Eskimo Foods and Botulism

Living a subsistence lifestyle—i.e., living off the land—requires a constant round of seasonal activities directed at acquiring food, heat, shelter and clothing. Most of the people living in villages, and quite a few living in Bethel, are doing exactly that. It is a constant procession of hard work with very few days off.

The Eskimos of southwest Alaska have traditionally had a nomadic hunter-gatherer culture. The tundra supports an abundance of life, and the native people are very attuned to collecting what Nature offers.

In the spring, migratory birds begin arriving from as far away as South America. They come in the millions, literally. Geese, crane, ducks, swans, plover, swallows, jagars, owls, falcons, eagles, hawks, all spend the summer here breeding. Almost all of southwest Alaska is a wildlife refuge, predominantly for birds. Some species are restricted from hunting, but most are not. The traditional native diet is heavy on bird, usually goose or duck, in early spring. A well-prepared swan or crane soup is absolutely delightful. The meat is all dark, and very juicy and tender; carrots, onions, and noodles are usually added, and a little salt. Always, a clear broth base, not thickened to a stew. It is generally served with Pilot Bread, a big semi-soft cracker, with butter and homemade berry jam.

As all these birds settle in for the business of nest building, egg laying, and brood hatching, the people begin collecting eggs. The nesting is, by necessity, on the ground, as we have almost no trees. Families travel to favorite tundra spots and spend days combing the land, collecting eggs. There is some hazard involved here, as the bird parents can be quite aggressive in their protection efforts.

The birds begin arriving before the river breaks up, and their activities are vigorous for a few weeks. Before and during the egging season, the paired activity is logging. As soon as the river is free of ice, boats start heading upriver to collect the deadfall left by the receeding ice. We don't have many trees here, and none of them are big, so a good wood supply for winter means a two-week logging trip in early spring. The logs are retrieved from the riverbank, cut to size (14 to 20 feet), rafted up and towed home by boat. Then another week of bucking, splitting, and stacking.

By late June, the earliest runs of salmon begin in the Kuskokwim and Yukon rivers. The mighty King (Chinook) come first, and are the most prized. They have the highest oil content and the finest flavor, and are the staple of the Eskimo diet year round. These are huge fish, weighing 20 to 60 pounds each. They are caught in drift nets, filleted, cut into strips or blankets, brined, dried, and then smoked. In three weeks, a family will catch and process enough fish to feed themselves until the following summer. Well made King strips are a savory delight, chewy like jerky, but oily and full of flavor (and omega 3 fatty acids).

The Kings are followed by Reds (Sockeye), Chum (Dog), Humpies (Pink), and Silvers (Coho). All are considered “people food”, but only Kings, Reds, and Silvers are prized. Around here, Chum and Humpy are dog food. If Chum is all you have, it is certainly good enough to eat, but it just can’t compare with Red or King.

By August the tundra is covered in berries, and berry-picking becomes the predominant activity. There are a half dozen different types of berries, each with a distinct flavor and peak season. Families travel together to their favorite berry picking spots and camp there for several weeks, where they will do nothing but pick berries for twelve to fourteen hours a day. With 22 hours of daylight and two hours of semi-darkness, it is an around-the-clock activity.

An Eskimo woman on a berry-picking mission can pick two 5 gallon buckets full in a day. When you consider that each berry is only about a quarter inch (half centimeter) in size, that’s a LOT of berries. Now consider that she performs this feat standing/walking completely bent over, as the berries grow on tiny ground cover no more than 3” high. And then she carries those full, 5 gallon buckets back to camp a mile or more, walking on squishy, very uneven tundra. If you are suspecting that clinic visits for back pain go up in August and September, you are quite right!

Berries are the primary source of Vitamin C in the Eskimo diet. Plenty will be eaten fresh, but most will be frozen for use throughout the winter. They are the flavor component of the dish known as agutuk, or Eskimo ice cream. Agutuk is quite a delicacy, and worthy of its own post.

By September, summer is over and fall is moving in fast. Now the focus becomes moose hunting. Every family hopes for a moose to supplement their supply of dried fish. The trick is to get one before the rut sets in. Once a bull moose is in rut, the flavor of the meat is sharply tainted. A moose hunt out of Bethel means going upriver two or three hundred miles. The moose population on this part of the river was very low until two years ago when a moratorium was instituted; now they are coming back, but it will be three more years before they can be hunted here.

Moose is one of the best game meats I have ever eaten. It is not “gamey” at all. It is very lean meat, especially compared to beef. Moose soup and baked moose roast are the primary dishes. Another dish, which I have not yet had the gumption to try, is jellied moose nose. There is a recipe for it in Cooking Alaskan, the bible of all Alaskan cooks. Somehow, I just can’t go there.

Hunting is a year-round activity, in addition to the seasonal work. Other game that I have eaten includes black bear, porcupine, beaver, and musk rat. It is all quite tasty, except for the musk rat. I have to admit to being a little squeamish on that one; can’t get over the “rat” part. Though beaver is also technically a rodent, it just doesn’t have the same effect on me.

The coastal villages are also hunting sea mammals year-round. Seal, walrus, and whale are prized for their tasty meat and fat. Seal fat is rendered into a light, clear oil which is used for cooking and dipping dried fish in. Whale fat (“blubber”) is cut into chunks and pickled; this is called muktuk. The one time I tried it, it was like chewing a rubber tire. Your teeth just bounce off it; eventually your muscles of mastication get so tired, you just swallow it whole in order to quit chewing it.


The Problem of Botulism

Fermenting is a food preservation method favored in many cultures around the world, and Eskimos are no exception. The primary fermented food in this culture is called “stinkhead”, and is definitely an acquired taste, like lutefisk and limburger cheese. Most Eskimos say that white people can’t eat stinkhead, and they are generally right. I have two friends who managed to hold their noses and swallow some, but it was quite a challenge.

Stinkhead is made from the whole head of a King salmon, which is somewhat larger than a football. The traditional method of preparation was to wrap the fish head in the long grasses which grow along rivers and streams, and then to bury it in a moss-lined pit in the ground for four to six weeks. Where it rots. And then dig it up and eat it. Yum. The bones soften up until the whole head has a mashable consistency. The dish gets its name from the smell, which is every bit as rancid as you might imagine. I can’t even be in the same room with it, much less consider putting it in my mouth.

Another fermented delicacy is “stinkeggs”. The female salmon have large roe sacks when they are caught in the summer. These are buried intact along with the heads; the surface dries out and becomes quite firm, leaving the interior soft.

As aesthetically distasteful as these dishes might seem, the health problem stems from the method of preparation, not from the dishes themselves. As long as the fish head was wrapped in grass before burial, it fermented aerobically and slowly at cool temperatures buried just on top of the permafrost. But then someone discovered that placing the fish head in a Ziplock bag, or plastic bucket with a lid, speeded up the fermenting process significantly. Stinkfood could be made in about half the time. Additionally, now the food is sometimes left unburied, so it ferments at warmer temperatures.

The result of these changes is an increased incidence of botulism. Botulism is a life-threatening disease. It is actually an intoxication, not an infection. The toxin is produced by a spore-forming obligate anaerobic bacterium, Clostridium botulinum, which is ubiquitous in Alaska. It is found in soil, ocean water, salmon and marine mammals. The most common food sources of botulism are whale, seal, and salmon. The toxin is inactivated by heat, so cooking these foods generally renders them safe to eat.

There are seven types of botulism; most human disease is caused by three of those. All cases in Alaska have been associated with consumption of traditional Alaska Native foods, including fermented foods, dried foods, and seal oil. Fermented foods are the most common source.

The toxin acts at cholinergic neuromuscular junctions by blocking the release of acetylcholine. The initial symptoms of botulism are usually gastrointestinal, and occur with 12 to 36 hours of consuming the contaminated food. Patients present with nausea, vomiting, diarrhea and abdominal pain. Neurologic symptoms are often present as well: dry mouth, blurry vision, double vision, dilated pupils, difficulty swallowing, and decreased gag reflex. Depending on the severity of the case, progressive skeletal muscle weakness may follow, including weakness of the muscles of respiration. Almost all of the early deaths from botulism in Alaska have been caused by respiratory arrest.

Laboratory testing for the toxin takes several days; in our hospital, treatment with anti-toxin is instituted before confirmation in any highly suspected case. Convalescence can be quite prolonged, even in milder cases that do not progress to respiratory collapse. And there may be periods of relapsing symptoms without new exposure up to several months after initial recovery. Also, surviving an episode of botulism does not confer immunity from future episodes resulting from new exposure.

One of the major concerns in our hospital is dealing with any large-scale outbreak of botulism. The hospital only has four ventilators, and a very small respiratory therapy department. We often have only two RTs, and they are on call all the time. Timely transfer of patients to Anchorage via medevac is crucial.

The most recent large outbreak in our area occurred a few years ago, in the coastal village of Kongiganak. A dead whale was found washed up on the beach a few miles from the village. No one knew how long it had been there. People cut away the seal bites and shark bites and obviously rotted outer portions, and proceeded to butcher the rest for human consumption. Four cases of botulism resulted from that event; three were mild, but one was medevac’d to Anchorage and maintained on a ventilator for several weeks.

Many people from the village ate the whale meat, but only a few got sick, which illustrates an interesting fact about the toxin. It is not distributed homogenously throughout the tainted food. Often only the inner portion contains toxin, so those who eat first, from the outer portions, do not become ill.

Fermented foods are an integral part of native culture in Alaska, and we, as health care providers, are not going to change that tradition. Our efforts at decreasing morbidity and mortality from botulism are focused on prevention education and early identification and treatment. We recommend hot soapy water wash of hands, containers, and utensils prior to handling foods, and cleanly washed foods prior to storage. We strongly urge the use of “the old way” to prepare fermented food—wrap the items in grass and ferment at cold temperatures, ideally less than 37 degrees F. Consider boiling the food before eating it. This suggestion is less well received; they say it changes the taste too much. And, if you don’t know how it was prepared, then don’t eat it.

If you are interested to know more about botulism in Alaska, you can Google up the Alaska Division of Public Health and search their website for botulism. Their monograph entitled “Botulism in Alaska, a guide for physicians and healthcare providers” lives on the resource shelf in both the ED and the clinic, and was the source of my more technical information here. A parenthetical footnote: in addition to being a PA, I also have a Master’s in Public Health.

So if you show up at our hospital clinic or ED complaining of a dry mouth, don’t be surprised if you get more than you bargained for! In milder cases of botulism, that can be the only presenting symptom.