LINDA:  The element of attrition is difficult because when a health aide leaves the job for so many different reasons, and you start with a new individual, is you've lost not only the training but the experience of -- of that element of providing health care. 

And you can rebuild that, but it does take a significant amount of time and energy, but more importantly, the community I think is then at a disadvantage.  I won't say -- because I think we have to be very careful how we label these things. 

I think in the -- you know, the rest of the world, if you went to a hospital, folks come and go all the time.  And there may be a shortage of staff, but there's always staff.  Or they turf patients.  You know, when Bethel is understaffed in nursing, they just send more of the patients to Anchorage.
So -- but in a community, when there are, you know, two health aides or one health aide and one leaves, that puts the whole community at a health care disadvantage. 

And so attrition is a -- is a really difficult piece of the puzzle.  And so I've looked at that over time.  And it's all sorts of things. 

It can be pay.  It can be time on and time off.  It can be how soon they receive training.  Because until they have training, they are feeling very, very vulnerable to take care of the next thing that walks in the door or the next phone call in the middle of the night.  So training is the key to feeling competent and comfortable in the role. 

The support that the community gives them in their jobs, sometimes communities are very supportive and people are able to stay for years and sometimes there can be politics in a community and an individual can't stay. 

So with that attrition of the program, it means that there will always -- you know, we'll just do some math.  Let's say 500 health aides.  And if we have an attrition rate of 10 percent, that's 50 health aides a year needing Session 1. 

Well, if you can do 6 health aides in a session, that's 10 Session 1s a year.  That's 40 weeks.  So that's one whole training center.  We've only got 4 in the state. 

So that element, but the other though is our attrition rate can climb as high as 20 percent.  Now you're looking at 100 individuals.  So the math becomes complex. 

So there's lots of issues regarding the training of health aides.  It's -- it's content, it's support, it's clarity, it's outcome, but it's also timing and sequence and modality -- how can we increase the training capacity is the word we use. 

And so distance education is now being very actively looked at again. 
And so I'm just smiling and, you know, looking back almost 15 years ago, 16 years ago to a pilot project that was very successful with those health aides. 

The other element is looking at materials again for learning for self-study. 
And so in the early '90s, we wrote a grant to the Robert Wood Johnson foundation to again look at how we could increase learning on an individual level.  And we created and distributed -- took us about four years.  What I find is that things take time, we'll come to that soon, but we distributed a CD ROM throughout the state called Body Systems and Health Care. 

And the CD ROM was created by one of the team members, Chester Mark and David Horish in Bethel and myself, and the Robert Wood Johnson grant was half a million dollars to help us to get this off the ground. 

At the time we wanted it to be cross platform, and even just printing a CD 10 years ago was a big deal.  It was, like, what?  You're creating your own CDs?  Now it would be so different to do that. 

But it really was successful in taking each of the body systems and breaking it down into anatomy and function, physical exam, findings, disease, treatment, and allowing them to sort of move through those materials.