Reservation Medicine in Alaska

I finished my rotation and left Metlakatla over 2 weeks ago, but I’m finally getting around to summarizing the medical part of my experiences. Some random things I noticed:

Obesity. This was a HUGE problem. Every chart had a BMI calculated, and I regularly saw BMIs in the 50s-70s. If I saw a patient with a BMI of 35, I didn’t even blink. A completely normal-sized person, clearly. I didn’t really think there were any restaurants on the island, but during my last week I finally went into one of the “convenience” stores on the island, and discovered them deep-frying all sorts of crap behind the counter in there.

Sexual health. I did several prenatal visits for 15-18 year-olds. The attitude of the health providers in the clinic was that this was completely normal, so I assume that routine teen and pre-teen visits don’t include how-to-avoid-pregnancy counseling. Of course, there’s probably only one or two women on the whole island who’s made it to the age of 20 without having a child, so that is probably the cultural expectation for high school girls there. If you don’t have a steady boyfriend by age 15, you probably feel doomed to be alone the rest of your life. Also of interest, apparently every single high school student’s pap smear lately was coming up positive for Chlamydia. Well, it is a small town. I guess while those high-schoolers desperately seek out their soul-mates, your boyfriend today is your best friend’s tomorrow. One of the providers doesn’t provide birth control for religious reasons. As she told me about the Chlamydia epidemic, “everyone in the school has Chlamydia except for my son. Because he’s the only virgin.” It’s possible. Meanwhile her 19 year-old single daughter was 6 months pregnant…

Drugs and alcohol. For a “dry” island community of just 1,300, drug and alcohol abuse are disturbingly prevalent. The island used to be completely dry, but in just the past one or two years the (tribal) law changed. Having alcohol and being intoxicated is now legal, but buying or selling it on the island remains illegal. Despite this being an island, alcohol’s obviously coming from somewhere. People must really load up their cars on ferry trips ($60 round-trip) to the neighboring (non-reservation) island. I was told that prior to this change in the law, the jail used to be overflowing every weekend with people arrested for intoxication and/or possession. So that wasn’t stopping anyone either. On the one weekend-call I took, I saw (and x-rayed, stitched, and otherwise patched up) 4 victims of violent assault, and in every case both the perpetrators and the victims were using alcohol. Of course, since everyone knows everyone, the victims all knew, and in the majority of cases were drinking with, their assailants. Angry-drunk personalities excluded, I never saw any victims of sober violence. There was no AA program on the island to my knowledge, but the clinic did offer substance abuse counseling. The clinic also sometimes arranged for people to fly to intensive detox/rehabilitation programs elsewhere in Alaska. The problem is, there is nothing to do on the island other than drink, and there are no other non-drinking friends around for you to make. Once you fall into that crowd/pattern, it’s tough to get out.

Also a big problem, especially for those of us prescribing and dispensing it, was prescription pain pill abuse. One patient told me he knows several “dealers” on the island. How many dealers does an island of 1300 need!? Unfortunately, I’d guess they’re getting the majority of their supply from our clinic pharmacy, which stocks Percocet, Vicodin, Tylenol-3s, benzos—if a controlled and abusable substance exists, we’ve got it free of charge for you. The two physicians in the clinic were both new, and they were trying to reinstate “pain management.” I thought this was going to be a pain protocol to put everyone on the same page about which situations should or should not be prescribed controlled substances, and in which order they should be prescribed (i.e. start with less heavy-duty stuff). However, it was actually just a meeting where “problem” patients were individually reviewed and a collective decision was made on where to draw the line on their refills. There were a lot of these problem patients.

In light of current healthcare reform debates, it’s interesting to see how a free healthcare system functions. As I mentioned earlier, Metlakatla is a federally-designated Indian Reservation, and as such the healthcare is administered by SEARHC, (Southeast Alaska Regional Health Consortium), a subsidiary of Indian Health Services. All native tribe members get unlimited physician visits, prescriptions, dental care, physical therapy, not to mention travel and lodging for specialty services in other cities, provided free of charge. This extensive amount of free benefits offsets the disadvantages in care that one has in a remote area without nearby doctors or trauma centers about as much as feasibly possible. Unfortunately, if you live on the island as a non-native, you are pretty much screwed. Anything serious requires a helicopter, plane, or boat ambulance, and routine medical care (colonoscopy, mammography, CT scan, etc.) also requires a boat trip. I’m sure that costs a pretty penny to those not getting it for free.

So, what can we learn from this example? I’m far from an expert, but expectations seem to be the biggest problem. If you get sick at midnight with a sore throat, would you call 911? I don’t think so. Would you even bother going to the emergency room? No. Because that would take at least 4 hours before you even got seen, and then told to gargle with some salt water. You also probably wouldn’t be able to see your PCP for a day or two. If you had a headache at 2AM, would you call your doctor and demand that she get out of bed and come give you some Tylenol, because poor-you, you don’t have any Tylenol at home? No. (This is because Tylenol at the store costs a small amount of money, but with free-care, patients are entitled to get free Tylenol from the clinic pharmacy, so they refuse to buy it over-the-counter.) But those are the routine types of calls that I would get after hours. Because we’re the only healthcare providers on an island, there does need to be someone on-call 24 hrs a day in case of a true emergency. However, because everyone there has become accustomed to instant gratification, there seem to be no limits to the types of things that warrant an “emergency” phone call. Once these sorts of expectations have been set up, it’s very difficult to convince people otherwise.