successful. On average, participants report that substance abuse, depression, and symptoms of trauma have been reduced by about 50 percent, and anxiety has been reduced by 25 percent. About two-thirds report an increase in self-esteem, cultural connectedness, and spiritual well-being. As a result, they are far less likely to inflict harm on themselves or others. Because of these results, the program has received the endorsement of the psychiatric community and garnered awards from the Alaska Public Health Association, the National Indian Health Board, and other organizations.
The Family Wellness Warriors Initiative counts among Gottlieb’s passions, and its vision of wellness echoes her own. “I have an image in my head of a 5-year-old child, a boy or girl, being able to be anywhere, in any place, in any environment and to stand in the middle of the room and twirl around and feel safe,” she says. “When every 5-year-old can do that, in every Alaska Native community, that’s wellness for me.”
In the years ahead, Gottlieb anticipates putting an end to domestic violence, child abuse, and child neglect. She insists that the Native community holds the power to accomplish this goal. “We’re like the people who drive a tiger out of the woods. They get the whole community, they line up side by side, and they make noise. In 10 years I expect it to be gone, gone, gone.”
But like other health-care organizations, SCF confronts an era of increasing financial and political uncertainty. The repeal of the Affordable Care Act (ACA), Vice President of Finance Lee Olson says, could cause tens of thousands of customer-owners to lose Medicaid coverage and hundreds of others to lose insurance through the federal marketplace. Additionally, Alaska’s massive budget deficit, due in part to the fall in oil prices, means that state funding will likely plummet. Other financial risks are specific to tribal organizations. Continued funding for IHS, the source of 43 percent of SCF’s budget, is uncertain under the Trump administration, and repeal of the ACA could also include repeal of the Indian Health Care Improvement Act, which authorizes tribal health-care providers to recover reasonable charges for services provided to those with private insurance. This alone could reduce insurance reimbursements by tens of millions of dollars annually.
As SCF confronts the prospect of financial precariousness, its strength remains in its close relationship with the community it serves. SCF’s revolutionary model of health care emerged from community partnerships during a time of scarce resources. The community will likewise work together to meet whatever challenges lie ahead.