Dr. Anne Zink: What Alaska has learned after two years of COVID-19
By Peter Loewi
In an interview with The Nome Nugget, Alaska State Chief Medical Officer, Dr. Anne Zink explains what Alaska has learned in two years of the COVID-19 pandemic, why it is about more than just fighting COVID and what’s next for Alaska.
Nome Nugget: What have you been seeing change in the last month or two? You probably see things at the clinical level before you see them at the state level?
Dr. Anne Zink: There’s a visceral sense of how the world is going in the emergency department. I do think that with COVID, we would clearly see an uptick in cases before it would show up in the data. It’s been a really nice place to double-check our data, get a gut check of what’s happening.
In general, since the Delta wave, things have been settling down significantly. With the Omicron wave, we had a lot of cases, but we weren’t seeing nearly as many people get sick.
Right now, what we’re seeing is delayed health care, people showing up with stage 3 stage 4 cancers because they missed a colonoscopy or their mammogram, or they lost their jobs and they lost insurance, so they didn’t follow up in that time. We’re seeing more of that.
And while our number of suicides has not increased, the number of suicide attempts have increased, particularly those between the ages of 11 and 14 and those over 60. It’s important to remember that nine out of 10 people who do attempt don’t go on to commit suicide, but they are struggling, and are needing mental health support and resources.
We’re seeing that kind of surge right now in the ER.
Nome Nugget: This feels like a silent pandemic, things we aren’t paying attention to?
AZ: They’re all being impacted by the pandemic, and I think that the infrastructure of public health has been cut for the last decade and has been diminishing over time. The healthcare system has increasingly become a “just in time,” instead of a “just in case” healthcare system, where mental health and physical health are separate. We are one person, mental and physical health, but how we deliver that care is often separate and different, and I think that the pandemic exacerbated many of those challenges and issues.
I think we need to be taking the lessons learned from this pandemic and realizing that they are in a much larger social context, health context, environmental context, and find solutions and ways that systems can make people better instead of people just working for systems.
Nome Nugget: What does ‘pandemic’ to ‘endemic’ mean in terms of the coronavirus, but on the other side of that, with a transition, are we going to start seeing proper care, or is just going to be back to not caring?
AZ: I think people love the word “endemic” because it has it the word “end” in it. That does not mean that it goes away. There are many endemic diseases such as influenza, measles, tuberculosis, that have variability. Endemic does not mean it’s ended and it has gone away. It just means that it is affecting local populations rather than the entire world. So, when I get questions from mayors or governors or local municipalities, “well, we want to make it endemic,” well, that’s great, but pandemic means the whole world. It’s a worldwide definition, not a local definition.
So, an endemic disease means that Public Health is still doing a lot of education, a lot of resources to try to figure out and explain the risk of the disease, mitigate the disease, contact tracing.
I was just on a call about this. Tuberculosis is endemic. We have the highest rates of tuberculosis in the country, and we are experiencing a pretty significant outbreak right now.
So many of the same things that the general public learned about during COVID like contact tracing, access to testing, R-naught value, treatments, those apply to all sorts of diseases, and particularly respiratory pathogens. And actually, there are similar resources that are used. In Bethel’s hospital right now, 75 percent of their negative pressure rooms in their hospital are for TB patients right now, because of their TB cases.
But the next question about are we just going to let it get back to normal, I mean, that is up to all of us. We live in a big, beautiful, incredibly messy democracy, and it depends on people’s willingness to go back to normal or to change things. What we have seen from essentially other major health challenge is that federally, we pour money into it, we put a lot of disease specific focus on it, be it Zika, Ebola, H1N1, those funds run out, they go away, and we don’t fundamentally change the system. Then the next challenge comes about, and it’s a little bit different than the one before, and we don’t have the tools and resources to pivot, and we forget about that issue and go forward.
There’s been a faster pressure to move away from this one, because people are so tired, and wanting it to quote “end,” and so I worry that we won’t take the lessons learned from this and make systemic changes.
Public health is not just public health. It is tribal health, it is school health, it is industry health, but it is also the cornerstone to our economic security as well as our military and physical security as a country. When we get sick, we don’t have the ability to go to work, let alone run our jobs, let alone respond, and so I think we really need to continue to think about our health in a similar way and our defenses against infectious diseases in a similar way that we think about our defenses against other foreign threats and other threats that we all face.
Thirty-two communities in this state don’t have active running water and sewer systems. So when I say “wash your hands,” that means something else when you don’t have access to running water or when you’ve got sewer challenges.
I think things like our community health aide system within our tribal health system is a very locally-based, community-driven tool to increase the health in communities that don’t have other providers. We have communities in the state that 100 percent of those eligible are vaccinated, and that is because of the role of trusted healthcare providers that are local, that understand the community. That’s not doctors in this community, those are community health aides who know the language, know the community. That community partnership in health really was incredibly helpful, as well. When we rely on high-end healthcare, we fail at the basic public health needs, which are the cornerstone, the foundation, of our health.
Nome Nugget: The Nome Census Area has had a small number of deaths. A lot of Alaska has had high case rates. The Nome and Bering Strait region has 10,000 people, we’ve had 6,000 cases, and six deaths. Why?
AZ: I think there’s a couple of things: One, we tend to have a pretty young population. Age is clearly a huge risk factor.
Two, we have the smallest, lowest number of nursing home beds per capita of any state. That has been a limitation in caring for elders, but we don’t big 200-person, 300-person nursing homes where it rips through really quickly.
Three, testing, I think, made a huge difference for our state. The testing landscape in this country was a huge failure early on. In Alaska, we 3D manufactured our own swabs. We had our public health laboratory set up an insane amount of testing. We quickly saw that Alaska was going to be cut out of testing and we were really on our own in this space. We could have spent a lot of time on ventilators, we could have spent a lot of time on ICU care, and we said, “let’s spend a lot of time and effort on testing.”
Think about Nome, think about the airport testing. When people were coming through a finite spot, and trying to test and identify cases super early, before it went out to smaller and more rural communities.
I think the independent sovereignty of our tribes allowed local communities to take some really significant actions that helped protect their communities.
And then we were fortunate enough to get vaccines. Alaska was the leader in getting vaccines out per capita for multiple months and we were the first state to get those 16 and over vaccinated and to open it up. And that was a lot of because of partnership with the tribes. Tribes had the opportunity to go with IHS or the State, and they took a risk. Their risk was to come partner with the State, and ultimately, all 226 tribes partnered with us. We are the only state where that happened, where the tribes completely partnered with the State. Through that we were able to create massive efficiencies in getting the vaccine out to communities very quickly, so that communities could then get it out and what made sense. I don’t know the best way to get vaccine out around the Nome area, so if I can get Nome vaccine, they can get it out and go from there. Our motto was “fast and fair.”
Every day that we got someone vaccinated earlier, saved lives. That made a really big difference. Because of all of those things, when you then saw the Delta wave, and then even the Omicron wave, they were at a later point in time when you had more testing, more treatment, and more people who had been vaccinated, so you had more protection against it. So when we did have really big waves, particularly that Delta wave, we were going into it much more prepared than New York did or the Navajo Nation did, where you just got massive deaths associated with those really big waves.
You know, we have BA.2 slowly going up right now, we still see cases and we still see hospitalizations, but we have resources like we never had before. And we have people who have protection like we never had before, and so it’s really not impacting Alaska like it is some place like China, where most of their population hasn’t seen it.
Nome Nugget: How have variants changed people’s perceptions of herd immunity?
AZ: Herd immunity is the concept that a community has enough protection overall from an infectious disease that it cannot find enough susceptible hosts to move from person to person and continue to spread. I think of it like a wildfire. If you have a fire, and there’s no more dry wood for it to jump to, it kind of fizzles out and dies out, and can’t move to that next person. But that is calculated on and depends on two major things. It depends on how much protection you have, or how much the population has, either from past infection or from vaccination, and it depends on the virus and how easily it moves from person to person. So when we were initially talking about this virus, it had an R naught of about 2 to 2.5. One person would spread it to about two to two and a half other people. To put that in perspective, influenza is about 1.3-1.5 for an R naught, versus measles, which is about 15, kind of our most highly contagious infectious disease, airborne, in that sense. With Omicron, and particularly BA.2, we’re now looking at an R naught of about 10 to 11. I mean, it spreads SO fast.
Omicron is not mild. Omicron spreads really easily, it’s just that we’re seeing it with the protection of either past infection or vaccination. Because it has become so much more transmissible, it becomes harder to be able to get that quote ‘herd immunity.’ I’ve seen patients who have been infected four times. Like, you’ve had every variant. Because of that, those are limitations to this concept of how to get herd immunity.
When people argue to me, “Well let’s just get it and get it over with,” wouldn’t you rather schedule that? And then they’re like, “of course I’d rather schedule it, it’s easier,” and I go then just schedule your booster or vaccine. You can schedule your immunity this Saturday, and it’s free! And you can do it with less risk of hospitalization and death. It’s the same idea, you’re getting a degree of immunity. You can do it on your schedule, and it comes with less risk. It’s the cheap, easy version rather than going the really long, hard version of it. Both give you some degree of protection, just one is schedulable and causes less risk.
Nome Nugget: One final question. What’s next?
AZ: The big thing I think that’s what’s next for me is to think about the systems that have failed us as Alaskans, as public health officials, as healthcare providers, and finding ways to make those systems better. Finding ways to make data information better, so I’m not having the National Guard in our state lab entering one positive into three different systems for a year so I can see how many cases there are. Not having rooms full of faxes where my Epi team is like, literally putting them on hand by hand. The hospital bed capacity, and knowing that capacity, that goes away with the public health emergency if that isn’t continued another way.
And then for Alaskans in general, we’ve really picked on Healthy You in the 2022 campaign. We’re really hoping all Alaskans join us in finding ways to recommit to their health. If we are physically and mentally well, we are more prepared for earthquakes, for volcanic eruptions, for COVID outbreaks, for all of our challenges.
Each quarter we have a different focus. The first quarter was physical activity, the second quarter is on mental health, the third one is on food, diet, and nutrition, and the fourth one is one habits and social connectivity. We have a bunch of videos out, we’re working with healthcare providers, in trying to engage Alaskans in committing to their health, because that is going to make our economy stronger, that’s going to make us more resilient to whatever challenges we have and finding a way to be healthier. That’s what’s next.
This interview has been edited for length and clarity.
