The Siberian Yupik town of Gambell, Alaska, sits on the western edge of St. Lawrence Island in the Bering Sea, closer to Russia than the Alaska mainland and two plane rides from Anchorage. Whale and walrus are among the primary stocks harvested for food; the nearest hospital is more than 100 miles away in Nome. But Gambell’s remoteness has not protected it from the coronavirus.

Now everyone in this 700-person Indigenous community knows someone who had the coronavirus. Thirty-three residents tested positive this month, part of a wave of coronavirus cases that have shut down small towns in Alaska. Currently, more than 20 communities in western Alaska are either on strict lockdown or advised to be on one.

For months, Alaska’s remote, mostly Indigenous rural communities protected themselves from the coronavirus through restrictions on travel and local health measures. Once the virus arrived, though, conditions enabled it to spread like wildfire. Cases have exploded in recent weeks in some of the country’s most geographically isolated regions, leaving residents and health officials fearful that acute cases could quickly overwhelm the state’s meager hospital system.

In Chevak, a town of 1,075 near the mouth of the Yukon River in far western Alaska, almost a fifth of its residents have tested positive for the coronavirus as of this week.

After a handful of positive tests, Mayor Richard Tuluk said, leaders and health officials in the region quickly arranged for widespread testing at Chevak’s small local clinic. More than 700 people submitted samples. Tuluk says around 170 came back positive.

Chevak and other towns in the region have suspended in-person instruction across dozens of tiny community schools, relying on distance learning in a region with inconsistent and expensive Internet. The community’s lone store closed for days, prompting complaints from residents unable to get necessities like milk or diapers. The post office is severely backlogged. Masking is more strictly observed, and gatherings beyond immediate family have all but ceased.

Alaska managed to contain the spread of the coronavirus in the first months of the pandemic by locking down early. But numbers crept up over the summer and are now rising exponentially, with hundreds of daily cases reported. At 48.3 new cases per 100,000 residents over the past week, the positivity rate is the eighth highest in the country, though Alaska has so far maintained among the lowest mortality rates for covid-19, the disease caused by the coronavirus.

Chevak hasn’t yet seen high numbers of people falling seriously ill after testing positive.

“Knock on wood,” Tuluk said. “So far we haven’t heard of any of our elders getting sick or things like that.”

Lockdowns, quarantines and self-isolation are difficult in rural Alaska, particularly in the state’s western and northern quadrants. Housing is cramped. The inadequate broadband system makes Internet distractions like video-streaming or gaming difficult.

“Every household is sticking to themselves as much as possible,” said Charlotte Apatiki, who is Siberian Yupik and city clerk in Gambell.

At the height of its lockdown in late September and early October, the community’s store would only take food orders called in ahead of time as supply shipments sputtered. The mayor and some village police officers delivered food and water to residents in isolation.

“There was no fresh produce for quite a while, no fresh meat, nothing but canned goods,” Apatiki said.

In spite of the fear and difficulty, the measures worked. Gambell hasn’t had a new case in three weeks, according to Mayor Joel James.

Hundreds of miles over water from St. Lawrence Island, around 23,000 mostly Yupik residents occupy 58 communities in the Yukon-Kuskokwim Region, all of which are disconnected from the state’s road system and accessible only by boat, plane or snowmobile. With more than a hundred cases per 100,000 people in the region, if it were a state, it would have the fourth highest rate of positive tests in the country, health officials told public radio station KYUK.

“I literally cannot sleep at night because of how worried I am,” said Ellen Hodges, chief of staff at the Yukon-Kuskokwim Health Corporation in Bethel. She fears the region will follow national trends, with early spread among the young giving way to infections among older adults that end up acutely sick in clinics or hospitals.

“Given our fragile health-care system and the remote nature of where we live, I’m concerned we will overwhelm our health-care system in a matter of weeks,” Hodges said.

Conditions are ripe for viral transmission. The region has some of the most dense housing in the country. It’s not uncommon for 10 people to live in a two-bedroom house with one bathroom, Hodges said. Forty percent of homes do not have water or sewer systems.

“Imagine if you had to pack every ounce of water to your house,” Hodges said. “You might not spend a lot of extra time washing your hands if you don’t have access to clean, fresh, running water.”

Contact tracing links many of the cases to spread within family groups but also to funerals, birthdays, religious services and even a gender reveal party, according to Hodges.

The alarm is not just that small rural clinics or regional hospitals will be overwhelmed, but that with cases also rising in Alaska’s population hubs along the road-system, there will be nowhere to send the acutely sick.

“You really start to see cracks manifest in the system,” said Jared Kosin, CEO of the Alaska State Hospital and Nursing Home Association in Anchorage, which is home to the bulk of the state’s medical capacity. “Covid hospitalizations and covid ICU stays are definitely on the rise.”

At 7.27 percent, the state’s hospital bed capacity is just below the national average of 8 percent. But the case acceleration has only started in the last few weeks.

Though Alaska has not yet had to take the kinds of emergency measures seen in some Western and Midwestern states in recent weeks, Kosin sees troubling indicators. Fall is a busy season for hospitals. The flu hits. And people who have met their annual deductibles access medical services more frequently. Although Kosin’s organization doesn’t track specific figures, he is hearing about more illness among staffers, as well as burnout. It’s a situation exacerbated by Alaska’s reliance on itinerant medical professionals from out of state, who travel in to work well-paid stints at facilities where it can be hard to retain permanent staff.

“It’s incredibly difficult right now to find any travelers, because they’re in such high demand from everywhere else in the Lower 48. And on top of that, it’s winter here, which might turn some of them off to begin with,” Koskin said. “We’re really kind of left on our own.”

Though emergency rooms and intensive care units are not yet overwhelmed in Anchorage, Kosin believes it’s only a matter of time until the surging case counts translate into hospitalizations.

“The math doesn’t work out,” he said.

Even with alarm bells going off, Alaska has fared better than many other states, thanks in part to widespread testing.

“We have had broad, sweeping testing from the beginning, so that has meant that our case fatality rate is lower,” said Anne Zink, Alaska’s chief medical officer.

In Chevak, initial early cases led health officials to launch the rapid testing process that turned up evidence of rampant community spread.

“That would be impossible to pull off in the same sort of way in Anchorage,” Zink said. “So I think it does identify a lot more asymptomatic and mildly symptomatic cases you wouldn’t identify.”

The state is focusing its latest public health push on testing capacity. It coordinated with private companies to send out hundreds more testing machines, shipped out 4,000 rapid antigen testing kits to the hub community of Bethel, with another 25,000 scheduled to be distributed in rural areas in the weeks ahead.

In a Wednesday press briefing, Gov. Mike Dunleavy (R) encouraged masking and social distancing but resisted broader measures like a mask mandate or mandatory business closures.

“If we keep working on this as individuals, and looking out for ourselves and each other, we should be able to get the cases flattening out,” Dunleavy said.

Dunleavy, who lived and worked for years in rural western Alaska, made little mention of specific provisions for the region beyond additional testing resources and protective equipment earmarked for communities.

Alaska has fared better than many states during the pandemic. It locked down early and strictly, and it has the lowest number of nursing homes per capita in the country, sites of some of the country’s most devastatingly fatal outbreaks.

Still, Zink, who continues working shifts as an ER physician taking care of sick patients, is concerned that the rising case counts are going to lead to more acute illness, suffering and death.

“I don’t wish this on anyone,” she said.