Dr. Michael "Mike" Carroll was interviewed on August 12, 2005 by Karen Brewster in his office at the Cancer Treatment Center at the Fairbanks Memorial Hospital in Fairbanks, Alaska. In this interview, Mike talks about the old hospital facility at Tanana, Alaska, traveling to villages to hold clinics, radio communication and the development of a satellite system, changes in medical care, and what the village and health aide experience meant to him personally.
Digital Asset Information
Project: Community Health Aide Program
Date of Interview: Aug 12, 2005
Narrator(s): Dr. Michael Carroll
Interviewer(s): Karen Brewster
Transcriber: Carol McCue
After clicking play, click on a section to navigate the audio or video clip.
His personal background information and coming to Alaska to be a doctor.
The hospital in Tanana and the medical care it provided, and why he became a doctor.
Training and working in Tanana.
Interacting and communicating with health aides in the villages.
Communication between the doctors and the health aides to treat patients, medivacing or going out to villages for emergency cases, and types of cases that had to be treated.
Improvements in the Alaskan health care system, and use of satellite communications for doctors and health aides to talk with each other.
Making a diagnosis without seeing the patient from what the health aide described over the radio.
Assessment of the Community Health Aide Program as a method for delivery of health care.
How working in Tanana in a rural setting affected him and his career, experience he had seeing the use of traditional medicine and healing, and the relationship between doctors and people in the villages.
Language barrier he may have faced, and what is was like working with the health aides.
Changes he has witnessed in rural health care and delivery of medical services.
How confidentiality was handled in these early days of rural medical care.
The closing of the Tanana Hospital in the early 1980s and Native control of the health care system in Interior Alaska.
What it was like working as a doctor in villages in the early 1970s.
What it was like living in Tanana, and his assessment of the Community Health Aide program as a model for other places.
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KAREN: Today is August 12th, 2005, and this is Karen Brewster. I'm here with Dr. Mike Carroll, his office at the Cancer Treatment Center at the Fairbanks Memorial Hospital. Thank you for agreeing to talk to me about your experiences as a doctor up in Tanana and the health aide program. If you could just start by telling me a little bit about yourself, your background, when and where you were born, education. DR. CARROLL: I'm a -- actually lived in Alaska continuously since 1977. I originally came to Alaska from the Pacific Northwest, Portland, Oregon, and first came up in 1968 when I was in medical school. After I graduated from medical school, I did my internship, and then came back to Alaska and spent two years on the Yukon River at the Indian Health Service Hospital in Tanana, Alaska. And that was from 1970 to 1972. And then I left and got additional training and returned to Fairbanks in 1977. KAREN: Okay. And where did you get your medical training? DR. CARROLL: I went to the University of Oregon Medical School, I did my internship at McGill in Montreal. Did my internal medicine residency at the University of Michigan in Ann Arbor, Michigan, and did my oncology fellowship at the University of Utah in Salt Lake City. KAREN: And why did you decide you wanted to come to Alaska? What got you to Tanana? DR. CARROLL: When I was a kid, I used to cut grass for a silver-haired stampeder who had come up during the Gold Rush. And I would cut the front yard, and I would sit on the stairs and have a Hires root beer and a Fig Newton and a story about Alaska. And on Saturday nights, I'd go up and we would look over the old National Geographics and identify things about Alaska, so it was always this place that had an allure to me. And so when I finally had the opportunity to come, you know, I jumped at it and worked at coming back in the Public Health Service so -- so that I could get a chance to work with the Native people. At that time and still, I've always felt that a vital part of Alaska are the Native people. They make up a huge part of what makes Alaska what it is, and that was just a wonderful experience to be out there in the village and taking care of them. KAREN: And so how does it work to get the job with the Public Health Service? I guess then it was Indian Health Service? DR. CARROLL: Yeah, it was Indian Health Service, and part of the United States Public Health Service. The Indian Health Service is a branch at that time of the United States Public Health Service. And it was a commissioned course, so you had an actual rank and military assignment. And you could have been assigned to take care of the Merchant Marine Academy, the Coast Guard, or Indian Health Service beneficiaries. And -- and I wanted to come to Alaska, so I worked very hard to get assigned up here and to have that tour of duty. You may or may not be old enough to recall that, you know, in the '60s and '70s there was a war called Vietnam on. KAREN: Yeah. DR. CARROLL: So most physicians had a military obligation, and this also counted as military duty -- service. KAREN: Okay.
KAREN: And so then how did you get involved with the health aides, with working with health aides? DR. CARROLL: So in the village of Tanana, we had a 25-bed hospital that was right at the mouth of the Tanana River as it comes into the Yukon. This was a hospital that was built, I think, in the '20s or '30s, in association with what was at what time known as Ft. Gibbon. The fort closed, the hospital facilities remained over the years, and served the Interior of Alaska Native communities. Generally speaking, those are Athabascan villages that ranged from Kaltag to Circle, from Nenana to Arctic Village, and Anaktuvuk Pass. Anaktuvuk Pass would be the only Eskimo village of any consequence within the subregion. And this was the hospital for many years for Native Americans in the Interior to be hospitalized. KAREN: So instead of coming to Fairbanks, they would go to Tanana? DR. CARROLL: Well, Fairbanks had the old St. Joseph's Hospital at that time, and then there was Bassett Army Hospital, and so some would be cared for in those two facilities. But many of the people in the Native villages, it was closer for them to come to Tanana, especially from the middle downriver areas, and others, it was a choice because they really weren't comfortable with coming to Fairbanks, it being quite a bit bigger than some of the villages that they were living in. And so they liked it being a smaller setting. The hospital existed up until, oh, I think about the mid '80s, and then was closed, and all of that function was transferred to the Tanana Chiefs' facility clinic in Fairbanks. KAREN: That's the -- DR. CARROLL: I'm sorry. KAREN: Chief Andrew Isaac's, is that the name? DR. CARROLL: It's referred to as the Andrew Isaac Clinic. Back in the '70s, it wasn't referred to as the Andrew Isaac Clinic, it was just -- it may have been the Indian Health Service Clinic, or I don't even know if we had a name at that time. It was probably in the mid '80s it was given a name, Andrew Isaac Health Center. KAREN: Okay. Why did you choose to become a physician? DR. CARROLL: Oh, I guess I was originally going to be an organic chemist, but I thought that that was not something that I really wanted to do for a lifetime when I really sat down and thought about it. Being a physician had some of the same intellectual challenges as far as chemistry and biochemistry, but it also gave you -- it gave myself and I think most of the people a chance to interact with individuals, and in the case of physician, patients, and I thought that that was something I wanted to do and have liked doing and continue to do. KAREN: And I didn't ask you when you were born. DR. CARROLL: I was born in 1944. KAREN: Okay. In Portland? DR. CARROLL: In Atlanta, Georgia. KAREN: Oh.
KAREN: So once you entered the Indian Health Service and got the job in Tanana, did you receive any specialized training for working with the health aides? How did that work? DR. CARROLL: I started the -- working in Tanana two weeks after I finished my internship. The only specialized training I received was a one-week indoctrination in Anchorage to the Indian Health Service kind of policies and procedures. A brief one-day educational session on how to fit eyeglasses and do eye refractions, and the -- a very brief introduction to -- to dental issues and how to pull teeth. And that was the extent of the introduction. KAREN: So as a doctor out there, you did everything? DR. CARROLL: As a doctor, we didn't do everything. You know, we would medevac things that were particularly com -- difficult to deal with, potentially life-threatening, but over the course of several years, you know, delivering babies, treating pneumonias, treating fairly straightforward fractures, simple surgical things like skin grafting, minor burns, occasional appendectomy, things that family practitioners oftentimes will do. KAREN: Uh-hum. And so what was the staff at the hospital, how many doctors, nurses? DR. CARROLL: There was three doctors. The nursing staff probably consisted of, oh, I would say probably about 15 nurses. And then some nurses aids that were usually from the Village of Tanana. And then a maintenance staff for that, we had one person who was a laboratory X-ray technician, and then we had a pharmacist who would send out medications to the villages and dispense what we needed in the hospital and all. There were no physicians assistants, no nurse practitioners. There were several sanitation officers, one in Galena, and I think one in Fort Yukon. And there was a small clinic that had a nurse, not a nurse practitioner, because that concept did not exist, a regular RN, in Fort Yukon. And then -- and that was, I think, about it. KAREN: So what is a sanitation officer? DR. CARROLL: Oh, the sanitation officers would -- they were kind of in charge to make sure the dogs were vaccinated. They were trying to deal with issues that they could as far as water and sewers. They would do some education in the villages as far as clean water. Most of the villages were taking their water from the river and just using it without any sort of precautions at that time. And so they were trying to help with that. As time evolved, some of the villages actually got some central facilities where they could wash clothes, take showers, and have access to clean water. And over the years, that's continued to change and improve. But many of the villages did not have electricity, did not have, you know, wells, and as I said, would get their water just from taking it from the Koyukuk or the Yukon or the Porcupine. KAREN: And then in terms of the medical care, what kind of equipment was available to you? DR. CARROLL: At Tanana, there were approximately 20 to 25 beds. Some of those were beds that were really used just for people waiting for either travel back to their villages or to have a baby. We had a large pediatric room that probably had 8 beds in it. We had a large male room that held, I think, five beds, and a female room there was the same size of that, even two private rooms for patients that were sicker and needed a little bit more privacy in their needs. There was a labor and delivery area, and there was a small operating room. We had a pharmacy both for the inpatient and outpatient side, we had an X-ray machine, and a small laboratory. KAREN: So you could do blood samples and things like that? DR. CARROLL: Yeah. Well, we had, as I said, a laboratory tech that did both the X-rays and the blood samples. Now, remember that this was in 1970, this is before CT scans and MRIs and nuclear medicine and ultrasound devices that we have now and take for granted. So you know, you just had kind of standard X-rays. KAREN: And -- and it was probably limited surgery facilities? DR. CARROLL: Yeah, pretty -- I mean, the actual operating room was a nice operating room. We didn't have any anesthesiologists, and so the anesthesia would usually have to be done by one of the physicians and the other physician may be doing the procedure. And anything very complicated would get sent out, either to Ft. Wainwright in Fairbanks or to Anchorage. KAREN: And the Native Hospital in Anchorage already was in existence? DR. CARROLL: The Native Hospital there had been there a number of years. I'm not quite sure when, but I think it was at least World War II vintage. It was an older hospital that was the major referral hospital for the entire Indian Health Service. In 1970, there were Indian Health Service hospitals in Kanakanak, in Bethel, in Kotzebue, in Barrow, in Sitka, and I think that's probably it. And then they had some smaller clinic facilities in some of the areas, and then they would contract for Native health care in places like Nome, which is -- at that time, had a significant non-Native population. And Kodiak and places like that. KAREN: Kanakanak? DR. CARROLL: Kanakanak, that's in -- KAREN: By Dillingham? DR. CARROLL: -- Dillingham. KAREN: Yeah. Okay. That's what I thought.
KAREN: So why don't you talk a little bit about how you interacted with the health aides and communicating with them in the villages and how that all worked. DR. CARROLL: So there were two ways that you would deal with the health aides. One was when you would go out to do the village for clinics. And generally speaking, one of the physicians at the hospital in Tanana, especially in the wintertime, not so much in the summer, but in the wintertime would be visiting one or two villages and spend anywhere from one to three days in a village doing things like school exams, pap smears, dental extractions, eye refractions, and, you know, general medical sick call. At that time, the health aide was the eminent personality that would help to organize that, and would assist you in those village field clinics. A few of the villages actually had real freestanding buildings and clinics and actually had some electricity. In some cases we would utilize, you know, a storeroom or a coat room in the schools. Sometimes in some villages, we would put a sheet up across part of the village buildings that may be used for public functions, and so you would have a sheet up in one corner and you'd have people sitting on benches that would be brought in. And I can remember having clinics, doing pap smears and eye refractions with a Coleman lantern because there was no electricity in the village. And so you do that on a fairly regular basis to try to -- to get some of the preventative things to -- to the villages. And as I say, pull teeth and eye refractions because dental care was not very available to even the children at that point in time. I mean, they did have a dentist who would perhaps come once a year, but the dentists were always overwhelmed with the amount of work that had to be done and never had enough time. So that was how you would get to know the health aides personally and through firsthand assistance. The other way was through communications over the very, very limited systems that existed. There were several villages like Galena and Fort Yukon that had telephones. Most villages did not have electricity and some only had electricity when the schools were in existence. And -- and the communications were through single-sideband radios. When school was out, the power was off, there may be weeks during the summer that they didn't even have single-sideband radios, so you wouldn't even have any communication with the village or the village health aide. What we tended to do is usually at a set time every day, would go into the radio room at the hospital, and commence radio traffic, I think it was probably one o'clock, and you'd go down the list starting with the As and finishing at the bottom of the alphabet, and call each village health aide with a village name and the call letters for the village on the single-sideband radio. And there were some days, especially in the summertime, because the schools were out, the way the sun was, and the antennas in the villages and in Tanana that you wouldn't be able to reach for weeks at a time. And you'd go through the list, you'd usually call them twice, and if they didn't, go on to the next village. And then at the end, ask for any more radio traffic, and once that was finished, sign off. And usually that could be accomplished in between 30 and 60 minutes. KAREN: Uh-hum. Now, is a single-sideband radio like a CB radio? DR. CARROLL: No, CBs would be a very, very short wave. This was actually -- these were shortwave radios that were, you know, fairly large, probably, you know, 24 by 24 inches across. KAREN: Uh-hum. DR. CARROLL: We had a large antenna that was probably 50 feet in the air that was out in the back of the hospital. And ideally, the villages would have the same antennas. So, you know, a CB radio has a pretty short distance of transmission. Theoretically, these had transmission distances of more than 200 miles because we really were talking about an area that the Tanana Hospital serviced at -- it was about the size of the state of Montana. KAREN: Yeah. DR. CARROLL: So from Eagle, which was over close to the Canadian border to the east, to Kaltag, which was just maybe 30 miles from the Bering Sea. So you know, it's the breadth was really quite significant.
KAREN: And as a physician not being able to communicate or not communicate with your patients and people in the villages, what was that like? DR. CARROLL: So, what you'd do is you'd reach a village health aide and ask her if she had any radio traffic. And she would say, yes, Dr. Carroll, I have Mr. So-and-So or Mrs. So-and-So, or an 8-year-old boy, and then they would relate the vital signs they had taken, the symptoms that they had taken, and sometimes would help you with the diagnosis of what was going on. Sometimes it would be a matter of relaying symptoms to you without getting a clear-cut picture diagnosis. And as a physician, you'd try to come up with what your impressions were and then make some recommendations as to what you thought would be the treatment. The stockpile of things that were available for the health aides in 1970 were pretty limited. They had some injectable penicillins, they had some sulfa, you know, they had some aspirin, they had some Tylenol. They may have had a little bit of Darvon as far as the pain pills. They may have had some medicine to help with diarrhea, they had some Ipecac to help if you thought somebody had accidentally or intentionally taken an overdose of something. But you know, I think the list is probably no more than 20 to 25 medications. And so your diagnosis and therapy pretty much had to limit itself with dealing with those issues. If you felt that the patient was sicker than what could be dealt with, then you could authorize the health aide to send the patient in. If it was an emergency, it would -- you would frequently arrange for a medevac. And at that time, a medevac would be, you know, a local bush pilot flying either out of Galena or Fort Yukon without the -- any help to pick up the patient, and then bring them to Tanana. If it was appropriate, you would sometimes fly the airplane from Tanana to the village. And occasionally, if we thought that it was a situation that a physician needed to go to, we would jump in the plane with the pilot and fly to the village and pick up the patient. If we had -- if they were a stretcher case, we had some steel wire baskets that we would put them in that would fit in the back of a 206 or a 185 or a Cherokee 6, and bring them back. If they could sit up, they would usually sit up. You know, we could deal with IVs to a limited extent, but it was always difficult trying to maintain an IV in a small plane like that. KAREN: Yeah. DR. CARROLL: Because it was bumpy. And back in 1970 we just didn't have the same venous access devices that we now take for granted. KAREN: So were you ever called out to a village that there was an accident? Were the doctors called out to -- DR. CARROLL: Well, oh, there was -- you know, one of the most memorable ones is one we didn't get to go on. And this was a particularly snowy winter in 1971 at Christmastime. And at that point, one of the villagers had become depressed, and depression is a big issue, even in the '70s, and had tried to commit suicide by shooting themselves. They had not succeeded in killing themselves right off, and so this was Christmas Eve, and we then spent the next four hours trying to arrange for some sort of medevac, but because the snow had been so heavy and the snow removal was not very good at that time, the state had not assumed much of a responsibility in this particular village, we could not get a pilot to fly in. The villages did not have electricity, and of course, that meant they didn't have lights on the runway. KAREN: Right. DR. CARROLL: And -- and so we would get reports every 30 minutes from the village health aide about the vital signs, and over a period of a number of hours, this patient that might have been saved, had we been able to get in there and get some medical help to them, gradually went into shock and died. Yeah, so that's, I think, a particularly difficult and always unsettling sort of memory from what health care was at that point in time. You know, I can remember having episodes where people would have seemingly minor accidents and I may have been at a location where I'd sometimes fly out and suture them up there. Most health aides at that time didn't have the skills or the tools to do any suturing, and sometimes it was easier to go out and suture them and let them stay home rather than have them fly in and then have to fly them back, you know, a day or two later. You know, there were examples of infants and children getting burned, there were examples of bad dog bites, you know, people being sick as far as bad pneumonias that required, you know, young mothers pregnant, and having seizures. Occasionally getting caught in delivering babies on kitchen tables in the villages. There was a whole spectrum of that. Gun shots of other types, accidental. You know, lots of different stories. KAREN: Uh-hum. You were -- that one you talked about, you know, other harrowing flights or close calls or particular memorable cases that come to mind? DR. CARROLL: Well, one time I was going to one of the villages and we were to land on the river with skis. And as we were setting down, the skis caught some gravel and -- and the plane crashed. No one was hurt, so you know, that worked out fine. I can remember going to -- great story is going to one of the villages for a field clinic and having worked there all day and was supposed to be picked up in this particular village, again, didn't have a runway, so in the wintertime we landed on skis on the river, and in the winter on floats on the river. And so the plane to pick me up was supposed to -- they only got mail service twice a month at this village. And they were supposed to pick me up the next day, and I'm all ready to go, and a wonderful blue sky in the middle of March, and the plane flies over and circles a couple times. The pilot opens the window and throws out this yellow mail sack to me down on the ground, and inside is a note saying that the skis are broken, I'll pick you up tomorrow. You know. There weren't -- again, no telephones, no electricity in that village, so you know, it was an era where this village didn't even have a single-sideband radio, so they were without communications, other than what happened when the pilots would land and tell us what it was.
KAREN: It's pretty amazing that that was only 30 years ago? DR. CARROLL: 1970. '71, '72. KAREN: 35 years ago. DR. CARROLL: Uh-hum (affirmative). KAREN: And that it's changed a lot. DR. CARROLL: Oh, the big change, I think, happened with electrification of the villages because that allowed, you know, people to have power in their houses. And at about the same time, the develop of satellite communications. In 1970, in Tanana, we had only the single-sideband radio, and as I say, some villages would go weeks before we could talk to them because there was no power, because the teachers were gone and schools were shut. Or the way the sunlight was, the shortwave radio bands did not work in that particular locations. 1971, we were lucky enough to have a demonstration project. There was some spare time on one of the old early satellites that we were allowed to become involved with as a demonstration project on the utilization of satellites. And -- and communications for health-related issues. And so we had a little box that was about the size of your tape recorder and similar to what the, maybe, a single sideband -- not a single sideband, but a CD -- CB radio would be, that we had installed in, I think, 9 of the 20 some villages that Tanana served. And so we were able to talk to these villages. We had one hour of traffic a day. That's all the time we would get. But we would have consistently an hour where you could be reached. And -- and it was reliable. It was like talking on the telephone almost, although it was, you know, still off-and-on radio system, but at least you could understand people, you weren't trying to figure out what they said, which sometimes the transmissions were poor quality with the single-sideband radios. And -- and you could get good information from the health aides that we used. And that was a demonstration project in conjunction with Stanford University that, as I mentioned earlier, was subsequently published as, I think, the first example of satellite communications for use with health care. And that was wonderful. We had that that year and those villages that had the demonstration project were always available for one hour. And the others struggled with the sideband radios and frequently were not that way. KAREN: And so did that then expand to the other villages? Obviously, sounds like it was successful -- DR. CARROLL: At the time there was an expansion of -- expansion of telephone communications because the development of satellite television. So I'm not quite sure when that happened, but I think within the next five years is when the villages started getting consistent telephone communications as they got power. And when that happened, then instead of a single-sideband radio, the health aides could pick up the telephones at any time during the day and call and say, gee, Mrs. So-and-So is sick with fever and cough and chest pain. I think she's got pneumonia, what should I do. Whereas before, you know, oftentimes the health aides, if they thought the patient was sick enough to need treatment before the traffic and if they couldn't get -- the single-sideband radios were on all the time, but they were so unreliable that frequently, frequently you -- you know, they couldn't get through. And so if somebody was really sick and they couldn't get through, maybe they could get to Galena or Fort Yukon, then they could get a plane to come out and pick them up and bring them to Tanana. And that was, you know, kind of the way. Or maybe the plane would land and the health aide would have to decide, well, this person's too sick for me to try and treat in the village, I'm going to just try and put them on the plane because I can't talk to Tanana and send them in. So we could always count on two or three or four people showing up about four or five or six o'clock in the evening when the downriver plane would come in from, you know, Nulato and Ruby and places like that with patients that the health aide was worried about and wanted seen by the doctor. KAREN: Uh-hum.
KAREN: How does it work, how are you able to diagnose and treat something when you can't see the patient? DR. CARROLL: Well, you have to rely on the eyes and ears of the health aide. And the information they give you. So some health aides were very experienced, and some health aides were not very experienced. The most experienced ones have been doing it for many years before the system existed. The ones with less experience may have been younger or people that had just come into the whole program as the village needs developed. Some health aides had maybe 6 to 12 weeks. There was a three-part program, and I think that it consisted of several weeks, and then they would come back at a later date and get some additional training, and then by the time they had finished the third part, in 1970, they had had some training in Anchorage in a more formal structure. But as I recall, I think the most anyone would have gotten would be between 6 and 12 weeks of -- of training. And oftentimes they were doing it with only part one of the training, which might have been a couple weeks. KAREN: Did you feel like -- DR. CARROLL: Some never. KAREN: Yeah. Did you feel like they got enough training to be able to communicate to you what you needed to be able to make a diagnosis? DR. CARROLL: You always, in medicine, work with what you get. And you certainly were -- we're not going to deny trying to treat somebody, you know, based on the fact that the health aide may not have had much training or the fact that they had no training at all. Oftentimes, if there was a question, maybe the health aide had hadn't taken the temperature or you wanted -- the temperature they had taken was last night or the morning, you'd have them go back and redo it. And most of the villages are small enough, they could run over and do it, and before you finished radio traffic, they would call back with more. Sometimes some of the humorous things would happen as all the health aides were listening to this radio traffic at the time is while you were talking to one person and then they -- maybe one of the other people would -- would come in and say, well, we've got this same problem here with everybody with strep throats. Or, you know, you know, you know, I think they were up -- they were here when I got sick, you know, with the potlatch or something. So it was very open, this discussion. And it was part of the education because they were -- the really interested health aides were listening to what we were telling other health aides and trying to come up with, you know -- you know, ways to approach problems. When you only have a handful of medications to work with, it's sometimes a little bit easier because you're not trying to sort through a formulary of a thousand drugs, you know, you only have a handful, so most infections either got treated with sulfa or penicillin. And, you know, there was an awful lot of strep throats and an awful lot of ear infections that I'm not sure were strep throats or ear infections, but you know, they got treated along those lines. Some health aides seemed to make the same diagnosis all the time, whereas others seemed to have the ability to come up with good assessments and plans. The really best health aides were those that had lots of experience and they would be able to tell you whether the person was sick or not sick. And that was always the most important thing. Because if somebody was sick, you needed to bring them in on a medevac. Or if they weren't quite so sick, you'd maybe have them come in on the next mail plane. And so you had to have a reliable person. And some of them, I can remember, would say, Dr. Carroll, I don't know what's wrong with this patient, but they look awfully sick and they need to come see the doctor. And so you'd bring them in without a diagnosis, but just on the assessment that there was something wrong, that they needed to -- you know, more assistance in dealing with. A lot of things, the day-to-day things got taken care of really quite well by the health aides, and considering, you know, their -- their limited training, I thought they did a great job. You know, saved, you know, I think lots of lives and lots of suffering.
KAREN: So you just answered my next question. And did you think that the health aide program has been a good thing? DR. CARROLL: Oh, absolutely. I mean, you know, you know, you know, I think some of them were good at trying to do preventative things and help in regards to vaccinations and helping with the Public Health nurse. At that time, there was a state Public Health nurse that usually would make several visits to the villages, to a village each year and try to do TB screening and monitor tuberculous medicines, vaccinate kids, things like that, and the health aides would help with that and make that program very successful. Now, the pap smear rate in the villages, even though they may not have electricity, was probably far better than the pap smear rates in Fairbanks because you had a captive audience. The health aide would -- in a village would say, okay, all the women are going to come in and get their pap smears, you know, from nine to three o'clock while the doctor is here. The men didn't even get to come to the clinic at that time. Okay? And so -- and if somebody didn't show up, the health aide would know who didn't, and oftentimes there had to be a reason why they didn't show up. Sometimes people didn't want to and they wouldn't be forced to do it, but you know, it was a pretty way -- good way to kind of get the people there and care for the things like that. KAREN: Sounded like the health aides were pretty committed to their work. DR. CARROLL: Most of them were really committed. They had done it for a number of years, I think without much pay. They had been asked to or given that responsibility by the Village Councils and were very well respected. And you know, as I say, they were doing it with, you know, no pay whatsoever just because they realized that something had to be done. I suspect that how it got started in some villages is, is the doctors realized that, you know, they needed to have some medicines out there for kids that had simple pneumonias and ear infections. And without somebody to control those medicines and dispense it, you know, some of the big problems with ruptured eardrums and the hearing problems and things like that were never going to get dealt with. KAREN: Back where you talked about the communication and, you know, when they got telephone, while you were involved, did the video conferencing, that hadn't come into play yet, had it? DR. CARROLL: Oh, no, no. No. KAREN: That -- DR. CARROLL: No. It was black and white TV in Alaska at that time. And -- and the -- and the television programming was not live, it was sent up on -- KAREN: Right. DR. CARROLL: -- Alaska Airlines, the evening news was sent up on a tape and played after the plane arrived. KAREN: Because now, don't they have video -- you can -- doctors and health aides can, in some places, they can see each other and talk to each other. DR. CARROLL: Yeah. Some communities that have the video teleconferencing, where the patient can be there and the doctor can see them, and the nurses or health aides can look back and forth. But no, we were just trying to get understandable verbal communication. And there were times that that was not even applicable. KAREN: All right. So the satellite -- DR. CARROLL: The satellite. KAREN: -- was as advanced as it got while you were there? DR. CARROLL: That was advanced as it got. Yeah. And that was just a one-year thing that went away after that. KAREN: Oh, it did? DR. CARROLL: Uh-hum (affirmative). And then, you know, after that I left so I can't tell you what happened in the next few years. KAREN: Yeah. Because I've seen photographs of the satellite dishes in some of the villages, and was that that demo project here? DR. CARROLL: Yes. Uh-hum. Uh-hum. KAREN: And you had mentioned that you had published an article. DR. CARROLL: It wasn't so much that I published an article, there was an article that was published in the New England Journal with the authors, primary authors being those from Stanford -- KAREN: Okay. DR. CARROLL: -- that dealt with satellite telecommunications. KAREN: And that would have been in '72? DR. CARROLL: It was probably '73, maybe. KAREN: Okay. DR. CARROLL: New England Journal of Medicine. KAREN: Okay. DR. CARROLL: It could have been '74, but, you know, '72, '73, you know, in that era probably. KAREN: Okay.
KAREN: In terms of you personally in your career, how did your experiences at Tanana, both working in a rural setting and working with health aides, how did that affect you? DR. CARROLL: Oh, I would say that probably as a doctor who has just come out of his internship, there were several things. One is I was so inexperienced and so young, I probably didn't know what I didn't know. With that said, it was also one of the most fun times to practice medicine because you really did get to do lots of things, you got to meet people in settings that you normally wouldn't get a chance to meet them. It was the opportunity to go into the villages to get to know these people very, very well. Some of these people I still know now, 35 years later, and I still care for 35 years later. And so it was a really good time. KAREN: Okay. Did you have any contact with the health aides in terms of were you aware that there was any use of traditional healing and traditional medicines going on at the time? DR. CARROLL: Traditional medicines were used at that time. Oftentimes, the health aides weren't the ones that were doing it. But it was still at a time when people would -- would exert traditional medicines. Probably one of the most common traditional medicines among the Athabascan peoples, and they would come in regularly, would be with spruce pitch on them. You know, they would get a burn or an injury or, say, an infection, and they would put spruce pitch on it or they may put spruce pitch and caribou skin. And so, you know, that's not at all uncommon to see that sort of thing. And that was probably the most common medicinal traditional thing. They would also take and make tea out of spruce needles and make tea out of birch bark. They didn't talk about it as much, but there were a couple villages that had some patients that still -- not patients, but some individuals that still did traditional healing. And so they would do cuts on the side of the head for headaches, and I suspect things that were not fully described to me because I was on the outside, not the inside. And clearly, I -- I know that some of that was happening. I think those probably, you know, became much less as those people passed on, and probably by the mid '80s, much less. And I can say that, you know, I have -- although I don't take care of nearly the same number of Native patients that I saw at that time, I have not seen a Native patient from any village come in to see me with spruce pitch for a number of years. But that was a really common sort of thing. KAREN: And was the spruce pitch treatment effective? DR. CARROLL: Well, they'd oftentimes be coming to see me because it had not been effective. You know, the ones that it was effective on, I have no idea. KAREN: You didn't even see them. Coming in as an out -- you mentioned being an outsider, I was wondering what the relationship was like as a doctor with the villages, when you went in. DR. CARROLL: Well, I -- one of the dilemmas that the Public Health Service had in those days, and still has to a certain degree now, is that there was a significant transition of the physician numbers. And about every two years, there would be new doctors coming in and taking care of their health care needs. And so they didn't have a doctor that was a doctor for 10, 20, 30 years. And that's unfortunate because I think a lot of health care involves rapport and relationships that develop. And when you have young doctors, and I'm sure I looked very young, coming in and only staying for a couple years, I think some patients and perhaps some health aides were reluctant to share some of their feelings and their concerns and some of the issues that may have been there as related to the physicians that might be serving in a particular region. More recently, I think the Indian Health Service, and with the way the contracting has gone, the employees of the Andrew Isaac Clinic and the regional health authorities have tried to keep physicians for a longer period of time, and so there's not the same transition that existed back in the '50s, '60s, and '70s. And so there's a little bit less of that, I think, happening. KAREN: But they -- but people were willing to come to you for care? I guess there was a period where you said transition, where the traditional healing was not as prevalent? DR. CARROLL: Yeah, I think most -- I think the traditional medicine was -- was -- it played a limited function. And certainly if anybody was very sick, they would deal with it. You know, I mean, if somebody had, you know, a broken arm, sometimes in some of the villages, they would try to take care of it there without coming in. If they had a broken leg. But, you know, you know, there was a real trend towards going to the hospital and getting care for significant problems. KAREN: Okay.
KAREN: And what about language issues? How did you deal with the -- DR. CARROLL: Well, the older people required translators in some of the villages, but many of the villages, even the older people, had had a long enough contact with English society that they could speak to us without much difficulty. There was two villages that had very, very traditional language patterns, and the villages of Arctic Village and Venetie in 1970, '71, and '72 were predominantly Indian-speaking villages. And most of the children at that time spoke limited English, and mostly Indian at the time they attended school. And so translators were always needed there. I mean, I tried to learn a few Indian words of the Gwich'n language, but, you know, never enough that it was more than something that they would smile at. You could always -- you always had a health aide or someone that could help translate, from that standpoint. By 19 -- the early 1980s, as a product of electrification and television and satellite TV, even those two villages had a huge drop-off in the number of children who spoke Indian. So one of the most remarkable things was -- was to see that transition from kind of aboriginal language and culture in the early '70s and what had happened just 10 years later. KAREN: Wow. Amazing. And so the health aides were often the translators? DR. CARROLL: Almost always. KAREN: Right. DR. CARROLL: You know, the health aides usually spoke the languages in those villages that you needed the -- the language. And were good enough at that. And some really excellent at it. KAREN: Yeah. Because I was thinking that the medical terms and health issues is not something necessarily in somebody's normal English conversational -- DR. CARROLL: Yeah, but the -- you know, the words about fever and pain and feeling sick, those are words that are in most languages. KAREN: Yeah. DR. CARROLL: And, you know, you maybe didn't use medical terms. KAREN: Right. DR. CARROLL: But -- and usually in the practice of medicine when you're dealing with patients, you -- you have to be careful about not using medical terms. KAREN: Right. If you're a good doctor. DR. CARROLL: Well, I think all doctors do that. Plus the health aides, you know, were sometimes very skilled and intelligent people. There was one health aide I could never beat at Scrabble. KAREN: They had to be. DR. CARROLL: Yes. You know, I mean. And oftentimes a lot of it was the self-taught, or through observation and learning by experience without somebody there as a teacher. A few of the villages had a couple people that would function as health aides, and that sometimes allowed them to exchange ideas. And they would both be there, and if they had a medical emergency, they would both try and sort out whether they thought the patient was really sick enough to need a medevac, or maybe they would be able to stabilize the patient well enough. But you know, they didn't have IVs, they didn't have things that they could do, really, for much intervention. They could -- they had hot water bottles and blankets and stretchers, and that was it. KAREN: Right. Well, that's why I find the whole health aide program so fascinating is that it was at a time when there weren't all this -- the modern equipment and they didn't get a whole lot of training. And what those people were able to do is amazing. I mean, they are very special, talented people. DR. CARROLL: Right. You know, I think sometimes the training wasn't as good as it should be, and, you know, sometimes the conclusions they would draw would be inaccurate, but they were still doing the best they could at the time. And one of the more humorous episodes I remember getting on radio traffic during that time was a call from one of the health aides saying that this whole family had gotten sick with nausea and vomiting and diarrhea. And they figured that they had food poisoning. Which the conclusion was right, the diagnosis was right. The health aides had in their stockpile of medications a medicine called Ipecac, which is used to induce vomiting for people who have taken an overdose of pills. And tried to self-poison. So this health aide took the leap of faith by thinking that food poisoning should be treated the same way as taking an overdose of aspirin or Tylenol. And gave the whole family Ipecac, which took this family that was already sick probably from getting some bad food, and made them throwing up now from the Ipecac medicine. And, you know. KAREN: And so how did you treat that? DR. CARROLL: Well, I didn't treat it at all. I just said, have them keep their stomach empty for six hours, and then start them on some Jell-O water or Seven-Up. And they all got better.
KAREN: Yeah. Yeah. I guess we could talk a little bit about the changes you've seen in rural health care and medical delivery. DR. CARROLL: Well, I think back in 1970, many of the villages would get mail traffic maybe once every two weeks to -- a one plane three times a week. And the biggest villages might get a plane every day and sometimes several planes a day. Now, all of these villages are getting airplanes every day. Most of them are getting these flights in two or three times a day. And just the fact that if somebody's sick, they could put them on the mail plane, and every day makes their access to health care without having to charter a medevac easier. So the frequency of travel is so much greater now than it was at that point in time. Many of the people didn't have the financial resources to travel much, and so you tried to do more in the villages that would get them the screening things that they needed because some of them really hadn't, you know -- you know, going to Tanana would be a big trip for them. KAREN: Uh-hum. DR. CARROLL: Coming to Fairbanks would be a huge trip, and some of them have never even been to Anchorage. So, you know, the travel really was a much bigger thing. I think now, most people in the villages, you know, travel regularly, you know, to bigger villages or to Fairbanks or Anchorage. And so there's just a lot more travel from that standpoint. I think the -- the parents of the villagers are much more sophisticated as far as their health care needs and dealing with symptoms. And so they're not so likely to delay a particular symptom for a long period of time waiting for the once or twice a year doctor visit that would happen in the village. And so they will come into Fairbanks or to Galena or Fort Yukon and try to get is the health care at an earlier point. You know, the ability to use the telephone is huge. I mean, instead of trying to struggle and get communications for a few moments, maybe every two weeks, you know, they can pick up the phone 24 hours a day and call. And I think all of the villages probably have lights on the runway, so unless the weather is just impossible, you know, they can get medevacs and medical care into the village 24 hours a day, 7 days a week, without the same issues that occurred back at that time. And if you lived in Anaktuvuk Pass and you got sick with appendicitis on Tuesday, and the mail plane came Monday, Wednesday, and Friday, and you couldn't talk on the single-sideband radio for four or five weeks, your appendicitis probably didn't get diagnosed or taken care of for days. And now, I think we would hope that those people, you know, have it recognized sooner, they can get access to that and get help that much more quickly. KAREN: So in your time, somebody like that with an appendicitis that couldn't get out, it would rupture and -- DR. CARROLL: Rupture. And we never had anybody die from appendicitis, but you know, a ruptured appendix takes a lot more effort to clear up and patients are usually much sicker and their wounds are much more difficult to deal with than if you have someone that you have caught early before it has a chance to rupture. And so that's an example of how, you know, better access to care gets better care and care is shorter. KAREN: Well, it sounds like you're lucky that nobody died from a ruptured appendicitis. DR. CARROLL: Yeah. Yeah. Yeah. I mean, you know, there were people, as I mentioned, the gun shot wound, that clearly they had four to six hours, and had we had the ability to get to that person with a gunshot wound, you know, I'm sure we could have done interventions that would have allowed us to hopefully have saved that patient, but did not. KAREN: Were there other situations? DR. CARROLL: Oh, you know, there were accidents that -- you know, snow machine accidents that people wouldn't make it in. People with broken hips that may take you 12 hours to get in. You know. And again, you remember there's no pain medicines, nothing you can give that person. So they are kind of laying there suffering. Heart attacks probably, you know, did not get timely medevaced and would end up dying in the village before help could get there. You know, that happened a few times. I don't remember any obstetrical disasters that ended in death during the two years that we were there. I think we were lucky, but I'm sure that could and did happen. And as I say, you need to very much get a chance to talk with Dr. James because he's got one of the great, you know, village emergency surgery stories that I think exists in Alaskan health care lore. KAREN: Okay. Well, I'll be sure to ask him about it. Yeah.
KAREN: One of my questions we talked about before we had the tape recorder going, so I wanted to talk a little bit about it on tape, which has to do with the issues of confidentiality. DR. CARROLL: Uh-hum (affirmative). KAREN: And I know that's very important in modern health care. I don't know how that was handled in the '70s when you were out in Tanana. DR. CARROLL: Well, I'm not sure the question of confidentiality was ever raised in regards to health care traffic. I mean, we -- we tried to be concerned, you know, when we were dealing with a patient and the record keeping of that patient, that it was kept confidential. You have to realize that if you're talking on a single-sideband radio and you've got 22 village health aides listening, waiting for their turn, that they are all hearing the same story. Now, what we did as far as health traffic, yeah, we generally did not have any names. So the health aide would report I have an 8-year-old boy with a temperature of 102 and he has a earache on the left side. And so we would treat without the names almost always, and if at all possible. I'm sure sometimes names would come up, and I'm sure sometimes other health aides would recognize, well, gee, I think I know who that family is. Or that person. But -- and I think that sometimes the patients in the villages were a little bit concerned about the health aides and how much information happened to get disbursed from that standpoint. And I would occasionally get people that would come into the clinic who would want to come in to talk about private issues that they didn't want to talk to their health aide about, but that was oftentimes because the health aide may have been a cousin or an uncle or a sister or, you know, a relative of some sort. And they had health issues that they really did want to keep quiet, whether it was related to spouses and kids, and whatever might have occurred. KAREN: Yeah. I was wondering -- yeah, I was wondering how that worked in the village, yeah, the health aide who is from the community and often related to many people in the community. DR. CARROLL: And it sometimes would be an issue. And if it was a big enough issue, then we would see that person would maybe just decide to come in on their own, pay their way into Tanana and see us in the clinic, other than go to the health aide and say that they had VD or, you know, some sort of sexually transmitted -- transmissible disease. Or, you know, maybe was worried that, you know, there was, you know, a mental illness that might -- that they didn't want to share. You know. And -- but, you know, the health aide still dealt with an awful lot of that. And there was lots of, you know, sexually transmitted diseases that were treated in the villages over the radio, again, you know, without the names going on. KAREN: Right. DR. CARROLL: And I suspect without it ever being reported to the Public Health authorities. KAREN: Right. Well, also you said in the clinics where you just have a sheet in the room? DR. CARROLL: Uh-hum (affirmative). KAREN: That's not very private. DR. CARROLL: There's no -- there's no verbal privacy in some of the community centers when we would be doing it. You know, we would have a potbellied stove over here, some benches at the back corner, and then some sheets up there with a Coleman lantern, and you know, a sheet's going to be very private. You felt you gave them about as much privacy as you could, and that's having -- by letting them put on a paper gown and be behind a sheet. But, you know, the verbal ones, you know, we will oftentimes, for things like when we were doing the pap smears, we would try to set that at a certain time in the morning. You could usually get the women to come in if they knew that they had that time. And -- and do that. And they knew that there were only going to be women in the clinic then. KAREN: Right. DR. CARROLL: And so that was one way to handle that. Usually, you know, there would be a more general clinic that would be in the evenings. You know, I'd always save the dental clinic and the eye clinic for the very last because those were oftentimes the most popular. People would want me to pull teeth or give them a new set of eyeglasses and so they would come in for that more than they might for other things. KAREN: Okay.
KAREN: I know I was thinking of that, was going to ask before, which is you said the Tanana Hospital closed in the '80s? DR. CARROLL: I think it was the early '80s, yes. KAREN: And what the impact of that was. DR. CARROLL: Well, health care changed a lot. You know, in the '80s. You know, airplane and mail traffic become much more common. Patients became more health care sophisticated. You know, they -- they wanted more diagnostic studies if they had a problem. In the '80s, you know, we started having CT scans and ultrasounds and things that, you know, you just didn't ever expect that you would be able to offer a patient in Tanana. And in addition to that, the really sick patients needed intensive care, we didn't really have an intensive care. And so you dealt with things as best you could with the nurses. When the hospital closed, its biggest impact probably was on the village of Tanana because it had a significant number of employees that were from the community who no longer had, you know, reasonably good paying jobs. And so as some of those end up, having lived much of their life there, moving to Fairbanks to get a regular job in town. It meant for the villages that were downriver from Tanana that they had to fly into Fairbanks for their health care rather than being able to stop. And so at that time, that added another hour or so of flying time and probably another $150 in travel expenses. Now, but also, you know, you have to realize that as more and more Native people migrated to Fairbanks, they had more family that they could stay with and visit and the shopping was also always part of some of the health care visits, you know. And Tanana had a pretty good store, but it didn't have anything that would compete with Safeway and Fred Meyer's and Foodland, like existed in Fairbanks. KAREN: I don't know if the timing of your contact with health aides in the health aide program, and the change to how now it's run by -- it's not the Public Health Service anymore, it's the regional corporations and TCC and whatever, if you have any observations on that changeover? DR. CARROLL: Well, at that time, the health aides were employed by the Public Health Service, I think. KAREN: Right. DR. CARROLL: The Tanana Chiefs existed, but they had mostly an advisory board and didn't have any direct administrative responsibility. Most of -- most of the organizations around the state, healthcare-related organizations within the Native communities had wanted to assume more power and responsibility and direction for the regional areas, and so they've taken over most of the administrative responsibilities. And so the funds goes to those regional health care consortiums to then be directly distributed to the representatives of the beneficiaries. KAREN: Uh-hum. DR. CARROLL: That's probably best because, you know, they are the ones that, I think, you know, have an important part to play in their health care, and perhaps when you have limited financial resources, are better suited to prioritizing how that -- those monies are spent. KAREN: Uh-hum. DR. CARROLL: There's never enough money, you know, for health care in that sort of a system, so there's always going to be someone or some individuals that feel like they are not getting the services that they would like. And the people responsible probably in the areas are best able to sort that out.
KAREN: Do you have any thoughts about if you did it all again, things you would have done differently, lessons you've learned along the way? DR. CARROLL: No, no, no. You know, I've worked real hard to get the opportunity to go out there. It was really exciting, as I say, fun. Yeah, it was hard work because I was usually going, you know, to a village at least for two weeks out of the month for nine or ten months out of the year. And I'd go out on a village on a Monday morning and come back Friday night or Saturday, and I'd be working from 8:30 in the morning until ten or eleven o'clock at night in some villages, and doing things that, you know, I always didn't feel totally competent in. As I said, I did eye refractions. There was one village one time that I dispensed 40 pairs of eyeglasses one night. There were some villages that, you know, I would put temporary fillings in and pull teeth in. And I never thought of myself as being a dentist and never felt particularly comfortable with that, but you know, the -- you know, if it was between what I did and no care at all, I felt like perhaps I could offer them, you know, a reasonably acceptable alternative. Again, doing that in that setting, you know, for an entire lifetime as a physician I think would be difficult. I think it would have been easy to have burned out and kind of lost enthusiasm for it. As it was, by being there and then coming back, I've been able to maintain some relationships with some of the patients that I took care of back in the '70s, and I'll still take care of some of those patients, even today. When I see patients now in the context of cancer and malignancies, unlike perhaps other physicians that live in Fairbanks and have never been to the villages, you know, I can generate an image of what their village is like, and oftentimes know who their parents were, you know, who their brothers and sisters are. And -- and just have a sense of what these people are more than just being, you know, a patient from a particular village that, you know, I haven't lost some of the context on. One of the sad things is, you know, over the years I've taken care of many of the elders, and I've seen a passing of many of these elders that were kind of leading their communities back in the '70s and no longer exist. And now there are new people that have filled in for that, but there were just some wonderful, you know, very traditional people back at that point. I probably, if there was something I wish and maybe would do over is I really, really would have loved to have done that in the late '50s because I think that was a time when Alaska had the beginnings of a health care system, but the -- it was still had all the magic of Alaska being almost foreign and exotic. And the people, you know, were at that time living exceedingly traditional life styles, and they all had lots of great stories to tell, but I'm sure the stories were even more exciting back in the '50s. KAREN: All right. So it sounded like you became involved in the community and interacted with people and -- DR. CARROLL: I think if you live in a village, you know, you know, that's part of the great thing is that you virtually know everybody. And, you know, become comfortable. Sometimes you might say, well, gee, that's not good, but it was one of the nice things was getting to -- you know, going to their dances at night and to their weddings and to their potlatches and things like that. KAREN: Yeah. I know that in some communities, some physicians or the teachers, the outsiders don't always interact with the local people in day-to-day life, they do it when, you know, somebody comes to see them or whatever, so it sounds like you made a point in getting out into the community and interacting. DR. CARROLL: The whole purpose I was there was to be with the Native people. It didn't make sense for me to spend the whole time with the non-Native population. KAREN: Now, was that common in Tanana with the hospital, the relation between the -- DR. CARROLL: I think it always varied over the years with how comfortable the individual professional staff felt with it. Some probably were more comfortable than others.
KAREN: And when you went there, were you single, were you -- DR. CARROLL: Married. KAREN: You were married? DR. CARROLL: Uh-hum (affirmative). KAREN: And what did your wife do? DR. CARROLL: She taught school and she was a -- she would substitute at the school. She didn't want to get a job as a teacher in Tanana because she felt that, again, teaching is one of the sources of income in the village, and she didn't want to kind of steal any potential income from people that really wanted to live there. KAREN: Uh-hum. So were there Native teachers at the time? DR. CARROLL: Just started the Native program where they were training and so there were a few Native teachers, yes. KAREN: And did you have children at the time? DR. CARROLL: We adopted a Native child at that time. KAREN: So your being gone two weeks out of the month, how did that affect your family? DR. CARROLL: Well, you know, it was easy. You know, yeah, it's a small community, so you know, yeah, my wife always had things to do and keep busy and it was a wonderful time. I didn't have a radio, I didn't have a television, I didn't have a telephone. See, I didn't have any of these things either. KAREN: Right. DR. CARROLL: I mean, we had electricity at the hospital and where I lived, but -- in the quarters of the hospital, but you know, the outside world was truly the outside world, even for me. KAREN: Uh-hum. DR. CARROLL: You know, the episodes of coming to Fairbanks and traveling excluded, you know, and you really didn't have to contend with some of the issues that were out there. There's a whole two years that I don't recognize the music. Yeah. KAREN: It sounds like you enjoyed your time out there. DR. CARROLL: Uh-hum (affirmative). Uh-hum. KAREN: And liked it. DR. CARROLL: Oh, no, it was a -- KAREN: Despite the hardships? DR. CARROLL: No. The hardships weren't a problem. I never felt that there were any hardships. It was a great opportunity, you know, to do things that were really wonderful. And so in the wintertime, I'd go to Nulato, you know, for a clinic for two or three days, and then I'd get somebody from the village to take me by snow machine to Koyukuk. And you know, what a wonderful experience to go by snow machine with, you know, to the next village. In the summer, we would take a boat up to Koyukuk and then to Bishop Mountain and to Galena and, you know, we, you know, did one clinic one summer where we went to Beaver and came all the way down the Yukon River and stopping in Stevens Village in Rampart doing clinics along the way. And how could that be a hardship? KAREN: Yeah. DR. CARROLL: Yeah. KAREN: Were people still using dog teams? DR. CARROLL: No. Dog teams were really not used for work, but dog teams at that time in the villages were still a part of the sport and recreation. And the Tanana Dog Mushers Association, I think, had probably the third best dog race program in all of Alaska at that point. And, you know, the great mushers like George Attla and Doc Lombard would come out there. But when I say, gee, what would it have been like in the '50s, I think that was before snow machines, so the people were out trapping more at that point in time. And they were living in camps and doing very traditional life-styles. And -- and doing it oftentimes with dogs and under more difficult circumstances. That would have been what I meant as a truly exciting time to kind -- KAREN: Right. DR. CARROLL: -- of see what, you know, the magic of the Bush Alaska was all about. KAREN: Have you ever thought about the health care -- health aide program as a model for other places for rural health delivery? DR. CARROLL: Probably not. I guess I'm not quite sure what you mean. KAREN: Well, do you think it's been a success and that other countries could model this in their programs? DR. CARROLL: So you mean -- so you mean underdeveloped countries training someone? KAREN: The idea of training local people. DR. CARROLL: Well, I think it's a logical sort of thing, and I suspect that's what's done, you know, in some areas. I don't know that for true, but I suspect that that's what's being done in places like that where, you know, physician access and, you know, more sophisticated health care resources are just not available. You know. I think the health aides now are far better trained than they were -- than they were. You know, I think they -- they have the ability to deal with medical situations better in most circumstances and health aides now can oftentimes start IVs and do blood tests and send blood in. You know. Which is a different level of sophistication. The most blood -- the only blood tests we were able to do was a dipstick urine and a hemoglobin, you know, in the villages at that time. KAREN: So you think the future of the health aide program is, what, strong? DR. CARROLL: I think that as long as there's -- there is some meaning and purpose to a particular village that's moderate in size, that the health aide program will be useful. You know, if a village gets too small, there is really not a role for a health aide. And if the village gets too big, the needs are too great for a health aide. And so you're seeing more regionalization, like what's happened, you know, in Fort Yukon is that they've gone from having a nurse, one nurse, who was trained as a nurse, kind of dealing with the health issues of that area to having a clinic and to having two or three PA's, and I understand now having a physician on a regular basis coming up. Galena, you know, has a -- actually a facility that has X-ray capabilities and can do many of the things that we did at the hospital, one step closer to the villages than the Tanana Hospital was. And then bringing those people that they can't deal with into Fairbanks. But -- but people also want, in many of the villages, as good a level of sophistication in their health care as exists any place in the state of Alaska. So what might have been acceptable medicine in 1970 or 1960 or 1950 is not an acceptable level of medicine now. I mean, you know, you know, I mean, you know, just from the simple fact that, you know, you have lights on the field -- runway. I mean, we wouldn't accept that, you know, unplowed runways with no lights is an acceptable way for people who live in those villages to exist. You know. So I think that just translates into their health care also. KAREN: All right. Okay. Any other things you could think of, stories or anything else you would want to mention that I haven't asked about? DR. CARROLL: We've talked about a lot of things, and you know, I think that pretty much covers it. KAREN: Okay.