WALTER:  Yeah. KAREN:  Your wife?  WALTER:  Yeah.  So my wife Judith's experience with the primary care in Anchorage was -- was also very good.  She saw the doctor within the same day or within a day or two of asking for an appointment, and the dental exam was -- was equally expeditious and thorough.  KAREN:  So you can go to that because you were in the corps?  WALTER:  Yes.  KAREN:  You were eligible versus -- WALTER:  Yes.  The -- the Southcentral Foundation board have chosen to extend health care to us retired physicians with the Public Health -- with the Indian Health Service, and our dependents.  Now, how long this will continue, we -- we don't know.  So for the -- for that reason, I -- I go -- go there for -- KAREN:  Right.  WALTER:  There.  My children, of course, they are not -- they are adults, so they are not eligible there.  But by choice, I go there.  And of course, it's the health service bill, Medicare, and are compensated 100 percent, rather than 80 percent, as I understand.  And I also have Aetna because I've worked with the university.  I also have TRICARE, which takes care of the supplemental because the Public Health Commission people have the same care as the military.  So I -- it's my observation that the -- the health service bill all of these people, so I -- the paperwork comes by and I am impressed by its quantity, but I don't get billed.  And I did get a $6 check from Aetna for some strange reason.  But anyway, the -- your first question, how is the health service working.  From my limited experience, it's -- it's working very well.  And I would have no hesitation to go to the -- to the local physicians, several of whom are ex-PHS doctors are friends, and should I need to.  And it's interesting that our property tax, a good portion of it goes to support this Homer Hospital, and they have a lot of facilities for such a small -- small place.  And which is a very nice service to have for all the citizens of the Lower Kenai Peninsula.

WALTER:  What else did -- would you like to talk about, here?  KAREN:  I do have some other questions -- I do have some other questions, but while we're still in the flow, let's finish off with what you see about the future for the rural medical care in Alaska, and the current health care -- health aide situation.  WALTER:  Well, the fact that -- that there are now, as I said at the beginning, I think, 500 health aides positions, not all of them filled at any one time because there is some rotation, in 178 villages in Alaska, funded with near $20 million a year budget is, I think, impressive and -- and would not happen even with Senator Stevens in Washington if it was not meeting a need.  And so I think it is -- it is functioning.  And I think it will continue for some time.  And I think that it seems that the -- that the workload of the MDs is not diminishing.  And the other individuals in the traditional health hierarchy, there seems to be a prediction that there's going to be a real shortage of primary care physicians in Alaska overall, period, per capita.  Leave out the scattered nature of the population.  And I think the same is going to be said for nurses, whether they are working in doctor's clinics or on a hospital ward.  So the health aides are not -- are not threatening the position of any of the current health workers, apparently.  And if anything, they add more -- more ancillary people.  The thing that -- the overall question that intrigues me is, well, you know, is relating this to the health aide system in the United States in general, which seems to be quite chaotic.  The figure I have watched for the last 40 years is the percentage of the national gross domestic product, GNP, that is spent on health around the world.  And I travel often to Europe and I used to go to and I've gone to Africa on projects, and been exposed to that, and had visitors here, friends who are involved in world health, and we, you know, discuss these things.  But 40 years ago, the percentage of the GDP spent on health in most of the developed countries seemed like it was around 4 to 6 percent.  And I think that it's -- and that's what it is today in a lot of countries.  Now, in a few of them it's gone up to maybe 8 percent.  But in the United States, we have been spending 14 percent.  And that is increasing.  So the amount of money that is spent on health care is staggering.  And at the same time, we have 43 million people who are without coverage.  So, you know, something is probably going to give.  I think one of the factors that will influence this is the -- is the commercial or economic one.  And as we enter more into a level field of international trade and production, the U.S. is finding companies -- take airlines, for example, or Boeing versus Aerobus, find that it's difficult to compete if the government is paying for the health care in these other countries.  And here, the government would now have to -- I mean, the company, private companies would have to -- would cost -- a huge percentage of their cost would be providing health care for their employees, which, again, would make it difficult for them to compete and would motivate them to, you know, make some changes.  And I -- I can see there's -- there's some -- would be some benefits to a single pay, but I'm -- I have serious questions of how it would work in the United States because until people accept more responsibility for their own health care and change the way they live, the costs will be so fantastic that -- that if you just open the floodgates, why, I think it's going to be difficult to pay for.  So I don't know what the -- the answer will be.  But anyway, the -- how does this relate to the health aide system.  Well, I think the -- the health aides will keep getting more and more, more training.  I think one of the problems that I imagine or assume that they are dealing with now is the turnover.  And how -- how do you get people to -- to stay in these positions, and then just to complicate it, what is the economy of the villages?  KAREN:  Right.  WALTER:  Why do -- why do young people stay there or will they stay there?  And become health aides and find that a fulfilling, you know, job.  So, you know, the villages themselves, you know, must be changing drastically, so.  Anyway, I guess it would just be the role will change, it will probably be around for -- for quite awhile.

KAREN:  Did you have any other things in your notes that you wanted to talk about that I haven't asked you about, we haven't talked about?  Because you had made some notes before I got here.  And what we talked about before we started recording.  WALTER:  Well, in -- you know, in sort of summary, we touched on the -- on the reasons why we thought the health aide program was successful, you know, local hire, brief, but increasing, training periods, and that it's a part of the system.  And it depends very much upon the support than to stand alone.  The doctors have been very cooperative in working with it.  And the manual is an essential component.  And I guess as far as the -- this discussion is concerned, I just -- I want to say it, you know, the success of it in the end is, of course, dependent upon the health aides themselves.  And their willingness and ability to rise to the challenge.  And also there are so many, many people have, you know, worked in the program that whenever you mention names and whatnot, for every one you mention, there are many other people who have done as much or more.  KAREN:  Right.  WALTER:  And, you know, we recognize those, too.  KAREN:  Right.  And then there are also, I've become aware of, there are also people who have been involved in the program, but maybe for not as long as some of these other people and are less well-known or chose not to continue the work for 30 years, like some of these people, and that their experiences may be a little bit different, and to make sure we acknowledge them, as well.  WALTER:  Right.  And so I encourage this, somebody to emphasize, you know, these last 20 years of our discussion, based on experience, is mostly in the earlier years, not the last 20 years.  So I'd encourage the people who have been active in it to try to sum that up and to let us know what they think about the -- the future.  You know, there are people like Dorothy Height who have been working for 20 years or so with the health aide program in Anchorage, and -- and I've already mentioned Linda Curda, that could -- could fill in more in the last 20 years, and have a shot at what they are actually planning and how they are directing the curriculum to meet the needs of tomorrow.  KAREN:  Right.  Yeah.  And I have heard from some of the conversations I've had with people about concerns about the turnover you mentioned.  WALTER:  Yeah.  So. KAREN:  And how to address that.  That seems to be a current problem -- WALTER:  Yeah.  So how do you deal with that, other than changing the dynamics of the whole village, is a real challenge.  But I guess you -- I think you just have to realize that the -- that the village -- that the condition that the current newcomers are coming into is not that which we -- for whom we wrote the curriculum, you know, 30 years ago.  And that just has to be taken in a given that things are fluid in the village and people are coming and going.  KAREN:  Right.  WALTER:  And the other thing is maybe -- maybe -- maybe we just need to focus more on working with everybody, every member of the community.  And actually what's happening is every time that somebody goes through this training and they -- if they continue to stay in the village, they are a different person, a different influence hopefully, or they move on to the next village and whatnot.  So I think that maybe the role of the health aide could be to -- to facilitate this -- let's call it the elevation of -- of health awareness and self-responsibility in the community at large.  If they could be the facilitator, because this is -- this is the problem nationally.  This is a problem worldwide.  How are you going to change people's behavior, you know.  And so -- and again, they have a better shot at that than -- presumably, than somebody from outside.  So, you know, they are on the health council and villages, you know, they are going to decide, like some of them in Southeast has, there's no more pop going to come in this village.  You know.  And we're going to have decent food in the schools.  And, you know, and the kids are not all going to break their neck on four-wheelers and, you know, things that are -- and, you know, they are going to find some way to look at life where you don't need to be dependent on alcohol, and this sort of thing.  And because if they can solve -- begin to solve some of those problems, then the medical problems will melt away.  And all this business of managing severe diabetics and gangrenous limbs and that sort of thing, just -- and high blood pressure will simply not exist.  KAREN:  Right.  WALTER:  So that's, I think, a challenge, that's something that the health aides could do is to -- well, first, they have to do it for themselves.  KAREN:  Right.  WALTER:  And then but, you know, it's not impossible because as I pointed out, the people lived in a way that was very healthful in many ways before, and the main problem was -- was the sugar and white flour.  Otherwise, they -- they had good diets, they were fairly high in fiber, and -- and fairly nutritious.  And they were active and they were lean.  KAREN:  Right.

KAREN:  How would you respond to a criticism that I've heard that nowadays, a health aide has switched from being mostly Native to many, many more non-Natives being the health aides?  WALTER:  Well, I -- you know, as the -- I don't -- you know, the Land Claims, of course, it sharpened the distinction between Native and non-Native.  And there were a lot of, you know, villages that were -- had -- were ethnically, you know, half or less than half Native, and you didn't really consider themselves Native before.  Now, because of the Land Claims, consider themselves Native.  But I -- I don't know just how that will work out in the village.  But I -- I guess that one goes back on the community, if they are selecting the health aides, if they choose to have a non-Native do that role, well, that's, you know, their choice.  I don't see anything wrong with it.  KAREN:  The thing I was wondering is how your work with the health aides through the years influenced you both personally and professionally. WALTER:  I probably am not a -- not a very good person to answer that because I'm probably not aware.  I guess you'll say that -- you know, I've enjoyed working with the health aides, and I have -- I'm not doing it right now, but my respect for them has, you know, has, if anything, increased rather than decreased.  And I -- I still, you know, believe in the system, and I think that both here and worldwide, I think that passing the responsibility down.  I guess the other really remarkable change is the -- that of the role of a physician.  What I experienced and learned and was taught in medical school in 1950s, over 50 years ago, actually, my graduation was over 50 years ago, was more that of the physician as that it's been for centuries, doctor knows best.  And then there were these hierarchal behavior patterns.  The nurses didn't all have to jump up when the doctor came -- came by, but there were clear hierarchal lines.  And the patient was taught to do as the doctor says and to sort of delegate responsibility for his health to the physician if -- if he came to him for care.  Now, there's a, I understand, quite a difference in the way physicians are taught to -- are accepted in the medical school.  50 years ago, there was a lot of emphasis just on grades, and particularly in -- in sciences.  Now, medical schools are very open to major -- and those who have majors in literature and humanities.  So -- and I believe there was always about 5 or 6 -- 4 or 6 percent of the upper class were women, women.  And I believe it was when I came through medical school, and I guess it's the way it has always been, as long as they had school, now I think it's up around 50 percent, and I think it's pass -- passing that in some of the schools.  And I think that's a very positive, very good change.  I mean, about believing in all the archetypes and all the right and left brain, but women being those who are more nurturing and see things -- can see in the gray area rather than the -- the left brain, right and wrong and less nuturing male.  So women.  And then the doctor's role, and I gather that the medical students are being taught to look on the patients as somebody that they work with rather than on now.  And the fact that people are consulting alternative medicine and the degree to which the medical schools and the medical profession are accepting alternative approach is changing a lot.  And, well, personally, it's just -- I'm fortunate, I'm healthy, for the most part, except for, you know, a few of the vicissitudes that come with time, and I depend, you know, mainly on diet and exercise and stress management and, you know, eliminating pollutions and -- KAREN:  Right.  WALTER:  -- and things like that to -- for my health rather than -- I don't use any prescribed drugs.  KAREN:  Right.  WALTER:  Or that sort of thing.  But, you know, obviously when I break my leg, I'm going to see the orthopedist, and if I get a severe infection, I'm going to be looking for a antibiotic prescription.  KAREN:  Right.  WALTER:  So on.

KAREN:  I have a couple more health aide related questions, and one of which you mentioned you were the medical director at the hospital in Anchorage.  WALTER:  Yeah.  KAREN:  Talk a little bit more about what that job was, what -- what you did there.  WALTER:  Well, the way it was organized is that that was a center for tertiary care.  In other words, the referral center for Alaska Natives throughout the state.  And it had representation from most of the major specialties.  There was, you know, internal medicine, which included tuberculosis is the big thing back when.  And surgery.  Which included thoracic surgery, which is still practiced a good bit, also with tuberculosis.  And orthopedics, obstetrics and so on.  And we had dentists there also, a dental there.  So I think there were about 40 doctors and dentists.  One of the little -- or not so little things that factored was that emergency care was taken care of by these physicians, and not just primary care physicians.  We had -- we had a couple of primary care physicians, too, but who -- at the outpatient clinic for the local folks in Anchorage and made field trips, and so on.  But to cover the emergency room around the clock, these doctors, in all the specialties, were assigned to -- to that, which meant -- well, in theory, if you were -- if you worked all night on emergency, you could have the next day off.  But most of them were too busy.  They -- they had patients on their ward, they had to make ward rounds, and they had patients that needed care.  So you often worked all day, then you were on call all night.  Sometimes you slept, but very often you were up delivering babies, even if you were an ENT specialist and suturing wounds and seeing infants and, you know, general emergency medicine.  And that was called OD, officer of the day.  And it was my job to assign that.  And I guess I did it almost 3- or 4,000 times, but I always took my turn at it, which made it a little easier to do.  But -- and then I met with the heads of the departments frequently and sort of tried to field their administrative problems, and I -- but I made rounds only on internal medicine.  I wasn't involved in the -- the day-to-day care of the other specialties.  And we had, during the ‘60s and ‘70s, it seems that the physicians were still being drafted back when out of their residency or out of medical school, and they -- a number of them chose to enter the Public Health Service versus going into the Army.  I presume on the -- on the theory that they could do actual medicine and see patients rather than physical exams in the Army.  And so I think we got sort of the cream of the crop.  We got a lot of very, very excellent young physicians.  And many of those, after two years, they went on and -- and studied a specialty and many of them returned back to Anchorage, or Alaska to practice.  Some of them whom were already specialists, they went into practice in Anchorage.  So a lot of the excellent physicians we have in Anchorage came through the Public Health Service.

KAREN:  What was that like for you going from being a patient care physician to being an administrator?  WALTER:  Well, I think it always, through the -- my connections on the -- with the tuberculosis service, and I was -- I got very involved with the tuberculosis activity and the big campaign to eliminate that.  So I spent quite a bit of time training the young physicians who came up without much TB experience how to conduct chest clinics and take a more active role in -- in TB management and not just leave that to the state.  TB control and Public Health nurse.  And then I was active on the -- on the medical and tuberculosis boards, and make rounds regularly with the doctors there.  And then I would see patients directly when -- you know, like in the emergency room.  So I didn't leave it entirely.  And then I'd get to see patients when I was teaching the health aides.  So I always managed to be involved some in patient care.  And the -- I found that the administrative chores were overall pleasant.  I also had a chance to get involved in the tuberculosis programs overseas.  Well, earlier, well, while I was Outside, when the Peace Corps came into existence in ‘62, I was -- I had just finished my medicine training, I volunteered without leaving the service to go and do the medical survey in Ethiopia and Somalia, in 1962.  I went to Washington for a while and worked with -- with Shriver when he was setting up the Peace Corps and that sort of thing.  And I was to go to Ethiopia for two years, but I -- my wife became pregnant at that time, and that was not practical to go.  Later, I was asked to be a -- to work with a doctor in Tunisia, to set up a tuberculosis control program there, using funds that had accumulated in local currency, and are -- through aid, but were not of any value to the U.S., but they wanted spent there on health projects.   So I worked with a very efficient Tunisian doctor, French trained.  French was my language in college, so I wasn't very competent at it, but at least I could -- it was useful.  And there we set up a program using the local person to train in, being in a Muslim country, they were all young males, but they did have small clinics in the village.  And we trained them to use a mic -- to do stains and to use a microscope, gave them good German microscopes, and we upgraded the laboratory in the capital, Tunis, and resulted in getting a much earlier diagnosis of the cases and -- and much better supervision.  So the same thing happened there in a few years.  They -- the TB rate dropped down.  I remember the old doctor at the hospital at Tunis said (spoke in French), you know.  And it's so much resist, and bad, bad.  And within, what, four years or so, their hospital, you know, emptied out.  And so anyway, that was fun to go over there.  And then I used to go to the international TB meetings.  And was sent over once to -- to Istanbul to train the Peace Corps doctors in the Near East in TB.  And then it was possible to travel over the Pole.  KAREN:  Right.  WALTER:  And so anyway, we -- I, along with my wife, we got to, had a chance to travel to Europe and Africa a number of times.

KAREN:  We had talked before about the training you provided to the health aides.  Were the doctors who were involved given any training about how to interact and work with the local people?  Other than -- WALTER:  Here?  KAREN:  Yeah, here in Alaska.   WALTER:  No.  No.  Not that I'm aware of.  It was -- I think the numbers and the ambiance was so -- was such that it just -- it happened.   KAREN:  Okay.  WALTER:  Because they found -- a doctor found themselves taking radio call, which they had never done during their internship or residency or seen elsewhere, but, you know, they just maybe somebody showed them the ropes at first, and then they started doing it.  And I think it was all informal.  KAREN:  Uh-hum.  WALTER:  Yeah.  So as far as, you know, having consultants in and behavior modification or public relations or, you know, some of those key words, I'm not aware that that happened.  KAREN:  Now, the other important thing that we didn't talk about is confidentiality.  You mentioned that you talked on the -- these public broadcast radios.  You know, nowadays, medicine, confidentiality is so important.  How was that handled when you were involved?  WALTER:  Well, in -- when we had single sideband radio medical traffic, it was -- it was handled by total ignorement, total deficit because there was none.  And everybody, you know, listened.  KAREN:  And so people weren't concerned with confidentiality?  WALTER:  But we were aware that everybody was listening.  And I'm sure that there are a number of conditions with women and whatnot that were -- that didn't surface because of that being an impediment.  But that was inevitable.  With the telephone should have eliminated that program.  And then the health aides were -- were certainly given instruction on confidentiality as a part of their beginning training.  So you know, and I really have no way of knowing what some of the patients may have felt, except intuitively.  But I -- intuitively, I was not aware that it was a big problem.  KAREN:  Or did any of the health aides express to you problems they felt they were having being from the village and dealing with their patients and having to maintain confidentiality?  Did that ever come up?  WALTER:  No.  There was -- there was -- there was a big -- there were big communication problems, of course.  At Bethel, we had, you know, very busy outpatient.  And we had -- we had somebody in the room with us almost constantly.  They may step out when I -- a White person came in and when a Native person who is very fluent in English, but otherwise, they were always there.  KAREN:  As an interpreter?  WALTER:  To interpret.  And then to both directions, for us to get a history and for us to give instructions to the patient.  And I -- I -- in Wiseman, and for seven years, I was there, you know, summers and one year all around, whatnot, Mrs. English, with whom I lived, was like a mother.  She was the mother of my partner Bill.   Anyway, she spoke limited English, and of course, her daughter lived next door.  So then I would go hunting with a local family and so I heard a lot of Inupiaq.  And we would use a few words around the table and stuff, but I -- I didn't really learn the language.  And so then when I went to Bethel, why, then there was -- then there was Yup'ik.  So then, well, if you try, like you'd say -- you'd be examining the abdomen or push on somebody, and say, (Native word).  Does it hurt?  Well, then, they would give you a big blast of Yup'ik, which you were lost in right away. So other than showing off that you could say a couple words in Yup'ik, you didn't -- it didn't speed up the communications because you had to depend on the interpreter to know what the answer was.  But then there were other aspects of that, some of which are sort of humorous, not in consequence, but in event.  A doctor would work and work with a patient to try to get a good history and find out what was going on, and eventually, maybe even later sometimes, there was a key point of information that was not brought out, and if the doctor would -- the patient would ask, well, why didn't you tell me.  The standard answer was, you didn't ask.  KAREN:  Right.  WALTER:  Because they were not -- the inclination was not to complain.  So that was something that the doctors had to learn to work around.  And there was a -- there was a lot of miscommunication and there was -- and then I'm sure there were a lot of hurt feelings, and I'm sure there was a lot of lack of awareness.  I mean, doctors, nurses, people thinking they were, you know, great do-gooders and all that, and yet, some of the things that they -- that we did inadvertently were not that helpful.  Take the example of drinking milk.  Later we found out, and I think Dr. Scott was maybe the one who demonstrated this, that many of the Natives, especially Yup'ik, are -- have the deficiency of lactase, intolerance for milk.  And when the TB patients are given milk and they were really pushed and so they were hiding it, they were emptying the toilet, and all this stuff, trying to avoid the milk.  And it was interpreted by the staff as, you know, lack of cooperation until they, you know, found out otherwise.  So -- so -- and then I think it -- a lot of these problems, a lot of problems came out on the tuberculosis boards, and Robert Fortuine's recent book on TB, he mentions that.  And -- and that.  So -- so the patient to adapt to these long periods of -- of the rest in the hospital was -- was certainly difficult.  And then when they would go on pass, why, they would sometimes all get in trouble.  Also, just grossly one obser -- one could observe that the people who broke down with clinical TB very often had a significant traumatic event in their life.  Death, of course, or something.

KAREN:  A question I had has to do with any particular events that come to mind in terms of what was particularly successful cases or particularly a case that failed because of the system.  WALTER:  No.  I guess I'm left with the form of the generalities.  But the individual health aides often can, you know, tell you of their -- of some of their most trying. KAREN:  Right.   WALTER:  Or most successful.  KAREN:  That is a question I've asked the health aides.  But to ask it also to a physician, if they had any similar or different experiences along those same lines.  WALTER:  You know, I guess I -- I mentioned, and you know, I wouldn't give all credit to them, but I mentioned this incidence of going to Kwiguk, Emmonak, to hold clinics.  And there I -- there I was told that the last time that a doctor visited there was when the Yukon Health Boat came by in ‘49, ‘48, had been six, seven years previously, and there Axel and Pearlie who were -- Axel was about one-fourth Finish or whatnot, and Pearlie was a descendant from the early Russians in there.  But they were Yup'ik in culture and language and whatnot.  And I was impressed there with the extent to which they had managed to work with the health problems there.  And I guess they were sort of an inspiration to me.  And I became friends with the family, and Axel would always stop in Anchorage when he went down to the legislature and that sort of thing.  And by the way, this list -- the list of buildings, his name is in his honor or in Anchorage.  So he was into Native organizations and politics, as well as health work.  But anyway, so there was people like that impressed me and influenced me a lot.  And Betty Guy was a very petite lady from Kwethluk, from the Kuskokwim originally.  She was operating in the school there.  And by the way, this was a log building that the people constructed out of logs they fished out of the Yukon, put up themselves, and petitioned for a teacher in order to begin the school year.  And she was doing a good job of introducing the language and getting a school started.  And later was active many years as a health aide back in Kwethluk.  Well, unrelated to any of this is that I did something that not -- I don't think most doctor -- doctors did.  I'd like to set aside one more night for a dance.  And we did that in Kwiguk.  And by that time the schoolhouse was actually down in Emmonak by then, I think.  And I don't know how we got in the building, but it kind -- there were a lot of problems.  Then we had had the tooth pulling night.  So many people, well, had just been relieved of their aching teeth, and by the way, I -- I asked them, what do you do when -- when somebody's not around to pull a tooth?  Well, one thing they said was that if you heat a nail red hot, hold it with a pliers and push that into the pulp of the tooth to -- to cauterize the nerve and the pain.  But anyway, the -- it would -- I enjoyed folk dancing up in Fairbanks a lot.  And then up in Wiseman, we used to have a drum there and we -- we did both old time folk dances, both the Scottish waltzes and stuff, and then the Eskimo dances intermittently.  But anyway, we had a big dance there.  And people did a lot of laughing and fun.  And one thing that when I asked Axel what they were laughing so much about, he said that when somebody offended another person, rather than react back against them right then, they might choose to think about it and think up some way to make fun of that person, and then act that out in the dance.  And everybody could have a good laugh and you could diffuse the insult that way.  Up in St. Michael's, which had been a big entry port during the Gold Rush day, people were still playing the fiddle and still playing the same old two-steps and tunes that they had learned during the Gold Rush days.  When I went back to Emmonak in 2001 and stayed for a week, why, they had invited in some of the neighboring villages that they particularly were mostly related to, and had dances at night.  And the young people were still, with all their electronic instruments and whatnot were still playing a lot of this same -- same old music that they had played before.  KAREN:  Neat.

KAREN:  And then my last question is about what lessons may have been learned in the process of developing the health aide program.  How things -- how -- mistakes that may have been made or things you think should have been done differently, if you were to do this all again.  WALTER:  Well, I -- I think that -- that that experiment of bringing people in for seven months at Bethel was probably less than successful.  And I think that the experience of breaking the training up into shorter periods was a -- was demonstrated to be a good approach.   And then I -- and then I -- well, we've already mentioned a number of times that in Alaska that the communications between the physicians and the health aides seemed to work pretty well.  If we had -- had had a more formal program to train -- to give the physicians training in how to interact with the health aides and do village clinics and whatnot, it could be that it would have improved things from -- from the patient's point of view.  KAREN:  Yeah.  I was thinking, you know, like if somebody in Mongolia came to you and said, we want to set up a program like the Alaska Community Health Aide Program, what -- what would we do, what would be your advice, you know, and pitfalls to avoid and that kind of thing?  WALTER:  Well, I think we've -- we've pretty much covered what we think we know about that and we went over the local hire, brief periods of training, adequate support, and a good manual.  KAREN:  Uh-hum.   WALTER:  I think that the approach to writing a manual has been a very trying experience and it has been a great deal of time and money spent on that and I think if -- if there could have been concurrence and maybe we could have written it up more succinctly and artfully at the beginning that questions of language to be used and maybe we should have had a -- somebody more expert in writing and editing involved from the beginning, because we began mostly with people who had expertise in health care, but not necessarily in communications.  So yeah.  Maybe that's one answer to your question.  Undoubtedly, communications could have been improved.  KAREN:  Okay.  WALTER:  And -- and among the -- among the health care providers, because lots of times arguing among ourselves, you know about how things should be done and repeating the arguments over and over to the -- of the newcomers come and go.  KAREN:  Okay.  That's it for all my questions.  Is there anything else you feel like you want to say we haven't covered?  WALTER:  No.  I just say thanks for your patience.  KAREN:  Well, thank you very much for being willing to sit here and talk to me for so long.  I hope I haven't tired you out too much.