Linda Curda was interviewed on August 25, 2005 by Karen Brewster at Linda's home/office in Anchorage, Alaska. In this first part of a two part interview, Linda talks about the community health aide (CHA) training program, the development of the new manual, the content of the new manual, ways to improve CHA training and practice, professionalizing the CHA job, issues of job attrition, and the importance of having good health care in rural Alaska.
Digital Asset Information
Project: Community Health Aide Program Project Jukebox
Date of Interview: Aug 25, 2005
Narrator(s): Linda Curda
Interviewer(s): Karen Brewster
Transcriber: Carol McCue
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Her education and training, and her role in the development of the training and academic programs for the Community Health Aide Program.
The training requirements and training facilities for health aides.
The health aide training process in the early days, and her role as a health aide trainer and educator.
Changes in health aide training from the early years to the present.
History of health aide training and testing methods.
Teaching methods and learning styles used in the training program.
Improvements in health aide training and the job-placement process.
Her involvement with developing the Community Health Aide Manual (CHAM).
Her involvement with instructor training and development.
Her personal interests in making health aide training accessible.
Attrition issues and problems with the length of time needed for health aide training and the demands of the job.
Her personal goal toward making health aide training accessible and practical, as well as her continuing involvement in training and development.
The Applied Science Degree requirements and the implementation of computers and the internet for distance delivery training.
The development of distance delivery courses.
The Community Health Aide Manual Project and on-going updates to the Community Health Aide Manual (CHAM).
How the Community Health Aide Program in Alaska is unique to the United States.
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After clicking play, click a section of the transcript to navigate the audio or video clip.
KAREN: Okay. This is Karen Brewster and I'm here in Anchorage with Linda Curda. Today is August 25th, 2005. And this is for the Community Health Aides Project. Thank you for being willing to be interviewed and taking time out of your busy day. LINDA: You're welcome. I'm glad that you're here and it's nice to be talking about this program, this incredible Community Health Aide Practitioner Program. KAREN: Great. Well, just to get us started, tell us a little bit about you, your background, you know, when and where you were born, education, how you ended up in Alaska --. LINDA: Okay. KAREN: -- doing what you do. LINDA: I was -- I grew up outside Washington D.C. in Chevy Chase, Maryland, and went to the University of Maryland School of Nursing. And when I graduated, my husband and I looked at each other one day and said, let's drive to Alaska. So we drove here in 1972 from the East Coast, landed in Anchorage, and within a week, we both had jobs in Bethel. And I was a staff nurse at the old Indian Health Service Hospital where the new YKHC office building is actually located. And went to work rotating shifts in the old hospital. And then became head of the obstetrical ward and did that for a while. And through my experience with birth and babies and all of that, I decided to go back to school. I had been interested in Public Health all my nursing career and Johns Hopkins University had a program of a combined Nurse Midwifery and Masters in Public Health. So I went back East from '75 to '77 at Hopkins, it was a dual program, sort of woven together as we took courses in world population and crisis issues, and then had patients in labor and delivery at night. It was -- it was a grueling two years, but it was very rewarding and I -- it was a good combination for my interest and skills. And my plan had been to come back to Bethel as the town midwife, and as I was graduating, two things happened. One was I was asked if I would stay and teach in the program, and I was surprised by that request by the director of the program. And my husband decided to go to law school. So he went to law school in Washington D.C., and I started teaching at Hopkins in 1977. We drove -- I drove north and he drove south, and taught at Hopkins in the midwifery program for three years. And my husband graduated from law school, and I had moved us East to graduate school, it was his turn to make a decision, and he wanted to move back to Alaska. So one day he got a call from a judge in Bethel who said -- who we didn't know directly but this is a small state. Dale had applied for jobs in Juneau, and the judge said we have a new position on the bench and we would like you to come and take it. So that was in 1980 and we drove back to Alaska. And I thought that I was -- by this time my daughter had been born and I thought that I would be the town midwife, that's all that I always thought that I'd do, and we moved back to Bethel, my daughter was one, and thought I would just sort of be a mom for a while. I had worked from the time I was 17 in -- as a nurse's aide and a scrub nurse in the OR and to nursing school, and so it's just sort of let's take a break. You know, it's been 14 years working, but I found that I really enjoy contributing, making a difference, and decided I would look at a part-time job. Well, there was a part-time job within the training program in Bethel, for the Community Health Aide Program. And that was in the fall of '80. And I started there as a part-time basis. And within a year, my son was born, took a little bit of time, and in the fall of 1982, I became the coordinator of the Bethel Community Health Aide Training Program, which, at that time, was located within the Kuskokwim Community College campus with a memorandum of agreement between the community college and YKHC for the training of their health aides. And that was the beginning of a long journey with the Health Aide Program. So for the last 25 years, I've primarily been on the training aspect of the program. Basic training center, and then been involved in a variety of the projects of the program, the health aide manual, the village medicine reference, the curriculum, materials that support and surround the program.
KAREN: And so the AAS degree, is that something required for health aides or -- LINDA: No. The training for health aides is -- and just to sort of review that a little bit, when an individual is hired, they start on the job, and depending on the corporation -- and again, I have 25 years of history, so in the early years, people often sort of worked without much training. Today the system is such that they start on the job, and we try to integrate them into training as soon as possible. And that training includes a Pre-Session 1 package of information that is delivered by the health corporation that gives them the basic information on use of the Community Health Aide Manual, history and exam, vital signs, so that they can start in the role. Then they go to a training center and they take Session 1, and that's a four-week session. And the current training centers in the state, there's the Anchorage Training Center through the Alaska Native Tribal Health Consortium; the Bethel Training Center, which is through YKHC, Yukon Kuskokwim Health Corporation; through Nome, and that's the Norton Sound Health Corporation; and then in Sitka, through the Southeast Area Health Corporation. We have four basic training centers. And the students -- it's a remarkable program. You get hired and on the job before your education. So we try to complement the program with not only basic training, but through each of the health corporations, and there's 26 entities. When I started, there were 12, but the health corporations have divided, villages have split off and formed their own administrative unit. KAREN: I didn't know that. LINDA: Uh-hum. So we had 12 in the original division of the state, for profit and nonprofit, it was a division of 12. KAREN: Right. LINDA: And now my understanding and this could have changed as we're speaking but I believe there's 26 administrative, whether they call themselves health corporations or some other title, but responsible for the delivery of health care in their region, or often now it's -- it can be single village entities. And so the corporations employ supervisor instructors, sometimes called coordinator instructors, who work with the health aides in the village to either teach new skills, but more often it's in the reinforcement of the skills and basic training. So an individual comes for Session 1, four weeks long, then they go back to the village. And one of the field staff will go out for a village visit and look at reinforcing and developing sort of the skill that they've learned in basic training, then they return to a training center, and it's Session 2, the same pattern again. They are required to complete 200 hours and a certain number of patient encounters to look at sort of rounding out their educational process in the village. And then they come back to Sessions 1, 2, 3 and 4, so it's a total of four sessions and 15 weeks spread over about two years, with the field component between. And once they finish that, they do a preceptorship, which is a process where they work with a midlevel practitioner, their village doc, and I think of it as sort of a final polishing. It's an opportunity to see a lot of patients and see what piece of the puzzle skills that they may have not gotten. And just to remind everyone that the Health Aide Program is remarkable in that when you think of health care and you think of an individual, health aides are taking care of all aspects. Emergency care, acute care, chronic and preventative services. And so the scope of theirs is very, very, very, very broad. It goes way out. And the depth of which their skills depends on that component. With time and experience, they are able to do a lot of additional -- with advanced training, say, women's health care, they may do additional skills there, or in well child and immunizations. The training component and the field piece sort of work together. And once they complete the preceptorship they attend, through their corporation usually -- and again, the state is so different -- but usually then they take a statewide certification that has both a written and a clinical component. And all of this, then, is fed through the certification board, which was created in 1998, to look at the continued certification of health aides.
KAREN: So in the early days, there was no certification? LINDA: There was a certification process and it did come -- it was the completing -- completion of basic training, their skills checklist, recommendations by their physician, their village doc, their Public Health nurse, the field folks, their statewide through the certification exam, written and clinical exam, but it wasn't a certification board. A certification board is relatively new in the network of pieces of the puzzle. And that board was created to look at sort of standardizing the review process and also granting certification so that allows for Medicaid reimbursement, which is very new on the scene, where the health aides are able to bill, that they are -- the care that they are giving is billed and payment, then, into the health corporations. KAREN: Okay. I thought as Indian Health Service type things that they wouldn't have Medicaid billing. LINDA: It depends on the individual and -- and whether they are registered for that. And those kinds of questions probably Steve Gage or some of the other health CHAP directors could talk more about in terms of how that network happens. KAREN: So what you -- your involvement, the health corporations were already the ones running the program. LINDA: Uh-hum. KAREN: You weren't involved when it was Indian Health Service in that transition? LINDA: I was. Uh-hum. I was. I just have always been on the training side. My -- my piece of the puzzle in this whole sort of network of folks has been basic training. Basic, then advanced, and now course work towards those who want to get their Associates of Applied Science degree. So that is the segment. And through networking with folks -- so I -- yes, going back to 1980, we had Indian Health Service Hospital relationship so that there was the IHS, YKHC, and the college. So there were sort of the three entities all involved in the training of health aides because we -- the training staff and center was within the community college, Kuskokwim Community College in Bethel. The corporation hired and paid and supervised, and the hospital was our clinical facility, so that we were working in the hospital on a daily basis, but it was sort of -- it was then a really true partnership between these three agencies for the training of health aides. KAREN: Uh-huh. LINDA: That's in the early use. And then in the late -- into the '80s and early '90s, you probably learned that's when the corporations then took over the -- the running of the hospitals throughout the state. And they also did sort of the compact era now in the '90s and as you know, the Alaska Native Tribal Health Consortium was formed in 1998. And so there's just been a tremendous shift in change over time in the administrative component. And I think to the betterment of health care and the networking of the issues.
LINDA: From a training component, there are lots of things that we looked at in the early years that have changed over time, but all supporting the role of the health aide in this sort of dynamic activity in terms of, you know, a patient coming in sort of to return to the -- the components of it. I'll give you an example. You know, someone who might be allergic peanuts, and this actually was a case where this person knew they were allergic so they have this chronic underlying condition, and went to a potluck, and something was cooked in peanut oil, didn't know it, ate it, and started to have a anaphylactic -- go into shock, and so went from, you know, sort of a chronic to an acute to an emergency situation. And it's all preventable. So it was just one of those moments where this very healthy person sort of collided with, you know, this one -- this one thing called peanut oil for her, and was in an emergency situation. And all of us, you know, that's just the nature of being human. KAREN: Right. LINDA: And so the health aide role to work within that scope and try to deal with all of those sort of issues on a daily basis. So -- so if someone comes in with acute otitis media, their role is not only to assess that, do a complete history and physical exam, but also then to treat and try to educate because that's a key part of it is our health care really belongs to the individual. We think it's a whole health care system, but it's really the individual, and the health aide role is to assist and to help people to get well. And that really is through the individual understanding their problem or disease, and following their treatment, whatever that may be. And so the health aide link between the physician in Bethel, out to -- and again, my experience, I'm living here in Anchorage, but my home and my life experience is really Bethel and the YKHC region. You know, as the health aides over time -- I mean, I'd go back in the early '70s to when it was the CB radio, and there was the radio room and you just, you know, sort of the whole Delta knew what was going on. KAREN: Right. LINDA: It was very interesting. And then I remember when there was one phone in a community. And that's, you know, how health care was -- we had talk on the phone. And then from phones to multiple phones to faxes and sort of the ability to send things back and forth all the way now to having the computer element or Telemedicine, Telehealth pictures, all of it, technology has been an interesting piece of the puzzle, but I think that it's still about the individual. It's still about the trained individual who has the human connection with the patient. And so many folks have said, oh, Telehealth will make all the difference. I think it has another element -- it's a tool. It's a tool just like all the tools of medicine. And we learn to use them appropriately and help to -- again, the goal, what's the goal of this program. I think we often lose sight of that and the goal of it is, you know, quality health care for each and every individual living in Rural Alaska. And that's been my underlying goal in all of the things that I've been involved in. And if we don't, if we lose sight of that, then I think we get too wrapped up in other issues, such as, you know, lesson plans or curriculum. If we don't remember what the goal is as we do training, and how we need to facilitate the learning within the individual, it's not about standing up in front of the room and lecturing adequately to folks, when we talk about the educational process of health aides, it's different than -- and it is, in the university, and it is given college credit and it is a fully accredited program in that regard, but when you think of it as an educational process, it's very different, I think, than most of us think of college. So that in the early years, in putting together, you know, the educational process, I found myself going through a huge evolution and looking at what our goal was and how we could do that.
KAREN: So how do you train them if you don't get up and stand up in front of the room and lecture? Give me an example. LINDA: Yeah. Well, I'll -- yeah. I guess we just get to talk about history. When I first came to the program, the students had about 80 percent to 90 percent of the time was in the classroom with about maybe 10 percent seeing patients. And what I observed was these were individuals with second language trying to listen to a lecture and take notes in a second language. Well, those of us in one language, we know that when we try to read our notes back and study from them, that that's very difficult. So I started to look at what it was that they were writing and how that might help them. What I found as a teacher is that I really believed that their job is the hardest, if not -- it's just an incredible job that these folks do. You know. 24 hours a day, 7 days a week, providing health care to family members and community members with all of the pluses and minuses that that creates in dynamics in relationships. But the most important thing is that the health aide, when they come to training, has to have an environment and an opportunity to learn the information and to feel good about being able to go home and do it. They need to feel comfortable, competent, empowered, whatever the words you want to use for that. And often in the early years, I met individuals who had sixth, eighth grade education, and not always a positive educational experience. Where education for many of us has sort of been almost thought competitive. If you have your arm up first, you then own the answer to that question. If you, you know, get good grades, or if you -- you know, it's -- it's -- and I don't believe that. To me, learning is -- and it's very Yup'ik in the values that I have found over time that are there is that it's -- it should be cooperative, it should really -- it's not about one individual being better than anyone else. It's really about everyone doing well, because these 6 to 8 to 12 individuals that are in the class, each of them are going home to give quality health care to the village folks. And so a number of things that I started in the early years is the training at that time, it was 70 percent to pass or fail a session, and I was concerned about that because that meant that, you know, you wouldn't want a pilot with an A in takeoff and a D in landing. You know. You want people to have really competent skills. So I believe watching and observing the students that if we, as instructors, could be very clear with very measurable, not only content but skills that we were looking for, the clearer we could be, that there was no question in my mind that these individuals could learn it. And so it didn't get -- it wasn't a graded affair, it became pass-fail, but we raised the point of deciding if someone could move on to 80 percent. And then it didn't mean an individual failed if they didn't get 80 percent, it meant remediation. It meant, okay, what -- and it wasn't 80 percent averaged, it was 80 percent on written and clinical skills separately. So that if someone wasn't able to master a skill, is, let's analyze that. What piece are they missing. So, for example, if someone's taking blood pressure and they are not giving you the same value as you're hearing, you have a double-headed stethoscope and you're listening at the same time, if someone has two different values, why is it? Is it because -- and it could be a variety of things. It can be that they have a hearing loss themselves and maybe it's never been detected until now. Maybe it's they need glasses and they can't read the dial and you need to. So it's not about the person, whether they tried. One element is on a blood pressure dial, the numbers read up, but the pointer comes down. And so it reads 60, 80, 100, 120, 140. So as the needle comes down and it's between 100 and 120, well, that line is actually 110. But you've just seen 120 so the health aide was reading the next line down as 130. KAREN: Right. LINDA: Okay. And so it was just a measure of taking more time to understand the dial. That analysis of what piece is missing, no assumption, no assumption that -- that they are -- I know one health aide had come from an educational process where if she was slower, she was called stupid. You know. And there's no such thing. It simply means that as the instructor, it's our job to figure out what is the piece missing. And not to move forward.
KAREN: It all sounds like that very one-on-one personal contact with individuals that you're teaching. LINDA: Yes. Essential. And so yes, the faculty-student ratio, just as in any school of medicine or nursing, is that you have a very -- the classroom, you know, small-size classroom, very important. But also then on the clinical, it has to be one-on-one. You can't supervise four health aides in a clinical situation. And so what we started to do in the early years is to look at not only what our expectations were as to -- and we -- we -- you have to put a score on it, you do have to put a level, and you have to grade it, if we want to call it that. So that was one piece of the puzzle. The next one was looking at the use of language. The first day I came to the -- the health aide training program there, a test was being given and the students were struggling. And I thought, hmm, I wonder what it is. And I just sort of just observed. And there was a question that said name three sites on the body where an intramuscular injection is given. What word do you think they had trouble with? It wasn't intramuscular or injection, it was a four letter word, site. Now, when we change that to name three places on the body where it would be given, they all knew the answer. So language was an interesting thing, it was just to not -- not make any assumptions of knowledge, but to really look at the -- how we presented things and the consistency and clarity of language and expectations. So from there, as an instructor, my evolution was, then, well, let's see, their notes are just incomplete. So how can I improve those? Well, I can write on the blackboard, which is a very common way that teachers try to get better notes for students, especially in the olden days. And so the difficult -- it was great. We certainly had better notes for the students, and they had something better to study from, which is the whole purpose, but what I found was, you know, when you're writing on the board and talking and you start to get down a line or two, s that people are now reading, writing, and trying to listen at the same time. Well, that's very, very difficult to do when you -- you can listen and write, but you add reading, listening, and writing, and they are reading and you're talking two lines down the board, they really are just sitting there transcribing. And what a waste of time. So my thought is we know that it takes at least three times through information to really learn it. So I moved in the early '80s to something that we developed in Bethel called Learning Unit Notebooks, which is where we wrote the information down in sentence, outline, sometimes paragraph, but mostly outline format, and the students then were given learning objectives for that section, and at the end of it they had study sections. These notebooks were put together so that when a student came to training, they were given a schedule and a notebook, and the expectation was before class, they were to read and go over the study guide questions. That gave them pass one, sort of the first time through the information. In class, then, we didn't have to lecture. It was much more of a Socratic dialogue and case presentation and understanding. And then when they went back through it, that would be their third time. And just that clarity of information, it's amazing how test scores changed. And I mean, it's not rocket science today, but back then, it was pretty revolutionary to give the students the information because I truly believe that the individual, as soon as they sign on to do that job, I believe that they owned the information. They may not have learned it yet but they own it. And I know when I was in school, I always felt like I wasn't ever good enough to learn the information. The teacher owned it. They owned it and if I could be -- work hard enough and do the right things that I would somehow be allowed to have that information. It was a very East Coast -- I don't call it East Coast. KAREN: Western? LINDA: Western, yes. European model of education. And my -- my belief is that it really needs to be hands on. So we cut the class time in half, we increased hands-on clinical time, we went to something called lab skills and really increased the opportunity to model, to practice, whether it was history, exam, whether it was any of the lab skills, and really started to open the program up into much more of a -- a learning style that was more fitting the Yup'ik. And again, that's the culture that I was a part of. Because the Yup'ik people have honored and believed in education, certainly they could not have survived in that climate if education and learning wasn't a core value of their society. But it wasn't taught at them, it wasn't in written form, it was more of an observation, practice, doing, and then. And again, I had taught at Hopkins for three years, at Johns Hopkins back East with masters-prepared folks, and I found people said, what are you doing teaching health aides, you know, with sixth and eighth grade education. And there was no question in my mind that not only did they -- could they learn it, but talk about observant, dexterous, capable individuals who, because they knew the community members, they -- if they said to me, this patient is sick, it wouldn't matter, they knew that the person was sick. And you'd listen to that. And so, you know, here I was teaching folks back East to do episiotomies, which is in the birth process an opening of the vaginal space down through the perineum, and suturing that, and here I was working with health aides in Alaska and suturing because of all of their dexterous skills. So I don't -- I don't believe -- I mean, I truly believe that health aides not only can and do learn the information, it's not them, it's us. It's the trainers and the program that need to be as clear and as organized and precise. And also consistent as part of the -- once I became the training coordinator, one of the things I required of the faculty is that you'd have consistency workshops so that as a team because you'd have a faculty of four to six faculty and students, and you know if you have three different ways that you're being shown how to do a skill, you won't learn it. You -- you need to have a very consistent way. So --
LINDA: In the early '80s, I -- I sort of upset the apple cart and went and said to the program, we need to go from 70 to 80 percent became the standard. At the time, the preceptorships that I mentioned earlier was one faculty and six students coming in and getting their skills list signed off. And I said, no, that's not a preceptorship, that's just basically following a gaggle of geese sort of thing. And I said, what we need is something that really tells us that they have the clinical skills that we feel that their basic training is completed. And so we created, in 1983, the one-to-one model for preceptorship. And that was the significant sort of change in how we looked at the -- the whole process of pulling it together. And then in 1984, '85, we created the pre-session because of the lag time from employment. And again, health aides are employed, there are 178 villages throughout the state and there is no sort of entry date of employment and termination. So every single day if you -- in any corporation, there's folks coming and going from -- from them. And so it could be that people have to wait months before they can get a slot in one of the basic training sessions. And so in order to sort of give them something to start with, we created a Pre-Session 1 that could be delivered by the corporation, in just giving them some sort of basic tools in starting patient care. So that was in '85. And one of my earliest experiences with the program, I mentioned before about the field folks, but one of the roles in early training, and they sort of returned to it now, is where the training instructors go out to the villages. Most training instructors are center based, but a key element is when those individuals get to go to the village themselves. And so in 198 -- spring of '81, I went out to Atmauthluak, and there was a health aide who was -- had finished Session 1, quote, unquote, finished. This is before we had some of these changes. And she wasn't getting it. People were concerned. And I went to work with her and I knew I had my list of things that I was going to be required to see how she was doing. And she was a very nice young woman, but lost. And she said, I don't know where to begin. If somebody's old or if they are young or if they are man or a woman, if they are a baby, I don't know where I begin the visit. When she shared that, and that took probably a half a day to get to that question, because we can have our own agenda, but if we don't listen to what the person's problem is -- and once I realized she's -- that was her key thing, she didn't know how to begin, and I just said, well, you just need one question. What brought you to clinic today? And as soon as she could see that everything started from the same place, she could organize her thoughts and get some clarity to it. But she really thought that she needed a separate script for each of these individuals. And that was the beginning of my education to see that we really hadn't provided the tools that individuals needed to do their job. They had, at this time in the program, the old Indian Health Service had what they call progress note paper that I used in patient charts that were blank, sort of like the paper you're using right there, a tablet. And health aides were to do their care and to write up the patient visit. Well, there was no -- there's nothing on the paper. So if you're someone who doesn't even know what your first question should be, at this -- my training, for those who know the program, this is prior to the 1987 CHAM, which was a focused history and exam. The earlier book, and the history of the program is really mirrored by the tools and the materials that we have for the program. They didn't have a scripted visit. So she really needed help in how to sort out her work. And so in 1985, I wrote the first Patient Encounter Form, which gave them a piece of paper, and it was made into triplicate, that allowed them to write up their patient visit. And it starts with chief complaint, then goes through history of present illness, down through past medical history, allergies, medications, habits, and then into the physical exam. Vital signs. Each of the body parts or systems are identified with blank lines for space down to the assessment, which is another way of saying sort of the medical diagnosis, assessment they come to conclusion by history and exam, and then a section for the plan, which is then patient education, medicine, treatment, return to clinic. The form has been revised a few times to add a few things, but it's sort of fun to watch it now 20 years later to be so similar to what the original one. And I think of all of the things that I've been a part of, that one piece of paper has impacted the care only in that it would allow people to have an organized way to record it, and then an organized way to report it to the physicians. But again, the health aide role is the connector. They are the connector between the physician in Bethel and their village community member in Anvik, Aniak, St. Mary's, Eek. And they are -- it's about communication. And you need, then, clear ways to communicate information. That also, then, allowed for a copy to go into patient records, and also to the supervisor instructors who could then review them for -- also, then, the information and know, well, it looks like the health aide needs help in this arena and they could go out and focus a visit. That was 1985.
LINDA: And then from 1982 to '87, I was fortunate to be a member of the committee to work on the, what we call the White Community Health Aide Manual, which was published in 1987 and the primary author was Dr. Rob Burgess. And that book made a significant change in how the material was organized for health aides. It allows you to go in with a symptom, and from that symptom, go in and collect a complete, focused, problem-specific history, exam, lab tests, and then it takes you to charts that allow you to analyze the information, sort of what we call compare and match, history and exam, for an assessment, and from that assessment, takes you directly to the page number for the plan. And the clarity of that book significantly improved health aides' not only ability to work with a patient, but I think ease in -- and that's the goal. My purpose in all of this over the years has been, you know, several. One is to improve quality health care through well-trained individuals who are supported and nurtured themselves, but also to provide materials that are easy to navigate, easy to use, that allow the health aide to do their job so that they really can focus on the patient and not on the -- the books or the materials. And so that they can just have a -- because the role of -- of being a medical provider is pretty complex, and it's not about the complexity of the information, I think, as much as the organization and the ability to use it, to find it and use it in whatever situation they find themselves in, whether it's a prenatal patient who is vomiting or if it's a child who has a sore throat or a gunshot wound or an emergency delivery, whatever it is, they will learn it in training, but they need then tools that assist them on a day-to-day, patient-by-patient visit that they have, the care they are giving. Yes. And what was exciting about that was to watch the health aides' ease, the ease with their work by having those materials. KAREN: So you could see that it really helped them? LINDA: Oh, yes. I mean, if you can imagine that you were going to give health care and you had a blank piece of paper and a book that guided you but wasn't clear in its -- each patient -- I mean, I'll always remember that individual in Atmauthluak who was lost and it wasn't her ability. And, you know, I can think of times when -- there's lots of things that I don't know and I -- I mean, well, talk about computers. I want them to work. I don't understand them. And if somebody were trying to teach me how to do that, I would feel pretty incompetent and, you know, not able to -- to make it work. I want it to work but I couldn't make it work. So I think that my belief is that the individuals who choose to be a health aide are amazing individual who, if you ask them why are they doing the job, it's about heart. And these are individuals who historically are the nurturers, the caretakers, healers in their community. And I know that that has changed over time now as it becomes sort of one of the things that's happened is that it's a job in the community. We're seeing a little different individual apply. I think they still come from the heart because you can't do this job without it. If you don't have a passion and a caring for people, I don't think that you can stay doing this year in and year out. It is just such a demanding job.
LINDA: The -- the piece of the puzzle was not only looking at how to empower the students and the health aides themselves in their work, but one of my -- my goals was to look at how we can make better trainers and teachers within the program. And so the key is just to find individuals who themselves have the knowledge and skills to teach it, but also have what I call the subjective ability to -- to share and to believe that their role is to facilitate learning, not to teach at but to facilitate learning, and then to help them to get the skills to do the hands-on, not only the training and the patients for that, but the understanding that you're going to get out of the way. That you're going to really provide the learning within an individual, and it's not about you, it's about them. And I've worked with a lot of trainers over the years, and there's really -- those individuals, it's another group of really amazing people who choose to be trainers and field supervisors because you are also trying to provide quality of care, and it is, again, through a trained individual, who you have to let go and sort of support in the village. But how do you give them that in terms of it's, again, about, to me, not only knowledge -- excuse me -- knowledge, but confidence, feeling capable that they can do that in an emergency situation, or in a difficult clinic visit, or a screaming baby, how you have that sort of support, and that they feel that. So that the trainers themselves, back in 1984, there are really no other folks doing quite -- as you know, the Health Aide Program is unique to Alaska. There's no other program like it in the United States. And so folks, whether they are physicians working with health aides doing radio medical traffic or whether it's trainers in a training center working with health aides, there's nothing like it in the Lower 48. So you don't come from that experience. So in the early '80s, I myself felt that as I was struggling with cutoff for grade level and how we could provide the materials for the students in a more supportive way, how we could look at consistency of faculty message, how could we do what I call objective testing versus subjective. All of these things I was personally grappling with, and the other people dealing with these issues were the other faculty around the state. So we started something called the Community Health Aide Forum, which has grown into the convocation now, which brought together the faculty around the state and field to look at elements of teaching. And through that, we found ourselves sharing, and how did we teach, how did we do things. And with that, we started to really improve the program. And one of the areas that we worked on is we brought in a program -- I had been struggling with the whole arena of -- we do clinical testing. Well, clinical testing can be very subjective, depending on the faculty member, the patient you have that the student is testing with, and how you look at whether students have proficiency in a clinical skill. And I believe it was Dartmouth, I'm trying to remember at this moment, but I started to look at where, I thought within the medical training somewhere in the country someone was looking at these same issues. And so we brought out an individual from Dartmouth and we created what we call OSCEs, which are Objectives-Structured Clinical Exams. O-S-C-E. And that training and that opportunity to look at how -- what -- what is the skill you want them to know, what are the components of it, to what level do you want them to be able to do that, and how can you measure it. Just to help get the picture clearer. You can learn anything if it's step by step and you know the expectations. There should be no surprises when you go to testing. It should all be very clear as to expectations, and then test to what you've been taught. So those -- those elements really began to standardize training, and then -- and we started doing OSCEs in the late '80s.
LINDA: And then I was personally interested in a few other elements of training. One is that we had in YKHC area, we have 100 -- at that time about 160, 180 health aides, and if we can only have 6 to 8 or 12 in a session, that isn't very efficient, and how could we -- and what we found is we could increase our class size, but there is a point which you can't, you still need that one-on-one. So you can't grow the classes too large. But I thought, well, how can we start to do training a little differently, instead of sitting in class, could they learn this information by distance. And then come to Bethel for clinic. So in the late '80s, through support from the corporation, we bought computers and we started -- it was -- the network, the system was called Optel, and it required two phone lines in the clinic, and we took computers out to six villages. And in 1989, this was pretty revolutionary. And we taught -- we -- at that time, there were three sessions instead of four, the curriculum was expanding and it's four sessions, but we taught Session 3 by Optel, which was a system that allowed you to have a picture on the screen and it gave you where each student could then respond back, and there could be different color codes. It was really quite sophisticated at the time. And we could teach the theory by distance and instead of being away from home for four weeks for training, they would be away from home for two weeks. And that -- we did that program through the campus very successfully for about three years, and then the program moved, as I said, moved to YKHC in 1993. Teaching by distance always sounds -- pluses and minuses. It actually takes more time and energy to prepare materials and teach by distance than it is to stand up in class and present the same information. You have to be very prepared for distance. And everything has, you know, to be organized in sort of a different way. So -- and you also have to believe in it as a method. And so the program lasted at the corporation only a few years, and the fun thing is that 10 years later, we're now recreating that. And through the whole network of computers, we are now looking at distance education for the basic training as an element of expanding opportunity to be in a training session. And I think within a few years we will see a very active theoretical component by distance and then the hands-on clinical. The difficulty is that you really do need to marry those together at the same time, and how do you choose what will be taught by distance and what really needs to be hands on. So it's going to be -- it's really an exciting time to watch the evolution of this now. The buzz word on that, you know, the educational synonym is called blended education, where you have the computer element, the materials, the hands on, probably some clinic visits, and then into the training center. So it's going to be really interesting to watch that, but I think it really will increase efficiency. And the difficulty with training now is it can take two, two and a half, three years to get through those four sessions.
LINDA: And the element of attrition for this program has always concerned me. The element of attrition is difficult because when a health aide leaves the job for so many different reasons, and you start with a new individual, is you've lost not only the training but the experience of -- of that element of providing health care. And you can rebuild that, but it does take a significant amount of time and energy, but more importantly, the community I think is then at a disadvantage. I won't say -- because I think we have to be very careful how we label these things. I think in the -- you know, the rest of the world, if you went to a hospital, folks come and go all the time. And there may be a shortage of staff, but there's always staff. Or they turf patients. You know, when Bethel is understaffed in nursing, they just send more of the patients to Anchorage. So -- but in a community, when there are, you know, two health aides or one health aide and one leaves, that puts the whole community at a health care disadvantage. And so attrition is a -- is a really difficult piece of the puzzle. And so I've looked at that over time. And it's all sorts of things. It can be pay. It can be time on and time off. It can be how soon they receive training. Because until they have training, they are feeling very, very vulnerable to take care of the next thing that walks in the door or the next phone call in the middle of the night. So training is the key to feeling competent and comfortable in the role. The support that the community gives them in their jobs, sometimes communities are very supportive and people are able to stay for years and sometimes there can be politics in a community and an individual can't stay. So with that attrition of the program, it means that there will always -- you know, we'll just do some math. Let's say 500 health aides. And if we have an attrition rate of 10 percent, that's 50 health aides a year needing Session 1. Well, if you can do 6 health aides in a session, that's 10 Session 1s a year. That's 40 weeks. So that's one whole training center. We've only got 4 in the state. So that element, but the other though is our attrition rate can climb as high as 20 percent. Now you're looking at 100 individuals. So the math becomes complex. So there's lots of issues regarding the training of health aides. It's -- it's content, it's support, it's clarity, it's outcome, but it's also timing and sequence and modality -- how can we increase the training capacity is the word we use. And so distance education is now being very actively looked at again. And so I'm just smiling and, you know, looking back almost 15 years ago, 16 years ago to a pilot project that was very successful with those health aides. The other element is looking at materials again for learning for self-study. And so in the early '90s, we wrote a grant to the Robert Wood Johnson foundation to again look at how we could increase learning on an individual level. And we created and distributed -- took us about four years. What I find is that things take time, we'll come to that soon, but we distributed a CD ROM throughout the state called Body Systems and Health Care. And the CD ROM was created by one of the team members, Chester Mark and David Horish in Bethel and myself, and the Robert Wood Johnson grant was half a million dollars to help us to get this off the ground. At the time we wanted it to be cross platform, and even just printing a CD 10 years ago was a big deal. It was, like, what? You're creating your own CDs? Now it would be so different to do that. But it really was successful in taking each of the body systems and breaking it down into anatomy and function, physical exam, findings, disease, treatment, and allowing them to sort of move through those materials.
LINDA: So my -- my goal has always been to look at how we can expand knowledge and allow the individual to take an active role in that and not just passively coming to training, but how can they continue either their own education for basic or then advanced. And so in 1993, when the basic training center turned to YKHC, I chose to stay on with the university -- and the Kuskokwim campus, the university's gone from restructuring several times over the last 15, 20 years. And then it used to be the community college system, and then in 1988, '89, we went through reorganization, and it's now the three major administrative units that we have currently in the state, University of Alaska Fairbanks, Anchorage, and Juneau. Southeast. And the Kuskokwim campus was then linked through the college of Rural Alaska through Fairbanks. And so staying on at the Bethel campus, my role changed from direct basic to a variety of hats, one of the hats being sort of looking at the statewide CHAP program. Also to do nursing support and trying to bring a nursing program to Bethel, which we were able to do. Allied health training, and high school, doing some, at the time it was sort of college course at the high school to interest people in health careers. So I had many different components to it, but the most important to me has always been the Health Aide Program. So in that role, I have really looked at the Associate of Applied Science Degree, which is the stepping stone from the Community Health Aide Program, as I mentioned, is within the university, and the basic training curriculum, they receive 34 credits. That's Session 1 through Session 4, and the preceptorship is 100 level credit in the university, and it's 34. Those 34 credits, they are able then to get a -- through the university, it's called the same thing, unfortunately it's certificate, Certificate in Community Health. Universities give certificates of 30 credits, thereabouts, for what we call applied arenas. And so those 34 credits are the major specialty area in the Community Health Associate of Applied Science degree, which is a 60-credit degree. 15 of those credits are general, which is your English, speech, math, and social science arena, and then the 34 credits for their basic, then they take 2000-level health courses and round out with some electives for a 60-credit program. So in 1993, I had already sort of helped a few people look at their AAS degree, but I started now looking at it as a statewide basis. And the first thing I realized is that once again, I believe that knowledge and information, it's -- the individual needs it. It's not systems or teachers or administrators, it's the individual. So I created a one-page Associate of Applied Science tracking tool. And that outlined for them what the degree required. With that tool, I then took their transcripts and made individual course profiles for individuals. Once you do that and people see what they have and what they need, and then give them -- a couple things happened. Because we were working statewide, I said to the university, I have a student in Southeast who needs an English class and it's taught through Kotzebue. Well, that was unheard of back then. You couldn't have a course cross the whole state system. And I said, well, this is a statewide program. They said, no, it's UAF. I said, no, it's a statewide program. It may be housed in UAF, but you need to find a mechanism where I can get this student to take English 211 so she can finish her degree. Well, they hemmed and they hawed, and they did it. And we were the first to do sort of statewide, and that was in 1993. KAREN: Wow. LINDA: And it was exciting. It was -- and but we rocked -- we rocked the boat and folks started getting their Associate of Applied Science degree, and looking at information sharing for the individual, but in the university, taking their -- you know, their distance courses and trying to then -- because the catalogs are difficult to read. And translating those into materials that were then what I called sneak previews that we published on what were the courses that match the degree, when were they available, and how. So each semester, those materials are sent out statewide to the health aides. And folks all over the state have just been quietly, I think we're up to 65, 70 health aides have received their Community Health Associate of Applied Science, and it is an applied science. It is a hands-on program, and so it was the AS profile sheet connecting university to allow students cross-regional to take courses. Now it's just accepted. I love the new president of the university because he's really knocked down more walls, but back then, there were high walls in the university between the MAUs. You certainly couldn't have students cross them. But we did and it was fun to watch that happen.
LINDA: And then the other piece of it is they are -- they need five elective credits at the 200 level. Well, how were they going to get those? These were individuals who can't come on campus. And at that time, we didn't have distance 200 level courses. So I thought, hmm. And I'm very much a face-to-face kind of person, and I've always taught, so I've been teaching since 1977. Oh, my goodness. That's -- that's an amazing thing to admit. Almost 30 years. But I've always enjoyed face-to-face in classroom, but in 1993, because of the degree, I realized that I had to stretch myself. And with that, I said, well, hmm, we are going to have to start teaching by distance. And the computer was a little different, because we had some element of face-to-face, but now we were going to cut all of those ties, students weren't going to be coming in, and it would be all -- at that time distance was just telephone. So I looked at maybe where we could go and what would be an appropriate course. And I had been asked to do a medical terminology course on the Bethel campus for a couple of students who were doing something different, and I started to look at that and realize that the whole arena of communication, that's been one of my -- I guess, one of the core things I believe in is -- is how to communicate with one another, and that medical language was a piece of the puzzle that could be improved upon. So in 1993, '94, I started the first distance course in medical terminology. And I approached it from the view of, once again, not just looking at a word and memorizing it, but there was a -- supported materials at that time to look at. And again, it sounds so funny to talk about it because I'm thinking now, of course, it's the only way we would do it, but at the time it's taking medical words and looking at the prefix, the suffix, the prefix at the beginning of the word, the suffix ending, and the word root, the combining form in the middle. And sort of taking words and exploring them and helping people to see it. And I found a good textbook that helped me and started teaching the course, and I thought, how can you have a dry, boring course like medical terminology and do it by telephone twice a week for 15 weeks and be successful. I was just really, really stretched to make that. And between a good textbook, materials that I used, a quiz method that I developed by distance, and my belief that words are stories themselves, we just had fun with it. And my belief is that even by distance, you need to engage the students. So my goal was to call on every student at least three to five times during the class. So what I loved about distance is that people could be in their pajamas and having a cup of tea and learning. And you know, we would start with things like suffix endings like itis. Inflammation of. And I would say, okay, think of an itis. You know, tonsillitis, appendicitis, conjunctivitis, gingivitis, and then we would look at the body system that that term was looking at. You know, whether it's a conjunctiva of the eye, the covering, you know. And then we started -- I started to actually research, you know, what was the origins of words. Because it's Greek. It's Latin. And they didn't have to know that those were Greek or Latin terms. And we did, as we said, okay, everyone, think of being -- you know, let's go back 3-, 4,000 years, and you're men, because women didn't do this, and there's a body on the table and you start to carve it up. And you name it for the world around you. And certainly within our elements out here, people have carved up seal and walrus and, you know, caribou, moose, and they've got the parts all named. KAREN: Right. LINDA: We just don't know. And the language is English. The language is coming from roots of, you know, Latin and Greek, and we started to look at that and you can laugh about them. Uvula, that little thing hanging down in the back of your throat, U-V-U-L-A, if that's not the oddest looking word, you don't even know how to say it. You know. And so -- and we just laugh about it. It means little grape. That's all it means, it means this little grape. Coccyx, which is your tailbone, C-O-C-C-Y-X. Well, there's another -- I mean, if I were Yup'ik and I came across that word, I'd go, what? And in our program, we have not made them learn all of the medical terms, but they will see them on doctors reports, they will see them in their world. So we teach them to say tailbone, but by learning the words, and just laughing and letting go, it meant the beak of a cuckoo bird. That's what that term meant. So we just were able to explore language and learn it. And I ended up teaching that course for 10 years by audio conference each -- once a year, and health aide -- I mean, it was wonderful. Health aides enjoyed it and wanted more of that as part of basic, but basic is so full in its curriculum, it really is sort of a supplementary course. From that offshoot developed a course in human anatomy, physiology, and medical language. And put together a textbook for that.
KAREN: Yeah, it makes sense that if you have something explained, the meaning, you're going to remember it better than just memorizing a list. LINDA: Right. And you can understand it. And you know, really what you should do is look at any medical word from the end of the word. Not the beginning. For example, itis. If you see I-T-I-S on the end of a word, you know it's an inflammation process of the some part of the body. You may not know that, you know, it's -- arthro is joint, you don't know which joint but you know it's a joint somewhere, so arthritis. It just unlocks the word for you. Ectomy, E-C-T-O-M-Y, on the end of any word means to cut out. Appendectomy. Tonsillectomy. Mastectomy. It's -- once you get that. You know. So it was -- it's -- again, it's just ownership. It's understanding and ownership and feeling like, oh, I -- I got it. It's not so difficult, it's not so foreign. And then developing -- as I said, one of my hats in Bethel was to help look at nursing and bringing nursing to Bethel. And so we worked closely as a team of us at the hospital, Marianne Schaeffer and myself, along with the earlier years looking at working with a program out of Utah, and then finally with the UAA School of Nursing, we were able to bring the LPN, the licensed practical nursing program, to Bethel. And then next the RN program. And that has been just very rewarding. My -- my belief is that, you know, we have to stop this rotation of Lower 48 folks to the state, especially rural communities, and so we need locally trained individuals and just as health aides, certainly nursing and physicians and lab techs and so forth. And then with that, develop, expanded the medical terminology to look at anatomy and physiology and medical language as an integrated approach. Because, for example, while you're learning the liver and what the liver does, if you learn that the word root for that is hepato, all of a sudden you can unlock hepatitis and hepatomegaly and you can just look at the word and go, oh, it's the liver. It doesn't -- it has no meaning other than to be a word that means liver. So that -- that has been an element over the last few years has been nursing the medical, trying to interest people in health careers and medical careers. KAREN: Have you guys been successful? LINDA: Yes. And we've really worked at the high school and did a -- several years did courses there with college credit, which were very rewarding. And I actually would love to be doing that again, but my life took a -- a detour two years ago when I moved here into Anchorage to work on the Community Health Aide Practitioner Manual full time. And I have just to sort of back up a minute. The program itself, as I've mentioned, is the health corporations who employ the health aides, within each health corporation there is an administrative team leader whether it's called a CHAP Director, Community Health Aide Program Director, Village Health Services, they have different titles, but they are basically the administrative team for the Health Aide Program. That group is the -- comes together and it's the Community Health Aide Program Directors Association, and Steve Gage, and serves as the current chairperson of that group. And that group has some standing subcommittees under that. One is the academic and review committee, which is responsible for curriculum and training activities, whether that be training center or a field based. A review -- it's called RAC, Review and Approval Committee of the training centers that actually -- again, we have a unique program, so we have to hand grow our own things. Just like you have accreditation of medical schools, we have a committee that's a very, very tight organization to approve the training programs. And then the third standing committee of the CHAP Directors is the Community Health Aide Practitioner Manual; and at the time, Village Medicine Reference, which has been a complementary book of the program. That committee was formed in the year 2000 and charged with first just looking at where we were at in terms of materials. We did a survey to look at the -- I mentioned the 1987 book was published, and in 1998 a new edition was put out. And the '98 edition went through a very different process than the earlier CHAM. And the 2000, when the committee was formed through the CHAP Directors, the charge was to look at the 1998 CHAM and whether it was meeting the needs of the health aides. And so a survey was done of health aides, trainers, field and physicians, and through the survey, we identified a number of concerns and problem areas and things that needed to be improved upon. And so the committee started into that. And we hired part-time writers, and over the last three and a half, almost four years, we have been revising, and actually, it's become, instead of a vision, a new edition of the Community Health Aide Manual. We have tried to return it to the approach and simplicity of the White manual, the '87 manual, but also expand and provide a simpler and more comprehensive approach to using the CHAM. And an example of that is in the old books, when you entered into it, it really only identified the role of the health aide in an emergency or acute care. And those are the only two entry points you had into the book. But as I mentioned earlier, the practice of being a health aide is much broader than that. KAREN: Yeah. LINDA: And so they really need an entry point into the book that allows them to triage a patient almost from the beginning. So the current entry point to the book is emergency, they get turfed right off. If there's a sick child younger than 8, those are the -- and 8 was cutoff because of CPR standards, but we're really looking at the infant, 2 and under, 3 and under, and what you're concerned about is those very sick children that can go bad so quickly. KAREN: Right. LINDA: And you -- again, distance, you want to be treating them right away. When you see patients in acute care, you often need to see them for recheck, to see if they are improving, the eardrum, et cetera, do a new lab test for someone who had, say, a urinary tract infection. And so we've created a re-check visit that allows you to turf right to that area, which is a much shorter history and focused visit. The other is that maybe the person's returning from staying in the hospital, or going into a regional clinic. And you actually weren't the last person to see them. And you need to follow-up on it, but how do you do that and where do you begin. And then the two other areas we've talked about is chronic care visits and preventative. And so those are actually listed and direct pages. So you don't have to -- just as I mentioned the health aide in Atmauthluak years ago, what brought you to clinic today. It really should help you to take the right road, then, to get to the care that the patient needs.
LINDA: And in the past two CHAMs, the road has been a very -- only sort of -- it's kind of like one way, and then you've had to really struggle to sort out if you had a recheck or if you had a chronic care. And a chronic care visit, to put more understanding on that, would be like if somebody has diabetes or high blood pressure, or chronic obstructive pulmonary disease, or emphysema. Those patients, you're not assessing a new problem, you're actually trying to support them in whatever element they are in their care now, whether that means just a recheck quick and given new meds, or maybe they have another problem, or it's getting worse. It's just a very different kind of case. And then preventative care, whether it's a well elder visit or prenatal or well child, et cetera. So that -- that has changed the use of the book. And then the elements that we looked at also was how to have a book that you can easily navigate. Again, you don't want to be lost in a -- in a book, you want to be able to quickly navigate. And whether we used -- we've used color to help sort of see where you are, but also we have had -- added headers at the top of the page, not only with the body system, but with the section that you're in. So you can quickly scan those, table of contents at the beginning of the CHAM, so you can always get an overview, but that's probably not how you get into the book. And then the reference to, as I mentioned before we had the CHAM and the Village Medicine Reference, which were two books actually published years apart. And so when a health aide, say, you know, gets through the visit, medication is often an element of treatment. And so they've had a book that goes in and gives them information about medicine because they are actually dispensing, based upon the physician's order or the plan in the CHAM, and when they have gone to the Village Medicine Reference, it's given them information about it and warnings and side effects and some information. But they've had to interpret and do patient education from those. The others, it took quite awhile to sort of sort -- sort of goes from one book to the next. So one element of the new materials is that the Community Health Aide Manual will have its own medicine book. And so, for example, in acute otitis media, if it says give amoxacillin, it -- it will give you a page number right there, and it will take you to the medicine book for amoxacillin. When you get to amoxacillin, you will see the plan that you just came from and the page. So if you close one, you have the other, and back and forth. And we've organized the materials very similarly, but we've added a new element which we hope and I think will really help the health aides, and again, that's been our goal is how do we make it easier for them so that they can do this very difficult, complex job. And so we have a new box called Warnings Before You Give This Medicine. So they don't have to interpret or look through, they can actually look at this quickly. And for example, if someone is taking one medicine, they may be contraindicated to take this new one, or they may be breast-feeding would be contraindicated in some cases. Just that warnings box. But it's not warnings for the patient, it's so that the health aide is directed -- KAREN: Right. LINDA: -- and can know what to do. KAREN: And know what questions to ask. LINDA: Exactly. And they may have to actually -- if the doctor -- we try to get all of that information before they talk to the doctor, but it may be one more thing that hadn't been considered so that they will have that. And then the other element that we've added to these is patient education pages for every medication that will -- will have a CD ROM that will accompany the four books, and allow them to print out patient education. So the CHAM project has been just an amazing process. And we're excited, we'll be actually going to the printers and sending this to press within the month. So the timing of this interview, I'm actually working on the index as we speak, and you know, I have had several people ask me, you know, how on earth did you come to this. KAREN: Yeah. LINDA: But I think it's been the 20, 25 years of prep to get here. It's been working closely with health aides, whether it's in basic training or in the village, but it's also being a part of writing the right CHAM to working on curriculum and all the curriculum revisions, and the BMR, and I think all of it's been training to this point. And we're excited to -- to put this into the hands of the health aides. And our goal has -- it continues to be the same, which is quality health care for each individual through well-trained health aides who are supported, whether they are supported by their community, their supervisor instructor, or supported by the materials they have to use. Just key. Because they are amazing individuals.
LINDA: And this program is unique in the United States but it's also being looked at very carefully by a variety of folks. And one of them, the U.S. Government itself, we're looking at if the Indian Health Care Improvement Act is some of the original legislation that created the Health Aide Program, and they are trying to -- there's an interest in rewriting that so the -- the Community Health Aide Program would actually be replicated in the Lower 48. Not only on the tribal reservations, but in other situations, as well. The model could work in Rural America, but easily in Urban. Look at the urban city situation. I worked at Hopkins and we certainly had problems of access of health care intercity Baltimore, Maryland. And you know, can you imagine if you had a -- well, a village is about 4- to 500 folks, average, and think of the tall buildings in New York City, 4- to 500 folks, and what if you trained a couple of people to be your access point to health care. Because that's what it is, it's about access. And they are data collectors. They are trained data collectors who can then contact the medical care system, whether it's by radio or telephone into Bethel, and the patient can be in the village or brought into Bethel, or then brought into Anchorage. But it's the same concept. And the Lower 48 desperately needs some new models for health care. The emergency rooms are overwhelmed. Well, they are being seen for somebody needing their blood pressure checked to whether they have an earache. KAREN: Right. LINDA: You know. And then the other arena is the world stage. And there's interest in looking at the model. Both folks from India have been here recently, China. The government has been talking about a program like this in Afghanistan. And I have -- did some work in the mid '90s in Saudi Arabia with this model, and there's a lot of elements that could work anywhere in the world. But my caution to folks is that you would need to adapt them. It is not -- you don't just pick up and dump it in a place. It has been almost 40 years since it was Federally funded, which is 1968, and certainly since its beginning in the early '60s were going on a long time and an evolution and a development of materials, curriculum, expectations. In the early days, the medical -- you know, it was about medication for tuberculosis. We saw the years of infectious diseases. We certainly -- you know, the years of meningitis now, we give vaccine, we don't see that as much, we are seeing actually now more life-style issues, whether it be tobacco -- cancer is now the number one cause of death of Alaska Natives. Well, many of those elements are life-style. So another course that we developed for distance with Melanie Quaver (phonetic) involves the docs over at the hospital is in cancer. And looking at cancer. I'm looking forward when this is finished to sort of the next -- next course and the next students.