bush medicine

It’s a Saturday night and I find myself setting up my sleeping bag on the floor of a building in the Western Alaskan hub city of Bethel.  My infant son sleeps fitfully on the other side of the room.  We flew to Bethel to go to the emergency room at the hospital, the only hospital for hundreds of miles, and we are waiting until 5 or 6 am to go to the E.R.  Every so often we have these experiences that are so outside of the “norm” that I grew up with that I want to tell the story to let people get a glimpse of life in the bush.

Two weeks ago, we couldn’t use our usual babysitter because her son wasn’t feeling well, had a fever, and ended up being diagnosed with an ear infection.  On Friday of that week we were looking for a sitter and I called them up and they said he was better, he was fine.  I dropped our kids off and then flew off to Napaskiak with the boys for some high school basketball (I’m coaching this year).  On Monday I had to get to Atmautluak to test a student before their IEP became due.  I took them to the same sitter.  I returned home around 5 pm and my wife told me we had to pick up our kids ASAP because the sitter had called to report that our son had a fever.

I went and picked the kids up, and he didn’t look good and was fussy.  We got home and I checked his temp and it was normal.  A couple of hours later and it had climbed to 100 or 101, and we gave him some ibuprofen.  This brought it back down, but after 4 or 5 hours the fever and fussiness would return, and generally speaking each was worse than the one before.  On Wednesday morning I was planning on calling the clinic and getting him an appointment.  But when he woke up, he had no fever.  Hooray!  I thought his fever had broken.  No.  By lunch time he had a fever that was 102 or 103.  It was too late to call the clinic.  You cannot get an appointment unless you call in the morning, and they stop seeing patients in the early afternoon.

So I called at 9:00 on Thursday morning and got an appointment for 11:00 am.  I called Tammy and she said she would go with me to the clinic since I can’t drive (snowmachine or the school truck) and hold the baby at the same time.  I called our other babysitter and she agreed to take our daughter while we took our son to the clinic.  Tammy had to wait for her sub and then explain to him what she wanted done with her classes, so that when she arrived we were running late.  She hadn’t had time to have breakfast or lunch yet.  We piled all four of us onto my Polaris 550 with the sticker that reads “Not intended for use by more than two people at any time,” and drove to the babysitter’s and our count went down to three.  From there to the clinic, driving slowly because of the precious cargo, the new pistons in my snowgo (another story), and the difficulty seeing the dips and bumps and gulleys along the way.  Tammy was on a snowgo that turned over a few years ago and she has some (justifiable) fear of this happening to her while holding the baby.

A mile and a half later and we were safely ensconced within Kasigluk’s large new clinic.  We saw a health aide who gave the baby a thorough inspection.  The health aides use the “Community Health Aide Manual,” aka the “health aide bible,” to help guide their physical inspection and patient interview.  After checking temp, oxygen, ears, nose, throat, heart, lungs, etc, the health aide felt that maybe we should take Bobo in to Bethel to see a doctor.  Very quickly if you don’t know already, the community health aide is not a doctor, physician’s assistant, nurse practitioner, nor a nurse.  They are trained in some basic medical knowledge and trained to gather the data and then fax (yes I think they are still FAXing) the information to the YKHC (Yukon Kuskokwim Health Corp) hospital in Bethel, where a doctor or nurse practitioner or physician’s assistant will read the report and then respond with the course of treatment.  The clinics are stocked with the most common prescriptions.  If you want to know a lot more about the community clinics, the health aides, the physician’s assistants and others in Bethel who work with the village clinics to prescribe meds and medivac serious cases, you can check out the now defunct Tundra Medicine Dreams blog.  Lots of good writing from a P.A. who used to be on the Bethel end of the service delivery model.  The village clinics, as well as the YKHC hospital, are all a part of the vast Indian Health Service, providing free health care to nearly all of my neighbors.  YKHC serves as the primary hospital for something like 56 villages.

Back to the story.  They were concerned about Bobo’s chest and lungs, based on what they could hear in his breathing, and felt he should go to Bethel, and the doctor in Bethel agreed.  However, it was too late to get an appointment for that day.  Our options were to go and sit in the E.R., or wait to the next day and call at 8:00 AM sharp and get a same-day appointment.  The last time we tried to do this I called over and over and only got busy signals or voicemail until 8:45, at which time someone answered and said the same-day appointments were all taken.  On that occasion, Tammy then flew in with our daughter and sat in the E.R. from roughly 10 am until 4:30 pm without seeing anyone and then she gave up and caught the last plane back to Kasigluk.  Our girl got better on her own, and Tammy figured that sitting in the crowded E.R. full of very sick people was not going to help things improve. We weren’t sure what to do.  One of the health aides advised us that the E.R. gets very crowded in the evening but if you go before 5:00 or so you can usually get seen right away.  They also mentioned that a plane was coming in the next couple of minutes, and we should try and get a seat as the next plane wouldn’t come for several hours.  We had no change of clothes, not for ourselves nor for the baby.  We had 1 extra diaper.  We decided to go for it.  We wanted to do what was best for our boy.  Less than five minutes later, Tammy and Bobo got the last seat on the 6-seat Yute Air 207 for the 15 minute flight to Bethel ($88 each way!).

Upon arrival in Mamterillermun (Bethel in Yup’ik), they headed via taxi ($8) to the E.R.  She got there around 2:00 pm and it was crowded.  She saw the triage nurse who told her it would be a long wait to see a doctor, even by their standards.  But the wait for the chest x-ray would not take more than a couple of hours.  Also, she was able to schedule an appointment for a doctor the next day, so she decided to wait in the E.R. for the x-ray, then take a taxi ($8) and check in to a hotel ($170).  Tammy is not the last of the big spenders, but with airfare, hotel, taxis, 4 meals from restaurants, clothing and diapers from the store, our 40% share of the medical bills (YKHC is not a “preferred provider” with our school district health insurance despite being almost the only option for hundreds of miles, go figure)…the whole trip cost upwards of $700.  Bethel and the bush in general can be very expensive.  Small demand, but teeny tiny supply.  She also had to order food (first she’d eaten all day, around dinner time) for her and the baby, she went to a store with the baby (cab ride) and bought him a change of clothes, diapers, etc, and even bought some hand-made booties made by a woman from our village because in our haste we had taken him to the clinic in a snowsuit and pajamas but no shoes.

After a rough night during which his temp climbed as high as 104, they took a taxi to the 10:40 appointment at YKHC on Friday morning.  He was given amoxicillin for otitis media (bad ear infection) and the x-rays were examined and they were negative, no problems.  So just a flu and ear infection combination.  They headed to the airport after getting meds from the YKHC pharmacy around 12:30.  OH, and by the way while at the hospital Tammy saw people who had been in the E.R. when she arrived the day before at 2:00, they got there before her.  She asked when they were seen by a doctor, and they told her 4:00 AM!  So it would have likely been more than a 14 hour wait in the E.R. had they stayed, with almost no sleep surrounded by lots of very sick people.  I think they made the right call about getting a next day appointment and going to a hotel! At the airport they found out noone was flying due to fog and snow that kept going up and down.  To cut this part of the story mercifully shorter, they waited all day and did eventually make it home around 7:00 pm.  Yute Air told me around 4:30 that she was on the plane and on the way, so I headed over to get her using the school truck, and with Claire.  By 6:00 Claire was cold (truck has no heat) and my hands were getting seriously cold too.  These sorts of miscommunications are commonplace with the small Bethel airlines, more the rule than the exception.  I took Claire home, and found a message on the machine that she had left Bethel already, so I raced back to the airport and waited another half hour or so and then they came in (she was delayed because the plane went to another village before it reached KUK).  Hooray!!  We drove home, and though Bobo was still noticeably fussy and tired, he seemed much better already, not needing to be held every second.

This was not the happy ending we thought it was.  On Saturday morning, after giving the baby his 2nd dosage of amox, Tammy noticed his back was all splotchy.  She remembered the pharmacist telling her that if he had a rash, to stop the meds immediately because it indicates an allergic reaction that would start as an isolated rash, then move to a rash all over, then move to difficulty breathing if he stayed on the meds.  I was coaching basketball at the school and not reachable.  She called the on-call health aide (the clinic is closed on weekends but they have a clinic cell phone that is answered 24/7 for emergencies), but was told that they couldn’t see him unless it was an emergency, but we could bring him in on Tuesday (Monday is a holiday and they are closed).  He has been sick since Monday, today is a Saturday, we didn’t want to wait another 3 full days to get him on the right antibiotics.  We called the YKHC E.R. and asked how the wait was, they said it was terrible, and when told why we might bring the baby in the person said the health aide should take care of it for us.  I went and spoke with the health aide, a family friend.  She was sympathetic and nice, but it sounds like she isn’t really allowed to intervene after hours except for real emergencies.  I explained that I’m concerned about the ear drum rupturing, and the high fevers returning, and he has been sick long enough, he hasn’t been eating hardly any solids for several days, etc.  She said that sometimes they will drain (through a perforated eardrum) even after getting on antibiotics, and said “If it drains then it’s meant to drain.” She wasn’t very concerned.  I don’t say all of this as a criticism.  The health aides do a really good job.  They have saved our bacon more than once, even once when Tammy broke her leg and they helped get her on a plane in a snowstorm.  But the healthcare is not what you can get in most of America after a short car ride.  You may have to wait until Tuesday.  Or you may have to pay to get on a plane, and then a cab.  And then wait a long, long time.  I think the Indian Health Service gets away with it because (1) hey, it’s “free” healthcare (in exchange for natives giving up land claims and other claims against the State) and (2) Yup’iks don’t complain.  It is not a Yup’ik value to complain, or be verbally assertive, aggressive, or pushy, or to call their congressman.  Things simply are accepted that would be “unacceptable” in suburban, white America.  And that gets taken advantage of sometimes by the kassaq institutions out here.

These sorts of interactions between cultures can be pretty fascinating, and its the kind of interesting interplay you can get a lot of on the aforementioned old Tundra Medicine Dreams blog.  My neighbors accept suffering with a lot of patience and stoicism.  Some outsiders might even say fatalism.  As a speech-language pathologist (SLP) I deal with kids with speech (articulation) and language delays all the time.  And I know that kids with recurrent otitis media and perforated eardrums are far, far more at risk for delays, and even behavior problems, than kids with healthy ears.  I also know from my dealings with audiologists in this region, that they all say that they’ve never, ever seen ear problems like we have out here, in terms of severity but mostly in terms of rates of incidence.  It is very common for kids here to go to ANMC in Anchorage for ear surgery to repair perforated eardrums.  When I say very common, I don’t have a percentage, but maybe 10% of all kids?  Maybe more?  These are kids who have grown enough to have the surgery.  You can’t have it as a  young child because your eardrum is still growing and the repair may not work.  So they live several or many years with the hole before it is patched, meaning they go through a lot of developmental years without proper hearing.  So needless to say, this is one cheechako/kassaq/dad who does not believe that my kid’s ears are meant to drain.  Us kassaqs are arrogant enough to think we can control such things.

I flew in to Bethel with Bobo on the last plane before the ceiling (poor visibility) came down on Saturday, just an hour or two after the visiting basketball teams had flown home.  Our friend Deanna drove us over on our snowmachine because the truck wouldn’t start (it is below zero today and it’s not plugged in) and Tammy (a) doesn’t know how to drive the snowgo and (b) needed to watch Claire.  We actually strongly considered flying on to Anchorage, because it is possible to get a mileage ticket that will fly us from kasigluk to Bethel to Anchorage, and it costs no money and only 15,000 miles.  Remember that Tammy just spent several hundred dollars on Thursday and Friday.  It can actually be a lot cheaper for us to get on a jet and fly 400 miles to Anchorage where we have our own car, friends to stay with, and medical that is covered at 90%.  Crazy.  But the ERA flights from BET-ANC were done for the day, and I didn’t want to spend 3 hours in the terminal waiting for the 8:30 Alaska Air jet with Bobo so I decided to stay elsewhere in Bethel, after calling the E.R. and being told they were “slammed.”  The guy said it has been that way for 2 weeks since the flu has been going around. I figured its better to get a good night’s sleep and go in at 5 or 6 am in hopes that we don’t have to endure the 14+ hour long wait.  Hopefully we can make it home by the Sunday evening flight, with antibiotics in hand that fix my son’s ears but don’t give him an allergic reaction.  I am sure he is even more tired of this whole process than his parents!

Living and teaching where we do is such a unique experience in almost every way from the “norms” of our majority culture.  And there are tons of things we love about village life.  Other aspects are difficult.  It’s different out here, for better and for worse.  I need to remember that we are richly blessed to be able to hop on planes and get the help we need.  It was not at all this way in Kasigluk when I was Bobo’s age.

first day of school

Our school appears to have a great staff this year!  They are all working hard and seem like they truly enjoy kids.  Noone just marking time until retirement.  Our principal will retire after this year, but he isn’t like that and is finishing strongly.   We are very lucky to have such a principal who really loves the kids, who fights for them, cries at graduation, etc.  When we travel to other schools for sports, sometimes we realize how great we have it.  (And no I’m not brown-nosing — nobody on the school staff reads this blog)

Anyway, yesterday was the first day of school, and there was a great energy to the day.  The young ones always try to come hours early, they’re so excited.  One little guy came home from a half-day of school and went right to bed (kids are still on summer schedule, staying up until 2 am or later and struggling to get up for breakfast at school at 8:15).  When he awoke, his mom said he got dressed for school and was ready to go, but it was only 4:00 in the afternoon or so!  After school was a staff meeting and cross country practice and then we had a 2-hour open gym in the evening.  Some kids just hang out at school from about 8 am to 9 pm!  Our staff consists of 1 student teacher, 1 first year teacher, 1 second year teacher, 1 third year teacher, 1 6th year teacher (Tammy), 1 veteran (maybe 20 years?) certified teacher, 2 veteran classified teachers (teaching in Yup’ik), and Carl, our longtime principal.

I think it’s going to be a good year at Akiuk Memorial School, for learning and having fun.

polystyrene (styrofoam) trays

So here is a random topic I’ve chewed on for a few years (no pun intended) and was just reminded of by a colleague. Our school district, like New York City public schools, uses styrofoam (well technically it’s called polystyrene) trays to serve breakfast and lunch to all students everyday. Keep in mind that our village dump is actually just a spot on the tundra half a mile from the village on the edge of a lake and everything is burned from time to time. So we’re paying for these trays, which appear to cost between $35 and $70 per case of 500.

Now keep in mind the shipping will greatly increase that cost. The district might be paying as little as $55 per case if they’re getting a good deal. Then there is the cost of driving over to the post office and picking them up (1.5 miles each way by boat or snowmachine, and school employees do this on the clock), and then 3 full trash bags that they fill (per meal), and then the cost of hauling those full trash bags by the handcart load out of the school, down the boardwalk to the school dock to the school boat and to the dump (.5 miles each way and again on the clock). This doesn’t take into account the environmental cost, nor the supreme irony of everyone in the lower 48 getting bent out of shape over global warming that is mostly only affecting people in the remote north, while we in the remote north burn our styrofoam to save a little $. Penny wise, pound foolish, I suspect. But this is what I wanted to examine, to find out.

So I thinking we’re paying at least 11 cents per tray just to get them to the post office. Then the gas (at $6 or more per gallon) to haul them everywhere and the salary of those doing the hauling, plus using up the big trash bags when they’re done. I think I can quite safely say 13 cents per tray. So we have about 65 kids and some staff and community members who eat at school every meal, so lets say 80 trays per meal. 80 trays * $.13 = $10.40. Meanwhile, we live in an area (see Wade-Hampton Census area and Bethel Census area) with outrageous unemployment over 25%, where you have no difficulty finding someone who would be willing to wash 80 reusable trays in an hour for around $8 in pay.  And if our district is paying a higher price than they should for the trays, and if I’m underestimating the other incidental costs, maybe it’s as much as 18 cents a tray, which would come to $14.40 per meal, about enough to pay for TWO hours of dish duty.  So…wouldn’t it be cheaper to go with the environmentally friendly, reusable lunch tray? I know this is a simplistic analysis, but surely I’m in the ballpark.  Correct me where I’m wrong.

warm bodies

I get copies of messages posted on the Alaska Teacher Placement forum.  It is THE site for those interested in teaching here, and you can visit them here.  The forum is where people ask questions in pursuit of better understanding of what they’d be getting themselves into.  Anyway, today I got a copy of a post with the subject “Getting to Kwethluk.”  Here is the message:  ***UPDATE - This thread has been generating a lot of traffic and I don’t want this new hire feeling singled out or ashamed.  I’ve changed the places they’re coming from and going to, and I removed the exact age of their child.***

is there any way to drive from the lower 48 (Phoenix) up the can-am (or whatever it is called) highway to Bethel-then put my vehicle on a boat to the village (Kwethluk) so we’d have a vehicle?(4wheel dr)?? Considering I’m coming with a middle schooler, 2 dogs, a cat, LOTS of books (heavy to ship $$$) #’s of boxes I thought it might be less hassle and possibly cheaper.

My intention here is not at all to mock or demean this person.  I just feel for them.  Not knowing if you can drive to Bethel or not?  It sounds like she already has a job and has signed a contract but doesn’t know the most basic information about this part of the world.  As a single teacher your first year in the village is stressful and very hard work in the midst of major culture shock and transition.  Having 1 pet is hard, because you don’t have the time to give them what they need.  Having 3 is going to be tough.  Can you imagine the three animals rattling around inside a little apartment for 6 months of winter?  Now the son/daughter might help give the animals attention, but giving them the time they need will be tough too, and he/she will probably need more than ever due to the culture shock.

Its just hard that we’re so desperate for teachers that we bring in lots of well-meaning, nice people and throw them in completely over their heads and then we bemoan our teacher turnover rate.  I’m not trying to single out any particular school district or that person or anything, this is par for the course.  I believe the average stay for teachers in LKSD, my district, is right around 2 years.  Someone correct me if I’m wrong. 

I think this might be the most devastating hardship that our village schools deal with.  New teachers usually arrive in the village less than a week before class starts.  They’re trying to unpack and find which box has the spaghetti so they can eat, and set up their room, and how do I get to the post office so I can find my boxes, and they’re often just learning what classes they’re going to be teaching in 3 days!  They’re tripping over the cultural differences all around them and making all kinds of questionable assumptions about their neighbors based on misunderstandings.  They’re intimidated about teaching (which is totally normal), sleep-deprived, and stressed out.  And often they have to figure out a curriculum that might be totally unique and nothing like they prepared for in school, like LKSD’s phase system.  If you ask many veteran teachers, they’ll tell you that the first year they did a pretty lame job teaching a lot of the material.  Not because they were lazy or at fault in any way, they were just new and totally overwhelmed and learning as they went.  Someone told us that your first year teaching in the bush is like getting run over by a train.  And the next year you see the train coming but can’t get out of the way in time, and the third year you MIGHT get out of the way barely, and then each year keeps improving.  This is only our 5th year, but its totally true in our experience.  When we have a first year teacher who leaves after 1 year, the next year we’ll often discover they spent the first semester treading water for the most part and the kids are way behind or there is little documentation of progress as there should be.

We sell the experience to college seniors as “adventure,” which it certainly is, and they want to believe “high pay,” which it mostly isn’t when you consider the cost of living & travel.  But don’t we owe our kids better than an “adventure” when it comes to knowing what kind of education they’ll get?  I think the thing we need to stress to prospective teachers is how very different the local culture is here.  This is less true in hub villages like Bethel, Nome, Barrow, etc.  But new teachers think the weather will be hard.  Or not being able to ever have a drink, or go shopping or to a movie, that will be tough.  Those things are pretty trivial compared to the culture shock most teachers find themselves in.   “Why won’t anyone answer me when I ask a question?  What did I do to them??  Even the native staff won’t look at me or answer my questions!  Or I don’t hear them and say “What?” and they don’t answer!”  Or “Why don’t people get plumbing in their homes?  What is wrong with them?  How can they be so lazy/nasty?”  “My only toilet is an incinerator toilet!?!” “My student has a BOIL on his arm – don’t these people take showers?!?”  “Why are these kids always harassing me wanting to VISIT at 11 pm??”

I know I move onto controversial ground, thin ice, when talking about culture.  Every culture has its strengths and weaknesses.  Alaska is made up of many different cultures and I’m not going to be so foolish as to try and list my take on all of them here.  But teachers should expect something similar to moving to the third world to teach.  They might not have running water, they might not understand their neighbors (language or behavior!), they might be forced to live in what they consider lousy housing and possibly with a roommate(s).  They might believe they’re being judged by people and they don’t even know why or what they did to offend anyone.  The huge cultural transition is a complex thing, not to be taken lightly.  But how do you educate someone about this at a job fair in a fancy hotel?  I think for the most part its not talked about that much.  If they had these expectations, the only surprise they might get is a pleasant one.

I realize that I’m throwing lots of stones so far and not providing any answers.  I don’t know.  There is no easy answer or don’t you think we’d have implemented it long ago?

I think its great if people can visit prospective villages before signing contracts.  Yes, expensive.  Maybe the district could agree to reimburse them for half of the cost only 3 months after they start teaching, so if they visit then say no thanks they get no reimbursement.  They could sleep on the floor of the school–the point is not a half-price vacation for 22 year olds.  Of course this would still be a cost for the districts, but I believe it would cut back on 1 year teachers (and especially the rare teacher who shows up, sees the village, and immediately leaves, which does happen occasionally).  Maybe they could get half of it reimbursed after their first year teaching, and the other half after their 3rd year or something.

In addition, I think teachers should be encouraged to live in the village in the SUMMER with reduced rent during those months.  Something really small just to cover utilities like $300/month.  My district is  penny-wise and pound-foolish in this regard, charging full rent for June & July if you stay (and even a “storage fee” for your stuff if you leave it).  We spent our first 3 summers here, and it would be every summer except I’ve been required to do summer internships in Anchorage for my master’s degree.  We think its the best time to be here.  Totally relaxing, beautiful, warm.  You sleep in and read and get your classroom and planning ready at a nice pace, while your neighbors work feverishly all summer fishing & hunting & berry picking, stocking up for the year.  We go with them sometimes and have a blast.  Anyway, by charging full rent, teachers are out of here to see friends and family.  Maybe if they could stay for cheap, some would leave to see friends and family but then return for the bulk of the summer.  They could form relationships with the village outside of their role as a school authority figure, play with the kids, go to feasts, go berry-picking and fishing with people, etc.  Totally different from the school year, and an experience that would help them understand the village better, and help the village understand THEM better, and ultimately that can only lead to more positive results.  Hardly any teachers stay at this point, so I don’t think this would reduce district revenue much, if at all.  Relationships are key to people being happy and staying, but new teachers have no energy or time to form those relationships during their first year or two.  So let’s be creative and make it easier to be there in summer!

My only other ideas are problematic.  A big bonus after every 5 years with the district?  I don’t like that it would be an incentive for bad teachers to stay (which reminds me of another soapbox of mine, I wish it were easier to get rid of the really bad teachers/principals, who are rare but they do exist and most people onsite know who they are).  Or some kind of merit pay or reward system?  I know the Chugach School District does this, or at least they used to.  Its based on a combination of factors like academic performance of students, parent/student questionnaires, etc.  The union would blow its stack at these ideas, but its a way to pay the best teachers a bonus and hopefully help them to stay.  Like I said, these ideas are problematic.  If you have an idea to add, put it in the comments!