Dr. Walter Johnson was interviewed on July 8, 2005 by Karen Brewster at his home in Homer, Alaska. The interview took place at his kitchen table on a warm summer day with a view of Kachemak Bay. In this first part of a two part interview, Dr. Johnson talks about establishing the Community Health Aide Program, training health aides, integrating health aides into the western health care system, communication systems used, curriculum development, the program as a model for rural health care, and what he sees for the future. After the interview, Walter led a tour of his apple and cherry orchard and vegetable and flower gardens.
Digital Asset Information
Project: Community Health Aide Program Project Jukebox
Date of Interview: Jul 8, 2005
Narrator(s): Walter Johnson
Interviewer(s): Karen Brewster
Transcriber: Carol McCue
After clicking play, click on a section to navigate the audio or video clip.
His personal and educational background, and coming to Alaska.
His inspiration for recommending development of a community health aide program.
Meeting of the Indian Health Service area directors in Anchorage as a key event in the evolution of the health aide program's development.
Pilot programs that were established to test the idea of having community health aides, the early training programs, and how things have changed.
Other aspects of training health aides, and key people involved in the development of the health aide program.
Health aides he remembers working with through the years.
Mixing of western medicine and traditional healers.
Relationship between health aides and doctors, and a particular case of local ingenuity in treatment of medical problems.
Challenges in training health aides.
Use of standard English language terms in teaching and in the manual for health aides.
Communication with health aides in the villages.
Relationship between doctors and health aides and background information about the program.
The medical community's reaction to the health aide program.
The future of the health aide program.
Management of the health aide program, and medical services Walter receives.
Click play, then use Sections or Transcript to navigate the interview.
After clicking play, click a section of the transcript to navigate the audio or video clip.
WALTER: We're sitting at Homer, Alaska, 8th of July, 2005. Karen is here from Oral History Department, Rasmuson Library of Fairbanks, and Walter is sitting at his home here. We're just talking now to see what level to set the machine at. KAREN: Okay. We're back after that little test, and why don't we just go ahead and get started. We'll start out with a little bit about you and when and where you were born and how you ended up in Alaska. WALTER: This is Walter Johnson speaking in Homer on July 8th, 2005. I was born 83 years ago in the prairies in Nebraska, grew up there, and came to Alaska in 19 -- first in 1941 for the summer, went back to do a year at the University of Alaska on a -- University of Nebraska on a regent's scholarship. And in the spring of ‘42, I got on my bicycle and rode to Seattle, came to Alaska where I have stayed more -- or forever. Or since, except for going out to school and training. In the fall of ‘42, 1942, I went to the University of Alaska in Fairbanks where I enrolled along with 116, 115 other students total at that time. After -- during the next seven years, I spent a couple years in the Army during the war at the hospital at Wainwright, then Ladd Field, and also spent a good bit of my time up at Wiseman, Alaska, up in the -- above the Arctic Circle in the Brooks Range. Up there, I managed -- my partner, Bill English, and I had a little store, and also I worked for the Road Commission, Cat scanning in the summer. After that -- KAREN: What did you say, Cat skinning? WALTER: I was -- KAREN: What is that? WALTER: Operator -- heavy equipment operator. KAREN: Oh, okay. WALTER: Yeah. Anyway, I went out to a -- took my medical training at the University of Nebraska Medical School, and in 1954, was the first graduate of the University of Alaska to come back to Alaska to practice. This was at the hospital in Bethel where there were two of us at that time, Dr. Harriet Jackson Schirmer (phonetic) and myself. I spent there -- two years there, and since this was the first time there were two doctors there, we began to make field trips. And Harriet went mostly to the Kuskokwim and myself to the Yukon. There I encountered villages where they had never or for -- or seldom seen a doctor. Some of them, the last time was seven years ago when the Yukon Health Boat came by to take X-rays in connection with the tuberculosis drive. We dealt with the local folks to -- over the radio, often through the BIA teacher in order to extend some health care to the villages because up until then, I would estimate that at least about a fourth of the children died of pneumonia before school age and many had repeated episodes of otitis media and ended up with draining ears. The teacher, in turn, needed to talk with a local person who would be an interpreter and actually see the patient. The teacher's training -- training consisted of stopping at Bethel for an hour to learn how to give a penicillin shot. Penicillin being available. KAREN: What motivated you to go to medical school? Why did you go out to become a doctor? WALTER: Well, I had registered from the beginning as a premed student. There were no other premed students at the University of Alaska. There was one pre-dental student, Richard Brothat (phonetic) from Nome, so there were very limited courses in biology, but -- so my major ended up in bio -- in anthropology and biology. But while -- well, because I was interested in medicine, I asked -- after boot camp training in Fairbanks, I asked to be assigned to the hospital and was, where I worked in the hospital laboratory for the duration, a couple years that I was in the service. While I lived at Wiseman -- and I lived there one year around because I enjoyed it up there, and it was nice to go hunt and hike and the country was essentially uninhabited then. Then I would spend summers, and long summers, because this school term was kept short so we could all work, and then I would usually have to put up wood and whatnot for Bill's mother, so I would have a fairly long summer before I came down to school, and they always let me in late. While I was there, of course, there was not -- very little illnesses, but I ended up dressing wounds and extracting aching teeth and things like that. So I could see what -- what it was like to be in a remote place where there was no care available. And then, of course, people did not have the money to go into the hospital and there was -- Wiseman was not a predominantly Native village, and so there was -- there were no -- no resources by way of drugs or contact with the physician. But anyway, I went into medicine because I -- that was the field I wanted to work in.
WALTER: Now we're back to Bethel. KAREN: Right. WALTER: 1954 to 1956. KAREN: Okay. WALTER: In the spring of ‘55, and again in ‘56, just before breakup, I would go down to the Lower Yukon and visited the villages there. Kwiguk, since renamed Emmonak, and Alakanuk and the adjacent villages. And would stay for, oh, a week or more. There -- well, in each village there was usually somebody who would help me as an interpreter and all the other chores that go with holding a clinic. In Emmonak, there was no BI -- BIA school. Only a two-year elementary school in a log cabin taught by Betty Guy, later a health aide from Kwethluk. And who was just beginning to introduce English. The -- the prime movers in the village were -- were Pearlie and Axel Johnson, both Natives of the area, who were handling the medical problems the best they could. So I would let them use the otoscope, the stethoscope, and we would examine patients together. And from that, and also from having lived in Wiseman where I lived with Mrs. English who was a very traditional Iñupiaq Eskimo, realized how keen observers local people were, and that they could make observations as well or as any physician. And so when I came back from the field trip to Emmonak, I wrote a letter to the ANS headquarters in Juneau proposing training for local persons. And my main point was that it really was not a question of -- of their having fully trained people or not, it was going to be somebody with less than full medical training or nothing at all because there's no way there was going to be a doctor around the year in these remote places. Dr. Ted Henson answered the letter saying that he was sympathetic with the idea, but questioned how it would be accepted by the medical community. And when or if it could actually be put into effect. I don't have a copy of the letter; I do have a copy of his answer. I didn't hear any more about this. I went out to the state's -- I joined the -- the U.S. Public Health Service in 1955 when that agency took responsibility for Native health care from the Alaska Native Health Service, BIA. That gave me an opportunity to apply for residency training while in the service. And so I went out to Boston for the internal medicine training and spent some years out there to qualify and pass my specialty boards in internal medicine, returning to Anchorage in 1962. As chief of medicine.
WALTER: A key time event in the evolution of the Community Health Aide Program, I would say, was the February 1964 meeting of the area service unit directors in Anchorage. That is, those individuals, in this case, physicians, that would be responsible for the various service units in Alaska having a -- you had a meeting in Anchorage. The thrust of this meeting was how to get the community involved. And I actually have the letter that was sent out by the area director, Dr. Holman Wherrit, to those of us who participated to talk about getting more community involvement. The idea of training local people came up at the meeting, and it was a very animated discussion. A number of the Public Health nurses who had carried this burden as itinerants, going to the villages, instructing people in midwifery and -- and giving immunizations and all the other things they did, always came back with a list of medical problems and would sit down with us physicians and try to resolve them. These problems that they had encountered in the villages. So that the health aide would then be assuming some of the things they had done before. And entering into the work at a much lower level of training and status than a Public Health nurse. John Hope from Southeast Alaska was there, Johnny Hope, and who was not primarily in health but was very active in promoting Native involvement, was, of course, a strong advocate. Arlie Bruce, who was the Deputy Director of the Public Health in Alaska, of the Public Health Nursing Program in Alaska, was a -- was a strong supporter. The upshot was that without any special budget, some of the -- several of the service unit directors would take it on themselves to call in for a two-week period villagers who had been doing some of this health aide work and give them some training, and return with a report on the consequences. Several of these people were James Justice in Sitka, Jay Keefer in Bethel, Gloria Park in Anchorage, and Tom Harrison in Kotzebue. Tom Harrison wrote his experience up, which was published in Alaska Medicine. This experience was used for headquarters, which by that time, was very active in moving into more Native involvement in the health program under Dr. Emery Johnson to present the idea to Congress. Congress did then approve and budget, in 1968, funds to support 185 health aide positions in 157 villages. That being the official beginning of the funded Community Health Aide Program. As a little sidelight, these folks were called -- were referred to as medical aides, usually, but because of all this emphasis on community was sort of the buzz word at the time, that's switched over. And also, it took -- in retrospect, that took a little of the sting out of the -- out of the threat to the -- the medical hierarchy, probably. And because they were “health” rather than “medical” was less of a hot button.
KAREN: You were going to talk a little bit about the pilot programs that started after the ‘68 -- WALTER: Yes. The pilot programs were successful, and it would only be limited, you know, via could be drawn from such brief experiences, but the essential point is that funds were made available and people were willing to put their shoulder to the wheel to get the program going. KAREN: So those pilot programs were before ‘68, they were in ‘64, right? WALTER: They were from ‘60 -- they were in ‘60 -- they began in ‘64 to ‘68. KAREN: Okay. WALTER: After 1968, there were three, as I recall, there were three training programs set up. One at Nome, one at Bethel, and one at Anchorage. And there must have been -- no, I think that Southeast, at the beginning, were sending their health aides up to Anchorage. So I think there were three then to begin with. And these were administered, of course, at that time, by the Indian Health Service that had responsibility for the total program. About that time, under Lyndon Johnson's economic opportunity program, so-called OEO, Office of Economic Opportunity, there were -- there was another agency set up to push this community involvement, and a number of people with considerable funds were assigned to Alaska. Among other things, they set up a training program in Bethel to bring people in and train them for seven months because they thought it was very bad to have people come in for two weeks. Well, actually, the program, as it was set up, consisted of coming in at least three times, two weeks, two weeks, and three weeks, I think. And admittedly, this was fairly brief. But those young fireballs, they didn't realize that it was really not possible for these folks who were chosen to be sent in were almost all married women with a lot of home responsibilities. And it was just not feasible for them to just leave for seven months. Some people did, and I think that Paula Ayunerak at Alakanuk was one of these early trainees, a very capable person. And I don't know what her experience was with in regard to the seven months, but she did continue as a health aide for many years. And her story is mentioned in this little book that Philip Nice wrote, "The Alaska Health Aide Program: A Tradition of Helping Ourselves," which was published in the 1890s -- I mean 19 -- 1990s. Anyway, these programs that were set up continued, and as mentioned before, there were 185 positions allotted across the -- which is now a state, no longer a territory, and in 157 villages. Now, to put this in perspective, we can look ahead and see that today, apparently, there are approximately 500 community health aide, slash, practitioners in 178 villages with a budget just under 20 million. So we could -- well, let's mention a few other points regarding the training. The candidates for training were -- were selected by the village, and the people who did the training were largely physician assistants, a category of workers that are just newly come into the medical hierarchy, and nurse practitioners. And of course, physicians, along with the nutritionists and other ancillary health workers. One of the challenges, of course, is to get real clinical bedside experience. And again, I happen to, by chance or design, to be in a unique position there associated with the large training program in Anchorage. I was still based in the hospital as the medical director, also, quote, clinical director, so that I was able to be involved in the health aide training. And it was possible for me to go on to the wards and encounter patients that had interesting physical findings, many of them whom I -- patients whom I knew or their families, and -- and then to take the health aides who were new arrivals from the village into the hospital in starched white coats with stethoscopes dangling from their pockets onto the wards. And assume physician roles, just to interview and actually observe the physical findings, the lung sounds, the palpable organs, and all that sort of thing. And I think that was a key part to -- of the training so that they could learn how to communicate better with the physician. At the same time, a manual was being written by of all people, a pharmacist, Joe Whitaker. In 1976, I moved over to the health aide program full time from being clinical director to being medical director of the health aide program and was full time in teaching. Joe Whitaker and I shared an office, and so as he was writing the manual, he could -- we could converse back and forth. And he produced a very usable book, which seemed to serve quite well for a number of years to get started that.
WALTER: Another aspect of the training was involvement of the university. The Kellogg Foundation funded a grant that was managed by a person named Rosaire Kennedy who -- whose goal was to associate the health aide training with the university. This grant was moved to the Robert Wood Johnson grant after a year or so where it continued for many years. Gradually, the -- the health aide curriculum was -- was accepted by the university in their College of Rural Education. Rosaire pioneered that work and several other people served as the -- the grant representative, including a health aide trainer from Kotzebue, Winnie Reeves. And later, after I retired from the Public Health Service in 1980, I worked in that position for several years until I left the program completely in 1987. The purpose of that was to integrate with the university, which was accomplished so that the -- as the training expanded a great deal, and the number of hours of training expanded, the name was changed on completion to Community Health Practitioner. And the individuals who completed the program could become or could be awarded a two-year degree. There was -- there were, of course, too many people to mention who were very active in this program. It's a -- it's taking a risk to begin to name names because there were so many who worked to make this -- this go. Among the health administrators of the Anchorage program and with statewide responsibilities were not positions, one was Roy Huhndorf. KAREN: Right. WALTER: And that was where he began his administrative experience, which eventually ended in his being director of the large Native corporation CIRI. KAREN: CIRI, right. WALTER: Following him was Jim Sosoff. Rob Burgess was involved with revising the manual. And as I said, there -- and Linda Curda has worked for a long time, first at Bethel, then with the university, and now with the academic review committee, and currently revising the -- the manual. So I -- KAREN: She's in Anchorage. WALTER: Stop there in mentioning names, and realizing that there are many, many others. KAREN: Well, were there any in particular that had a great influence on you or who were mentors of yours? WALTER: Well, I would say that Roy Huhndorf and Jim Sosoff and myself both worked together very -- very closely. And, you know, are friends -- we've continued our friendship. And we used to always have lunch together on holidays for many years after that.
KAREN: Were there any health aides that were particularly inspiring to you? WALTER: The relation with the health aides was -- was very rewarding. And we -- some of us had been friends before, like Hannah Anderson, Hannah Tobuk before, and myself were both kids together at the same time around Fairbanks and the Koyukuk. Well, just to -- to mention some of the original health aides that I was very impressed with, starting in Southeast, there was Alma Cook from Hydaburg who is sort of a pillar in the SEARHC, the health corporation down there. KAREN: Southeast Alaska? WALTER: Southeast Alaska. And Trudy Wolfe. And of course, Barbara Johnson. And -- and going down to some of their meetings and to the Alaska Native sisterhood meetings and so on was -- was a very, you know, rewarding experience. And then going further north, there was Joyce Smith of Kodiak, Ouzinkie. And Marge Jensen from Pedro Bay. And Wassillie Nicolai, one of the few -- few male -- KAREN: Right. WALTER: -- health -- health aides. And Phil Tutiakoff from the Aleutians, from Unalaska. And in the Nome area is the health aide from White Mountain, Willa Ashenfelter. When the -- when the director of the Robert Wood Johnson Foundation, the largest foundation giving to health in the United States, was up there and made a visit, we went out to -- to Mountain Village, and there he was very impressed because -- forgive me for forgetting his name, but he was President Kennedy's personal physician. He was a dean at Johns Hopkins. And he and Willa were sitting down and discussing cases, and he happened to pick out a chart and a very obscure case and that they were comparing notes. In fact, it was an adrenal insufficiency and how difficult it was to diagnose, a condition which went undiagnosed for many years in President Kennedy. And Willa had picked up on this very early in her patient out there. Going on further north is Esther Curtis in the Kotzebue area. Irma Hunnicutt. And then we interacted with the traditional healers there in Kotzebue, and of course, there was Della Keats, who was -- was the head of the traditional medicine, and she and I did a workshop at the same time once there. In the Interior, there's Rose Ambrose and -- and many others. Well, again, I apologize to all -- all those whose names I haven't mentioned and -- and deserve equal attention.
KAREN: You just mentioned the interacting with the traditional healers, and that's actually one of the questions I have is how that worked with traditional healers and now more Western medicine coming in. WALTER: Well, it -- there was never any big interchange because what -- what the Native healers were doing did not really come up with specific maneuvers or medications or practices that were compatible with allopathic traditional, or Western medicine, that had been subjected to our, you know, scientific criteria. Just as an example, when we were doing physical exams in Kotzebue, after I had done my little thing, why, then, I turned to Rose, who was Della's understudy then, and asked her if she would do her exam, which she, without hesitation, did because apparently part of the diagnosis and therapy that the traditional healer used was manipulation of internal organs. But there was no real meeting of the minds of, you know, what was being done and what was being accomplished. KAREN: And people seemed willing to come to health aides in the clinics instead of relying on their traditional healers? WALTER: I was never aware of -- of any real conflict where the local traditional healers felt seriously threatened. I can give one example where the traditional medicine was not very successful and the outcome was rather tragic. In about 1955, a patient came into the Bethel hospital with a severely infected boil, what it started out as a boil on his -- on his leg, from Nelson Island to the west of Bethel. And by the time he reached us, he was very sick, generally. And there was this boil which had been opened and packed with feathers or down from a bird. And this apparently resulted in a -- in a septicemia that the organism introduced, just went into the bloodstream. The result was that these clusters of organisms went into the circulation, and we observed that all of a sudden this person developed spots all over his body. And was going into shock. At which point we referred the patient into Anchorage, which had a lot better and faster lab facilities to -- to track this down. But it was too late. The patient didn't survive -- did not survive. KAREN: And so the use is that -- WALTER: But I don't want to take that as an example to bad-mouth -- KAREN: No, no. WALTER: -- traditional medicine. The whole -- well, I'm not going to get into the whole issue of allopathic versus alternative medicine, but we all now, the journals frequently say that people in the United States in general are spending as much or more money on alternative medicine than traditional allopathic medicine. So that -- that's a subject of common discussion now. KAREN: Uh-hum.
WALTER: When we were -- we were talking about in relation to health aides and whatnot. Well, I was -- I've been -- I frequently get calls from health aides out of the blue that I haven't seen for -- for many years, which -- and, you know, probably 2001 I -- in the spring, I got a call from -- from Emmonak, and I hadn't heard from them for 30 or 40 years, really. It was from Jake Johnson, the son of Pearlie and Axel Johnson. Saying that -- that they were opening a clinic dedicated to his mother and that she had asked that I come. And so I said, sure. And went down there, and rather than stay the afternoon, I stayed for a week and stayed with Pearlie, who I discovered then had -- was the same age as myself, within a month, and she had delivered 68 babies, all successfully, herself in the village. KAREN: Wow. WALTER: And she, along with her husband, had given the health care there. And I could relate many, you know, things that they had taken care of in -- with very innovative methods. KAREN: Can you think of just one example? WALTER: Well, there was an old timer, a Gussuk, a White man there, who had developed urinary obstruction. And at a time before, they were in radio contact with -- with the hospital. Because as I say, there was no BIA school in Kwiguk. And you know, this, well, it would be fatal. And I can remember getting such a call from St. Lawrence Island, and I have to admit that I was at a loss as to what they should do about it. And since I would say now that they should just put a needle in, just over, right over the pubic bone, and hopefully they could drain the bladder. But Axel had taken a willow and used as a catheter and relieved the obstruction. And I -- I could never quite envision how he would get the bark of the willow to make a tube that would be inserted. But while I was sitting with Pearlie, she happened to bring that up and described how he had actually taken the bark off and very carefully rounded the point of this limber willow twig and had used that as a probe to -- to relieve the urinary obstruction. And I guess it was used a number of times and -- and years later, O'Connor ended up in the Pioneer Home down in Sitka, and I think lived another 15 years, into his 90s down there. KAREN: Neat.
WALTER: Regarding the health aide training, one of the challenges, of course, was to -- to maintain some uniformity and to avoid a lot of repetition of effort by maintaining a rather uniform curriculum throughout the state. And here's where the Robert Wood Johnson grant and the CHAP liaison position funded by Robert Wood Johnson based at the university came into play. This person, or the individual in this position, had responsibility to -- to provide leadership to what they called the academic review committee. This was composed of the directors of all of the health aide training programs, which had expanded from the original three or -- in the state. And they would meet and help the -- and advise the -- the CHAP liaison in publishing a uniform curriculum. KAREN: The academic review committee -- WALTER: Yes. KAREN: -- revised the curriculum development? WALTER: They revised the CHAP liaison whose job it was to -- to maintain a uniform curriculum, which was accepted by the university as a basis of awarding university credit. KAREN: Okay. And what kind of people were on that committee? WALTER: It was the -- the directors of the various training programs, which is people like Rosaire Kennedy from Nome, Winnie Reeves from Kotzebue, Linda Curda originally from Bethel, and later held the liaison position. And a number of others. But they were essentially the people who were out in the field. And under them were mid-level practitioners usually who would actually make the trips into the villages, spend time with the health aides, and observing their practice and checking off their skills list and reporting back on the health aide's progress so that there was actual validation that what was listed in the curriculum was being accomplished. KAREN: What kind of -- back to the training program, how that was set up, you had mentioned they did two weeks or -- and then they came back. And what kinds of things -- how was the training organized and what were they taught? WALTER: Well, when they first came in, as I recall, it was -- there were three sessions, two weeks, two weeks, and three weeks. And during the first sessions, a lot of emphasis on -- on patient encounter, the taking of a history and how to report it. And then how to carry out the most common directions, such as giving a penicillin shot, suturing a wound and -- or dressing it. And/or maybe prenatal care and that sort of thing. Then this clinical training continued all the way through, but later there was a lot more emphasis on well-child development and nutrition, and the usual preventative and health maintenance activities. And then, of course, there were added return visits for special periods of training to culminate in enough hours of training and supervised experience to -- to fulfill this university requirement. KAREN: And then what was your role with the training? WALTER: Well, my role initially, beginning in ‘68, was to do some -- do some of the clinical teaching on the wards at the Alaska Native Medical Center. Then in 1976, I moved over, I left the hospital in the position of medical director of the hospital, and became the medical director of the health aide program at Anchorage, working with and under Roy Huhndorf and Jim Sosoff. And there I did a lot of -- a lot of the lectures and -- and also the ward round. In 1980, I retired from the U.S. Public Health Service and assumed the position of CHAP liaison at the university just as a part-time job or part-year job, 10 months, I think. And then later part time. And that I did until ‘87. And we have already mentioned that the academic review committee and the curriculum. One of the physicians at Bethel, Marilyn Chahaney and I, we did a -- we did a curriculum which was published in about -- in the early 1980s, which was one of the early uniform curriculum. So anyway, then, my relationship with -- formal relationship with the health aide program ended in 1987, and since then I've just gone back as a visitor.
KAREN: And now when you were the medical director at the hospital, what kind of an interaction did you have with the health aides and how did you communicate with them? WALTER: The setting would be in ward rounds and in the lectures, but this might be a good place to bring up the language. As you know, one of the aspects of medical has been to use all these medical terms, a lot of them based in Latin and in Greek. And these were hardly terms that were familiar to -- to a villager. So I felt it was useful to use for all of us who were in the teaching to insert into the manual rather standard terms. And it was preferable that these be good Anglo Saxon words, as much as possible, that were descriptive. And that had a meaning that was clearly understood by both the physician who was not accustomed to village language. And just to give an example, if you're listening to a chest, the health aide should learn to know if breath sounds were either present or absent, and what that meant, or if they did hear them, they were normal, or there were rales consistent with pneumonia, or rhonchi, suggesting bronchitis, or wheezing suggesting asthma. Now, wheezing is pretty self-evident I think. Rhonchi would be the real coarse sounds originating in the big tubes. That they would have to learn. And the rales, the crackling sound, meaning it's suggesting inflammation out in the lung tissue. And I guess less important would be a pleural rub. But mainly, those -- those sounds that you -- breath sounds are either present or absent, they were normal, or you heard rales, rhonchi, or wheezing. And with those five terms, you could take care of 99 percent of the lung findings. And -- and that -- that we -- we use those consistently. And then the -- well, then they learned certain things that -- that were a little more difficult, I suppose, is how to palpate organs. You know, could feel the edge of a liver and tell -- and determine whether it's enlarged. And of course, there we usually use the word palpable. And I guess the health aide just has to learn that that's what doctors say, can you feel it or not. And -- and you examine a joint, you know, you know, we don't necessarily use the old Latin term is there -- is there rubor or tumor or dolor. Redness, swelling, and pain, and you know, we just use the common word -- KAREN: Right. WALTER: -- redness, swelling, and pain. Also, well, we could talk endlessly about the manual, and that's been a long struggle. The original one seemed to work fairly well, and of course, it had its limitation. And then it came out next as a two-volume manual and it was many years in coming out. And it was a little more difficult to handle. And then the next revision was -- kind of fell more into the hands of physicians who were really not equipped by background to -- to deal with the simplified language and that sort of thing. They had had years of training that was based on learning medical jargon. KAREN: Right. WALTER: And now Linda Curda had been working very diligently for a number of years -- years, actually, I guess, on that manual revision which, I think, has a lot of good input from the people who are actually working in the training and from the health aides, and every indication is it's going to be a very successful manual.
KAREN: How did you communicate with those health aides out in the villages? How did that work? They called in with a medical question? WALTER: Yeah. The mechanics of communication in the 1950s were a single sideband radio that was placed in the schoolhouse, and in some cases, in the village store. And this was a two-way broadcast, which could be listened to by anyone who tuned in. And actually, it, in retrospect, was a wonderful training device, because not only did the other health aides learn, but everybody in the village became very familiar with the description and prescribed treatment of all the common conditions. And now that medicine has changed its attitude so tremendously that they recognize the desire to put the patient in charge of their own care and not -- that was quite a proper thing to do in judging by today's standards. KAREN: And so that two-way broadcast radio would work from, like, Bethel to Anchorage? WALTER: No, that would work from the fields to -- from Anchorage to places in the Anchorage service unit only, but it would work from the center to the surrounding villages. Bethel to the Lower Yukon and Kuskokwim, Tanana to the Interior, Kotzebue to the Northwest, et cetera. Then after that, why, of course, the telephones came. And now, we have Telemedicine, which is another whole subject. And another individual who was very active in health aide training was, or is Kari Lundgren, based in Southeast Alaska, Sitka. She was active in health aide training quite a few years ago, and has been one of the pioneers in developing Telemedicine. KAREN: Okay. WALTER: To where -- whereby the individual, the health caregiver in the village, can -- can actually transmit the image of the patient, of the condition such as the skin condition, or the electrocardiogram, et cetera, to the -- to the consultant to issue. KAREN: Now, do you think that's made a difference in the way medical care is given? WALTER: Well, it -- yeah, I think so, but I haven't been out there to see it, but when I look at a clinic like the one that was dedicated in 2001 in Emmonak and see all the facilities they have, it's like a moonscape. I mean, it's -- it's just, you know, light years different from before. And there are different people assigned there, including physician assistants, nurse practitioners, and who are sort of intermarried -- intermediaries between the health aide and the doctor to some extent there, now, I think. And then they have -- they have these capacities to communicate. I can only predict that there is a limit to the doctor's time at the other end to sit and look at these images and whatnot, so the technology, as I would guess, has outrun the time limits of the -- of the people involved. But the capacity is there and it's -- and I'm sure they find very good uses. But I think the telephone probably must be one of the main -- had been one of the main things that followed the radio. KAREN: And how do you feel about the making diagnosis over the phone with information communicated to you verbally or seeing a picture? WALTER: Yeah. KAREN: As a physician, how would you feel about doing that? WALTER: In looking at the health aide program as a whole, I think there are several factors to consider. And maybe I'll just go back a little bit further, and start and say one, of course, is the selection and the fact that they are chosen locally from local people, of course, is very important. That -- another factor is the period of training. I think it's been demonstrated that having relatively brief periods of training that does not break the individual's tie with his or her family in the village, but in repeating these periods, is preferable to single long periods of training away from home. Key to all of this is -- is to realize that the health aide role is a part of a system. It is not an individual, free-standing role. The health aide originally, and I think it still does, acts as the ears, the eyes, and the hands of the physician. They learn because it's just not going to be possible or practical to have the physician on hand in the villages all the time. So somehow or another, that information about the patient needs to get there. Other than bringing the patient in. Which is not practical for everybody and every condition. So that means that the health aide needs to learn to listen to the patient and get a few essential facts that can be related to -- to the MD, needs to look and observe, and that can include using an otoscope to look into the ear, a flashlight to look into the eye, and so on. And it could mean using a stethoscope to look at the lung. Using their hands to -- to move the joints, using their eyes to describe the condition and -- and so on. And then how to report that. It also means that there's a physician who is willing to -- to listen to this and to -- to risk making a diagnosis and prescribing a treatment based on that. KAREN: Right. WALTER: That transfer of information. So what we have here is a system, and the health aide is just -- is one role in it. You need the central physician, and then, of course, you need the -- all this other support. The drugs that are out there. And -- and the facility to work in. The health aides at the beginning, they will all tell you about how they carried their little black bag, and, you know, went into the house with a lot of other kids looking or making noise, and trying to, you know, do their history and physical there. And these funds being available to transfer patients because the doctor says, or the health aide says, this patient needs to be moved into a higher level of care, well, the airplane has to fly and there has to be money to pay for it. So all of that together results in a fairly complicated system that -- in which the health aide is -- is just -- has just one role.
KAREN: Where you talked about how the health aides were selected by their village, but what about the doctors? Were all the doctors required to work with health aides or were you volunteered or chosen or what? WALTER: Well, we're aware that people have come all over the world to look at the health -- the Alaska health aide system. And we realize that as -- that there's a problem, especially in the developing world and in the urban centers, of people getting direct physician care. And some of us believe that if they -- you know, four of the six billion people in the world are going to get very much medical care, the primary part of that's going to be through somebody that's like the barefoot doctor or the health aide. But there's been -- well, the system does exist, and of course, in China, it's been quite successful. And -- and it's been tried in Mexico. There was one who wrote a book about where there is no doctor. But -- and I did some work and involved in projects in Africa, in Tunisia, where we used auxiliary workers in connection with the tuberculosis control. But my observations has been that the physicians in general in the world are not accustomed to interacting with a health aide. The reason it worked in Alaska is sort of fortuitous, I think, because physicians chose to come and work or they were assigned as they entered the PHS, either to -- in lieu of military service a number of years ago, or by choice now, they were -- they found themselves working in a -- again, in a position where the role was quite clearly defined. If you were assigned to Bethel, you -- you -- back in the radio days, you -- you did the radio call, which means that you sat down for an hour or so and you talked on the radio and went by every village, whether they had traffic or not, and interacted. And so the role was there and they fell into it and were willing to do it. And then after they did it awhile and made field trips and became acquainted with the health aides, they learned from experience which ones they could rely on more comfortably than others and -- and you had a physician that was -- was interacting with a health aide because he found himself in that role. I don't know of any medical schools that -- where this is a part of their, you know, formal medical training. So I -- that's why it apparently worked in Alaska. KAREN: Well, yeah, I was wondering, too, as if, you know, not -- as you say, not everybody would have the skill set or the desire to work under those conditions. So were all the doctors required, or it was I fell into this and I like it, I'm going to keep doing this, versus I fell into this, I'm uncomfortable, I'm going to stop? WALTER: No. It was -- it was required. And actually, it would result in their leaving a position, I guess, if -- if it were not fulfilled. I might mention here a little book that Philip Nice wrote and published in -- actually, it was copywrited as recent as 1998. Philip Nice was associate -- was a pathologist professor at -- at the University of New England. He came up to Alaska toward his retirement to volunteer first, and then later worked in Bethel and later than that in the Washington, Alaska, Montana medical school program associated with the University of Washington. But he developed a real interest in the health aides. So he wrote this book entitled the health -- "The Alaska Health Aide Program: A Tradition of Helping Ourselves." I loaned him a good bit of material and worked with him on that. And the book covers the period from the ‘68 to the roughly ‘90, 1968 to 1990. And of course, the time is not -- since then hasn't been covered. There is some good little vignettes in here by the health aides themselves about their role. Now, I have a -- I did a chronology, which I gave to Phil, in about -- the date I have on it here is in 1992, which involves my recollection and a review of the health aide files up until that time, which I will -- would like to share with people. Now, it had been my hope that it would have been published directly in this manual, but Phil had cancer toward the end and was ill and he moved Outside and our -- our contact was -- was not very good. A lot of the little -- some of these things are mentioned in the single column, highlight columns on the left, but it -- it's intermixed with other things there. So I -- I'm going to give Karen Brewster a copy of this chronology of the Community Health Aide Program. Actually, it says, from 1820 to 1991, but it's essentially all from -- from 50 -- from the 1950s to 1990s. Now, there are other people, and there are a number of documents and reports that have come out, like "The Health Aide in Crisis" that was published by the academic review committee, and some -- the CHAP directors a number of years ago that gives an excellent summary. And Linda Curda came to Anchorage -- was at Bethel working in the health aide program, but originally at the hospital, I think, as a midwife, she came to an academic review committee for the first time in 1980 or ‘81 and has been in the middle of the program since and still is. So she probably has the great evidence repository of papers and I think memory of the program in the last 20 years.
KAREN: You had mentioned before that, you know, you had confidence in the local people and their skills, and you believed in them and their abilities to do this type of work and, you know, were out there promoting the creation of the rural health care system. What kind of opposition and support did you get for that position? WALTER: Well, interestingly enough, we -- the health aide program, to my knowledge, never experienced any serious opposition from the organized medical community. There was some feeling of being threatened among the Public Health nurses at the beginning, but this was not widespread. And I'll have -- I want to recognize one person, particularly, the deputy director of the Public Health Service in Alaska, Arlie Bruce, who has retired and moved Outside, was always very supportive, as were most of the Public Health nurses. The Alaska Medical Association were -- never voiced formal opposition. One of the reasons may have been that a number of us worked very closely with the local practitioners, including the -- the more influential ones, the Alaska Native Medical Center in Alaska had a number of consultants that almost all of the major fields from the community who came in weekly and saw patients with us who were always on call to consult and give advice. And for myself, I had lived in Alaska before I went out to medical school, I lived in the village, and I think had some credibility. And I was involved in developing a library, not just for the Public Health doctors, but for all Alaska under grant. And so I think we reacted with the -- with the medical community on a -- on a one-to-one basis by that. There were a number of physicians who were opposed to government medicine on principle, and there were several who were quite vocal in criticizing the -- the -- especially the Alaska Native Health Service under the BIA, and later the Indian Health Service, more -- more on principle of -- political principle of being opposed to government bureaucracy in general. But I will not open too far the question of the dental aides, which currently is in the -- on the radar screen and apparently has -- has received a lot of opposition. Not -- not only from the Alaska Dental Association, but from the national organization of dentists to the use of dental aides. When you look at that, I think one of the -- some of the reasons might be that the things that the health aide would -- were doing were a little bit different in the medical field. They were reporting on the -- the findings, doing a history and physical, which is normally a doctor's work, and actually administering medicines, but never without this connection. They either looked at the manual or they talked to the doctor, and if there was anything very involved, it always -- the doctor was involved specifically in that case. With a dental assistant, if you're going to have somebody out there examining a patient without the benefit of X-ray, with -- and filling a cavity without the benefit of initial X-ray, I don't know whether they would have that capacity as it's designed. And extracting teeth, the dentist isn't there and he's not really involved, so what you have is somebody who is attempting to do the dentist's work, who is, in fact, unlicensed and limited in training. And, you know, it does work in some parts of the world, and it would have limitations, but it -- and it seems to touch a hot button that is not true with the medical practitioners.
WALTER: And I -- and as to the future of the health aides, it's interesting to speculate. Certainly the rule will have to change, especially with these new clinics that are -- that are equipped in an entirely different way, and people who are being stationed there, such as trained nurse practitioners and PAs. And the means of communication, telemedicine and all that. So the health aide's role, undoubtedly, will change. Another aspect is that the whole practice of medicine is -- seems to be undergoing a big change. And a few decades ago, I think it was still common to think of going to the doctor and do as the doctor says. And not question it much. Now we understand, and I think it's being taught in the medical schools, that the patient is primarily the one responsible for their own health. And that the doctor is more of a consultant. And of course, we see that most of the illnesses that people have or the causes that the basic remedy is in their behavior, you know. And it's not in pills. So what they -- what intrigues me is what could the health aide's role be. Because it doesn't seem to be any doubt that if people would change the way they eat and live, there would be a big change. Some of this change is so dramatic. For example, it's, what, now, 40 years ago, 55 -- I mean, 50 years ago in Bethel, ‘55 to ‘05, why, when I was in Bethel, we didn't see any diabetes. Among the Natives. A biochemist, Dr. Scott, came out and looked sedulously for diabetics and could never find them. Now, it's rampant. KAREN: Right. WALTER: Obesity was -- I remember one obese person. And now, of course, it's rampant. And so, you know, how -- how are you going to change people's diet, exercise, and stress management, the factors that would -- of course, could theoretically eliminate the -- all these great problems of obesity, diabetes, hypertension, et cetera. So the other observation is that when -- before the snow machines and before the affluence in the villages, when the people lived on fish and berries and beans and rice and had to exercise a lot to cut their own wood, get their fish, they were lean and, in many ways, very healthy, you know, bar tuberculosis and et cetera, but -- and free of these big problems of diabetes, obesity, hypertension, et cetera. The big culprit back then, of course, was sugar. KAREN: Right. WALTER: And their teeth went bad early. And is still a big problem. But if a village were to suddenly -- and some are trying to return to the situation where their diet and exercise was -- and stress management, attitude was good, why, hopefully they would be -- would be healthy. But -- and if the health aide could perform that miracle, why, I think they would again be an example to both the developed and the developing world.
KAREN: What about the management of the health aide program? Now it's managed, health aides are under the jurisdiction of their regional health corporations, like Norton Sound Health Corporation, Kodiak Area Native Association, how is that different from the Public Health Service running it when you were involved? WALTER: Well, again, I was able to observe this through most of the changes. I came up as a civil service employee to the Alaska Native Health Service BIA, and worked for the first year at Bethel in that role. When the Public Health Service took over in July of 1955, I applied and entered the commission corps, I guess probably the only person ever to enter the corps as a regular in Alaska. This required a oral examination by three commissioned officers. There being only two regular corps doctors in Alaska, they brought in a veterinarian as the third one. So I spent my career as a commissioned officer, and then I was with the university later. But for the administration, the -- the Indian Health Service was, I think, or tried to be quite cooperative in moving control to the Native groups. Dr. Emery Johnson, who was the director of the Indian Health Service in Washington for many years, had a strong commitment to this. But even so, control is never easy to let go, of course. And so there were struggles, and especially in places like Southeast where the Natives are exceptionally well organized, and this, sort of. There were struggles to gain more complete Native control, which we have now, and it was interesting to observe how this, you know, might affect the service. My observation has it's been eminently successful. Now, as a retired officer, I am a beneficiary rather than a provider. And since I've switched over mostly to alternative medicine and raised my garden and I actually make my own soil and compost it and make sure the plants are healthy and live on fish and vegetables here. But -- and keep exercising. But anyway, I go in and get a physical or make contact with the current medical service for my medical needs, and I -- I'm very favorably impressed with the efficiency and courtesy of the operation. Of course, with the new hospital and much improved funding and facilities, the speed with which the health records move and the short time that it takes to get an appointment and overall is very impressive. But I see only the primary care. I haven't experienced the heavier inpatient care, but I assume that that's working well. KAREN: And here in Homer, you have a hospital with physicians and nurses who are here all the time, correct? Where you were relying on health aides. WALTER: Well, that's entirely private. And I have never been to use their facilities. And to try to walk the talk, I go to the Seldovia Tribal Council Clinic, which is here. KAREN: Oh. WALTER: For some little things. KAREN: So you do use the health -- the health aide system. WALTER: There I see a nurse practitioner. But mostly I go to the primary care center in Anchorage because I'm up there a part of the time, especially in the winter. And there I -- I see the doctor that's -- whose area that I live in. And that happens to be Dr. Edwards whose father was -- was in the PHS at one time, I think. And now that I'm recently married, my wife, fortunately, is eligible and so she can go there for her care.