She meant to die

Dear Friends,

I have completed my fifth week in Northwest Alaska. It has been a time of work - taking care of the people up here and continuing my spiritual journey now three months after Daniele's death. It's been a rollercoaster for sure. But always interesting. I have spent time in three villages. The first was Kivalina about which I have written. The piece below is about my second village visit in Selowik, which means three rivers converging in the Inupiat language.

I am sending this to a much smaller group of people because I have identified the village by name and it contains patients' very personal stories. I would ask that you not share this piece with anyone else. A few of you share with your close family members and that continues to be fine. I am mostly concerned about HIPPA violations. Although I don't use patient's names, there is the potential for someone who lives locally to read this with all the ramifications implicit in a place where everyone knows everyone. As always I appreciate so much your reactions, thoughts, feelings about the stories I am writing.

Selawik, the biggest village in our group, is located at the mouth of the Selawik River where it empties into Selawik Lake, about 112 km southeast of Kotzebue. When I asked Warren, the Health Aide and Baptisit minister, why it grew so big, he said it was the place people went when they misbehaved, kind of like a penal colony, a tiny Australia. Now I understood its reputation as maybe the craziest of the 11 villages in the Northwest Arctic Burrrough.

The nearby Selawik Wildlife Refuge has 21,000 lakes so it beats my home state. The village is at the confluence of 3 rivers, the most important being the Selawik River which is 140 miles long and runs from the Purcell Mountains through the refuge and passes by the town on the way to Selawik Lake, the third biggest lake in Alaska.

The trip had a promising start as Kevin, the pilot, asked me to sit in the copilot seat -- signaling vaguely towards the planes outside -- "it's the Navaho." I can't distinguish a Chevy from a Ford -- not even when you could tell them apart a few decades ago.

He was the chattiest bush pilot I had ever encountered. He looked a little like Richard Dreyfus as Duddy Kravitz with a couple days of facial hair growth -- for a nonswarthy guy. He chattered to the assembled seven of us about the various and sundries of getting the plane off the ground -- in marked contrast to the strong, silent image most Bush pilots project.

We flew over the myriad tundra lakes and rivers on our way, low at a thousand feet so we could see the caribou herds easily. At one point we saw a single large critter booking it somewhere. I wondered if it wasn't a bear. The lakes, not yet frozen, have a gray color to them. Kevin noticed a brown lake off to the south and decided to go off course to explore it, banking the plane just enough to make my innards flip flop. Not even the Inupiats on board could explain the brackish color.

As we came into Selawik Kevin pointed out the DC6 that had missed the runway some years back and halted on the edge of town. After we had come to a stop ourselves on the gravel runway, he handed me his card with all his personal particulars. There's a dearth of eligible women (if eligible is defined racially anyway) in these parts. I was flattered of course but noncommital. I bet he wished he had shaved that day.

Leo, the clinic janitor, picked me up with my assorted baggage. I was amazed to find myself on the backside of a four-wheeler flying along these nine-foot-wide wooden boardwalks that are everywhere in town. First off we crossed a fairly level bridge over the smaller Fish River. Then we zigged and zagged, taking Wild Mouse right-angle turns, until we came to a long bridge that passes over the larger Selawik River. We slowed as the four-wheelers lined up making the 35 degree- ascent, our speed now determined by the most cautious driver ahead of us. Then whizzed down the descent, barely missing pedestrians in the awful moments when two four-wheelers passed each other.

A new maze of elevated boardwalks were put in this past summer. They used to be at tundra level, which kept people's feet dry until the boards rotted and needed replacement. At least then a pedestrian could step out of the way of motorized vehicles.

Now this nine-foot-wide path is shared by everyone and there's no wiggle room, or place to step away to avoid getting "bumped" as they say here. The problem is, it's pretty difficult to look ahead and behind for approaching four wheelers. I basically don't trust anyone on a four-wheeler in northwest Alaska because the person behind the wheel could be eight years old, Fetal Alchohol syndrome cursed, or inebriated at the time. Or a driver with poor judgment for no particular reason.

The clinic, which was in its last week of operation, was chaotic. Even with four health aides, it's disorganized in the best of times. And this was the worst since many things had been moved to the new clinic across town.

So when a man came in with shortness of breath, having been discharged from the hospital in Alnchorage the week before with pneumonia and exacerbation of chronic lung disease, I was unable to give him a nebulizer to facilitate his breathing treatments because all but one of them was in the new clinic and we needed the sole remaining machine for anyone coming into the clinic with breathing problems. Whoever triaged what things moved when, wasn't thinking about the ABCs -- breathing is second but real important.

A man with an enormous scar on his right arm, reminding me of the local riparian geography, came in for a blood pressure check. When I asked about his arm, he told me his wife had tried to kill him. Almost bled to death before they could get him to Kotzebue and then Anchorage. He was very calm, stoic as Inupiat men are. We could have been talking about an ingrown toenail. I tried to probe to assess his risk for further bodily damage at the hands of his spouse. He said his daughter had come to live with them after that and everything was just fine.

The next patient was his wife. They had come together on their four-wheeler. As she explained that night, they were both drunk and he was beating her up as usual and she tore into him with a knife. And that's all there was to it. She didn't do any time after the judge found out about her husband's domestic assault history. She was equally complacent. I tried to probe -- "So you don't continue to feel angry at your husband, fearful, anything? You sleep ok at night? No sad depressed feelings, thoughts. Not even a periodic homicidal longing?" She looked at me like maybe I was a little off myself. Everybody has a different point of reference on normal domestic life, I guess.

A woman walked in holding one leg completely stiff. She was there for leg pain. She removed her pants and her right leg prosthesis to reveal the remaining thigh with its smooth but very abrupt termination above the knee. Someone had "bumped" her with their snow machine while she was walking on the ice-covered Selawik River a few years back. She had phantom limb pain as well as localized stump pain from her ill-fitting prosthesis. I looked over her list of medications and there was nothing beyond Advil for pain. Now this was someone I think I could help. We talked about the dreadful changes in her body image. She was remarkably courageous as she talked about how this event had disabled her from work and from life too. Just thinking about her dragging her right limb around the town boardwalks, hoping not to get hit again, made me wince. This place was worse than Paris for people with disabilities.

Phantom limb pain is one of those fascinating areas of medicine. The brain is still wired up as though the leg was still there. It put me in mind of my family configuration now. I think Jon, Mike, and I are suffering from the same malady. Our brains are very much configured to think of ourselves as a family of four. And part of us has been amputated.

People up here are particularly vulnerable to snow blindness, which occurs when ultraviolet light from the sun reflects off the ice and snow and damages the cornea. The Eskimo created sunglasses from caribou antlers, carving two thin horizontal slits which reduced the UV exposure considerably while allowing them to see to hunt and fish on the winter tundra.

A blind middle-aged gentleman came in asking for a referral for surgery to recover his sight. When he was 11 he suffered a case of snow blindness and lost some of his sight. Then he lost most of the rest of it when he went out on a search and rescue mission and forgot to bring his sunglasses. He needs corneal transplantation. Unfortunately he has a very vexing problem as he needs to see an optometrist in order to have his disability paperwork completed so that he can get Medical Assistance to fund the transplant. Because he can't save the money to fly to see the eye specialist, for reasons I can easily imagine, he is stuck waiting for his luck to change so he can see again. I suggested to the health aides that the village hold a fundraiser for him. Better yet, they could call him when the private optometrists come to town so he would not have to fly anywhere. I pleaded with him not to spend his dividend check this November on anything but this problem. I sure wish I could have signed his papers.

One early evening I was staring out the back window at the tundra and nearby windmills and fuel tanks, when I saw a red fox, or kayuktuk, prance within spitting distance of the clinic. I have romanticized the red fox ever since I saw one in the hills of West Virginia just at the time I was inhaling Carlos Casteneda's books in my mid-twenties. Casteneda describes how each person has an ally in the animal world and I imagined mine was the red fox because of my own auburn pelt.

When I started working in Alaska I noticed that my patients had a hard time remembering my name. So I decided to name myself Kayuktuk so people could ask for me without having to recall my name. I thought it natural that they might remember me as red fox because of my hair.

One day in the outpatient clinic in Kotzebue last summer, a woman asked who named me Kayuktuk, and I said, "why me!" And she gave me the most peculiar look like what I had just said was amusing bordering on bizarre. Later, I read about how important names are to the Inupiat people. They name babies after recently deceased individuals who are highly esteemed.

The traditional belief is that the name of a person has a life of its own independent of its bearer. It is the sum of all the best qualities of all the people who have ever been called that name. There was a time when people believed that a baby cried at birth because it wanted its name. Names were believed to protect the bearers - like an amulet, which was also in common useage. One of the first things I noticed when I came here was how many young people have old fashioned names like Herbert, Enoch, Alford,Vernon, Emmanuel, and Grace.

So I made two capital cultural blunders: 1)naming myself 2)after an animal.

The Friday before I came, the health aide from Selawik had called me in Kivalina to talk about my schedule for the coming week. I told her that it was very important that I have a real bed to sleep on. She said the dentist and her assistant would be there also. I told her my back was bothering me, especially after these past four days on the floor -- practically -- in Kivalina, so could I not preempt my dental colleagues -- perhaps the younger of the two?

On arrival, when I found the second floor lodging area above the clinic, the two bedrooms there were full of OTHER people's belongings. I noticed an office with a single mattress on its side, one that I would soon find out was hard as a flat rock.

My second night there I had the idea of cutting down on my sleeping pill. I was worried my brain was becoming accustomed to the higher dose I'd been taking since Daniele's death, and I wondered if some of my recent memory loss was from the sleeping pill instead of the grieving. I wasn't thinking about how badly I was sleeping, adjusting myself through the night to avoid pressure from the hard mattress against my hip bursae which were inflamed from my mountain climbing exertions in Washington ten days before.

I slept poorly and woke for good at 6:00 AM -- too early for me.

I picked up the book I was reading, Care of the Soul by Thomas Moore, a psychoanalyst's take on life. I read the chapter on "Jealousy and Envy: the Healing Poisons." He tells a client who is contending with his jealousy that "this very active and influential child in your soul wants complete openness and freedom. That leaves a sense of order and limit in the garbage can of repression, where it stirs and becomes wild and unreasonable, and potentially violent." That sounded like our Daniele. Then I read on about envy as "a hyperopia of the soul," when one fails to see the value of one's own life. This, too, resonated with what I knew about Daniele. In June, she had walked out of a musical event at the Cedar Cultural Center that Mike and I attended with her because the East Indian singer-songwriter was also a physician, who started referencing her experiences as a doctor as it affected her songwriting. Pure envy on Daniele's part. She said more than once that she never wanted to be a professional anything. I read on and started crying -- some of the rawness of my emotional state attributable to my inadequate sleep.

My thoughts blackened as I thought about the dental staff sleeping in their comfortable beds and my sense of entitlement raged full speed ahead as I thought about my special vulnerability at this time. The dentist even had her own assistant! I was at the mercy of whatever health aide happened to be there to give someone whom I had seen a vaccination or a medication. And there were four of them floating about seeing patients, on the computer, doing errands for the clinic. It was all mass confusion -- something that in the pre-suicide days would have rolled right off my back.

As I made coffee in the little kitchen, Wanda, the middle-aged very sanguine dentist sat down with her cereal. My face tear-stained, I told her that I was having a terrible time sleeping on the hard mattress on the floor hemmed in by office furniture. I told her my daughter had died eight weeks earlier and I needed to be able to sleep if I was going to see patients competently. I told her I had asked the week before for a real bed and bedroom and the dental staff preempted me. She said she had heard about Daniele's death and then she embraced me for a bit too long, given that I hardly knew her and hugging her was not consonant with my current mood. To the contrary, I really wanted to turn on my heel and leave the room. I had already embarassed myself with my self-pitying, accusatory monologue.

Instead I settled down, and we had a conversation about her travels to Nepal and the recent death of her best friend who had accompanied her there so many years ago. It seems that people often want to talk about the deaths in their own lives as a way of feeling more at ease with me and my story.

A little later she brought me an egg-crate bedcovering that she found in her room -- exactly the fix I needed along with a return to the higher Lorazepam dose. I would just have to live with a few verbal garblings and forgotten names of people and medications. And the mispelled words ...

When I went downstairs to start the day I told Warren, the health aide and Baptist minister, that I needed a dedicated helper. I matter-of-factly mentioned Daniele's death, and he promised me himself for the whole day. And invited me for dinner.

He picked me up at clinic the following evening on his four wheeler with his two children. He said the rumor mill in town would really start cranking if people saw just the two of us cruising around town together. He gave me a tour. We passed children ice-skating on the Selawik River - it looked like a scene from Hans and the Silver Skates. We passed the Native store, the two churches, and the new clinic.

His house was newly renovated on the outskirts of town - near the bridge to the airport - an ex-ex-urb's ex-urb. His wife, Gayle, made the most delicious freshly ground Caribou stroganoff and real Alaskan blueberry cake. I stuffed myself for the first time in ages. I think Gayle was grateful, maybe starved, for conversation with a middle-aged middle class educated woman. She was home schooling her children including an adopted Inupiat boy. The children never went anywhere alone in the village.

Originally from Texas, they had ministered to the Native people in the village for thirteen years. Warren had seen the darker side of human nature. I intentionally did not ask him to elaborate that night. He had alluded earlier in the evening to a little child's blistered feet from running away from a predator at home into the freezing Arctic night only to find everyone's door locked until she found shelter at the home of a health aide.

Just after dessert, Warren got a call from the health aide on-call that a man had slipped on the ice and injured his wrist, so Warren and I took off on the four wheeler. We entered a dark one room shack with just a single light bulb on, marijuana smoke thick in the air. The injured man lay on a bed, smelling of spirits too. His two friends watched as I examined him. He yelped wherever I touched him along his wrist and forearm. We took him to clinic and placed a splint on him. He'd fly to Kotzebue for an x-ray the next day. He kept repeating, "Man, I never hurt myself before." Meaning, while high, I presumed.

When we reached the clinic, a medivac plane was on the way. A 28 year old woman had swollowed fewer than 5 antibiotic pills because her boyfriend of one year broke up with her. As I talked to her, it became apparent to me that she was at very low risk for suicide that night and the 20,000 dollar plane ride totally unwarranted. Because I was at Warren's house, the on-call health aide had reported the problem to the emergency room doctor in Kotzebue, and the patient was pretty much automatically flown in. In a place with the highest suicide rate in the country, very few questions are asked if someone says they took pills to die. It's a free exciting way to get to Kotzebue for a few. Other times it saves lives. Deciphering the potential for self harm is challenging - everywhere.

Five weeks after her death, I learned how Daniele spent her last day alive as told by her boy friend of three months. Brian approached me at the Triple Rock Social Club, her favorite bar and venue for the Daniele Frazin Finley Foundation fundraiser on September 27. He had not come forward at her funeral to meet Mike and me. She had mentioned him as an intimate friend when we spent our last day together three days before she died. He was surprised I knew who he was. Daniele was not able to commit herself to a relationship in the past few years, and made sure her closest male intimates knew it.

They had driven around all that day, and she kept repeating, "If I lost my other Pizza Luce job I'll hang myself." They drank and drove for hours and saw a comedy show at Hell's Kitchen that evening in Minneapolis. He said to me, "I know it's not good but she could drive really well while drunk." As her manager, he knew she was fired from both restaurants where she worked, as it was one family-owned company. He did not confirm for her that day what she knew to be true - she hadn't lost the one job when she walked out mad at Sunday brunch. She was out of both jobs. She dropped him off at Pizza Luce Uptown around 11 PM and went home and swollowed Oxydodone, Ambien, and Xanax. She was dead in about an hour and a half.

He was beside himself in grief and guilt that he hadn't known she meant it. Sobbing, he said,"Everyone says they want to hang themselves but they don't actually do it." Poor Brian. I kept hugging him in the booth where we were sitting that night at the Triple Rock bar, telling him over and over, "It wasn't your fault. You couldn't have known. We who knew her better than anyone didn't know." Daniele had called Mike at 3 PM that day saying she had lost her one job and was worried she would lose the other. His last words to her were, " I love you Daniele."

She suffered quietly. Angrily. Pridefully. She would never have shown up at any clinic or hospital to announce that she was done. Unlike the woman in Selawik that night, Daniele meant to die.

Kivalina

Dear Friends,

After a wonderful time seeing my dear friends, Carol Jones and Peggy Visher in Seattle, including day hikes on Mount Rainier and Cascades' Mount Baker, I flew up Sunday october 11 to Kotzebue, Alaska for my sixth trip since June of 2008.

My employer, Maniilaq Health Organization, is adrift in change and chaos. No one has stepped forward to be the medical director given the way things have gone the past few years. I decided I'd deal with whatever presented itself, making no inquiries ahead of time about the state of affairs.

First thing I discovered on my arrival is that this place, which is 85% Native Alaskan, shuts down on Columbus Day! That meant no income Monday for temps like me who don't staff the ER. I have never worked anywhere that closed for this particular American holiday so I found it disturbingly ironic that people up here wanted to celebrate it.

The schedule showed I was assigned to travel Tuesday to Kivalina, a small Inupiat village on the tip of an 8-mile barrier island between the Chukchi Sea and a lagoon, 80 miles north of Kotzebue.

Kivalina was inhabited 1000 years ago by a pre-Thule community called the Ipiutak. The people hunt bowhead whales, seals, and fish with seines or rod and reel. It had its first school and electricity in the 1970s.

Before I left, Sandy, a nurse midwife colleague, reminded me that the village's health center has no running water. She regaled me with her adventure falling backward while trying to sit on the "honey pot." I did not ask for details. I'd deal with those logistics later.

I showed up at the bush airport, Bering Air, in Kotzebue at 10 AM Tuesday and waited until noon to find out that the plane wasn't flying due to fog in Kivalina. I walked home, ate, and waited some more. The afternoon flight was lovely -- mostly flying low over burnt orange Arctic willows and brown tundra dotted by small bodies of water everywhere. As we approached the airstrip near town, the little village of less than 400 inhabitants looked vulnerable surrounded by all that water.

The village aide-in-training arrived right on time to take me from the airstrip to the clinic on a four-wheel ATV. The only problem was that my bags did not make it onto the plane, probably because of the flight delay.

I quickly asked the critical questions about bedding and keys. Everyone who works in the smaller village clinics deserts right at 5 PM, and I had 30 minutes to figure out how I was going to eat and sleep and get in and out. No keys and I'm a prisoner inside for the night.

Most of the food in the village store is packaged and the fresh food is, well, not very. I knew that this is a fisherman's paradise -- a place people with airplanes fly for fishing -- so I straightforwardly asked all assembled in the clinic if anyone could get me a fish for dinner. No response.

I had nothing with me but my stethoscope, Blackberry without phone capability here, and my wallet and ID. No food, clothes besides the ones I was wearing, nor toothbrush. I figured I was in training for my future Third World endeavors.

I noted the "honey pot" or puk-vik, which looks just a little bigger than a toddler's potty chair. It's a 5-gallon bucket with a 13-inch-diameter toilet seat stuck on top. The rim of the seat is two inches on the sides and less in front. The name on the bucket is "Luggable Loo."

The sign on the wall tells you to scrub your hands for 20 seconds -- or sing Happy Birthday two times through; however, the bucket below the sink that catches the washwater looked small, which put a dent in my handwashing -- I maybe did a half a happy birthday. My fear of germs could not compare with my dread of water flowing all over that tiny bathroom floor. Fear of flooding is something borne from home ownership I suspect.

The custodian, Terry, who has a hell of a hard job, what with no running water and a honey bucket filled with assorted doots to empty every day, entered just before closing. He stuck out his hand and introduced himself. I shook it immediately, not thinking clearly about the risks entailed, unless he was one scrupulous janitor. He had an incredibly sweet smile so I asked him if he could find me a fish for dinner. He asked if I liked whitefish and before ten minutes were up, he handed me a whole fish, a cup of oil, and a skillet to fry it in. "Just cut it in half, cook it scale side down, and don't eat the scales or the skin!"

I had never gutted a fish. First thing that pops out is the circulatory system, I think. Then a bunch of blood. I finally just ripped the spine and most of the bones out, after cutting off the head. I guess I was pretty hungry. It fried up real nice with just a little salt. I wished for cutlery and plates but used a tongue blade and emesis basin, which is used more commonly for food going the other direction.

I was grateful but uneasy remembering that this generous man was going to be responsible for dumping my doo-doo everyday.

I slept on an ancient water(?)-stained mattress with bulging springs on the floor of the only exam room. The other two smaller offices have various electronically-driven machinery that make too much humming noise to get a good night's sleep. As I have to drug myself to sleep every night, I was fearful of having to alert for an emergency while clearing out my bedding to make room for the patient.

My main job was to provide primary care to all the patients with chronic diseases. No medical provider had been to the village for six months so there was a big need among the older people to get referrals to specialists who come up to Kotzebue periodically and to change or simply reorder medications. I have a health summary for each patient, which helps enormously in making a quick survey of what the person needs to stay healthy and ahead of complications from their heart disease, diabetes, high blood pressure, and assorted other problems. I did a pretty complete history and physical on everyone I saw, which was time-consuming but rewarding.

Some of the men looked a little surprised when I asked them to take down their pants to examine their testes and discuss testicular self-exam. A man in his middle 50s was missing his right testicle and acted like it was the most natural thing in the world. I, on the other hand, was conjuring up testicular cancer if the organ in question has been sitting in his lower abdomen all these years. When I mentioned the problem to the health aide, she looked startled and said, "I didn't know he was missing a testicle!" It's hard to pull a fast one on these health aides, who have been seeing the same 400 people for "how many years?" The latter is an Eskimo colloquialism often used to express uncertainy or certainty about a measure of time.

I spent evenings walking along the black sand beach watching the surf roll in on the Chukchi Sea side, the sun dipping in the northwest sky against low-lying clouds. Sometimes I would wander over to the quiet lagoon side where the seagulls cavort, and boats are tied for ready use. The hills east across the water reflect pink, blue, and orange hues from the setting sun.

No wonder people don't want to stray very far from this skinny piece of land. If this were anywhere else almost, there would be beach restaurants and noisy bars, people body surfing the waves, and houses crowding the water. These people don't mind a stiff cold breeze and ice underfoot when it means the freedom to fish from the water that is everywhere, hunt marine mammals, and watch endless beautiful sunrises and sunsets among people known and trusted.

But Kivalina, which lies at 13 feet above sea level, must move to higher ground at a cost of $400 million. Severe soil erosion during storms has threatened its future livability. The village governance or IRA (Indian Reorganization Act, not Irish Republican Army) is suing nine oil companies including Exxon Mobil and 14 power companies for the production of greenhouse gases that are contributing to global warming.

They are evidently hedging their bets on the success of their lawsuit and the engendered moving funds, since they are constructing a new health clinic about 100 yards from the sea side that will have running water and all the modern amenities except regular on-site professional medical care.

....................................................

Daniele's face pops into view the moment I alert each morning. I am nauseated and cannot eat. Post-death is like a bookend with pre-birth. Except eating made me feel better when I was nauseated in pregnancy -- to the tune of a 44-pound weight gain. I've lost aout 15 pounds since she died.

Nights were lonely for me in the village. No Mike there. Thoughts of my dead daughter crowded my mind unbidden. I became angry about her death, not for the first time, but more intensely. On the third day, I wrote Mike a letter that expressed the disparate snatches of daytime thoughts and nightly subterranean wanderings. I worried the letter would destabilize him emotionally and me not there to soften the images, and make everything better again.

I was dissecting my ambivalence about her. We were so completely different. I knew I had kept my distance from her these past seven years. I was always ready to help out with medication prescriptions for her urinary tract infections -- she never had to suffer more than a couple of hours from the burning pain. I even helped her long-distance through her bowel difficulties after her surgeries, as her rectal surgeon was remiss in treating this most basic post-op function. But this was mechanistic mothering.

We found it hard to find meaningful common ground with one another. Our values were in deep discord. I was always kind, no disparaging words, no anger manifest. But she knew I disapproved of her choices: binge drinking; avoiding any kind of training that would have enabled her to work for a sustainable wage with benefits; smoking cigarettes; and playing hard with her punk friends, the need to find acceptance in her chosen subculture more important than her independent development as a young woman.

And as always, I tempered my judgment with the understanding that all of it was engendered by her unique gyrating neurowiring. How culpable was she for her choices? It wasn't my job to judge, just to support and maintain an attitude of patience. But because she admired me and knew she was disappointing me, her lousy self-esteem since childhood suffered accordingly.

I railed. "You said after the failed OD over Roy in 2004 that it was the stupidest thing you ever did. We had an unspoken contract. We wait it out, helping you in focused ways to get through your young adulthood, and you hang in there until something better in life shows up for you."

What a miserable defiance of the most basic life tenet, Thou shalt not kill! You, who have been given so much all of your life, even by first world standards. You threw it all away. How could you do this to us? Especially to Mike, who loved you just as you were, always ready to pick up the messy pieces, drive you to work for two months during the Minneapolis bus strike, accompany you everywhere until you could finally get your driver's license at 21? Who wrote poems celebrating you during childhood and then letters by the score in these later years about how to feel less anxious and more in control of your life?

Why did you have to die in order for us to find out all the wonderful things you did for your friends? The thoughtfulness you showed them, not us? We would have pounced on these gifts you gave others -- something of great value that we could authentically endorse.

It wasn't enough to tell all your friends how great we were. No consolation prize, that.

I feel like both the victim and the perpetrator, a paradigm I usually abhor. She trumps my stepfather David, if that's possible, because I was never responsible for his ugly behavior.

I question everything. Grieving homework must be done to get to the other side. We were a doomed dyad, that's what I know this week.

.....................................................

The Washeteria, where people go to shower for three dollars and do laundry, is open noon to five, closed on Wednesday. I remembered one of the permanent staff telling me that this village has the highest methacillin-resistant staph infection rate (bad and harder to treat) in the entire burrough, probably due to poor hygiene from lack of running water.

I recalled working in radiotraffic one day last summer and receiving a picture of an 11-year-old boy's red, hot buttocks. I authorized him in from Kivalina to our hospital in Kotzebue to have the infection incised and drained. This is one of those times when a picture did not convey the extent of the problem. Working in the hospital clinic the next day, I heard this little boy wail for about an hour while the nurse practitioner cut into his infection. I deeply regretted not sending him to Anchorage to see a surgeon and get some decent anesthesia.

By day three I was ready for a shower. The health aide told me I could sneak into the high school during volleyball practice after clinic closing. As she ushered me into the girl's bathroom, two young volleyball players who were gregariously showering together froze and then giggled. I waited for them to cover up and then headed in myself for ten minutes of hot watery pleasure.

The clinic power went out at 6 PM one night just as I was ushering the last patient out the door. I panicked a little thinking about no phone, computer, maybe furnace, or light to read by. Even worse was the squawking noise that the alarm system was making every 60 seconds.

I asked the elderly woman I was seeing if I could accompany her back to her home to use a phone to remedy the situation. Her exceedingly deaf husband, whom I had had to practically yell at to be understood earlier that day, greeted me warmly. I glanced around the spacious HUD-built main room to see a three-month-old baby in a stroller with a bottle hanging out of its mouth. This is the imfamous "bottle propping" that we try to discourage. His mother sat vacantly on the couch watching TV without looking up at me. A toddler wearing only diapers (the temp was 30 degrees outside) ran into the room to see what the commotion was about. It was a brief window into the multigenerational households that are the norm up here.

Small children somehow manage to play near their houses and avoid being hit by the four-wheelers that race around despite all the signs posting 15 MPH. They often ask me my name. One little girl squinted up at me and answered "But aren't you a boy?" It got me to thinking about the Eskimo beauty esthetic. Round, chubby, high cheeks with a small nose is highly regarded in these parts. She was likely responding very openly to my Jewish Lithuanian face. "Boy" from an eight-year-old's perspective surely does not mean pretty.

Friday night entertainment included an all night Gospel songfest at the Friend's Church, a high school volleyball meet costing $6 for adults, and Bingo. After seeing patients all day, I chose to spend the night alone. The ever present VHS radio babble caught my attention with a warning that there were two bears and a cub at the town dump so we should "be careful out there." Only problem for me was I didn't know where there was.

On Saturday I flew back to Kotzebue. I found a pustule -- like a zit dotted with pus on top -- on the back of my right thigh, just where the lid of the honey pot had touched it each time I sat down in the Kivalina Clinic! I guess the germs don't discriminate between villager and visitor when bathing is at a premium.

I hope you are all well, dear friends. Love,Rachel

Disarray

Although it's just the three of us this year, plus Beau, it isn't all that different from the past few years. Daniele would spend part of the 25th with us and last year, just Christmas Eve. We had to trace further back to get a sense of our family as we once celebrated Christmas. The memories fuse together with little to distinguish one year from the next. Once the presents were ripped open, the day was always a peaceful one, just us reading the books we received, eating the big midday meal, napping, and, when the kids got older, going to a matinee movie.

I returned in November to a house in disarray due to a total kitchen and bath makeover, the kitchen's contents strewn all over the dining room and living room. Within the chaos, Mike cooked up some remarkably good dinners with just a skillet and hot plate. He is one resourceful homemaker. Anyway, I only have myself to blame as I chose to go forward with a project I had been planning the two years before Daniele's death.

Being back in the Twin Cities brings reminders of her that are inescapable. As I travel about town, I acknowledge the people and places connected with her -- a kind of emotional-visual brief embrace -- followed by a letting go. It's like walking a line between remembrance and the moment, leaning one way and then the other.

My boys are doing well, all things considered. Jon just recorded seven of his finger-style guitar compositions in a professional recording studio. You can hear them soon on MySpace. Michael is writing more poems than he has in years. Now he sends them off to magazines or "zines" run by people several decades his junior. Many pieces were "in the drawer" and he's polished and edited them. He has more to say now than ever.

We decided to get out of town for Christmas, spending three days in the North Shore at the end of the Gunflint Trail, an hour's paddle (in the summer, that is) from the Canadian border. We occupied a cabin flush with sauna, jacuzzi, and deer hanging around our picture window. (They were paid in feed supplied by the lodge.)

The ski trails wend their way through pine, birch, and spruce forests along a tall ridge of snow-covered granite. There was no sun at all -- just a light continuous dusting of snow. I'm not sure I am ever happier than being alone in the woods, herring-boning up and gliding down the hills on my cross country skis.

Thanks to you all for your love, words of wisdom and encouragement, thoughts and prayers.

...................................................................

Here is my most recently written Alaska narrative. I did not finish it when I came home due to all the tasks at hand with the remodel. The work I do there is so meaningful to me and has helped me get through these early months of grieving.

In mid-November I returned to Noatak, one of the eleven bush villages we service. This is the place where I described the aftermath of an adolescent boy's suicide by gunshot last January. This time I brought my own tale of loss.

I spoke of it first to C., the health aide whose 13-year-old foster brother shot himself last December. She was the one who had found him with his face half gone. She reacted calmly to my news. Suicide touches everyone here. Because it is not shocking, people respond with an air of resigned empathy when they are given the news. They understand what it's about.

I bore up well until the third day of the village visit.

The day began with home visits to elders whose mobility is impaired. We entered the first house just after the old man had taken his shot of insulin. This meant we had to wait patiently while he finished his breakfast mush to ensure he did not become hypoglycemic. After describing his concern about his cough, he spit a sizable blood-tinged specimen into the garbage can. Diagnostically speaking, it doesn't get better than that in the absence of X-ray machines and scanners. But now it was too late to visit an elderly woman with breathing problems, since people with appointments were lining up in the clinic waiting room on the other side of town.

The father of my friend from Kotzebue came in with vomiting and a 20-pound weight loss. He'd already been seen a couple of times in our bush hospital without a diagnosis. So I decided to arrange for a direct admission to the Native hospital in Anchorage for an extensive evaluation. First, however, I had to convince the internist on call there that I had good reason to bypass our local hospital.

When I reached the on-call doctor, a sassy Aussie, she said he should go to our regional hospital for a third go-round instead of a direct flight to Anchorage. After a few volleys back and forth, I gave up and said goodbye. I called our hospital and discovered he would have to wait a month for the barium swallow study she recommended he get first. I called her back to make a final plea. She said, "Well, if you had been listening to me, then you would know I wanted him to come here for the swallow study." My anger sparked and I said, "I suspect I may not have understood what you were communicating to me." I could feel my mood shifting in that moment from equanimity to fragility.

I started tearing up while examining an 84-year-old man after he told me his foster daughter was caring for him. Her two-year-old child gave him enormous pleasure. He tries to teach the little one Eskimo words but she usually replies in English because her mom does not know Inupiak. He was a very vigorous man for his age, still ice fishing despite his immobile left shoulder. He showed me how he uses his right arm to do all the real work of digging the hole in the ice with an upward and then downward movement diagonally across his body.

A seventeen-year-old young woman came in for her first prenatal exam. She had to quit sports because of a school rule against participation while pregnant. This seemed to be her main regret about her unplanned pregnancy. The father of the child listened quietly with gleaming eyes as I used the doppler to amplify the baby's heart sounds -- whoosh, whoosh at about 150 beats a minute. The father lived in a different village, and no one seemed to know where this incipient little family would settle. The grandparents will have to do a dance -- indirectly, Inupiat style -- to see who has the honors and responsibility. Some young people perform admirably as young parents, while others want to party and rely on older extended family members to take care of their children. These two struck me as responsible.

The elderly foster mother of the boy who shot himself last December came in for problems related to a pharyngeal cancer diagnosed last February. Our visit last January had centered on her grief and feelings of guilt because she did not sense her son's intention to kill himself. She had complained at the time of an earache, the sole symptom of her cancer.

Now she was suffering from post-radiation dry mouth and vertigo. I watched her daughter help her ever so gently onto the exam table so she could do her vertigo exercises there instead of on the bed at home, where it was logistically more difficult. I was moved by how tenderly her daughter arranged her mother's body on the table.

After the clinic closed, I tried to email Mike. I was feeling emotionally raw and needed to let off a little steam. The internet was down, so I called him on the company's dime. My voice seized up with emotion and with the effort to suppress tears. There is a 1-second delay that makes communication frustrating even while discussing mundane topics like the weather. We had to pause after completing a thought or we tripped over each others' words. I have a terrible habit normally of interrupting Mike so the delay was exacerbating our usual conversational dynamic.

We relived our regrets. "I could feel her going down," said Mike, referring to the aftermath of the second failed fistula repair in July when I was in Alaska. "I couldn't cross the bridge to keep her from spinning away. I sympathized. I tried to be her friend. I feel like a failure as a parent."

And I said, "The feeling of responsibility and the loss of control to act on it -- what a terrible duality."

"You know, I gave the children over to God four years ago," Mike said. "I just decided I couldn't be responsible for them anymore. I was feeling neurotic -- always on the hot seat to come up with a winning strategy. It brought me comfort. It freed me to be a person, not Daniele's spiritual adviser." I said I did not know he had done that -- our religious views were like two Venn diagrams barely overlapping over the years.

"It all ended catastrophically. For my faith and optimism. I am angry every day -- at God, Daniele, people from the church, friends. I spent five years praying to God to save my daughter. And it didn't work. She's dead and gone. That case is solved. That case is closed."

He said now he was redefining God as a force who is suffering with us instead of saving us. The anger in his voice transmitted well despite the distance.

"Our friends mean well but nothing they say can really help. No one can understand what we are going through. Some days I think I can never be friends with old friends again." He talked about our dear friends Mab and Larry, who had taken him and Jon out for pizza a few days before. He and Jon felt like they had to climb out of their bad moods to be good company. And it wasn't worth the pain. Some days it just cannot be done well.

Mike lamented the fact that Jon delimits our family constellation to the three of us. "The Berubes are his brothers" -- referring to our neighbors and the sons of pastor Ned and his wife, Susan, of Christ Community Church where Mike and Jon had gone to church for many years. "They bring comfort and annoyance like any biological brothers."

We both agreed that we want to embrace our close friends as family. But we understand that it is a more challenging notion for our introverted 21-year-old son who didn't grow up with accessible extended family members. Mike says he wishes Jon could accept the love of others more easily.

The conversation swings back to Daniele. We wonder aloud again if we should have pushed her harder to get help. I remind him that over the years it was like rats pushing a a bar for treats. After a while we just gave up. No treats.

He countered: "It was your optimism over the years that kept her going. I was the one who withdrew. The helper in me had come to a halt."

We acknowledged our fear of her. We did not want her to get mad at us. She had the power to break our hearts -- to slam the door in our faces. So we tread lightly. It did not matter. She slammed it anyway and forever.

As I feel ourselves hurtling down the emotional vortex, I feel impelled to pull us back out. I remind him of all our beliefs that are positive and true -- our essential blamelessness.

I remind him of all the wonderful letters, calls, and visits from friends who were amazed by our courage throughout the first few weeks. Did we not go to her posthumous 25th birthday party at her favorite punk bar on Minneapolis' West Bank two days after her funeral to celebrate her life and support her friends? And what about the foundation we established for suicide prevention? We were making good on the awfulness.

I speak of the opportunity to grow from this, to put the experience into the "soul bank."

Mike argues, "I can't put it in. Brave? Isn't it dishonest to pretend that we have accepted and transcended this? Premature?"

I argue back. "But you have -- you spoke the truth about how difficult she was, how she would have been an adolescent suicide but for all the negotiations, decisions, compromises we made while she lived under our roof. She was a wild child, a Zombie girl -- with her volatile negativity and marvelous creativity and authenticity." I remind him about how strong we have been in these mere TEN weeks since her death.

Mike relents: "You did not give up on her -- always expecting her to become independent despite the difficulties. When she talked about going on social security disability after her first overdose in 2004, you said no way. You showed confidence in her -- that she could make it on her own -- which was exactly what she wanted and needed."

But then he says, with an air of defeat, "What's the use of all our consciousness?"

I have no answer. Today. I only know that helping others is keeping me sane no matter what I think about from day to day.

By the time we got off the phone it was well past the time I was supposed to do the second home visit. I was sitting in a puddle of tears and tiredness when the clinic phone rang at 8 PM. I'm always reluctant to answer it and it's not my responsibility. But I worried it was the home bound elder with the breathing problems I missed earlier that morning, and sure enough it was.

I apologized repeatedly for not going to her house. My voice was catching all the time as I talked so I finally blurted out the truth. "I haven't made it because I've been on the phone with my husband in Minnesota talking about our daughter's recent death by suicide." She says not to worry, she can wait. My professional self kicks in: "But what kind of breathing problems are you having?" After she describes the problem, I inhale and promise to be right over. After looking over her health summary, I pack along steroid pills and and an antibiotic.

I walk out to the ambulance, vaguely reaching around my pockets for the keys out of habit. I forgot that they're always left in the ignition. This vehicle, which is a cross between a pickup and hearse, would be just right for a joy ride. The radio pops on as I look around the cabin, figuring out where the mirrors and sight lines are. Kotzebue's AM station is playing nonstop Christian music -- some live -- as it's pledge week. The voices are a wee off-tune with a steady thrum-thrum of the guitar behind them. The sky is clear with stars, the moon three-quarters, and the air is very cold but still.

The village is divided into three parts: the village center on the big Noatak River, "Beverly Hills" which is on higher ground with newer houses overlooking the river, and the outskirts inland from the river where the clinic and school are. It's a crooked ride into the center village. She had told me she lived near the large "tank" in the blue house. I knocked on the door of a blue house not far from a storage tank and it was the wrong house. Too many tanks in town storing all kinds of stuff from over all the years. And a rash of blue houses to add to my confusion.

As I entered the house, I was hit with the acrid smell of tobacco coming from my patient's bedroom. I asked her from the entryway to put out her cigarette as I have asthma. I hated being so blunt when I hadn't even met the woman yet, in person.

An elderly woman sitting on the couch in the living room beckoned to me with her hands upheld in a V. Hugging me, she said, "I'm MB's friend. I help take care of her. She told me about your daughter. I lost three of my fifteen to it." I asked whether they were living home at the time. She said, "just my foster son" -- one of the other two boys was married at the time of his suicide. An evangelist is preaching on the TV, the cadences so familiar I don't need to hear the words to know. I asked her how she managed to deal with the losses. She says "Jesus. And he will make you well." I told her I didn't believe in Jesus as savior but I appreciated her words of encouragement. I immediately felt guilty about speaking the truth, not wanting to violate this well-intentioned elder.

I headed back to the bedroom. M.B., a 79-year-old with long gray-blond hair and twinkly eyes, lay half-reclining on her bed in her 6 by 8 foot bedroom. You could see how beautiful she once was. Her breath came at about 40 times a minute, shallowly but quietly.

She presented a confusing history. Her upper back had bothered her the night before and the tribal doctor had come over and massaged it. Her shortness of breath and cough are like always. "Show me your nuvuk" and she spit into a nearby orange juice bottle. Frothy white -- chronic lung disease and maybe heart failure. This was the fourth hocker I had seen that day. The Inupiat people do not feel shame or embarrassment talking about or producing phlegm. Maybe it's because noses run so frequently in cold air. Mothers from the old times were accustomed to sucking it out of their babies' noses. Some still do.

She tells me she had 16 children with two sets of twins but many died when they were young from diseases like Influenza. When I ask her how many are alive she starts to name each living one, using her fingers. I tallied it at six. By percentages, she is batting 3/8 to my 4/8. I think about how impossible it is to compare suffering, or to even measure it.

I listen to her breathe -- wheezes everywhere in her lungs, she is barely moving air. We collect all her inhalers and I find out she does not know how or what to use when. She complains that the health aides never bring her medicine (which is not their job.) And I ask if the sons who live there can do it. She shrugs no as they have no vehicle to get to the clinic. Walking is evidently not an option for the younger generation in this home.

She has great compassion in her eyes as I answer her questions about my daughter. I feel this sense of connection -- I am no longer only the Naluagmiut (white) nurse practitioner coming to treat her medical problems.

She asks me if I want canned soup for dinner. I thank her and say no, worrying a rejection is implied in my refusal. Then I see two big bags of candy on her dresser. "But I would love some candy." She breaks open the bag left over from Halloween, eager to give me something, as is the custom when someone pays a visit. I grab Smarties, Sweet Tarts, and Tootsie Rolls. I didn't realize until that moment that I was craving sweets. My dopamine receptors (the brain chemical that makes addicts keep looking for more) were parched.

After teaching her about her inhalers and extracting a promise from her son to go get her medicines when they run low, I don my layers of clothes as she tells me I am welcome any time to eat or sleep in her home. I climb onto the ambulance seat and try to find my way back to the main road. There are no street lights or signs. I find myself becoming increasingly confused about where I am. Turning around is tricky since I can't see very well behind me without a rear-view mirror. I worry about crunching some wandering child if I back up. Or that I'll get stuck in a hill of gravel, which is like a mound of snow, which is unaccountably absent.

Then I spot a car stopped in front of a house, the man leaving the engine running. I feel around quickly for the door handle. He's already inside by the time I finally find it and pull. I turn off the engine, leaving the ambulance in the middle of the road. Without knocking, I tail him inside and find myself in a living room stocked with boxes of candy and coolers with soft drinks. A baby is standing in a nearby playpen. The man tending the customer who has just walked in ahead of me finally looks up at me. A little embarrassed, I ask how to get back to the clinic. He starts to draw me a map and then I hear someone say, "I thought I recognized that voice." One of the villagers I know enters the room and gives me a big hug. "I was wondering when you would get down to our store." Their business kicks in when the big Native general store closes at 6 PM.

As I step back into the frigid night with the map, I am greeted by a woman wearing an official-looking hat and badge over her snowsuit. "Anything wrong here?" It's the village peace officer. Her eyes mean business. After I explain my recent predicament, she makes me an offer. "Would you like me to drive you where you need to go?" With relief, I slide into the passenger side and she takes the wheel. Except she thinks I'm on my way to, not from, the home visit. So we wind up back at MB's house.

"Do you work with someone else?"

"No, just me, twenty-four seven." I register my amazement. "It must be hard and scary to handle domestics by yourself." Two squads always go to scenes involving domestic violence in the city because of the high risk of injury to the response team.

She says,"Nothing scares me." I comment with a question in my vocal pitch, "Some of your own life experiences must've toughened you up for this line of work?" No comment.

"How many years?"

'Twelve."

"I'll bet you know where all the trouble houses are."

"I do."

After we pull up to the clinic, she offers me her cell phone number, in case I get into any more trouble. I stammer something about not usually needing help while I'm in the village. I ask her to come in and have hot chocolate or tea. She comes in briefly to write her cell and email address for me. She has to keep patrolling the village -- 9PM to midnight -- every night by foot or vehicle. Only now her truck needs repairs so it's all on foot.

I ask her how she does this work without a weapon. She pulls out pepper spray from the left upper pocket of her snowsuit, then her baton from her right side. She shows me the flashlight in her back pocket. No further explanation needed.

She says, "Gotta get going to the other side of town now and ring the curfew bell at 10." Then for the first time she smiles at me and I open my arms to embrace her, briefly.

Night in and night out, no matter what the weather, she makes the rounds. Puts herself in harm's way. She is the keeper of many village stories, including a few of her own I suspect.

Love,

Rachel

Forensic Ed (Reader Discretion Advised)

August 1, 2009

One of the best parts about working in a remote hospital is the opportunity to rub elbows with people who are doing work that would normally isolate them in some dank office downtown.

One of our physicians, Dr. M, is a young man with cerebral palsy. His spasticity prevents him from getting a license to do family practice in other states, even though it's pretty well controlled with a spinal shunt that infuses medication to help relax his muscles. He does not want to make the Arctic his permanent home, so he decided to become a forensic expert in child abuse. He'll start his 3-year residency next summer. In the meantime he'll continue to provide expert testimony on cases of adult assault and abuse of children here.

I thought I should take advantage of Dr. M's expertise while I could, since sexual abuse and domestic assault are so pervasive here. Alaska has six times more child abuse than the lower 48 and here in the Northwest Arctic Borough, the highest rate in the state. I was spoiled while working in Minnesota as St.Paul has the world-class Midwest Children's Resource Center, where I referred all suspected cases of childhood sexual abuse during my 20 years of practice there.

Although I feel the need to be more knowledgeable because I am working on the front line here, the basic practice rule stays the same: if the story sounds plausible, the nonspecialist like me needs to send the victim right on to the child abuse specialist because of the chance of contaminating the story by leading the victim. A clinician's innocent blunder can ruin a court case. As Dr. M explained to me, there are volumes written about how to extract the story and analyze the physical evidence in order to elicit the truth about what happened. Generalists don't make time to study those tomes. Except maybe the most curious or perverse practitioners. Seven percent of doctors are psychopaths, so who knows what they study in their spare time.

Dr. M was preparing expert testimony for a trial the following day and invited me to join him as he made a last pass through the evidence. This case involved an adult instead of a child, but I was eager to learn more about the physical manifestations of assault as it would help me hone my powers of observation during routine exams. Well-practiced medicine is after all a matter of astute sleuthing.

Dr. M read me the report he wrote based on the interview of a young woman who was strangled to the point of lost consciousness and then raped. The accused is up for rape and attempted murder charges. He proceeded to show me 180 pictures of her injuries as well as normal skin findings taken the night of her assault. He quizzed me as we went. I used my common sense but was sometimes clueless as to the signs he was showing me. The story is registered on the skin like the print on this page to those who can see.

Ninety-nine percent of rape here involves a woman who has lost all judgment and control from alcohol. I feel vindicated. Several of my female colleagues have told me it's unsafe to wander around town alone. So I can walk around town any time of day or night -- just as long as I'm sober.

We scan her arms. The paw prints on her arms are easy to decipher. The initial grab.

Two symmetrical bruises on the mid inner thigh? Cunnilingus. But which direction is he facing? Shouldn't his body be smothering her in case she wakes and resists? No, Dr. M says, the other way. He is stabilizing her legs with his thumbs to keep her from moving suddenly. Good hunch though, as women usually do come to during the rape.

When we get to the detailed photos of the vaginal area, I feel a comfortable sense of familiarity. During a pelvic exam there is a tendency to look comprehensively but briefly. Now I stare and study in a way that would be inappropriate with a live patient.

There is a vertical tear in the posterior fourchette, which is below the labia minora or inner lips. He tells me this is critical, classic evidence of forced entry. Like the cracked glass of the back door in a burglary.

He uses a colposcope, a microscope tailored to exploring human epithelial anatomy, to search the vagina for more evidence. Once, he tells me, he found a hair left by the perpetrator. This single piece of DNA-encripted evidence put the guy away for forty years.

We move up to the neck. There are bruises but not as impressive as I imagined they would be.

He had forced a kiss on her. She remembered that because it occurred before she had lost consciousness from strangulation. I made conjectures about the abrasions on her chin and lips and how his teeth or chin may have caused them. Dr. M appears at a loss at this point. He says, not too self-consciously, that he isn't much of an expert on kissing. I joke about my own knowledge and proclivities. What a strange moment, talking to this sweet, spastic, drooling man, who is 25 years my junior, about our respective experiences and acumen in the area of kissing.

Now we come to the most crucial piece of evidence. It is a centimeter-long superficial laceration along the jaw line. He asks me about its significance. I squint, cock my head and shrug. Jubilantly, as only Dr. M can be, with his infectious laugh that lasts just a beat too long due to his spasticity, he says, "Self-inflicted from her own fingernail, it proves that she was trying to pry his hands away from her neck as he was strangling her." They weren't playing a sexual game of asphyxiation as the defense will surely suggest.

We are just wrapping it up with a few pictures from inside her mouth when Dr. M points excitedly at something he missed before. There are petechiae (minute exploded blood vessels) on the inside cheek -- evidence of prolonged strangulation. This will help support the attempted murder plea because it suggests a greater degree of asphyxiation indicating an intent to do serious harm. This is important, he explains, because this is this perp's fourth victim in a town of 3500 people.

Although Dr. M assures me his job is "one hundred percent non-biased" as an expert witness, he wasn't exactly exuding neutrality at this moment, or throughout the examination. Instead I saw passion, and mission, and utmost seriousness. I can't help but think that all the childhood punishment he must have received for being a weird-looking spastic boy had to have made its mark on him. And what a functional if arduous way to get back at the dark side of human behavior.

Alaskan Animal Stories Amid a Little Night Music

July 30,2009

Dear Friends,

Last night after a hectic day spent in radiotraffic at Maniilaq Hospital in Kotzebue, I headed over to my friends' house for some R and R. Wendell Stalker and his wife Mary have a small beachfront home laden with animal skins, garlands of artificial flowers punctuated by pots of the real thing, pictures of family everywhere, and 5 or 6 guitars huddled along one wall of the living room. I detected as before the faint odor of dog, the scent of its rearend apocrine glands subtly wafting across the room.

Mary, who is usually the first to give me a big hug and big smile, hung back while Wendell, a gentle small Inupiat man in his fifties greeted me in his reserved way with a pat on the back and a mere meeting of chests. Wendell, pony-tailed, wears large glasses which allow one to track his very expressive eyes as he tells his stories in sotto voice. He met Mary five years ago in church where they began singing and playing guitar together. She's a down-sized Mama Cass, a California transplant who has spent her adult life in Alaska.

We started by talking about Wendell's music career. He and his four brothers taught themselves how to drum and play guitar. He played in an underground bar in Kotzebue in the 60's where he had a "chaperone" because he was underage afterhours in an alcohol saturated environment. After high school, Wendell took off for the Jobs Corps, a track many motivated Inupiat youth take to get work that pays. He started playing in a blues band and pretty soon he was making way more money than he was likely to make after graduating from the Corps with a technical skill. He and two other dropouts -- Native Americans from the West -- formed a band called The Local Blues Band -- and they got an agent and made some really great money playing all over the Northwest. He said, "Man, people in Missoula were only good for C and W until we came to town." No one up there knew how much they could like the blues. They made $15,000 on one gig -- gone getting high. Mary laughs then saying, "Yeah, we were all doing drugs, sex, and rock and roll back then." Wendell eventually played with Muddie Waters.

The Inupiat have a long tradition of partying for days on end after a successful hunt. It's like a prolonged carnivorous harvest celebration. Then they sleep for days. Wendell describes Thanksgiving homecomings in the 80's when all five brothers would stay up Thursday through Sunday playing music. "That's how many songs we knew back then." Now two of his brothers are dead and those are bygone days.

A break in the conversation, and Mary tells me that four days ago someone shot and killed Hunter, their 7-year-old dog she raised from just 4 weeks. She starts to tear up and says "I am so mad and I don't want to be mad." Somehow Hunter got out onto the road and when the neighbor children found him he was floating in the ocean face down. I looked blankly at her and asked why anyone would do that and she said, "it's fishing season." I just held her hand and said how sorry I was because a dog is as close to your heart as a child. And I knew too that her oldest son was killed in an auto accident in Fairbanks.

I said,"Well there's nothing like music to raise the spirits -- how bout you guys playing me some songs?" Then they dueted on "The Sweet By and By" and several Christian songs that seemed somehow familiar but I couldn't have named them. And it worked and before you know it they were telling me stories about living "at camp," which means the tundra, wild tundra of northwest Alaska.

Wendell reminisces about the years he and his brothers left their home in Kotzebue to help their aunt and uncle with chores on their homestead in Point Lay, a windy, forsaken settlement on the Arctic Ocean west of Barrow. They squatted in the abandoned sod homes, eventually building new places for themselves. It was a hard place to live for long as the wind never seemed to blow less than 35 miles per hour, 70 to 80 mph being the norm. Two of his brothers stayed on, married, and brought their wives to live there making it a tiny settlement without any amenities in the 80s.

"So," I asked Wendell, "tell me the truth about bears. How dangerous are they really?" The two of them then told me the story of their trip out to Wendell's family camp in a remote part of the tundra two years ago. They only had a tent and a fish-drying rack so this wasn't like a second vacation home. It was spring and a good time to hunt ugruk (bearded seal) from an immobile ice flow, shoot migratory ducks and geese, and fish.

They chose a fishing spot about a thousand yards from their camp where two streams meet forming a little peninsula. About three hours into an idyllic afternoon, Mary, Wendell, and their friend, Roy, spotted two grizzly bears moving aggressively toward them on the peninsula.

"They looked hungry," Mary said. Mary and Roy were very frightened. Wendell said he knew he could not let their fear enter him. He started yelling loudly in Inupiat telling the bears he would kill them if they ventured across the stream. He yelled at them for a very long time. He shot his duck rifle in the air to show them he meant it.

Wendell explains that he had to intimidate them with his body language, his vocal inflection, his eyes or they would surely cross the stream and attack the three of them. He described it as a very spirit-driven confrontation. Underlying it was a fierce cultivation of mutual respect between man and wild animal.

The problem was they had no weapon adequate to kill the bears. Now Mary talks about how stupid she was to have come unprepared. She left her Magmum 375 in the tent and her handgun had no ammo because she had removed it for safety reasons while on the bush airplane. She says this was the only time in all her years in Alaska when she wasn't prepared. "I let my husband down," she said, her disappointment in herself still palpable in the retelling of the story.

The bears turned around and ambled up the hill a ways. Then they turned back again and lay down facing Wendell, and watched and waited for 4 hours. He explains he couldn't retreat or they would have attacked. Mary by that time had rejoined Wendell with her Magnum 375. But they didn't want to kill the two bears except in self-defense. Killing them meant skinning and gutting them without proper equipment or the means to get them home. And a true Eskimo hunter never kills an animal only to leave it there to fester. This is considered deeply disrespectful to the animal's spirit.

Finally the bears went up and over the hill and soon the humans heard a great deal of squalking in the distance as the bears plundered the duck and geese nests, gobbling the eggs and the birds that remained to protect their young.

I asked Wendell how many times he had encountered bears in his life. He said about 15 times -- always with other male Inupiat hunters. I asked how those encounters were different. He said "The bears always ran away."

At the end of the evening I asked what happened to the brothers who stayed on in Point Lay. Wendell said one was eaten by a polar bear. I didn't have the courage to ask about the other.

Cultural Considerations

March 2009 Stint in Kotzebue, Alaska

Dear Friends,

I am a fish out of water - which may explain why I felt bad when I pulled my first sheefish out of a hole in the Chukchi sea ice last week, watching as it flailed about gasping for air for 20 minutes. My fishing companion and instructor, Chuck Luck, said "absolutely not" when I asked if I could throw all 15 pounds back down the hole.

The strangeness of my surroundings gets me to thinking about what's acceptable and what's not. How propriety evolves according to the needs and desires of people living in a specific place with its own unique cultural history.

As I flew from Anchorage to the Inupiat village of Kotzebue on March 1, I sat next to the a 12 year old boy who is an avid hunter. Mostly Arctic hares so far. But he's pretty sure his uncle will take him inland to find wolves - to thin them out as there's too many of them this year. For the record, Eskimos don't hunt wolves but wolves do eat their beloved caribou so I thought he might be telling me the truth.

He thought they could kill 40 wolves, maybe more. He's never gotten a caribou but soon enough he thought he would. I found myself encouraging him, thinking about other interests a young teen can have up here - mood-altering substances, sex, tobacco, and racing around on a snow machine without a helmet.

The truth is there's not much to do up here for children or teens. If a kid doesn't like to wrestle or play basketball, he or she is out of luck. There aren't any organized activities at the boys and girls club because it's hard to find people who have the time to volunteer who don't have some sort of criminal record. Kids don't take lessons up here. There's no baseball diamonds. Not even an ice-skating rink even though our lagoon could be made skating ready. Cross-country skiing? Nope. No bowling alleys. No swimming pool. And you can forget dance lessons. There is a small park near the cemetery equipped for the under 10 set.

So children learn to hunt early in life. During a sports physical last week, I found myself asking a 9 year old if he locked up his shot gun when he was done with it. His dad told me that once it's deployed there aren't any more bullets left. That's how much I don't know about guns.

Hunting up here is a cultural affirmation. Maybe even a kind of therapy, an appropriate way to release the destructive emotions like pent up anger. Better to kill to feed your family than violate your family. Better to pass on this cultural competency to the young. A suitable violence.

And fur attire only makes sense in this cold place. Wolf or wolverine ruff is best for keeping one's breath from condensing on the glasses and mustaches. Many of the women are able seamstresses making hats from seal skin or everyday leather and using beaver or fox fur for the earflaps and to warm the forehead. Animal rights activists would be laughed out of this place.

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Eskimos were hunter-gatherers until the late 1800s when white traders introduced items like rifles, tobacco and alcohol. The simple but brutal life off the land gradually became a mix of cash/carry and subsistence.

Now there are those that do some "subsistence" and those that don't. This word, subsistence, seems like a euphenism that some anthropologist made up in order to show respect for people who have until recently lived off the land. These "simple" people have a stoic core, a propensity for doing - not analyzing - that made it possible to survive in this hostile environment.

The material life didn't pass the Eskimos by any more than it has any other people who've had the option to indulge themselves. But now they must hold jobs in order to buy gas for their "snowgos", having abandoned their dog teams for the ease and power of zipping along on a machine fit with skis. Electricity, piped in water, and sewers are costly. Mushing is now a sport for the few people who have the desire,time, and money to do it. Hard to believe the inhabitants of Kotzebue illuminated their homes with seal oil and and then kerosene until as recently as the 1960's.

As I was leaving the small village of Shungnak a few weeks ago, the health aide who had driven me on her snowgo to the airstrip reminisced about life before bills. She wished she could go back to the old days. Much simpler then. Everyone knew what they were supposed to do. Now that she works full time as a health aide, she doesn't have the time and energy for hunting. As we looked out to the distant mountains, she told me their names -" Beautiful Lady" with her sculpted breast and abdomen and "Old Man Mountain" with his rugged face.

Mostly it's the elders who crave the caribou flank, muktuk (whale skin with its blubber), seal ribs, and muskrats. I met the director of the hospital's program to provide wild animal meat to those who can no longer hunt. He explained that the younger still hardy men are paid to go out to make the kill. Given the 10 dollar a gallon gas, this is a necessary compensation.

I struck up a conversation with a woman I met at the Nullagvik Hotel where I live this time. She told me about caring for her mom with Alzheimer's. The doctor had told her at the Alaskan Native Hospital 600 miles away in Anchorage that her mom was going fast - maybe 1 or 2 weeks to live. She brought her home and made all the old time foods - chewed her caribou meat for her, made her the soup she loved from childhood. Triumphantly she said, "Mom made it 2 more months!"

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The first Inupiat word I learned on the job was nuvuk - snot. There does seem to be a preoccupation with nasal discharge up here. When I work in radiotraffic advising the village health aides about children with plugged up noses, I try to delicately inquire about congestion relief. There are mothers and grandmothers who suck the snot out with their mouths and those that don't, preferring the blue bulb that is dispensed at the hospital on discharge of mom and babe.

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As a white medical professional I have recently learned a hard lesson: I am not Native, therefore the statements I make about unhealthy health habits can be misconstrued. I received an overhead page a little after 6 the other evening. My medical director had a letter in hand from a patient I had seen that day. He reported that I had said that Natives are drunks.

An elegantly dressed older man had come into walk-in clinic for his narcotic refill. Because a policy for prescribing controlled substances has been recently created so as to dramatically reduce the use, abuse, and sale of prescription drugs at our Bush hospital and clinics, I am allowed as a temporary medical provider to give no more than a 5 day supply of medication. This gentleman had received a 2 week supply with 5 refills of 2 very potent narcotics in January -prescribed by a temp internist who is now back in Seattle.

I took meticulous notes outlining the history of his chronic pain syndrome and response to medications. I asked him about past or current substance use, and he gave me a detailed history of his alcohol use starting at age 11 when his father handed him two beers. He emphasized his sporatic use as an adult. I talked with him casually about the relationship between substance abuse and reduced pain threshold and the genetic vulnerability including ethnicity to alcoholism. We talked of many things, and I never detected a note of hostility. I explained the new narcotic policy and gave him a five day supply of his meds until he could see a permanent provider here next week for a larger supply.

Someone might say his accusation is an example of reverse racism. If I had been an Eskimo doctor (there are none here), he wouldn't have made the complaint. But my sense is this isn't about racism, reverse or otherwise. It's about pain. Individual and collectively as a culture.

White people have had a long history of misbehavior up here, starting with suppressing the local language, music and dance and continuing through much of the twentieth century with shipping Native children to the lower 48 to become "civilized", under the pretension of providing them a better education. It was shocking for Native teens to go from a private bedroom with TV (after it came in) back home to a cramped sod house shared by as many as 10 or 12 people with no electricity. Store bought food was a luxury here that could be a few days away or more if the weather prohibited travel. The teachers down south were less likely to wrap one's hand or denigrate the child who had a harder time sitting in his or her seat.

I have often wished I had a little more pigment in my skin where there aren't any freckles. I think it would have comforted all the people of color I've seen over the years. People seem to gravitate to people who are more like themselves. Trust is kindled more quickly. I've always been a contrarian in this respect - a little bored with people like me and intrigued by otherness.

Growing up in suburban Chicago in the 1950's, the only dark-skinned person I saw in my neighborhood was the occasional woman who came by bus from the city to clean peoples' homes. I have a very clear memory of driving with my family past a city pool filled to the brim with African-American kids. My dad made a disparaging remark to the effect that the water was not safe for swimming because of the Schvartzes - a Yiddish term that has thankfully fallen out of use. I knew that day there was something impure about what Dad said.

My high school in Indianapolis integrated in 1967. Kids with names like Darn were bused in from downtown. I remember how isolated those kids were. I saw the teachers' repulsion. The middle class Blacks - there were 3 girls I remember well - did ok, although I'm sure they experienced their fair share of discrimination. Even I was on the receiving end of a few teachers' discriminatory remarks and behavior. But it was still a heck of a lot better to be Jewish than African-American.

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Three mornings a week the medical, psychological, social, and nursing staffs meet to discuss problem cases in the hospital, community, or villages. Rushing into these 8 AM meetings, I strip off my pants and jacket as I go. It's the only staff meeting I've ever attended that regularly includes a weather report. The explosion of Mount Redoubt 100 miles from Anchorage has thrown a monkey wrench into the best laid plans, including the likelihood of flying home as people complete their stints here.

Local weather in the farflung villages we service is most important as it determines whether seriously ill or injured people will be "weathered in" the village without professional medical care or can be safely flown into our Bush hospital. The responsibility for medical care when the weather is foul falls squarely on the village health aides. I asked the aides in Shungnak the worst time they could remember having to care for patients who couldn't be flown out of town. It was 15 years ago when a man was shot by the Alaskan State trooper in the abdomen, and a woman miscarried and bled for 3 days. The two village aides took turns caring for the two patients over 72 hours until the medevak plane could safely fly from Kotzebue to get them.

After the morning rounds a Code Review is done if a cardiopulmonary resuscitation occurred in the preceding week. Last week two 18 years olds hit a truck while they were riding on a snowmachine at 70 MPH at 3rd and Lagoon in the center of Kotzebue. The ambulance brought them in where resuscitation was performed for at least an hour on the driver. He died but the code was judged to have been done efficiently and well, with just the right number of people doing the right things at the right time. His heart was on the right side of his chest. The doctor who led the code admitted they probably went on too long but it made the family feel better. There were some comments about how it was difficult working around both families of these two young men due to some logistical problems with the layout and design of the ER. The second man was taken by medevac to Anchorage with multiple grave injuries.

I can't help but wish they had a Code Preview. What can be done to stop all the injuries and deaths from accidents in this part of the world? But that would require a deep culturally- considered conversation.