KAREN:  So the next course and students, what's next? 

LINDA:  Well, as I mentioned, population's aging, and the whole arena of chronic illness and the elder patient, I think that putting together a course that would blend understanding elder issues and the whole arena of life-style and chronic care would be an excellent -- it's sort of like we have the pediatric.  We've really worked on pediatrics, but I think it's time to put some focus on sort of that component of the population. 

And with that, I think we could increase community -- community events, community action for broader public awareness and education.  There's a lot in the television and the radio and so forth.  

But the health aide role, they have such a complex, but one of them is being an educator.  Just as they learned the information, their role is also to educate their individual patients, but their community.  

And I think that another course that would be wonderful is to look at community advocacy.  And I know that they have a 24/7 job, but if you can look at how you're -- the issues in your community and try to target them, maybe you can get ahead of some of those health care problems and reduce your, you know, sickness.  

You know, we're finding, you know, back to the early years of Public Health, you know, water and sanitation.  We're learning that washing our hands, you know, just washing hands at school, what do we start -- you know, I think we could reduce the amount of colds and flu. 

I know one community started look at the foods available in their local store, and they had such a high incidence of diabetes, we are seeing, you know, diabetes, we know that cancer is directly related between smoking or tobacco use, whether it's chewing the tobacco or diet, it makes up to 60 percent of the risk factors for the common cancers of Alaska Natives.  So those two alone.  

I just -- I think the program that individuals, certainly a new health aide, that's overwhelming, but we have a whole cadre of health aides that are out there with 10, 20 years' experience, and I think helping them to have some other skills.  

And I don't -- you know, people say, well, are you -- are you teaching epidemiology or anything?  No, but I think they are case finders.  They can look at their community and look at how they might impact that, in terms of Public Health issue and to give them some skills in sort of awareness, data collection, and community education.  

In the cancer course that we've been teaching now for six years, one of the final projects for the part -- the course is that the students can take any question about cancer, it can be nutrition, it can be breast cancer, it can be one specific arena, or it could be a whole -- one person looked at exercise, and they take that and then they research it and then they have to do a community activity.  

They have to take that and use it in the community in some way, whether it's offering a class in the school, one class, or whether it's having -- one individual did a tea for women, to teach breast exam, and how to remember to do that.  Very creative ideas.  

And over the six years, we've had, oh, about 12, 14 students.  So we have this whole history now of projects in communities where the health aide has taken this knowledge, applied it in the community, and then they have to do a write-up of the content and the event, and then they do a class presentation of it to us.  

And what the key is, so what did they learn and what would they do different, and how would they use this with some other element.  And so that course has taught me that we can really go beyond basic and look at their role in a larger arena of Public Health.

KAREN:  So the idea with this manual is it's something they can use when they are in with the patient and quickly reference.

LINDA:  Oh.  Yes.  Sorry.  Let me -- yeah. 

KAREN:  Through the exam?  

LINDA:  Right.  And in fact, I need to be clearer than that, and I keep forgetting that this interview is separate from other things that are --  yeah.  

The Community Health Aide Manual is their guidelines for patient care.  And it is to be used with each and every patient.  It is not just something you go and put on the shelf and reference to if you need it.  

It -- it is -- for those health aides that have used it and the passion for years, you memorize.  You won't have to read every question in the front of this book, but it is expected to be used with every patient visit.  

And so, yes, you get the history.  It takes you in -- give me a symptom.  Tell me something you'd like to -- to know about that you came in -- that you came today to see me for.  Sore throat?   

KAREN:  Sore throat.  Sure.  

LINDA:  Okay.  So you have a sore throat.  So we know we're going to be in the respiratory and we're going to go to the section.  

And I've already asked you when did the problem start, and you've described the program -- the problem.  If it's getting worse or better.  And then I want to know if you've done anything to treat it and if you've had it before and when and how it was treated.  

And then I found out a little bit more about any past history, like do you have any other respiratory problems?  I found that out.  I found out if you used tobacco and alcohol, and I found out as a woman when your last menstrual period was, though it's not as connected to this problem, but I would know that.  

And once I've gotten this inside cover questions, I go quickly into the body system, and I can look up the sore throat in the index, and that takes me, then, to a focused -- more focused history.  

And I will go through and ask you for additional questions, like do you have a runny nose, do you have a cough.  And then I will find out if you've had some other problems, like do you have a fever, chills, so forth.  

Once I get the history, the manual then will tell me as a health aide what exam I need to do.  So I'm going to get your vital signs, I need -- because we know that a sore throat can be linked to other body parts, we will do a quick head, ears, nose.  We'll look at your throat.  We may do a lab test depending on what.  

And once I have that, history and exam, then the assessment.  And when I get to the assessment chart, it will help me to sort what, based on the findings.
  
So I will match the history you've given to the exam, and it will bring me -- and let's say I have the opportunity in this to decide if you have laryngitis or viral pharyngitis, which is a virus and a sore throat, or do you have a strep throat, which, again, has different findings.  

So based on that, I then can turn to the plan.  And let's just say that you do have a strep throat and I've done a throat culture, but I have to wait, depending on my clinic, whether I can do a rapid strep test or I have to send it, and then it will take me to my plan.
  
And I have a standing order, which means that I have finished my training through this content and my physician in Bethel has signed me off to take care of you without calling him.  So I can just follow this plan.  

And you don't have any of these what I call, you're not really sick looking, so all of these things, you're not drooling and unable to swallow.  So I don't have to report you.  You're -- you're actually sick, but you're not as sick as these qualities would make me call the doctor.  

For example, if you were very short of breath with sore throat, maybe there's some other underlying respiratory problem, and I would need to call the doctor.  Then I'm able to go through my medication.  

And again, this links me straight to my medicine book, patient education is here, I will be able to print you off about your strep throat and what it is and why, and I will ask you to come back in three days, sooner if you're feeling worse.  When you come back in three days, I'll check you up and you're doing great.  

So the book will guide you through any --

LINDA: And again, that goes back, for me anyway, to the health aide in Atmauthluak in 1981 who didn't know where to begin or where to go. 

And I've had a lot of folks who have looked at this who are nonmedical and say, oh, my goodness, oh, my goodness, you mean I just -- I can do that?  And you know, and they begin to understand that the whole arena of health care is -- there's an entry point.  

Now, certainly if your symptoms are more severe or more complex, I talk to the doctor, and it may be that you need to be seen in Bethel and you actually need a whole treatment regime that is not village based.  But in the village, I can do nebulizer treatment if you're down into your lungs.  If it's just simply your throat -- now, maybe it's more than that, maybe there's something else.  

So the health aides are able to assess and treat, I would say, if you want to think of it as the common and uncommon conditions, but if it's beyond what they can accurately assess in the village, then they call and the doctor helps to make that assessment.  

For example, acute abdomen.  If you came in and your stomach -- and again, we try to say if your stomach or is it the abdomen, where's the location, and after history and exam, the health aide would be able to say acute abdomen, but they would not be able to say that it was appendicitis or -- now, if you were a woman, you might have, you know, varying problems.  

So they would -- you know, is it diverticulitis.  They've got the information but we don't expect them to make that further.  In fact, the physician wouldn't be able to make that diagnosis without more lab tests.  

So the manual is used with each and every patient.  And again, there's -- this new set of materials is different from the past.  There's four books, and everyone says, Linda, how can there be four books?  And I say, wait.  
Let's just -- the first one is an emergency care handbook.  And it's a small 5 and a half by 8 and a half little booklet, it's 120 pages, spiral bound, that the health aides, as we've been developing it, it's a first edition to this book, we've actually gone to the health aide forum where they have done emergency scenarios using it.  

And it takes you from walk in the door, seeing of the accident, and do you have trauma or do you have a medical emergency.  If the patient and child is an adult, so you quickly get turfed one of three ways.  And then step by step it tells you what to do.  Is the patient conscious, airway, breathing, right down through, all the way to the plan of whether they are in shock or you have a big impaled object in your chest, whatever it is.  

If you're about to deliver, this book will teach you how to do that.  So the first one is the emergency handbook.
  
The second book is the CHAM itself, which is the symptom-based patient encounter for acute.  It also has emergency acute, chronic, and preventative services.  

The third book is the medicine book, which we've mentioned, that has medicine skills.  So if you had to review how to give a shot, again, these materials are not for the untrained, but you could review materials in there, then also immunizations, medicines.  

And then the fourth book is their reference and procedure book.  And that has information on lab skills, procedures, clinic management, anatomy, physiology, history and physical exam.  

It also has an excellent new section that's in more detail on wellness and all of the elements you want to think of, whether it's adult health surveillance or injury prevention, nutrition, exercise, tobacco cessation, that's all in there.  So those are sort of reference materials that you would use.  

So those are the four books that complement each other in -- in their practice.

LINDA: Another element that I've been really pleased to be a part of over the years is the whole issue of support for the health aides.  And in 1988, we wrote a paper, CHAP in Crisis, that at the time the funding for the program was $5 million statewide.  And this is the Reagan era. 

Deborah Caldera and a group of CHAP Directors came together, and I was the primary editor of the project, and we -- we wrote a paper that went to Congress and we were able to increase the dollars that year by 5 million and the following year by 10 million.  And it's continued to increase over time.  

And then in 19 -- well, it was actually -- we published it in 2001, was an update on the status of the Health Aide Program.  

And once again, we had begun to lag behind in salary and supervision and training needs for the program.  And we wrote a paper, again through the CHAP Directors, Rosemary Simone from Nome was the lead, and I was the -- I seem to always be sort of in the editing, coordinating role.  

We published that in 2001, and I'm pleased that this year we've just been awarded for the Health Aide Program an additional $2 million recurring for the program statewide, of which 800,000 is being put into training to expand the training, and one is a new effort in distance delivery as part of that, and then a million is going into the corporations for field support and health aides themselves.  

So it's not all that we need to bring the program up to sort of full funding, but it is -- it's a -- being a part of that over the last 20, 25 years, to balance both the educational and the learning aspect, but also recognizing that if we don't deal with the issues of retention and attrition, it doesn't matter what I do in training.  And so I've been very active in sort of the support of the program.  

You asked another element that I'd like to work on after the CHAM, and that would be sort of what I would call statewide -- I don't want to say recognition, really statewide understanding of the program.  You talk to folks here in Anchorage and they've never even heard of it.  

And so it's certainly recognition, but it's also professionalism.  You know, the title is Community Health Aide, which is the original name that was given at the time, but the program recognized over time that the training is that the job is really as a practitioner.  

It's not quite the same as a nurse practitioner, as a PA, but it is really the elements of -- they have an interdependent, meaning they have a role with the physician if they are oversight, but that physician is hundreds of miles apart.  So they are doing, you know, history, exam, assessment, and plan, and providing patient services.  

When people hear the name community health aide, in the medical system, the only other place you hear the name "aide" or word "aide" is nurse's aide.  And so people's minds go, oh, well, they do vital signs and support of the patient and bed care and that sort of thing.  But it's not the role of the health aide at all. 

And so some folks have come into this thing saying, well, we just need nurses in the villages.  Well, nurses can't do anything near the capacity of what a health aide is trained to do in those diagnostic assessment and plan components.  

And so I think that there's a misunderstanding of the program.  There's a -- and so sort of that public awareness and real -- the health aides themselves are isolated village by village.  

Over time, they've tried to have a health aide association for sort of statewide networking, and, you know, sort of power in numbers, and it has, you know, grown and ebbed and waned, just because of the isolation of each other.  They don't have like a, you know, statewide office and a support system.  

So I just watched them, and I think that they are due more respect.  They are due more kudos and recognition that in Alaska, they see over 300,000 patient visits a year. 

KAREN:  Wow.  

LINDA:  And remarkable care that is given at the village level. 

And I -- you know, I remember when my mother was sick back East and she lived in Florida, a little community in Florida, and I would have given anything for a Health Aide Program where my mother could walk up the block and be seen.  

And I would know that her lungs had been -- she had emphysema -- that her lungs had been listened to and that she wasn't alone, there was someone nearby.  But you know, she -- her doctor was around town, and the emergency room at nighttime, she wouldn't go, and so as --



LINDA: You know, people talk about the quality of health care in rural Alaska.  I think it's astounding.  And I think -- I think that those folks get better care in some ways than certainly a vast majority of the people in the Lower 48 because it is right there for them, and it really is in our whole network about access and quality of -- of the caring and the services.
  
I mean, I would go to a health aide -- everyone says, well, would you go to a health aide?  Absolutely.  Because I know that they know their scope, I know that they know their limits, I know that they will be in contact with the doc.  They are not practicing by themselves, they are in a very key part of a system that I think most of the state doesn't know about.  And I mean, the urban areas.  

And with that professionalism and respect, I think there would also change an attitude in the villages.  

I think that they -- some health aides are -- and I use this word with quotes, are "abused," in that patients will call them in the middle of the night for things that could wait for the next day.  They will come to clinic at the end of the day when it's -- you know, the health aide really needs to get home to their family.  

When the health aides are out for training, the communities that understand that the husband and family need a little more support when the woman's gone, whether that be for fishing or subsistence or whatever.  

That individual -- those individuals are caring for their community, and those communities that care for them, I have seen longevity.  

But because I think it really is about the whole community.  The health of the community belongs to the community.  And the health aides are hired by their community, but they are not the slaves to that community.  It's a partnership.  And so -- and I think that they are not respected enough.  Whether that be in any element.  

So I know that we've had Governor's proclamations for health aide week, it's much more than a week.  It's -- it's an understanding of their educational process, the scope of the activities that they can do, the kind of quality care that they provide, the sheer numbers of their work, and this state wouldn't work without the Community Health Aide Program. 

You -- you can't have in communities of 100 or 200, everyone says, well, just put PA's there.  Well, that's not going to work.  They are not going to stay.  And the sheer number, they wouldn't -- it wouldn't work.

LINDA: And so I -- I would really like to support the program in a -- I don't want to call it public relations because it's more than that, but an educational process, weather it be through television or print. 

And what we've found as part of the process of working on the CHAM is that I really believe that the key to this is how we work together.  

And so in putting this materials together, we went to the clinical directors of the state, all of the hospitals around the state have a physician clinical director, and we went to that body of folks and told them that we were in the process and we wanted their input, to decide, for example, the standing orders, which medical conditions can a health aide see the patient after training and experience without calling the doctor.  

Now, that's really an extension, the doctors have to let go of that, and what plans, what conditions could they do.  They hadn't been included in the past in that same way as part of that process.  

So from the clinical directors, they put together a team of six rural docs who then reviewed all of that with us.  

So and then we've been back to the clinic directors to the point of being able to just quickly work through clinical questions, and also a dialogue for physician orientation to the materials when they come out.  

That group has been, in developing that relationship between the CHAP program and the physicians rurally, but then with the medical specialty docs here at AMTHC and at the Native Medical Hospital, so that -- because they -- they get the patient from the village to Bethel into here, but what -- and what is their -- you know, what do they want to see in the practice of health aides and how things are treated.  

KAREN:  Well they are part -- the docs are part of the relationship. 

LINDA:  Exactly. 

KAREN:  And what kind of training do they get with interacting with health aides? 

LINDA:  Very little.  It depends on the corporation.  Some corporations have really tried to expand so that new docs receive, you know, reviewing, say, a videotape of some materials.  Others walk on the job and -- and don't even know what a health aide is.  It's the whole gamut.
  
And the docs themselves at a clinical directors meeting about six months ago said, you know, we've learned a lot from this process and we realize that we've not been using the CHAM to our advantage to improve care because so many of the docs just sort of quickly decide something, and if the health aides themselves are trained to be in the CHAM, to be on the page, and those docs who know that say, okay, Page 307, they turn to it together, it's a very quick dynamic and everything.  

Other docs say, gosh, you know, I just don't even use it.

LINDA: And so we're trying to bring that into a more -- and what was fun -- from my perspective is that the clinical directors invited us to do that, to put together the orientation materials for docs to the new CHAM.  And how that process might work for any new doc.
  
Or even a TDY, a temporary duty doc, because again, they are coming from the Lower 48 and have no experience with the extension of their practice in the rural communities through the health aides.
  
And again, if you say community health practitioner, they are still not quite sure what that means.  Certainly Community Health Aide, the title, doesn't convey the scope of their skills.  

KAREN:  And now, did you have Community Health Aides reviewing --

 LINDA:  Yes. 

KAREN:  -- the manual and telling you from their previous experience what they liked and didn't like?  

LINDA:  Yes. 

KAREN:  What worked about things?
  
LINDA:  We did a couple of things.  We had a survey that gave us a lot of input in the beginning.  Then we've had on the team, from the beginning, health aides on the committee itself.  And then after, as we've written the materials, we've done a variety of things.  

As I mentioned for the emergency handbook, we actually took 18 health aides and ran a half a day's scenarios, having them look and use and give us feedback, which was invaluable.  

And it was really cute, when it was finished we had to collect them all back, and they wanted to keep them because even at that point, and it was actually three drafts ago that they did that, because we've really -- input has really helped to add more sections, but they -- one said, you know, I just want to take it home with me.  I won't use it but it will help me a lot.  I'll just put it under my pillow, you know.  

And another one was, she goes, you know, I'm going to have my husband read this.  You know, he often comes to emergencies with me and he could just read this out loud while I do the steps.  And it would make a huge difference.
  
So we've went in -- and then the chapters themselves, what we did for those is we did a lot of field-based testing, and we sent the materials to field supervisors, trainers, and health aides, but we had them do -- for example, the field folks had to find a health aide and we gave them clinical scenarios where the health aide -- where the supervised instructor played a patient, and the health aide used the materials as if they were seeing the patient.  And had the book.  And got feedback that way.  

Because just reading the chapters, the medical folks are able, you know, to help us with that, and we're looking at language and appropriateness of language and clarity and all of that, but the key that we wanted to know is does it work. 

KAREN:  Right.  

LINDA:  And the only way to know if it works is to do it by case.  It means, you know, you have a 27-year-old patient with dah-ta-ta-dah, and actually give a little history and exam findings, that they would work through the problems.  So we felt, you know, the evaluation by the field was essential.

KAREN:  Because it's a huge amount of material and so complex, how do you figure out how to put it all together? 

LINDA:  Well, that -- that has been a challenge.
  
Certainly it has been organized as it has in the past by body systems, and then what we really focused on this time around is that it's symptom based.  

And so if you come in, you go into where the problem presents.  As opposed to in the past, even in the White CHAM, you had to know that someone had a leg circulatory problem to get to the right place.  Well, all you have to know now is that it's leg pain.  It's -- and then it will help you go from there. 

So it's really, what does the patient present with, and how do we get into the book.  And that clarity -- and the other thing we really tried to look at is children and how do children present.  They are very different in their ability not only to communicate, but they get sick so quickly.  

KAREN:  Right.  

LINDA:  So we had to differentiate those really sick little ones from others, and we don't have a pediatric book.  

So this book has to work for not only for, you know, age from birth to -- to life, men and women, but it's how do you take -- for example, if somebody had a sore throat, is that different in a child than it is -- and yes, it can be. 

And so we have within each section that's appropriate to a child, we have some questions that look at the general health of the child.  And depending on their temperature, which is an indicator of how sick they are, whether you need to do more.  So we've really tried to differentiate that.  

And then the other thing that has been a challenge is to write one book for the state this large, and I don't mean that large just geographically, but also 26 tribal entities, and try to really listen to what are the medical expectations in their community and what do they want to make sure is in the book or not in the book. 

And the other is this book has to work.  If you're a brand new health aide and you've been on the job one month, and it has to still guide you if you've been out there 20 years, and how does that do it, and how does it keep you, then, still excited and engaged in it.  

And so one element we looked at was in the prior, especially in the '98 Blue CHAM, was that there was a lot of textual knowledge information sort of woven into the history and the exam and kind of cluttering it.  And so you couldn't get just the visit, you had all this other stuff to read.  

Well, it doesn't help in the visit.  You need it as background, but you need it clearly distinguished as sort of information that you want to read and know.  

And so we've really kind of cleaned that out so that the history can go quicker.  Because that's what you want.  The patients don't want to -- you know, they want a quick visit.  

KAREN:  Right.  

LINDA:  But they want a complete visit.  And so we've tried to really separate that out.  And also what health aides need to know and sort of must know that visit versus that sort of extra stuff.  

Like an acute abdomen is an example.  They used to have two assessment charts, one was did you have an acute abdomen as opposed to other abdominal pain, and then an assessment chart that you actually had to try and decide what kind of an acute abdomen you had.  

Well, you don't need to do that.  That was -- that was an extra step that just added to their process that would either delay or just add to -- now, is it helpful for them to have that understanding?  Yes.  Do they have to make that differential diagnosis?  No.  

So we've tried to clean that out and we -- we think the feedback we've gotten from folks is it's really helping to understand.

LINDA: Another element that -- because my background is nursing and midwifery, and I'm not a generalist, I'm sort of good at looking at some of this because I don't know it myself.  And so I am like a health aide.  And it has to be clear.  It has to make sense in steps.
  
And one of the things that I found for both the White and the Blue Manual is that they have no other textbook that accompanies the program.  It's -- it's -- it's all there.  

And so if I'm going to talk to a mother about croup, I want to have a little bit of an understanding of what it is, what and why, so that as I, you know, talk with her about the care and so forth, that I understand it.  And that element has been missing consistently in the past books.  

So each plan starts with a short description of the problem so that you know whether it's bacterial, which then you can treat with antibiotics, or it's a viral cause, and with viruses, and then you can clearly explain it.  
Because most patients walking in today, because of the way the medical system is, is you expect to get medicine, a pill, a pill will make me better.  And often -- often that's not true, and in some cases, it actually can make you sicker.  

KAREN:  Yeah.  

LINDA:  Or if you don't take it correctly, which is a long history of this whole country and certainly Alaska, is the misuse of antibiotics so that we're now having resistance strains of -- and you've probably read about that in the press today, is that we're having to go to more and more sophisticated and sort of generational, we're talking about sort of the next generation of antibiotics.  

And that, you know, it's key again, the patient understanding.  And especially for mothers to understand, or for fathers, both the parents, to comply with the medication because kids get better in two or three days, and getting them to take that medicine for 10 days is a pain.  But it's key that they do because then the bugs come right back again.  

So the -- the materials are, again, the same principles throughout my years of the program is clarity, navigation, ownership, and really respect for them as being able to -- to, you know, sort through complex issues in a very straightforward way.  

And people have said, but Linda, you mean simple?  No, it's not simple.  I don't believe it is.  I think it is complex information.  But I think we can say it concisely and simply to make it understandable.  It doesn't have to be beyond, you know, an individual learning that information.  

And I -- you know, I -- folks that ask me, you know, Washington D.C., Chevy Chase, Maryland, how on earth did I get here, and what am I doing here.  And I feel when I moved to Bethel and certainly when I came back in 1980 that I was coming home and this is my home.
  
The Delta has taught me so much and the culture is what keeps me really -- the Health Aide Program is certainly just an element of it, but the Yup'ik culture where the words cooperation and sharing and family and community, they are not words, it's the fabric of life there.  It's the -- it's -- they are real and meaningful terms that you live every day.  And coming from a society where it's competition and me and mine, I never fit there. 

So for me, working in a program that really believes in not only the individual for health care, but the extension of their knowledge to others, and that's sharing.  We don't have to compete.  It's really cooperative principles of being healthy.  How can we be healthy.  And that comes through a system that supports that.

KAREN:  You mentioned how the health aides are from the communities.  I have heard a criticism of the way the program has transformed more recently that perhaps there's more people from outside coming in and becoming the health aides.  And is that true and how does that affect things?  

LINDA:  I think that there's certainly -- and I -- let me back up and just share that not being an administrator of the program and listening at CHAP directors meetings and they meet quarterly, and part of that is they do a round table and talk about issues, and I would say that in the last few years, I'm hearing more of that.  So that would be my perspective in answering this question.  

And what I hear from the CHAP Directors is that it's, again, many components, but the main one is that the health aide job is so difficult that in some communities, they cannot find anyone to take that job.  And when you can't find someone and you're still responsible, as the corporation, for health care for those people, you have to then seek someone else.  

And so there are sometimes Non-Native folks that move to communities through maybe teach -- the spouse of a teacher or it could be someone who came to the community for another reason, they may be hired to be the health aide in sort of a non-village resident and considered an outsider.  Though often those people stay for years and are really the prime health care provider and become part of the community.  

And then for some health corporations, in order to keep those clinic doors open, have had to recruit from other parts of the state.  

And we're not sort of going out of state yet, but we do get interest from people in the Lower 48 who have either heard of the program or have looked at the university catalog and see this program in there, and you can't just come to the state and be a health aide, but there are still -- you know, there are holes in the program, and when a health aide position is unfilled, the corporations are having to rely on -- and come up with creative ways.  

Another one is that a number of health aides are now itinerating across the state.  They live in one part of the state and cover in others.  There are a number of health aides that live in the Tanana region and itinerate up to the Fairbanks -- or excuse me, the Barrow region because the Barrow folks aren't able to keep all of their clinic's positions covered.  

I think that again, it goes back to the complexity of village life in rural Alaska today.  Certainly the Alaska -- the Anchorage newspaper has been doing a series on just going down the Yukon, and all the complexity of issues, whether it be lack of funding or the increase in oil prices that have bankrupt communities, or if it's erosion and falling into, or if it's school system issues, sewer and water.  It's just -- there's lots of issues.  

And I personally really believe in village life and would not -- would not like to see that end.  Where would folks go?  They can't all move to Anchorage.  

KAREN:  Right.  

LINDA:  And village life is remarkable in its sense of community and who you are.  

Are the communities equipped to deal with teen issues today?  No.  I've raised two kids in Bethel and I can tell you their teen years was very hard.  But I also know family members who raised teen kids in Seattle or Illinois, there is difficult issues.  You know, boredom.  That big word boredom. 

And the Savoonga article, which I thought was amazing, I didn't like that he came sort of as a -- under the microscope, I'm going to go see this community on the edge of the world, I don't -- I was astounded at his findings, but I think he did say a key thing that's true in rural Alaska today, which is survival of the culture and survival of the individual and where is that -- that's the -- that's the -- and culture is all -- and I don't mean it in terms of, you know, that people do things the way they used to, I mean, it's a recognition of the cultural heritage and language and the elements of it in day-to-day life when you're bombarded with all of the outside elements.  So.

KAREN:  So I was wondering back about the attrition, and how you handle that or what -- one of the factors of attrition and then how you handle that in this whole system of training that you're spending all this time and energy, you've put an investment in somebody, that then may or may not stay with it.  

LINDA:  Uh-hum.  Attrition is a complex issue because it can be for -- I'm going to tackle this question from a few perspectives.  

In terms of training, it is hard to watch someone leave, but I've learned over time it's when you have the long view, it's really very healthy.  
If you've come as a new person from the outside, it seems overwhelming and you can't see it, but so many health aides return, and they bring -- and come back to the job.  

Whatever life event was happening, whether it was a sick parent or a child or something that -- or they just needed a break, so many health aides return to the job.  And you -- you just support that.  

So there's no -- I don't feel that, you know, there's no berating someone's choice to do that.  It's, again, supporting their personal choice, with the idea that thank you for your service, please don't leave, not -- you know, well, that's fine you're leaving kind of thing, and we'll look forward to when you come back.  

So with that, I think that that's a different way of leaving a position.  If you keep the doors open to coming back.  So that's my personal place on that.  

The other is I've watched a tremendous number of CHAP directors come through the program over the years, and yes, there are lots of complex village issues, and one of them is alcohol.  And do health aides drink?  Absolutely.  And you know what?  That is as hard an issue as any.  And when they are not on call, they have a personal life, and yet they are role models.  So there's that balance.  

But I had a wonderful health aide out in Hooper Bay years ago, and I won't say her name, but she was -- what a difficult village to be in.  Very complex and lots of trauma.  And she worked very, very hard.
  
And a new supervisor came on and she mentioned, she goes, well, this person has a real alcohol problem, and I thought, that's not what I saw.  That's not what I saw in training.  And I said, let's -- let's look at this.  Let's talk about it.  

And we got together, and what it was, was this individual, and I asked her, why do you drink like this.  And she goes, it's the only way I can get away.  She can't leave the village, not connected by a road system.  She couldn't be unavailable because people would knock on her door.  So the only way she could get away from all of it was to drink. 

And once people started to hear why she drank, then they were able to -- actually they hired more health aides.  And she was able to get more time off.  And she stayed and was a wonderful health aide.
  
So I think that the key to it, and I -- working with one CHAP director years ago who understood it is the role of all of us is to help people stay.  Even if they seem like they have lots of problems, is the next person will have problems, too.  We're human and living in rural Alaska is not an easy place to be.  

And so this CHAP director was wonderful.  She understood that if the person needed help with baby-sitting that she didn't say to the health aide, well, you were late to work today, and therefore, I'm going to dock you, she would say, okay, what happened?  Oh, well my baby-sitter was sick and I had to bring my child.  

Well, she listened to that and to the point where in one case she actually went and bought one of those child pens and brought it to clinic and the child would come to clinic.  It's working with the individual to help them stay.  And that takes listening beyond the outward expression of a problem.  

So I think attrition, and again, it takes a team who have been around.  And if you come from the Lower 48 and you certainly look at rural health problems, it just seems like it's just dismal, and it's not.  It's their home, it's their life, the community is tremendous.  

And you can't -- don't come with your values.  Don't come with this, you know, looking down your nose at -- at folks and deciding that if they have -- and there are awful issues, but there are awful issues everywhere.
  
So I think attrition is difficult.  I do think that it's a combination of, you know, salary, which we were able to increase significantly in the CHAP in crisis, that was where the first and all of the money was put into salary, to increasing the number of health aides.  No village was allowed to have less than two.  Prior to that it had been one individual.  Just bringing on a second person was significant.  

And then actually looking at number of patient encounters, and some clinics have up to 4, 6 health aides, and some, maybe the larger villages, more than that, to looking at a schedule of time off and time on that was genuine.  

Folks now looking at subsistence activity and recognizing that that's part of life and not just part of holiday.  I mean, it's work and it's -- and it needs to be recognized.  

So things that support communities that are stepping forward and actually doing more to support their health aides than just lip service.  Clinics that are good to work in.  New clinics with running water that make it easier, adequate equipment.  
And then there's the whole arena of you just may need time off.  And to support that.  

And I -- I think that one of the -- the, you know, second hardest job in the state is being a CHAP director.  And they have the job of keeping those clinics open every day, and all of the personal dynamics that are going on in the village.  

So it's -- it's multifaceted and pretty complex, but it's -- I think it really is about respecting one another, and again, communication and listening to why someone has to leave.  

And -- and just saying, oh, okay, well, we'll get someone else, which has -- I've seen that where people say, "Oh well, we'll just get someone else." And not recognizing all of the loss of just, it's not like here where we say, "Oh, okay, we'll just get another nurse or another sales person or another teacher." community.  

And that's why the program works.  It wouldn't work if these were outside folks coming in.  It really is home grown, folks who have incredible inner strength and nurturing quality that they really want to help people.  
And so I can't believe 25 years has gone by.

LINDA: I think that attrition and this issue of hiring people in -- you know, I know that our health aides are very vocal about how bad that is, but I would invite those vocal individuals to help change those communities where there's tremendous turnover.  

You know, or to help to have a -- you know, I've actually spoken at meetings where I've invited -- part of this process is working with the Alaska Native Health Board and with the tribal health directors who, you know, are responsible at the very top of this organizational structure for health care, and one of the key elements is the support by the village councils.  

And it sounds -- and I know I've mentioned it, but it's so real and so true that, you know, if somebody has been up all night with an emergency and the clinic doesn't open until noon instead of ten o'clock in the morning, don't listen to that complaint and take it as genuine.  Support the health aide and say maybe -- you know what I mean?  But it doesn't.  It's well, you know small-town politics. 

KAREN:  Right.  Well, that's what I was wondering, if the health aide is a non-local person, if that's starting to happen, what receptiveness of the community, of having somebody -- and how that affects the health care, if it's better to have a local person, or in some cases it might be better to have an outsider?  

LINDA:  I think it would depend upon the individual and the support.  
One -- the one thing you can't say in this state is that I -- I really believe that every community is unique and the elements that affect that community, whether it's, you know, two sister communities just downriver from each other, it can -- it can even be language.  I mean, you can have a language difference.  

And -- but I still think that the values of the culture, of Alaska, the Native American culture is one that needs to be exported to the Lower 48, and instead it's going the other way.  

And so in my personal life, I work with the Bethel Council on the Arts and Camai Dance Festival, and really believe that a strong sort of expression of language, dance, dress, culture, crafts, food, and that public celebration and display and notoriety, whether it be in the press, that all of that is -- makes you smile, makes you celebrate, makes you feel proud of -- of that.
  
And so I've seen -- you know, since 1972, I've seen a tremendous change in the Delta.  And again, it's the long view.  And alcohol is a problem, it is anywhere, but the alcohol issue is now being owned by the individuals themselves.  

And part of that is if you look at when alcohol came to the Delta, and the leaders of today are themselves publicly alcoholics who came through the other side and now lead the sobriety movement, lead the programs that are making a difference.  

And in those communities that have -- I would say are centered and balanced, the health aide role is very different and their job is very different.  In villages that are still in sort of turmoil and chaos, whether it be due to activities or an individual who is, you know, terrorizing the community, I mean, health aides face all kinds of situations, whether it's a gun brought to clinic or, you know, somebody harming someone in the home, or --

KAREN:  Well, as you said, they provide such a broad sweep of care that in Western society, it's all compartmentalized. 

LINDA:  Yes.  Yes.  

KAREN:  And it's just amazing. 

LINDA:  Yes.  And in fact, someone said, well, why does it take a health aide so long to see a patient.  Excuse me?  They do intake, they do -- get the chart, they have to go find the chart, then they do vital signs, they do all the job that the receptionist and the clerk and the nurse's aide and the doctor and the nurse does, then they run the lab test, then they are the pharmacy. 

KAREN:  Right. 

LINDA:  Then they are the reporter then they put it all away and they clean up and they restock.  

KAREN:  And sometimes they are a social worker --

 LINDA:  Right. 

KAREN:  -- and counselor -- 

LINDA:  Oh, absolutely.  

KAREN:  -- and educator. 

LINDA:  Absolutely.  And the manual has always supported that role because it's part of health care.  It's in the preventative services of mental health.  

And you can even have chronic mental health problems.  And so that has been part of the program.  That's a whole level of care that takes a different kind of not only knowledge, but also just in time and weighted.  

And in fact, in dental, dental is a huge issue on the horizon right now because we have huge, huge dental problems in rural Alaska, and primarily I think due to diet, change in diet and soda, but the Health Aide Program has always supported dental education, prevention, fluoride treatment, so forth, but whether the health aide had the time to go and do that kind of work and school, you know, going to the schools and doing fluoride treatments, some communities yes, many communities no.  

And so now there's a whole new program that has grown and is sort of a sister partner to the Health Aide Program which is the dental health aide.  And it is, again, based on need.  Just as the early years was based on tuberculosis and acute infectious diseases, it is on -- and it will be very successful when it's allowed to grow.  

The third element is the behavioral health issues.  Recognizing that so much of the underlying health care issues can be behavioral and social service issues, there is a third element.  

And yes, did the health aide have all of that?  But again, it's time, a time crunch.  When you've got all of those health care concerns, broadening the team out.  

And some portions of the state have actually broadened the team out more than others.  Southeast has a very strong program of multi-teamed folks in a clinic.  And others, every combination.

KAREN:  Okay.  And my last question, we talked about before we started the interview, so now we can end the interview with that, and that's the telemedicine and the changes in the communication systems. 

LINDA:  Uh-hum.  

KAREN:  From the two-way radios, telephones, and what the impact of this telemedicine has been. 

LINDA:  Well, I think that, you know, throughout the Health Aide Program, and I -- actually Esther Curtis in the early years tells this wonderful story of writing a letter to the doctor, and it going off by snow -- dog team through, you know, coming back two weeks later telling her how to treat a patient. 

So yes, I've been around the program to kind of move to CB radios and one telephone in the village, which was really interesting because we all thought we had communication, but when you have one telephone and everyone's lining up to use it, it had -- it's pluses and minuses, and then telephones broadly through communities, though it still goes down.  

We, you know, here on the hillside in Anchorage, the phones were down and electricity is down; certainly in rural Alaska.  So we always have to remember that as good as it is, there are moments.  

So telephones, and then with that faxing, so that radio medical traffic each day, the doctors are able to read information on patients and then respond to the health aides.

LINDA: And now with computers and the telemedicine, which is now changing names to be calling telehealth, from I guess a national change in language, which is allowing folks to have computers in the clinic and two-way visualization.  It's a store-forward function where you can look, for example, at eardrums and send the picture to the doctor, who can then analyze that and get back to you on it. 

And some portions of the state have embraced the whole network and technology.  It's actually not that new.  

And up in Barrow, they had two earlier systems of sort of the telehealth concept of computers and imaging and so forth.  The -- the equipment, you know, sort of just sat in the corner and grew dust on it.  

So I think the -- it -- again, it's a tool that can be used inappropriate cases.  If you have, you know, a gaping wound and you want the doctor to see it and to help you to decide on closure and whether you should have -- how deep that wound is, whether you should be trying to close it or leave it open or send the patient in, very appropriate.  Ears, it's really helping to look at ears.  

The other side of the coin is that it can also be helpful to the health aides, but also changing their role in terms of expectations.  

And a story that comes out of Kotzebue that a friend shared with me who is a supervisor up there is where the health aides had a patient in clinic who would have historically been transferred.  There would have been a medevac and out, but because the doctors could visualize the problem, the patient was kept in the village overnight and into the next day.  

Well, it meant that the health aides -- and there are only two in this village -- were expected to be with that one patient for that length of time.  And so regular clinic and other things were either, you know, attended to or put on hold or just those two folks got won out in caring for that patient.  And everything turned out okay, but what it is, is that in the village, that's all there is.  

In a hospital situation or in a clinic, you have the staff that's coming on fresh and new in the morning at eight o'clock to take on the next shift.  You're not trying to round the clock nurse care for and be ready for the next day.  

So I think the telemedicine is a tool that we'll all continue to explore the best use of it.  We do reference it in the CHAM manual where we say to the health aide that it is appropriate to the case, it's not expected on every case, and that they get to decide that with a physician the use of it.  

So I know it's -- at one point, there was a -- at the beginning, you know, as the tool came out, everyone says, well, we can have every patient just line up and they will be seen and the doctor will order it.  Well, that doesn't work.  

And it -- it doesn't mean that the health aides don't need to be trained on ears.  Yes.  They still need to be able to do all of that.  In fact, even more so because now there's more of a collegial discussion about cases that the health aides really do need, you know, to have a full understanding of what they are seeing and why they are seeing it.  

And the other is it's a time element, but it's also -- I think that there just being one more tools.  

I watched it over time, and it, again, is about the physician knowing the health aide, knowing their capabilities, supporting them, respecting them, listening to them.  

And I'm a little concerned that between faxing and telehealth that there is less personal dialogue.  And I don't know that the physicians know the health aides as well as they used to. 

So I think there's pluses, but I think with everything you need to just -- you know, at one point people said, whoa, we won't have to train health aides, we'll just have the patient in front of this machine, and very, you know, to -- but it was amazing when I first heard that, I thought, what?  How can you possibly believe that?  But this machine was going to do what the health aide could do.

 There will be advances and there will be others, but there will always need to be, I think anyway, you know, a well-trained individual who greets that patient and assesses what's going on and then appropriately -- and again, health aide's about access.  Access to health care right next door.