It’s time to put the ukulele down and pick up the laptop once more…and in this ‘episode’ I’d like to start the Alaska tour. So; seatbelts on, hold tight, it’s going to be a full on ride...
I’ll kick off by saying that Alaska is BIG in every way imaginable. Even in viewing it from the air I was struck by the enormity of the mountains and the vastness of its open spaces; all a hue of greenish grey, beautiful and menacing in equal measure.
I was greeted by a stuffed moose in the arrivals lounge. Also sizeable. I won’t include the numerous selfies I insisted on taking with him, I really do look quite terrible after 15 hours of travelling, but will say that this encounter was the first of many in Alaska that would leave me feeling dwarfed but awestruck by the things around me.
The state is known as ‘the last frontier’ and attracts those seeking true wilderness and adventure. I was aware of this reputation and had been advised by two previous Churchill fellows that Anchorage in particular was ‘wild’ and I would need to have my wits about me. I therefore stepped off the plane half channeling Christopher McCandless’ burning desire to escape civilisation and half feeling, for the first time, very far from home.
When you’re close to it, the lure of Alaska’s natural environment is intoxicating and it’s easy to understand why so many want to fully immerse themselves, ‘into the wild-style’. Unfortunately, though, it’s also easy to see why so many underestimate its potential hostility in favour of achieving a sort of survivalist nirvana and end up suffering the consequences of poor decisions; indeed a not insignificant number of movie and book fans have perished in recent years trying to reach the infamous ‘magic bus’ where McCandless lived and later died.
I found myself not immune to the bug. Having chosen to stay in a hostel (it being the only affordable bed in town), for two weeks I was surrounded by an ever-changing stream of adventurers ranging from deep sea fishermen and Denail-summiting mountaineers to British public school boys embarking on their first ‘wilderness experience’. Meeting them and listening to their stories left me feeling conflicted; I was there for work and would, at least for the first week, be confined to an indoor conference setting yet only a few hours in I was already feeling the itch to get into nature. I was going to have to find a way to scratch it at some point.
But itch or not, Anchorage was to be my base for the majority of my stay and so I set about getting under its skin. In honesty my initial impressions weren’t great. Although surrounded by stunning scenery, Anchorage itself resembles in many parts a concrete wasteland; it’s grid system, typical of many American cities, lends itself to seemingly endless strip malls with no walkable route in between. Similarly, the coastline is beautiful but many of the more promising views are marred by ugly industrial infrastructure.
There’s a large homeless population in Anchorage and they are predominantly native. Many clearly mentally distressed; they line the streets, sleep on buses and frequent the dive bars downtown at night. I would later learn that native Alaskans in trouble with the law either because of substance abuse, mental illness or other issues would often be rejected by rural tribes who felt they could not provide a space for them. They would be offered a one-way ride to the city and end up here, with nothing and nowhere to go.
My hostel was not in the most salubrious part of town. Deep in the heart of the wasteland it bordered ‘Chilcoot Charlie’s’; a bar once famous for its Alaskan charm and now more so for its police attendances and heavy metal music, and shared the street with several marijuana sellers who I suspect weren’t quite sticking to the ‘only for medicinal purposes’ rule.
knowing where was safe to go and what was safe to do took time to learn, but despite all of this you might be surprised to hear that I grew to love Anchorage during those few weeks and here’s why…
Alaska’s largest city is in many ways still today how I imagine a frontier town would have been in the past. Gone are the days of pistol duels (or so I believe), but it retains a roughness around the edges and a resilience in its residents that comes from growing up with grizzly bears wandering the streets and enduring winters that last three quarters of the year.
If Alaska were a scent, it would be called ‘Intimidating’ by Calvin Klein. When embarking on any sight or activity there, one must embrace that it will likely be 100 times bigger, harder and involving of danger than expected. Our conference delegate came a cropper of this one evening when advised we were undertaking a short ‘town hike’ only to find ourselves three hours later scrambling on hands and knees(some unfortunately in flip flops) up a mountain, easily surpassing in size England’s highest peak. I’ll also throw into the mix my experience cycling the local city bike trail. Described as ‘urban’ and having the potential for ‘occasional wildlife sightings’ ten minutes in we were immersed in deep forest fighting off mosquitoes the size of small birds with ‘wildlife sightings’ coming fast and furious. The climax being a mother moose and child smack bang in the middle of the path necessitating a hasty abortion of our trip. But I came to really respect this laid back approach to encountering a bear on one’s lunch break and in my more nervous moments took comfort in accepting that for me it was all very new; a Hyde Park squirrel is hardly comparable.
The old-fashioned frontier feel permeates all aspects of life in Anchorage and how this translates to cultural activities is, in comparison, something I felt very comfortable with. I may have played at moving ‘cowgirl-style’ in clubs at home but my first proper experience of line dancing was everything I’d hoped for: men in stetsons, sweating so much I thought I might die(though reeling can compare on that front) and being addressed as ‘Ma’am' when asked to dance. Apparently a half decent grasp of swing can get you through the cowboy 2 step and enthusiasm and forgiving locals through pretty much anything else.
Now I’m not going to claim that all of this was undertaken in the name of ethnographic inquiry, I would be hard pushed to justify karaoke for research purposes, but I will say that making the effort to get out into a community is not only incredibly enjoyable(especially for a western-obsessed person like me) but also allows for a different kind of insight into the stories of the people living there. Sitting in front of someone in conversation taking notes is one thing but being taught to line dance by a 70 year old native Alaskan or having your Bonnie Tyler rendition applauded and then smashed by some epic local country singer is quite another.
I’m coming to learn that one of the keys to connecting is to achieve a plane where we are all equal and where we are all open to learning from each other. In my case this seems to repeatedly manifest through embarrassment and the need for rescue, think Indian beading, but I’m happy to report I’ve had the opportunity to share my knowledge as well. That’s right, a select group of native Alaskans can now strip the willow!
This brings me nicely onto the work side of things, though as above I’m coming to realise how wonderfully blurry the lines are between ‘work’ and ‘play’ in this kind of project.
I was in Anchorage primarily to attend the NUKA system of care annual conference at SouthCentral Foundation and for months I’d been excitedly anticipating it. I hadn’t planned to include such an event in my journey initially and in fact had intended to base myself further north in Fairbanks. But SouthCentral’s work is famous throughout the state, and indeed the world, and therefore it wasn’t long before I was being directed there to ‘see what those folks were up to’.
It’s difficult to know where to start in describing the week that followed. I’m not sure that I’ve taken that many notes, thought that much and asked so many questions in a long time. I’m sure my colleagues at home will be happy to hear that(I promise I do think about things a fair amount at work!). But whilst by the end of the week I was officially on the bandwagon, to the point of asking about employment opportunities, I’ll be honest and say that it took me some time to buy into it.
In a nutshell, SouthCentral Foundation is a primary care operation serving the Native Alaskan people of south central Alaska. Unlike the majority of the country’s citizens, Native Americans, Native Alaskans and Veterans are entitled to socialised healthcare which is government funded and delivered by the Indian Health Service and the Veterans Association. Therefore SouthCentral Foundation (SCF) receives financial backing partly from the government, partly through billing from private insurers and partly through private donors.
Up until about 20 years ago SCF was operating much like many similar services throughout the country; it was struggling to offer access and availability resulting in most care being delivered and triaged through the Emergency Room. The situation was a mess and people were unhappy.
And then things turned around. Fast forward to 2019 and SCF tops all of the charts for patient satisfaction and health outcomes, has a thriving and aesthetically stunning site and has won the Malcolm Baldrige National Quality Award twice. So there I am on my first day and I wanted to know how. Great changes had occurred and for the better, that was indisputable and I wanted to know ‘the secret sauce’.
I now know that I’d missed the point. With my western hat on on I’d approached the changes in terms of nuts and bolts. I wanted to know how such changes had been made when really the question I should have been asking was why? I would come to realise that the reasons behind the change, the events that had occurred and the voices that had spoken out, were the real foundation and the real influencers for what had happened over the past 20 years. To understand the nuts and bolts I first needed to understand that.
To begin to explain that here, we need to touch on history again and how past events have shaped modern-day behaviour in Alaska. Unlike the formation of reservations in the ‘lower 48’, Native Alaskans were not moved from their land in the same way; land in Alaska was considered by many settlers as too hostile to be worth it. However, the impacts of how life changed regardless of this, were for many traumatic and have left lasting effects. Children were again removed from families, put in boarding schools and punished for speaking native languages. I won’t ever forget hearing a native elder woman describe in a talking circle how her mouth was ‘taped shut’ for this reason. In that vein much of Native Alaskan culture was outlawed when the state was colonised, but to understand the impact this had on the people it is important to recognise that this went far further than the banning of language and practices.
An influx of newcomers and the resulting cultural shift left many Native Alaskans unable to exist in their traditional ways. Used to subsistence living through hunting and fishing the changes in population brought money into towns and resulted in many Native Alaskans finding themselves unable to support their families as they had previously. The physical and financial struggles this brought about were obvious, but perhaps less obvious at the time was the emotional distress this caused, particularly amongst tribal men. It is felt that this loss of identity and psychological emasculation is a root cause for the high prevalence of substance use, domestic violence and sexual abuse seen in the Alaska Native population today.
These problems aren’t academic; in their lifetimes, 40.4% of adult women in Alaska have experienced intimate partner violence and Alaska has six times the national average of reported child abuse cases. Alaska ranks highest in the nation for forcible rape and Alaska Native women are 10 times more likely than non-native women to be sexually assaulted in their lifetime. From my own very small experience in Alaska, of hearing the stories of native women both in passing and in circle, I’m sad to say that while I still find these statistics shocking, I can completely believe them.
Couple violence with a culture that doesn’t speak of such things and you have a breeding ground for generational abuse. It won’t surprise you to know that traditionally this ‘not speaking of such things’, this internal repression of trauma, has led to a devastating deterioration in mental health. In 2014, the rate of Alaska Native males that died by suicide was 50.9 per 100,000, nearly four times the national average.
These facts are hard to read but important to know and in this context go someway to explaining why the changes happened at SCF and why those changes took the form that they did. So, if you’re still with me after such difficult reading, hold on just a little longer and we’ll move onto how a lost culture has both triggered the need for and formed the foundation of rebuilding a healthcare system.
The changes at SCF have been largely championed by Katherine Gottlieb, the current President and CEO. Her story is a remarkable one. Alaska Native and coming from a violent and abusive childhood herself, she worked her way up from receptionist to CEO in a matter of four years and through her passion for openness and disclosure has challenged the very heart of the native community in order to bring about meaningful change.
She felt early on that the route to repairing an ineffective health system was to go to the people themselves and simply ask, ‘what do you want to change?’ and so this is what she did. During her opening address at the conference she described to us her heartache at hearing the answers to this question.
Expecting responses such as ‘shorter waiting times’ or ‘easier appointment access’ what she actually received on asking this question were peoples’ stories. Stories of abuse and neglect, of feeling unsafe in their own homes; stories about the shame of growing up native and the fear that alcoholism and substance abuse were inevitable. Despite being a part of a society where such subjects were taboo, people had chosen to speak out about what mattered to them and now the door had been opened she had no choice but to address it.
NUKA is a native word meaning ‘large, strong structure’. It symbolises the strength needed to overcome the challenges experienced by the Alaska Native people, challenges both big and intimidating(truly Alaskan). But for Katherine and everyone at SCF it also represents how their structure of care is based on core concepts that lie at the heart of native culture, those concepts being story-telling, relationship building and holistic healing.
I won’t get into the nuts and bolts of how it works right now, I’ve taken too much of your time already and there’s plenty more to come, but let’s close with this idea of how a culture can both be the trigger for change and the change itself.
Katherine knew she couldn’t shy away from the real problems in the community, but that’s not to say exploring them was easy; her descriptions of meeting with elders who refused to vocalise the word ‘abuse’ , as an example, were painful to listen to. But in really understanding these issues and fundamentally the root causes behind them she has been able to design a system that openly addresses them in a way that people can relate to. The NUKA system of care takes an approach to healing that is based in traditional practices that have been lost whilst introducing elements that challenge the more negative or detrimental aspects of indigenous culture.
I’ll touch on all of this next time, like me in my first few days I’m guessing you’re feeling a little overwhelmed. My advice would be this: take off your western hat(unless you’re line dancing of course) and let the ideas flow past you, don’t think about the technicalities right now but about the principles. And if you have a moment think on these questions...what foundation is our health system based on, what are our ‘core concepts’? Does it seek to address the real problems in our communities or what really matters to the people who use it? What has happened to our culture that might manifest as problems today and how often do we really open that door and encourage real answers that might be difficult to respond to?
I used to think I had the answers to some of those questions, I could have rolled them out on request, now I’m not so sure.