Water in the Village

1/21/2015, Chefornak, Alaska: I recently learned how much effort is involved in getting drinking water to the clinic. Chefornak does not have piped in water - which means water fluoridation is not feasible. Running water is a luxury, requiring large holding tanks that need to be filled manually (usually once every few days). In the clinic, the sewage and water system are linked. When the sewage holding tank fills up, the water turns off to prevent overflows. This system encourages users to conserve water, particularly since the holding tanks fill up without any notification system. The local store sells commercially bottled drinking water, which costs about $8-$10 per gallon. To save money, locals will drink rainwater, which is collected through rooftop systems on top of homes during the year and stored in outdoor ponds. In the clinic, there is a water distiller that makes the rainwater safe to drink.

Last June, the water distiller was up and running. There was a slightly brown color to the water even after being distilled, but the water tasted just fine. This trip, the distiller is broken. When I arrived in Chefornak about 10 days ago, there was a large plastic container filled with drinking water.

Like over the summer, I assumed during the winter that water was simply brought to the clinic. Not so simple in sub-zero degree terrain. Where would water be stored in the village? Outside?

After running out of water over the MLK day weekend, I learned about the drinking water procurement process during winters in the YK. Drinking water starts off looking like this, which is hand-chipped from an outside pond.

9:43AM

It's quite the process to melt the ice into water, one pot at a time.

The most recent update on the clinic's drinking water status.

10:28PM

Chefornak 2015

01/19/2015, Chefornak, Alaska: I'm heading to Chefornak, Alaska - a small Yukon Kuskokwim community (population 418 according to the 2010 U.S. Census) - for my first winter clinic trip to a village. I was in Chefornak in June 2014. This time I had to pack winter gear in preparation for the cold weather, including my -40 degree coat. I left the Bunny Boots at home. I also packed 2 weeks of food, clothing, and entertainment (i.e., laptop and external hard drive full of data to process and analyze, one book, a couple of dental journals, dozens of hours of archived Dan Savage podcasts). Amazingly, I only had to check one bag at the airport.

On the flight from Seattle to Anchorage, I met a cute service dog named Teddy. She was sitting on the floor next to me. By the time we hit 10,000 feet, Teddy's head was resting on my right foot. An hour later, she had taken up most of my leg room. She was a very friendly, well-behaved dog.

The rest of the flight to Anchorage and the flight to Bethel was uneventful. Woke up early the next morning and arrived at the Era Terminal in Bethel, where I had at least 8 cups of complimentary Folgers coffee with instant powdered cream. The airport was pretty quiet when I first arrived, but it got pretty busy close to boarding time. This is one of the only places I know of in Bethel (besides the Bethel library) that has free wifi. This was the last time I'd be able to check email on my iPhone, access episodes of Glee and Downton Abbey through Amazon Prime, and check Facebook status updates.

It's January, which means it stays dark until pretty late in the morning and starts to get dark early in the evening. The winter solstice has passed and the length of daylight is increasing each day, but it's hard to tell. I complain a lot about how dark it is in Seattle during the winter. But we have it pretty good in comparison.

9:09 AM (liftoff)

9:21AM (midflight)

9:46AM (landing)

It takes about 35 minutes to complete the direct flight from Bethel to Chefornak. It was still pretty dark when we landed. It wasn't as cold as I thought it would be, which was a good thing given that I had not packed snow pants. The ride to the clinic was chilly but unseasonable warm (20s). The left side of my face got pretty cold. Thankfully, I didn't develop Bell's Palsy.

During the first few days in Chefornak, we spent our time at the Head Start Center and K-12 Chefornak School (Amaqigciq/Caputnguaq) screening children for dental disease. At the Head Start Center, it was nice to see a toothbrushing operation set up near the sink. Most importantly, the kids were brushing with fluoridated toothpaste.

It was nice to see the Yupik word for mouth, teeth, or smile near the toothbrushing sink (right up there with hair and ear).

It's been a great trip so far. We were able to meet with the Chefornak Village Council earlier in the week to share findings from our sugar sweetened beverage study. Our hope is to include Chefornak as a partner community for our next NIH grant. Over the week, the temperature has dropped and there's been a bit of snowfall. Today it's -7. The sunset is absolutely stunning. Just a few more days and I'll be heading back to the land of the 12th Man.

5:07PM (sunset)

Sugar Sweetened Beverages and Tooth Decay in the YK Delta

09/09/14, Bethel, Alaska: Sugar sweetened beverage consumption in the YK is implicated as the driving force in the Alaska Native childhood tooth decay epidemic. Sugar sweetened beverages include instant Tang, Kool Aid, Sunny Delight, energy drinks, and soda. Tap water is either unavailable or tastes bad in the YK.

Sugar sweetened beverages are relatively inexpensive and abundantly available in village grocery stores. In addition, while it is well known that soda pop contains high concentrations of sugar, many parents are unaware of the amount of hidden sugars present in juices and other sugared beverages.

Our research team, consisting of collaborators from UW, UAF, and YKHC, received pilot funding from the UW Royalty Research Fund. Our goal was to use a novel biomarker to measure sugar sweetened beverage (added sugar) consumption in childrens' diets and to develop a community-based intervention aimed at reducing added sugar intake by targeting sugar sweetened beverage intake.

In January 2014, we traveled to Bethel and spent about 2 weeks enrolling study participants. We enrolled 54 children and adolescents ages 6 to 17 into our study. We spent the next few months processing and analyzing data. Our findings indicate that YK children consume the equivalent of 5 cans of Coke each day. This is over 16 times the maximum amount of added sugars recommended for children. Parents and community members were stunned.

During our 2-day stay in Bethel, we presented study findings to parents of participants, disseminated study findings to YKHC health providers and community stakeholders, recruited members of a Community Planning Group (CPG), and convened our first CPG meeting to generate a series of community-based interventions.

The trip was very successful and we generated a preliminary intervention. In the next few months, we will work with our CPG and YKHC partners to fine tune our intervention and apply for NIH research funding.

Sour dock and tundra

06/10/14, Chefornak, Alaska: After a productive day in clinic, I met the Dental Assistant and her two sisters, niece, nephew, and Golden Retriever puppy (Zola) near the local store so we could take a walk on the Alaksa tundra. Our goal was to look for and pick sour dock – a redish-greenish leaf that grows wild near ponds in the summer. When we got close to one of the many large ponds, I saw sour dock growing in small patches. As I picked the leaves, I tried a few and found that it is sour (thus the name) and really tasty. It would a great addition to a leafy summer salad. We picked two large bags of sour dock and quickly began walking back to town – it was extremely wind and about 42 degrees.

Sour dock is chopped into small pieces and boiled for a few minutes.It is then frozen and used in sour dock agudak, an Alaska Native dessert that consists of instant potato flakes (a binder), hot water, Crisco (or seal oil), and sugar. The Dental Assistant’s mother made a special batch of sour dock agudak and brought it to the clinic. I was only able to take a few bites before heading to the airport. It was a super interesting treat. Two nights ago, when I went over to the Assistant's home for dinner, I had a large serving of homemade blackberry agudak. It was awesome.

As we walked back, I quickly learned that it’s easy to lose your footing. The tundra is soft and soggy. There were berry blossoms all over and a rich moss that looked like wood shavings.

Half-way point - fish, fish, fish

06/07/14, Chefornak, Alaska: It’s the start of day 6 of 12. During the long summer days, Alaskan villagers are busy catching and preparing fish, picking berries, and hunting – all in preparation for the nose-hair-freezing winter. Subsistence fishing/farming/hunting help Alaska Natives survive the long winter. Currently, it’s the height of the fishing season. Later in the summer will be berry picking and hunting. Of course, the specific harvested goods vary from community to community.

I walked to the local grocery store on day 3 to explore Chefornak and get some exercise. Throughout Chefornak, you can see fish hanging on outdoor wooden structures and drying on boards matressing the Alaskan tundra. From the village boardwalk, you can smell fish, which reminded me of my childhood and early 20s – wonderfully familiar scents that wafted through mom's kitchen on weekend mornings and during trips I’d take to old villages in Korea. Each household has a slightly different wooden structure constructed for drying fish in the Alaskan summer heat. Though it was cold when we first arrived, it’s been warm the past few days and the sunshine has been intense.

One afternoon, I was chatting with the Chefornak health clinic receptionist, who mentioned that she was keeping busy outside of clinic hours preparing fish for the winter. Mothers of children I’d been treating in clinic talked about similarly busy summer schedules. In the village, men and boys take their boats and fish on the river, bringing back gunny sacks filled with halibut, salmon, anchovies, herring, white fish, and other river delicacies. Women and girls clean, prepare, and hang the fish to be dried. It’s a time sensitive process (to prevent spoiling of fish and to take optimal advantage of weather conditions to dry the fish properly).

There are apparently dozens of ways to prepare fish. Some fish are dried and then frozen – and eaten like jerky except that it is dipped into seal oil, which helps villagers keep warm in the winter. Other preparations include fermentation and drying, salt curing, and drying then soaking fish in seal oil. I asked the receptionist if we could stop by after work to watch her prepare fish and she warmly welcomed us to her home on the river. I was able to watch her and her three daughters prepare semi-dried fish to be soaked in seal oil. It was an amazing experience.

 We also got to see families braid anchovies onto beautifully crafted ropes made of dried tundra grass.

Most of the fish will be ready to consume in the late fall and early winter. The food preparation activities require intense family effort. I’m not sure how many families involve children in these activities, but from an outsider’s perspective, it seems like most do - and what a great way for children to contribute to the household and stay busy during the long summer days.

The little things in life

06/02/14, Chefornak, Alaska: Day 1. This is my third clinic trip to a Yukon Kuskokwim village (first trip was to Kipuk in August 2013 and second was to Chevak in October 2013). I arrived into Bethel on June 1 at 8:30PM. The first thing I noticed after landing was how bright it was outside – and then it struck me that I had entered the land of the Midnight Sun. It wasn’t sunny but it was super bright most of the evening. I woke up early to pick up my travel bag from the YKHC dental clinic and arrived the next morning at the Era Airlines counter in Bethel at 8:00 AM, about an hour before my flight to Chefornak. I met the super friendly Dental Assistant who had been assigned to this village trip along with 3 or 4 YKHC social workers who were getting ready to travel out to different villages in the YK. I had 3 requisite cups of very strong Folgers coffee (compliments of the airport). We walked onto the tarmac about 30 minutes after our scheduled departure time to allow for some time for the morning clouds to lift.

Riding aboard a 7-passenger place Cessna is a really cool experience. It's small enough where you have you crouch to get to your seat. You can hear everything - the engines, the propellers, all of the other machinery. Earplugs are a must - I forgot to grab a pair during check in at the Era Airlines counter.

We flew for about an hour and landed in Kipnuk to drop off a few passengers and then continued onto Chefornak, which took about 20 minutes from the Kipnuk airport. When we landed in Chefornak, we were greeted by a Primary Dental Health Aide (PDHA) with whom I had worked during my first village trip to Kipnuk. PDHAs are an integral member of the dental care delivery system in rural Alaska and provide preventive dental care services to villagers. The PDHA met us on her sparkling red 4x4 (all terrain vehicle). After loading our personal belongings onto a second 4x4 with a wooden trailer in tote, we hopped onto the back of the red ATV and rode to the dental clinic.

Once we arrived to the Denali clinic (the name of pre-fabricated structures that serve as health care centers in the YK Delta), we unpacked our dental supplies and started setting up the clinic. Denali clinics are really nice – they contain primary care medical care examination room, an emergency room, and a dental clinic. There is also a room set aside for itinerant health care providers that contains 2 bunk beds and a kitchen with a sink, a small fridge, and microwave. There is also water treatment equipment used to produce drinking water.

After setting up the clinic, I unpacked my large “immigrant suitcase” I had stored in Bethel with one of the dentists. I bought this abnormally large suitcase back in the early 2000s when world travelers were allowed to pack bags that weighed 75 pounds (and sometimes, in my case of jetsetting between Seattle and Seoul, 100+ pounds) unlike today where the strict limit is 50 pounds. The bag contained a portable air mattress, sleeping bag, a small stash of non-perishable snacks, and other random items needed for village trips.

Which brings me to the reason I titled this blog post (the little things in life). First, all of my food for the 2 weeks fit into the small fridge. The dental assistant and I had to play a little bit of “fridge puzzle” but it all fit. SCORE! I can’t believe what a relief it is to know that your perishable foods will stay cold the whole 2 week trip. During past village trips, I’d spend the first few days nervously and voraciously consuming food that wouldn’t fit into the fridge, which is really stressful. Second, when I opened up the front zipper of the immigrant suitcase, I found 2 items that were icing on this wonderful day: a stash of Tazo teabags and a set of Krogers toenail clippers. It felt like Christmas. I can’t describe how unbelievably happy I was to rediscover these precious items I had left in Alaska after my last village trip.

In terms of clinic, it was wonderful to keep busy. We saw 15 patients on day 1 for exams and cleanings and have a full day of patients scheduled for day 2. It helps tremendously to work with a local PDHA who knows the families and is able to call households for same day dental appointments. It’s summer in the YK and the school kids have been on vacation since May 15, which can make it hard to schedule children.

After work, I reheated a bowl of Basmati rice along with General Tso’s Fish and Kung Pao Tofu from my favorite Chinese restaurant in Seattle – a place called Sichuanese Cuisine Restaurant. I took a lukewarm shower, which was wonderful. There have been times in the past when an-end-of-clinic-day shower wasn’t possible (e.g., sewer was backed up, water was turned off, water was ice cold, gym lockers were locked). Also, this trip I brought with me a cordless 1.7L hot water kettle - one the best ways to ensure easy access to cuppa. The planned kettle coupled with a fistful of surprise Tazo teabags are the perfect pairing.

Lesson reinforced on day 1: enjoy the little things in life. Teabags, toenail clippers, and the ability to shower – I feel like the luckiest itinerant village dentist in the world!