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.

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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.

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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