KAREN:  How did you communicate with those health aides out in the villages?  How did that work?  They called in with a medical question? 

WALTER:  Yeah.  The mechanics of communication in the 1950s were a single sideband radio that was placed in the schoolhouse, and in some cases, in the village store.  And this was a two-way broadcast, which could be listened to by anyone who tuned in.  And actually, it, in retrospect, was a wonderful training device, because not only did the other health aides learn, but everybody in the village became very familiar with the description and prescribed treatment of all the common conditions.  And now that medicine has changed its attitude so tremendously that they recognize the desire to put the patient in charge of their own care and not -- that was quite a proper thing to do in judging by today's standards. 

KAREN:  And so that two-way broadcast radio would work from, like, Bethel to Anchorage? 

WALTER:  No, that would work from the fields to -- from Anchorage to places in the Anchorage service unit only, but it would work from the center to the surrounding villages.  Bethel to the Lower Yukon and Kuskokwim, Tanana to the Interior, Kotzebue to the Northwest, et cetera.  Then after that, why, of course, the telephones came.  And now, we have Telemedicine, which is another whole subject.  And another individual who was very active in health aide training was, or is Kari Lundgren, based in Southeast Alaska, Sitka.  She was active in health aide training quite a few years ago, and has been one of the pioneers in developing Telemedicine. 

KAREN:  Okay. 

WALTER:  To where -- whereby the individual, the health caregiver in the village, can -- can actually transmit the image of the patient, of the condition such as the skin condition, or the electrocardiogram, et cetera, to the -- to the consultant to issue. 

KAREN:  Now, do you think that's made a difference in the way medical care is given? 

WALTER:  Well, it -- yeah, I think so, but I haven't been out there to see it, but when I look at a clinic like the one that was dedicated in 2001 in Emmonak and see all the facilities they have, it's like a moonscape.  I mean, it's -- it's just, you know, light years different from before. 

And there are different people assigned there, including physician assistants, nurse practitioners, and who are sort of intermarried -- intermediaries between the health aide and the doctor to some extent there, now, I think.  And then they have -- they have these capacities to communicate.  I can only predict that there is a limit to the doctor's time at the other end to sit and look at these images and whatnot, so the technology, as I would guess, has outrun the time limits of the -- of the people involved. 
But the capacity is there and it's -- and I'm sure they find very good uses.  But I think the telephone probably must be one of the main -- had been one of the main things that followed the radio. 

KAREN:  And how do you feel about the making diagnosis over the phone with information communicated to you verbally or seeing a picture? 

WALTER:  Yeah.

KAREN:  As a physician, how would you feel about doing that? 

WALTER:  In looking at the health aide program as a whole, I think there are several factors to consider.  And maybe I'll just go back a little bit further, and start and say one, of course, is the selection and the fact that they are chosen locally from local people, of course, is very important. 

That -- another factor is the period of training.  I think it's been demonstrated that having relatively brief periods of training that does not break the individual's tie with his or her family in the village, but in repeating these periods, is preferable to single long periods of training away from home. 

Key to all of this is -- is to realize that the health aide role is a part of a system.  It is not an individual, free-standing role.  The health aide originally, and I think it still does, acts as the ears, the eyes, and the hands of the physician.  They learn because it's just not going to be possible or practical to have the physician on hand in the villages all the time.  So somehow or another, that information about the patient needs to get there.  Other than bringing the patient in.  Which is not practical for everybody and every condition. 

So that means that the health aide needs to learn to listen to the patient and get a few essential facts that can be related to -- to the MD, needs to look and observe, and that can include using an otoscope to look into the ear, a flashlight to look into the eye, and so on.  And it could mean using a stethoscope to look at the lung.  Using their hands to -- to move the joints, using their eyes to describe the condition and -- and so on.  And then how to report that.  It also means that there's a physician who is willing to -- to listen to this and to -- to risk making a diagnosis and prescribing a treatment based on that. 

KAREN:  Right. 

WALTER:  That transfer of information. 
So what we have here is a system, and the health aide is just -- is one role in it.  You need the central physician, and then, of course, you need the -- all this other support.  The drugs that are out there.  And -- and the facility to work in.  The health aides at the beginning, they will all tell you about how they carried their little black bag, and, you know, went into the house with a lot of other kids looking or making noise, and trying to, you know, do their history and physical there.  And these funds being available to transfer patients because the doctor says, or the health aide says, this patient needs to be moved into a higher level of care, well, the airplane has to fly and there has to be money to pay for it.  So all of that together results in a fairly complicated system that -- in which the health aide is -- is just -- has just one role.