Halloween Grand Rounds

A fiendishly clever and totally delightful edition of Grand Rounds is up at the aesthetically tasteful blog of Dr. Michael Hebert, Dr. Hebert's Medical Gumbo. Dr. Hebert is a Cajun physician, formerly a resident of New Orleans, displaced since Hurricane Katrina to a community in Mississippi. He is an excellent writer and crafts his posts elegantly; I encourage TMD readers to spend some time browsing through his archives. You won't be disappointed.

What he has created for our Halloween delight is an entire Grand Rounds in the format of Edgar Allen Poe's poem The Raven. It is amusing and clever and quite impressive, all at the same time. Well done, Dr. H!

You can find his pre-Rounds interview with Dr. Nick Genes on Medscape by clicking here.

Happy Qaariitaaryik!

Long before the missionaries came to Alaska bringing Christianity to the Native peoples, the Yupik Eskimos had a festival which they celebrated every autumn in late October. It was called Qaariitaaryik (ka-GEE-da-gik). In modern times the word has come to mean “October,” as well as “Halloween.” One of my favorite patients, a delightful elder who lives here in Bethel, came in to see me this morning for a blood pressure check and to get her medications renewed, and I was able to get her talking about Qaariitaaryik and how the festival was celebrated in the old days.

She said the festival was about honoring the spirits of ancestors and those who had passed on. First the young people of the village would go to the qasegiq (council house) and two of the old men would take charcoal and ashes and decorate their faces with designs. The old men would laugh a lot while they did this. The young people loved seeing each other’s faces with the designs on them.

Then the young people would go from house to house in the village. Some adults would go too. The rule was that you had to be silent going from house to house, to honor the spirits. If you made noise the spirits would be mad and would pull you down under the earth. In front of each house the young people would jump in the air and say “Umm-pah!” three times. Those who lived in the house would let them in and they would all sit down in the main room facing the elder of the house. Each person carried a bowl to hold food. Each young person would be given a small amount of food. There was no candy back then. They would be given some frozen fish or agutuk (a mixture of fat, sugar, berries and whitefish known as “Eskimo ice cream,” a highly prized treat). Each person would throw a little piece of food over their shoulder, for the spirits. They said they could hear the spirits chomping and smacking their lips over these morsels. Then they would eat the food in their bowls and go on to the next house.

After every house had been visited, the young people would go home, very full. Children rarely experienced full stomachs in those times. They were told not to clean their faces of the charcoal designs. The spirits would come in the night and clean their faces for them. Some children would try to stay awake all night, only pretending to be asleep, so they could see the spirits come and clean their faces. But they never did. They woke up in the morning with clean faces and knew the spirits had come.

Happy Qaariitaaryik!

Yupik Eskimo Ghost Stories

In the ancient pagan and nature-based polytheistic spiritual traditions, the important festivals were celebrated on days that were significant in the natural order of life: summer solstice (the longest day), winter solstice (the shortest day), and spring and autumn equinox, when the days and nights were of equal length. The half-way points between these festivals were celebrated as minor festivals, and Halloween is one of these: the half-way point between the autumn equinox and the winter solstice. In many traditions around the world and throughout history, this has been the festival associated with death; a time to honor one’s ancestors, a time when the veil between the living and the dead, between this life and the afterlife, is said to be the thinnest. A time when spirit-tales and ghost stories are right at home.

In southwest Alaska, October is the month of heading-into-winter. Most years, the huge Kuskokwim River is frozen solid by Halloween (this year being an exception). The hours of daylight have dwindled significantly; we are down to about seven hours a day now. As the long dark nights begin, the oral traditions of the Yupik Eskimos are handed down in stories told around the crackling warmth of the wood stove.

In my search for information about Yupik ghost stories, my friend Joan loaned me some materials she had from a class on Yupik culture that she took back in the early 1990s. I was immediately drawn to a yellowed, spiral-bound booklet entitled Kaliikaq Yugnek (loosely translated: written stories of the Yupik people). It is a sort of magazine (Volume 2, Number 1) published by the students and teachers of Bethel Regional High School in the fall and winter of 1975. The booklet consists of stories and legends told by village elders, and recorded and translated by the students.

I would like to share two of the stories with you. I searched for anyone from whom I might obtain permission to reprint, but as this was over thirty years ago, the editors are long gone. Given the age of the document, I hope that full attribution of the source is adequate. I have done some minor editing for clarity and correction of typographical errors.

The first story is called “Ghosts and Rules” and was told by Bethel elder Lucy Beaver. As an aside here, I actually met Lucy Beaver when I first came to Bethel in 1998. She was a well-respected skin sewer (a maker of fur and leather garments) for much of her life. I went to her home and she showed me a suitcase full of fur hats, mukluks (knee-high boots), and dolls that she had made. I bought a beautiful hat and pair of mukluks from her.

She became somewhat famous in Alaska in the mid 1980s as the subject of a well-known photograph by Myron Rosenberg (photo at right).


PHOTO COPYRIGHT MYRON ROSENBERG, USED WITH HIS PERMISSION.



She was 69 years old when that photo was taken, holding her great grandson. The second photo of her is one that I took in her home that day; she was 83. She still lives in Bethel and is now 91 years old, in frail health but good spirits, and still with that infectious smile.

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Ghosts and Rules

by Lucy Beaver, translated by Janet Kasayuli

My name is Lucy Beaver and I’m 61 years old. I am from Nunapitchuk and now live here in Bethel, it’s not too long that I have lived here. I am going to tell you what I know about what us young people were scared about. When we were young, they told us to never walk around at night and they let us go to bed early. [Ed. note: in village English, “let” does not mean “to allow”, it means “to compel, to require, to force.” Lucy means that they made her go to bed early.] They always let us go to bed early because if somebody walks around at night he will see a disembodied spirit or images of ghosts in front of the door. When they told us this it would make us scared so we never wanted to walk around at night. We were scared because something might happen to us. We used to believe what [the elders] told us without mistrusting them. In those times when I asked my mom what that spirit or image of a ghost was, she would say when a person walks around at night too much he would see a person standing [coming up] out of the ground. And if he sees this, there is a rule that even though he is very scared he should go over to the ghost and find his collar and try to touch his skin. That was the rule, even though he was very scared. When he touched the ghost’s skin, his hand would get cold immediately and [the ghost] could not be held for a long time because it was very cold. After that happens, you should try and touch the head of [the ghost] with your hands, then slowly push down with all your might. That way [the ghost] goes down, then all of a sudden the land turns as the thing is pressed down. As it is pressed down it comes up a little, but yet goes down as it is pushed, and then the world turns even though it is very cold in the winter. As it turns, use your hands and rub the [ghost’s] head, never look at it until it really stops the earth completely. What was that thing out of the ground? It was an image of a man who had been dead. That’s how they used to tell us to believe when we were young.

[A man who experienced this] took care of the image [of the ghost] then goes in the house and right after he goes into the house he gets very sick and starts throwing up lots of green stuff that was very bad. That’s what happens to every person that had the same experience.

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The second story is told by someone from a different village, but conveys similar beliefs about what to do when you see a ghost.

Seeing a Ghost

by Minnie Carter, translated by Annie Carter

Once upon a time there was a white man who traveled from Quinhagak to Bethel by dogsled with an Eskimo man from Eek. The weather was really cold. The time was after Christmas. They came to the abandoned fish camp at Enhiak. They brought their food and stuff into a house and found out that they had no kettle. The white man couldn’t have tea in this cold weather. They were camped near a grave yard. The white man said that he had seen kettles and pots by the graves. The Eskimo just wanted to make a campfire and have something to eat. The white man really couldn’t wait to have tea, but the Eskimo told him not to get a kettle from the graves. But the white man went up to the graves and picked up a kettle to make tea. The kettles and pots had small bird eggs in them. He dumped the junk out of the kettle and as he was coming back to the camp he bent down and put snow in the kettle and went into the house and put it on the fire. The kettle started to boil.

The white man made tea. The Eskimo didn’t want any tea. After tea, when the Eskimo had eaten and the white man had had his tea, they got warm. They put wood on the camp fire. They got sleepy. When the days got shorter they started getting ready for bed early. Just when they were getting ready for bed they heard something which seemed to crack. It cracked harder at the door. They wondered what it was. The door was shaking and it seemed as though fog was coming around the door. The white man asked, “What is it?” And the Eskimo said the ghost was coming in. The fog went whirling up toward the ceiling. The white man didn’t believe there could be a ghost coming. On the floor, the grasses (grass mats used as floor coverings) stood up, even though the white man and the Eskimo stood on them, pinning them to the ground. The grasses stood straight up on the floor. The door had not opened when the ghost came in; it came in at the bottom of the door. The ghost came in all white, his face was covered with something like leather, like muskrat on an old parka. The ghost came in all the way. The white man got scared and started running in the house. He was crying in the house, running around trying to get out, but the door could not be opened. The white man went over beside the Eskimo, and the Eskimo tried to think of what to do. The ghost was coming and the Eskimo stood up very fast. While this was going on they were afraid that the ghost might kill them by whirling them like a bome [ed. note: ? ... no idea]. Then the Eskimo went right over to the ghost as he used to hear was the right thing to do with ghosts and put his hand on the ghost’s neck and it felt very cold, it was like the ashes from a burned wood fire, and as he had heard about ghosts, he put his hand on the ghost’s head. Then the ghost started going down under the ground, disappearing. When the Eskimo thought he’d try to push it harder, the ghost came back up a little. The ghost disappeared into the ground and the ground where the ghost disappeared was whirling. The Eskimo remembered that he used to hear stories about what to do about ghosts so he used his mukluks to step on the whirling ground and it stopped whirling. The grass mats on the ground that had stood up fell to the ground and the white man took the grasses and threw them outside very fast.

They started getting ready to go. They packed their bags. They packed their sleds and didn’t put out the campfire. They left the dogs ready to go when they went in the house. They didn’t want to waste time getting the dogsled ready.

They traveled not too far from where the graves were. Then the white man patted the Eskimo on the back and told him to look behind. It looked like a sun, a really red ball was following them. The Eskimo took out his knife and put marks on the snow crossways. They continued traveling. The red fire ball got to those marks and started sinking into the ground.

They started to get sick before they got to the village of Eek. Where the trash was, the Eskimo man told the white man that they would have to roll in the trash after they had seen a ghost. They rolled for a while. Then they got really sick. They went to the preacher’s house and left the dogs by the trash. In the house the preacher realized why they came and made some tea for them. They got really sick and started vomiting.

They were well the next day. They left and got to Napakiak safely. They were still scared and were really looking out for ghosts. Even though it was in the day time, they were scared.

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This little booklet is a treasure trove of Yupik culture, and I am delighted to have come across it. Many thanks to Joan for sharing it with me. And a happy Halloween to one and all! May the spirits of your ancestors be pleased with you...

A Response to California Medicine Man

Last night I was reading through the many excellent posts included in this week’s Grand Rounds (yes! It’s up at Health Care Law Blog). I clicked on a blog I had not visited before called California Medicine Man, written by Dr. John Ford, a physician in southern California who is on the faculty of the UCLA Medical School. I was stunned and amazed to see his post “Regarding Tundra Medicine Dreams”:

I have read extensively from the blog of this southwest Alaskan-based physician assistant. She is a incredibly authentic writer and has an amazing story to tell. Her descriptions of "tundra medicine" and her beautiful, evocative photographs are captivating.

Click on the link and read his entire post; he says even more nice things about my work. I read through his post several times, with my vision becoming blurred by the accumulating moisture. I was so deeply touched I was speechless. I wanted to respond and tell him how much I appreciated his kind words, but I wasn’t sure how to do so. Leave a comment on his post? Write him a private email? For several hours, all I could do was to hold his words like a beautiful crystal, turn them over and over, and feel the warm glow inside me that they generated.

This morning I decided to put up a post thanking him publicly, and that is what this is. I went to his blog to get the precise URL of his post, and found a new post entitled “Why I’m Not a Hunter”, inspired by my moose-hunting story from last month.

This post is an eloquent description of how many people in the lower 48 feel about hunting, and with good reason. Down there, hunting is not a necessity, it is purely recreational. Hunters quite often spend huge amounts of money on all the right gear, pay a knowledgeable guide to take them to just the right spot, kill whatever walks in range of their high-powered rifle scope, then pay a taxidermist lots of money to mount the animal’s head so they can hang it proudly in their home. If the hunter is responsible, he will pack the meat out and pay to have it processed by someone else; but he may or may not have had the knowledge and spent the time and energy to field-dress the meat properly. And when he gets the processed packages of meat back, he may or may not have much luck getting his family and friends to eat it. “Tastes too gamey,” they usually say; and they are usually right.

Hunting in southwest Alaska, at least by the people who live here, is not recreational. It is part of survival. It is necessary to a subsistence lifestyle; most families here would go hungry through the winter without a few successful hunts. Certainly, there is plenty of beef for sale in the meat department of the two grocery stores in Bethel. New York Strip steak sells for $10.79/lb. Most Yupik families in Bethel can’t afford to eat beef very often. In the villages there simply is no fresh meat for sale. The small village stores carry canned, boxed, and some frozen goods, all at prices even higher than Bethel’s. And let me say it right here: moose is fabulous! Sweet, tender, succulent, flavorful. I'll take moose over beef any time.

My friend and I are adequately compensated for our work as health care providers, and we can afford to buy fresh meat at the store. But part of one’s acceptance in this culture, and one's understanding of it, is governed by one’s participation in it. Yupik culture is entirely oriented around subsistence activities, and the people here appreciate that I participate in their activities. My credibility as a health care provider is markedly increased by the fact that I mush dogs, fish for salmon with a drift net, travel alone on the river, pick berries, and eat agutuk.

What I tried to convey in the story about my one-and-only moose hunting experience is that hunting has a completely different context here than it does in the lower 48 (or any other highly populated area of the world). Certainly, the trip I described was a tremendous experience that was a lot of fun, and a lot of hard work. There was respect, and a certain level of grace in our attitude towards the trip, the river, the people who helped us, and the moose whose life we took.

I left a very long comment to Dr. Ford’s post on hunting. I hope it did not come across as strident or defensive, as that was not my intent. It was passionate, however, which I hope did not override the context I was trying to present.

I think it is extremely difficult—if not nearly impossible—for people born and raised in urban American culture to understand just how vastly different life is here. The difference is not just about fancy houses and paved roads. It’s not just about wearing high-heeled shoes or dry-cleaned clothes. It’s not just about going to movies, plays, and nice restaurants. We don’t have all those things, and that constitutes an obvious difference; but it runs much deeper than that. Life here is about survival—in a cold, harsh, unforgiving and often cruel environment. The things that matter here are about taking care of each other and helping those around us. That is the most basic value in the Yupik tradition. Underneath all the noise, that is basically what life everywhere is about.

So, Medicine Man, thank you from the bottom of my heart for your beautiful tribute. It means more to me than you know. I think, underneath it all, we are not very different. I think our hearts are in the same place, it’s just the rest of our bodies that live in two different worlds. I hope, someday, you can make it up here for a visit.

A Village Funeral

Note: If you read this post before Monday, Oct. 23rd, photos were added after I received permission from the family and Father Gregory.

One of my patients died last week, in the small Yupik Eskimo village on the Yukon River where he had lived his entire life. Sergai was a relatively young man, in his fifties, who had intermittently been quite ill over the last two years. Recently, though, he had been doing well. His death came as a surprise and a shock to all of us.

Every death in a small village is deeply felt by all. The great majority of people in a village have lived there for their entire lives, and everyone not only knows everyone, but is also somehow generally related to everyone. When someone dies, the life of the village comes nearly to a halt until that person is buried. It is as if the village holds its collective breath for three days.

There is no “funeral industry” in any village, or in Bethel. No funeral homes, no undertakers, no hearses, no grave-digging services, no florists. If there is no suspicion of foul play, then no autopsy will be done, and the body of the deceased will remain at home. Family members will wash and dress the body (gender specific; men will wash the men who die, women will wash the women). Some of the men in the village will build a box to be the coffin, and the women will line it with the nicest fabric they have. Several men with shovels and pick axes will dig the grave; in the winter it may take two to three days to dig a hole deep enough.

The coffin with its occupant will lie in state in his or her home for two days. Candles will burn constantly and the family will keep a vigil the entire time. Villagers will come and go, bringing food, offering comfort, praying, frequently kissing the deceased. Tears and whispers prevail.

On the day before the funeral, the coffin is moved to the church and placed in the center of the sanctuary. The vigil is maintained by extended family and friends, and the deceased is never left alone.

The funeral is held on the third day after death, and most of the village attends, regardless of faith; half the village is Catholic and half is Russian Orthodox. Sergai and his wife Beatrice are Orthodox. The family requested that I attend the funeral; I was honored to do so, and very pleased that Dutch was able to attend with me. It meant a lot to the village that we came.

This was my first experience of an Orthodox funeral. Dutch and I flew to the village on Wednesday morning, carrying boxes of food as gifts for the family. We arrived just before noon, and by the time we were dropped off at the clinic, word had already spread that we had come. Several people called immediately to see if they could make an appointment with me. The health aides said no, I wasn’t there to see patients, only to attend the funeral; but in the two hours before it started, one patient did come in to have me inject her bad arthritic knee.

I had asked one of the health aides what to wear for the service, and she simply said “Kuspuk!”

Duh. Of course. So I wore my favorite one, a blueberry-print fabric that my mother made for me. And jeans and mud boots. “Dressed up” has a whole different context here, and elegant footwear is senseless. Dutch and I caught a ride from the clinic to the church on the back of a four-wheeler, and arrived with mud spatters to our knees.

The big, deep-throated bell next to the church was tolling loudly as we entered. The church was about half full. There are no pews or chairs in the Orthodox church; the congregation stands for the entire service. And the Orthodox are known for looooong services. There are two tiny benches along the back wall for elders who are unable to stand. The congregation is gender segregated; men stand on the right and women stand on the left.

The altar at the front of the sanctuary is behind a wall, and only the priests and altarboys may go through the door. The door remains closed except during the actual service; the congregation can only see the altar when it is open.

Almost the entire service consisted of prayers chanted/sung by Father Gregory, the village priest, two assistant priests, and the lay reader, Father Gregory's wife Janet. And though the prayers were in English, I could not understand most of the words. Several phrases repeated often, and those I could understand. Many times Sergai was referred to as being asleep. The opening prayers lasted for about an hour and a half. The congregation occasionally sang a response and frequently made the sign of the cross upon themselves, but there was no kneeling. And no sitting.

When prayers were done, the entire congregation was led by the priests and then the widow and then the immediate family to file past the coffin one by one and kiss the deceased’s forehead, his lips, and the icon image propped on his chest. Small children were lifted up by their parents to kiss the dead man.

This part took a while, as the church was quite full. Dutch and I stood quietly watching, and I was very aware that we were the only non-villagers (i.e., Caucasians) in attendance. He looked down at me with eyebrows raised and whispered “I don’t think I need to do this part.” I listened to the coughs and sniffles all around me and wondered whether I could. In the end I went up as the last person in line. I leaned close to his face and whispered goodbye to him, but I couldn’t kiss him. It was enough, and it mattered to the family that I participated. His niece later showed me the photo that she took of me bending over the coffin.

After the kissing was done, the main priest gave a short homily about the impermanence of life and the importance of living each day so that you could be proud if it were your last. Another prayer ended the service, and eight strong men came forward to carry the coffin out to the graveyard behind the church. Beatrice walked behind them with her hand on the coffin. Because Sergai had been a veteran of military service, his coffin was draped in an American flag.

At the graveside more prayers were said. Seven men from the village (who I think were all veterans, but they were not in uniform) fired a 21-gun rifle volley over the river. The flag was folded military style and presented to Beatrice. The eight strong men used ropes to lower the coffin into the grave.

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A plywood box covered in plastic sheeting had been constructed to fit over the coffin, and this was lowered on top of it. When I asked someone about this later, I was told it was to “protect” the coffin. I wondered…why?

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Then the eight men picked up their shovels with a load of dirt and walked around the grave offering anyone who wanted to take a handful of dirt and throw it into the grave. The congregation and the priests remained at the graveside until the shoveling was done and the grave was filled. Only then was the funeral concluded.

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A feast was held at Sergai’s house afterward, and Dutch and I were invited to come. It was not your average potluck; ritual was involved here too. A table was placed in the center of the main room where his coffin had been before it went to the church. The table had eight chairs around it. The room was packed with people, but no one sat at the table. Father Gregory led a lengthy blessing, then the three priests seated themselves at the table with the oldest men present. The women of the family served them food. No one spoke; the room full of people was completely quiet. After they had eaten, all eight men stood up as one and left the table. The younger men came forward and sat down. As honored guests, Dutch and I were invited to join this seating, along with the oldest woman present, Beatrice’s mother.

The food was delicious. There was a thick whitefish chowder, moose soup in a clear broth with noodles and vegetables, cole slaw, potato salad, macaroni salad, several kinds of bread, sliced ham, and lots of desserts, including homemade tundra blueberry pie.

The cultural expectation at a feast is to come in, eat and leave. Houses are small, and once you have eaten you need to clear out and make room for the next person. So when we finished eating Dutch and I left; it was about 7 pm, and just getting dark. The feast went on for several hours, until everyone who wanted to eat had been fed. The family will feed the village twice more in the upcoming weeks, at a 20-Day feast and a 40-Day feast. And forever after, they will hold an annual feast on the anniversary of Sergai’s death.

After the feast, Dutch and I returned to the clinic where we would stay overnight. Scheduled plane service to the village is limited to twice a day and the last plane leaves about 4:30pm. We could have chartered a later flight, but that would have cost over $600 one way. The clinic has an itinerant sleeping room with two bunk beds in it, so we brought sleeping bags and were glad for a slow internet connection and flush toilets.

Around 9 pm, Father Gregory's wife Janet called over to see if I would like to come and “mukiaq” (take a steambath) with her and some other women. I’ll almost never say no to a steambath, so I was delighted. I grabbed my towels and steam hat and left Dutch happily surfing his blogs. It was midnight when I returned, with skin glowing red from the heat and the quiet satisfaction of enjoyable time spent with people I have come to care about.

Our plane back to Bethel was slightly delayed by fog the next morning, but we were home before noon without any problem. As soon as we left, I missed the village. I love the closeness and supportiveness of the people there for each other. There is a tremendous bond among people from the same village, and it provides an incredible level of emotional support to each individual villager. Surrounding and suffusing that bond is the very strong sense of tribal identity that Yupiks feel because they are Yupik. In a melting pot world, they have a relatively intact culture that is thousands of years old. I can never truly be a part of their culture because I was not born into it; but I am incredibly grateful for what they so warmly share with me.

Note: I spoke with Beatrice and with Father Gregory on Monday morning, and both gave permission for me to post these photos. I thank them for allowing me to share this deeply personal experience with you.

PFDs, Binge Drinking and Therapeutic Court

Wassilie is a small man, less than 135 pounds, in his mid thirties. He is married, has three children with his wife, and three other children with his former girlfriend. When he is sober, which is most of the time, he is a hard-working man who fishes and hunts to provide for his family and intermittently holds short-term jobs sweeping up the village school or stocking grocery shelves to bring in a few dollars.

The problem is that Wassilie is a binge drinker. Every two or three months the cravings will start and he will hit the bottle hard. For several days to two weeks, he will drink until he passes out and start again as soon as he wakes up. The cycle will only stop when he runs out of booze and money to buy more. The time between achieving inebriation and passing out may last the better part of a day, during which he is raging around and often quite violent. His wife Agnes takes the children and crosses the river by boat or snowmachine to the smaller village where her parents live to wait out Wassilie’s binge.

“He’s such a good man when he is not drinking,” she tells me. “I love him, and I don’t want to leave him. He’s a good dad to the kids, and he takes care of us. But I just can’t stand this any more.” She had brought the youngest child in to see me for a six-month Well Child Exam. This was in October of last year. Wassilie had been gone for two days; he said he was going to Bethel, and she knew what for. To get drunk.

Wassilie’s last binge was almost exactly one year ago. It was how he spent his PFD check. Every year in October, the State of Alaska issues a check to each resident from the Permanent Fund Division; the money so divided represents the interest made on oil in the previous year. The check that each resident receives can be as little as $300 or as much as $1200. Last year, the PFD checks were about $800, as I recall. A family with eight or ten children receives quite a little nest egg every year; some use it responsibly and some don’t.

Wassilie never touched his children’s PFD checks; he always gave them to his wife to buy things the children needed. A few years back, she insisted that he turn over his own as well, and the five checks together were enough to buy them a nearly-new snowmachine. He built a plywood sled to pull behind it, which meant transportation for the whole family.

Most of the villages of the Yukon-Kuskokwim Delta are completely dry; it is illegal to possess alcohol in them. Bethel is “damp”; no alcohol is legally sold here, but it is legal to purchase it elsewhere (like Anchorage) and bring it in. But you must be a Bethel resident to do so; if you live in a village, the bootleggers are your only recourse. Bootlegged alcohol is expensive; a 750 ml bottle of R&R or MD20/20, which sells for less than $10 in Anchorage, goes for $50 in Bethel. Folks like Wassilie have a hard time staying drunk for long; they just can’t afford it.

The big exception is PFD time. $800 will buy a lot of booze, even in Bethel. Last year, Wassilie bought a dozen bottles, holed up at the cheap-and-sleazy Louse-bag motel, and proceeded to get rip-roaring drunk.

By the fifth day he had finished off eight bottles. He was beyond remembering details of anything that had happened. He had a vague sense that some partying had gone on with several other drinkers, and he thought he had probably had sex with one or two women, but he really wasn’t sure. It had happened before. The black eye and the cut on his cheek were evidence that he had fought about something. He didn’t know what.

When Wassilie is drunk and still standing, he tends to vacillate between morose sadness and murderous, unfocused anger. Once he can no longer stand, but before he passes out, the anger usually gives way to crying. He was half way through the ninth bottle on that last binge when the anger became overwhelming and he felt like he had to hit someone or just explode. Maybe his cousin back in the village who had called the Village Public Safety Officer on him that time. When he felt this way, he never knew exactly what he was angry at; any excuse for a target would do. Maybe he would go back to the village that afternoon and beat the guy up. He deserved it.

Wassilie was staggering through the mud near the edge of the river looking for his boat. He had left it near the small boat harbor several days ago when he came in from the village. It had gotten wedged between two other boats, but he managed to free it. And the gas can was still there. He maneuvered the boat out into the slough that leads to the small boat harbor when the motor died. He leaned over the back to unhook the cowling, but he was too drunk to keep his balance. He tumbled right into the river.

He might have drowned if someone hadn’t seen it happen and called the police. He was still mad, but too cold to fight much by the time they hauled him out. He was charged with Driving Under the Influence, and taken to the hospital. Blood alcohol level 0.6. He went to jail.

When he was sober, he went before the judge for sentencing. This was Wassilie’s third DUI in less than five years, once on a snowmachine and twice in a boat. Alaska has a “three strikes” law: the third DUI is a felony and carries a $10,000 fine. A felony means never getting a job with the school district, and places limitations on employment with the state or the hospital. And he knew the judge could put him in jail for a while, in addition to the fine.

He wanted another chance. When the judge offered him the option of attending Therapeutic Court, he knew it was the opportunity to get his act straightened out. He didn’t want a felony on his record, and he did not want to be sent to the penitentiary for two years. He chose Therapeutic Court. As always, when he was sober, he knew that alcohol was ruining his life, his marriage, his relationships with his children. He really wanted to quit drinking; he just did not know how to resist the urges when they came. Because he was sincere about wanting to recover, the District Attorney agreed to reduce his sentence to reckless driving and suspend the fine, once he completed the program successfully.

Therapeutic Court is an 18-month-long program. Clients are required to take daily breath tests, undergo random urine drug screens, attend daily therapy sessions, and take oral naltrexone for the first three to six months in the program. Therapeutic Court requires Directly Observed Therapy for naltrexone compliance, so the clients can’t stop taking it and remain in the program, unless they have a medical provider’s permission. Most clients take it for six months.


Naltrexone has become widely used in alcohol and drug dependence treatment programs. It is an opioid receptor antagonist; it blocks the opioid receptors in the brain. If someone on naltrexone uses drugs or alcohol, they don’t get high from it. Cognitive abilities and motor skills will still be impaired by using; the naltrexone does not change that. It simply eliminates any pleasure from the experience. With time it also seems to help eliminate the cravings to drink.

Because it is blocking opioid receptors, naltrexone reduces the ability of pain medications to relieve pain. When patients on naltrexone have a painful injury, treating their pain can be difficult. They require higher than normal amounts of opioid meds to overcome the blockade caused by naltrexone. If they were to stop the naltrexone, which sensitizes the receptors, they could overdose on the pain meds.

Counselors in the program strongly encourage only the use of anti-inflammatory drugs like Ibuprofen, combined with acetaminophen, for management of all but severe injuries. All too often, they say, giving Therapeutic Court clients any pain meds such as hydrocodone or oxycodone is the first step towards them falling completely off the wagon. The cravings to drink that had been under control with naltrexone come back strong and clients often give in.

Naltrexone has few drug-drug interactions, and generally few side effects. About ten percent of people taking it will feel some mild nausea for the first two to six weeks, but not usually enough to make the drug intolerable. Occasionally it may affect liver enzymes, so those are checked before placing a patient on it, and rechecked about every six months during the course of treatment. Interestingly, many of our chronic alcoholics have pretty normal liver function tests, despite the heavy use of alcohol. The binge pattern, often with long periods of sobriety between binges, is thought to be responsible.

My friend Joan is a counselor for Therapeutic Court. The staff there works closely with the hospital’s behavioral health program; the behavioral health mid-level generally does the intake physicals and prescribes the naltrexone. That position is currently vacant (and being recruited for—anyone interested?); in the interim, Joan asked me if I would be willing to see their clients for these needs. It would mean two or three physicals each month with counseling about the naltrexone use and screening for co-morbid depression and anxiety; and clinic visits for any non-emergent illness or injury complaints the clients might have during the year and a half they are in the program. Particularly important is addressing pain management issues with the client. I agreed to fill in until the new mental health provider comes on board.

Wassilie brought his wife and children in last week for Well Child Exams and flu shots. He wanted one too; “I can’t get flu this winter, you know? Got too much to do.” Agnes smiled at him.

Wassilie has been in the program for almost a year now, and he is doing well. He is proud of his sobriety and his wife is proud of him for doing it. He is still on naltrexone, because he believes it helps him “be strong against the cravings.” It has been six months since he had one, so he thinks at his one-year anniversary he will be able to stop taking it.

He looks so much better than the last time I saw him. His eyes are clear, his skin color looks healthy, and his pride in himself is evident. He makes eye contact with me for more than two seconds. He smiles more. He doesn’t seem defensive when we talk about how his life is going. He recently obtained a Commercial Driver’s License and has gotten a job in Dutch’s department as a sewer truck driver for the City of Bethel. The job pays well, has good benefits, and will require random drug screens to maintain the CDL. He has turned his life around. He has reason to be proud. This year his PFD check will go into a savings account.

Wassillie is a fictionalized composite, not a real person.

First Snow

Tuesday was mostly a rainy day, with temperatures just above freezing. In the late afternoon I was working at my desk when I heard someone behind me say "Holy cow!" I looked up to see big round eyes focused on the windows, and this is what she was looking at. Holy cow, indeed! The snow was coming down like a blizzard. It lasted for about an hour, and then the clouds cleared off and we had a bright, sunny, blue-skied early evening. The inch or so of snow that accumulated was quickly gone. Two hours later, you would never know it had happened.



The next day, as I ran around doing errands on my day off, I couldn't help snapping this photo, just to give you a little taste of Bethel's "pothole goodness". This is one of the worst streets in town, and doesn't get much traffic (?!). This is a commercial area; on the left is a snowmachine dealer, a lumber yard, and the Catholic church. The red buildings on the right are a grocery and hardware store. Do you notice the lack of signs for these businesses at the edge of the street? That is one of the things I've always enjoyed about Bethel. Almost zero signage. There is not a single billboard in town. There are no business signs at the edge of the road, except for the occasional homemade, hand-painted sandwich board which someone puts out each morning and brings in at night. Business names are on the buildings themselves.

The visual chaos of signage is another part of the culture shock I mentioned in an earlier post when I leave this charming place. Even Anchorage has a huge amount of it. Compared to what we have here, the signage is a bombardment of the senses.

Actually, Bethel does not even have very many street signs with street names on them. It can be a challenge to give a newcomer directions, but we manage. Individual names of streets don't seem to matter that much; people go by bigger landmarks anyway. And most people know where the businesses are. It is hard to get lost here, and if you do, folks are quite helpful. Another part of life on the edge.

Go Ahead, Laugh! It's Good For You

Don't you just love a good laugh? I'm talking about one of those thigh-slapping, side-holding, tear-streaming belly laughs that comes from your toenails up and leaves you gasping for air and mercy. I had one of those recently, and just had to share the source with you. If laughter is the best medicine, then this piece was the latest godzillacillin for me. After five or six readings, I am down to mere chuckles, but the first two times I laughed so hard my stomach muscles were sore for hours afterwards.

One of the physicians at the hospital shared this website with me. Thanks, Dr. G! You made my day! Maybe it only appeals to medical types, I don't know. Tell me what you think: http://www.qfever.com/issues/20010502/medstud.html. Be sure to read past the photo.


On other news fronts, I forgot to post yesterday that Grand Rounds 3:3 is up at Unbounded Medicine. Dr. Jon-Mikel has hosted a clear and concise edition with lots of good links, and I was pleased to be included.

And...I want to wish a HAPPY BIRTHDAY to my Dad today! He is a full-bore, going-strong seventy-something who is an endless source of wisdom about Things I Need To Know. You're just the BEST, Dad! Thanks for all you do, and give, and are.

Eskimo Ingenuity

One of the responsibilities of my job as a health care provider in southwest Alaska is to spend some time each day on the phone talking with health aides about the patients they see in their villages. (I have written before about the unique role that health aides play in the delivery of health care in rural Alaska here and here.) This phone consultation is called Radio Medical Traffic (or RMT), so-named because it was once done over VHF radio (before the days of HIPPA).

Last week I was doing RMT with a health aide in one of the downriver villages. His name is Abe; he is a forty-something Yupik Eskimo man and one of the few male health aides. I always enjoy talking with him; he is an excellent health aide, with a good grasp of the basic essentials of medicine and a lively curiosity and desire to learn more. We usually have interesting discussions about his patients, and he always has good questions. I have encouraged him to apply to PA school, but he does not have the prerequisite college coursework, and he does not want to leave the village for two years; and he really enjoys being a health aide.

One of Abe’s patients that day was a young man with a beaver in his lungs (asthmatic bronchitis). He’d had a chest cold with a productive cough for about a week (no fever), but the day before he had started wheezing and feeling somewhat short of breath. His respiratory rate was up to 28 and his oxygen saturation was down to 94%.

Abe and I discussed getting him started on albuterol. All the village clinics have several nebulizer machines which they loan out to patients for short-term use, but Abe said that none were available that day in his clinic. He did have a good supply of albuterol metered dose inhalers in the drug cabinet, however.

“OK,” I said. “Give him an MDI with a spacer, and show him how to use it properly.” A spacer vastly improves the efficacy of an MDI, even for an experienced user; for novices, I consider them essential. A spacer is basically a plastic tube; the MDI attaches at one end, discharges its “puff” into the tube, and the user slowly inhales the puff from the other end. Some even have fancy bells and whistles, like an alarm that sounds if the user inhales too quickly.

This technique allows more of the medication to get deeper into the lungs. When the MDI is held to the lips and discharged, more medication sticks to the mucous membranes in the mouth and less gets down into the lungs. The force of the discharge hitting the back of the throat may also cause the user to cough, preventing any medication from getting into the lungs. And the user’s timing of discharge-and-inhalation is crucial. A spacer eliminates these problems.

“But,” said Abe, “we’re out of spacers. The hospital pharmacy only sends us two per month, and they’ve already gone out.”

“No problem,” I answered. “Take the cardboard core out of a toilet paper roll. Show him how to hold the MDI at one end with his hand wrapped around the junction. It’ll work just fine.”

“OK!” Abe said enthusiastically. “We can Eskimo him up!”

I could just see the grin on his face.
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A few days later I told this story to my friend Henry, who has lived here for over thirty years. He laughed and nodded.

“One of the things the Yupik people are very proud of is their ingenuity in rigging up something to solve a problem. I once saw a man carve a piston from a piece of ivory to make a snowmachine engine work. I’ve seen a washing machine motor rigged to push a boat when the outboard motor failed. They are amazingly inventive when it comes to making things work.”

I thought about Abe and the spacer problem. I knew he would take care of his patient, and find a way to get the albuterol where it needed to go.

Driving a Bethel Rig

Every year I make at least one trip to the lower 48, to visit immediate family in Washington State and Florida, and extended family in Alabama and Kentucky. Often this trip is paired with attendance at the annual conference of the American Academy of Physician Assistants; in recent years I have attended conferences in Atlanta, Chicago, Boston, New Orleans, Orlando and San Francisco. Trips “Outside” (meaning out of Alaska) tend to reset one’s perspect-o-meter on many topics, particularly those related to population density and attitudes towards conveniences, among others. It really is a whole different world down there.

One of the things I never cease to marvel at is the high percentage of brand-new, spanking-clean cars I see on the (always paved) roads. If I stand on a street corner and watch the cars go by, it seems like nine out of ten are less than five years old (maybe even less than three years old, but I’m not really up on year-to-year model changes) and recently washed. The one out of ten that is older than five years is often an obviously cherished antique, even more lovingly cared for than the new vehicles. The bombs and the wrecks are pretty few and far between, especially in the big cities. My grandmother lives in a fairly rural part of Kentucky, and when I visit her I do see many older vehicles; but there are still quite a few shiny new ones cruising around her small town—including hers! At 93, she lives alone and drives her nearly-new Cadillac everywhere she wants to go. She’s quite the pistol.

Vehicles in Bethel tell a completely different story. Our local transportation falls into three categories: trucks, cars and cabs. The cabs are a story unto themselves; we have a huge number of them. Our cab-to-population ratio probably equals that of New York City. Most of the cabs are older, low-slung sedans like Crown Victorias, which makes no sense in this environment. They get stuck in the mud or snow quite frequently. About 80% of Bethel is unpaved, and the town is built on the dirt banks of a wide, shallow river. We know about mud. Each of the half-dozen or so cab companies has its own tow truck, which it sends out regularly to haul its minions out of bad situations.

Of the other two categories, trucks outnumber cars by about two to one. Most people drive pick-up trucks, with Ford F-150s being highly favored. Very few of them are newer than 2001 models, and many are earlier than 1996. Almost none of them are clean. Some of them make you wonder if anything besides caked-on mud is holding them together. The word “rattletrap” springs to mind. If Bethel had any type of emission-control testing or requirement to pass a vehicle inspection, I would bet 75% of the vehicles in Bethel would be taken off the road.

Part of the reason we have so many clunkers is that most people bring at least one vehicle with them when they move here, but hardly anyone takes them when they leave. Bethel is essentially a land-locked island; access is only by air or water, as no roads come here from anywhere else. To bring a vehicle to Bethel costs about $2500; taking it away is only slightly less, so people mostly don’t. There are plenty of old beaters for sale around town with a few more years of life in them. Those with unique appearances become like acquaintances in and of themselves, and their successive owners simply faces in a revolving door. Every few years the face driving it changes, and you know it’s been sold again.


One of the items of interest to the knowledgeable used-vehicle buyer in Bethel is how many “Bethel miles” the vehicle has. Since all vehicles come here from somewhere else, most of the miles on the odometer are presumed to have been acquired there. Which probably means on paved roads.

Bethel miles are about the toughest and most destructive a vehicle can take on. The six paved miles of state highway that run out to the airport are patched and repatched due to the sudden appearance of axle-bending potholes, and have lots of little up-and-down hills due to shifting tundra. Tough on the suspension.

The 20+ miles of streets in town are all dirt and gravel. They are constantly sinking due to the frost-heaving tundra they are built on. A day of two of rain and most have a washboard surface with lots of potholes. Add to that the fact that most of Bethel does not have piped water and sewer; these services are provided by large, heavy trucks running six days a week year round, which provides a huge wear factor on the condition of the streets.

This is a delicate item of discussion in our house, as both Bethel’s streets and the water/sewer systems are city services that fall under Dutch’s management. He has a personal concern regarding criticisms about either. It is important to understand (attention newcomers!) that maintenance of Bethel’s streets is a never-ending proposition. They must be raised (read: LOTS of dirt hauled in and spread) every couple of years. And topped with gravel, which the tundra eats. Washboards and potholes are a given, and grading the roads to smooth them out cannot happen in the rain. If the roads are too wet when the grader passes, it turns the road into mud soup, which is worse than the potholes. Most of the complaints that reach Dutch’s office are from newbies who move here with Beverly Hills expectations about how the streets should be.

Bethel miles also include those acquired driving on the Ice Road. In the winter the Kuskokwim River freezes into an ice sheet more than five feet thick. By late December, cars and trucks are driving on it to the nearby villages, some years as far as Aniak, 150 miles away. If the weather is windy and stormy in the last few days and weeks of freeze-up, the frozen surface of the river can be quite rough; if it is calm, the ice surface can be slick as glass. After a few snowfalls, the constant transitions from packed snow to bare ice on different parts of the Ice Road are also pretty rough on vehicles.

If you are getting the impression that this is not a place you would want to bring a brand-new car or truck, you are right. Bethel is tough on vehicles, and most folks would rather drive something dependable (with a good heater) but not necessarily gorgeous. Around here, one’s “ride” is not a projection of one’s persona or one’s status.


So meet my truck. A 1996 F-150 with the wooden rails and chain snaps around the bed that designate it a “dog truck.” It can carry up to 20 sled dogs (tightly packed; they have to be friends) and two sleds at a time. At ten years old, my truck falls into the “newer” category of Bethel rigs. Henry’s truck is a 1984 F-150 (seen below with a load of dogs headed for summer bare-ground training); Joan’s truck is a 1982 F-150. Both run great and are quite dependable, though you’d never accuse either of being pretty.


How I acquired this truck is one of those “it could only happen in Bethel” stories. In February of 2000, I bought a team of sled dogs and became a real musher (before that, I drove one of Henry’s teams, which is only being a fake musher). I needed a way to transport them to summer training sites outside the town limits, and the 1994 Ford Explorer I was driving wouldn’t do it. I started looking around at the trucks in town and talking to various owners to get an idea of what I wanted. I’d never owned a full-size pick-up before.

One day I stopped at the grocery store and noticed a guy sitting in his F-150 in the parking lot, so I went over to ask him how he liked his rig. He said it was fine as trucks went, but with two kids and his wife pregnant, he really needed a family car.

“What are you driving?” he asked.

I pointed out my Explorer and his eyes narrowed. He got out and walked around it, looked inside, checked the mileage (“How many Bethel miles?”), and said “Wanna just trade?”

Wow. I wasn’t sure what to say except “Sure!” Being newer and lots more vehicle, his truck was worth quite a bit more than my car; after checking blue book estimates on both, we made the trade the next day and I gave him an additional $2,000. We were both quite happy with the deal. I built the rails on the back, complete with drop chains for the dogs, and became the proud owner of what Henry proclaimed to be “Bethel’s finest dog truck.”

This is a photo of my truck with outstanding musher Aliy Zirkle and her dog team loaded up and headed to the start of the Kuskokwim 300, Bethel’s annual mid-distance sled dog race. This past January was Aliy’s first running of the K-300; she did the race to put some experience on her puppy team in preparation for upcoming Iditarods, and they did well. Dutch and I were her host family, and we hope she will come back every year and stay with us. She is a charming young woman and a very talented musher. She was the first woman musher to win the Yukon Quest, a 1000 mile sled dog race between Fairbanks and White Horse, in 2000. You can learn more about Aliy and her mushing program at her website, www.aliyzirkle.com.
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Bethel’s musical claim to fame is a CD I’ve mentioned before, Greetings from Paris on the Kuskokwim by Michael Faubion. He used to live here, but moved to Anchorage a few years ago. One of the songs on the album is entitled “Badass Rig” and is a tribute to the type of truck most of us drive here. The chorus goes:

It’s big and it’s ugly; it gobbles up the gas.
If the Bethel roads’d let it, it’d go real fast.
Four-wheel drive and the motor’s real big,
It’s a rut-ridin’, boat-totin’, dog-haulin’ badass Bethel rig!



So back to the start of this post. Those annual visits to the lower 48 feel like treks to the Heart of Civilization (Anchorage is only an Outpost). I go through something akin to culture shock every time, not only on arriving there, but also on returning here. These trips are a regular reminder that I live on America’s Last Frontier. It’s just different here.

Grand Rounds Vol. 3 No. 2 Is Up...

...at R Doctor Medical. This week's edition of the best of the medical blogosphere is hosted by Dr. Aleksandr Kavokin, a physician born in Kazakhstan and trained in Moscow. His research into medical applications of artificial intelligence has led to the nickname "the robot doctor." His pre-Rounds interview by Nick Genes, M.D., of Blogborygmi, is posted at Medscape.

This week's edition is, as usual, an interesting assortment of articles. I was thrilled to have been chosen for Editor's Pick! Stop by, pour yourself a cup of hot coffee and enjoy some good reading.