(The following article contains an interview with one of Wilderness Medical Staffing’s contracted healthcare providers, Timothy Jones, PA-C. All photos contained in this article were also taken by Tim.)
The Community Health Aide Program (CHAP) is an innovative community health program launched in the 1960s that hires from within Alaska Native villages and trains health aides to practice independently as medical providers. Many of our providers have questions about this program and the amazing health aides they work with. Continue reading for an introduction, history, and explanation of the CHAP in Alaska.
The Reason for the Community Health Aide Program
Alaska is well-known as the “Last Frontier State.” The interior, coastal regions, Aleutian chain, and Southeastern archipelago are all sparsely populated, with few roads connecting any communities. For many who are uninitiated to Alaska, it’s easy to look at the map and see the major cities of Fairbanks and Anchorage, then some familiar towns like Ketchikan or Juneau, and assume the rest of the land is wilderness. What many don’t know is hundreds of Alaska Native villages dot the entire state, going all the way out the Aleutian chain and through the Interior, to every island in the Southeast Alaskan archipelago. Most of these villages are very small, many of them settlements of previously nomadic peoples like the Eskimo and Athabascan, who settled in permanent villages as white settlers arrived. Many of these villages are populated by a majority of Alaska Natives, with few from the outside who become permanent residents.
As long as Western healthcare has existed in Alaska, the problem of getting consistent medical care in every village has been a serious challenge. The sheer size of Alaska, with its many mountain ranges and few roads, makes infrastructure development and travel difficult. The challenging weather and dark winters slowed progress as well. Another serious challenge has been the socio-economic and educational barriers these communities experience compared to the rest of America. Few permanent residents come to these villages from the outside with medical backgrounds. This was the case in Alaska one hundred years ago and still is to a large degree. All of these challenges together were the impetus for the ambitious and innovative solution that is the Community Health Aide Program (CHAP) in Alaska.
The Community Health Aide Program in Alaska is, to many, a story of successfully decentralizing healthcare and putting medical care in the hands of local community members, showing them the respect and trust to care for their friends and family as no one else can. As you will see, healthcare in Alaska has, over the centuries, developed from occasional visits from missionaries or traveling doctors to a widespread community-based healthcare system that meets almost every Alaskan where they are.
A Brief History of Community Health in Alaska
The history of community health in Alaska goes much further back than the CHAP program’s inception. The first Western hospitals and pharmacies were set up by the Russians in the mid-1800s in areas that were populated by Westerners at the time, Kodiak Island being one location. With the US acquisition of Alaska in 1867, the federal government took over those hospitals left behind. Western medical care in the territory at this time was predominantly provided by sparse traveling missionaries, doctors, and nurses. Alaska Native life gradually became less nomadic as the territory was westernized and villages solidified into year-round communities.
By the 1940s, World War II was bringing a massive influx of money and people to Alaska. At this time, before Alaska achieved statehood, public health nurses were employed by the Territorial Department of Health to travel to villages and instruct the local midwives to lower infant mortality rates.
The Community Health Aide Program’s early stages were in the 1950s in response to the tuberculosis epidemic ravaging Alaska at the time. Volunteers distributed oral chemotherapy and TB medications in the villages under the remote supervision of a physician. As the devastating effects of that wave of TB epidemic waned, community members of Alaska Native villages continued to seek healthcare from those volunteers. For the next ten years, formal training was gradually offered, and then in 1968, the Alaska Community Health Aide Program as we know it was officially recognized and funded.
With the passing of the Indian Self-Determination and Education Assistance Act in the early 1970s, responsibility for CHAP was passed from the federal government to regional tribal organizations. Today, the Alaska Native Tribal Health Consortium (ANTHC) plays a vital role in supporting and training CHAs across the state. With federal funding, every aspect of the Community Health Aide Program is managed within the state of Alaska. Pay, administration, and training for these community health providers is done inside Alaska as it has been for the past 50 years.
CHAP has grown to over 500 active health aides practicing in over 170 Alaska Native villages across the state. Additional funds granted in the 1980s grew the training program into what it is today, an indispensable backbone of Alaska Native healthcare. The Community Health program has expanded to include dental health aides in 2004 and behavioral health aides in 2009.
Who are Community Health Aides?
The answer is simple: members of the community who are responsible for the front-line medical care where they live. Alaska Native villages typically will select health aides from within their own communities. Hiring decisions are usually made by the village council. Unlike most healthcare professionals, CHAs are first selected and hired, then they are trained. Since the program’s inception, health aides have increasingly been hired from outside the community or from non-native ancestry. Read to the end of this article for the great story of a WMS locum PA who began his medical career as a community health aide. Overall, the vast majority of all community health aides in Alaska serve the communities they are from.
After hiring, community health aides start with the completion of a first-responder training program like the EMT or ETT certification. From there, health aides take a 16-week CHA (Community Health Aide) course followed by a preceptorship. When their training is complete, health aides return to their community and provide the full spectrum of medical care available in that community. This includes general health and wellness, primary care, and emergency procedures. Health aides are not registered nurses or medical assistants. Health aides practice independently and make care decisions with a physician’s oversight.
Every CHA works under the medical supervision of a physician, but this physician is very rarely in the same facility. Physician oversight can be direct, or indirect via a designated APP in the village. (If you are an Advance Practice Provider interested in remote locums work in Alaska, that would be you!) Most physician oversight is indirect. CHAs trained in the EMT/ETT courses can begin emergency care before contacting a doctor, and there is often a “standing order” that allows the CHA to follow the Community Health Aide Manual without direct physician authorization.
The CHAM: Alaska Community Health Aide/Practitioner Manual
This manual was developed by Alaska medical providers to direct every step a community health aide takes, including patient care plans that a CHA can follow independently. The manual will often instruct the CHA to “report to your referral doctor”, for further instruction as needed. This “referral doctor” is not necessarily a physician, but rather the next level of provider available. This may be an optometrist for eye problems, a dentist, a psychiatric provider for behavioral health, or, most commonly, an APP who is acting as the intermediary for the physician in the village. Previously printed in multiple volumes, the CHAM is now fully online and continuously updated.
Working with Community Health Aides
The abilities, training, and independence that a CHA practices with can vary depending on the community and that individual’s level of training. Overall, CHAP has been very successful in training local community members to respond to emergencies and continue primary care management of patients. If you are an Advance Practice Provider working in Alaska alongside community health aides, it will be important to familiarize yourself with the local clinic situation and get to know the community health aides well. Also, establish a relationship with the CHA’s supervising physician, as you will be often acting as an intermediary between them.
Health aides typically take emergency call in the villages, so there’s a commonly shared schedule between them and locum providers, but locum providers may need to be available as a backup. It is important to remember that health aides are not RNs or MAs. They are the sole medical providers for the communities they live in when higher levels of care are not available. For an APP coming to work with health aides, it is supremely important to remember you are working alongside the health aides. They are not working for you. Health aides typically see their own patients and are not expected to room patients or run vitals like a typical nurse would.
An Interview with WMS Provider, Timothy Jones
Timothy Jones, PA-C, is a veteran WMS locum provider who has deep ties with Alaska and the Community Health Aide Program. As you will learn, his medical career began when he found his way into a community health aide job, no small feat for an outsider to pull off. Below is Tim’s story, as told over a phone call. The story was edited in some places for clarity. All communities mentioned are Alaska Native villages.
Tim: “In 1990, I was in Kotzebue visiting a friend and had some thoughts about joining the PA program at the time; I wanted to get into medicine. I enrolled in an EMT-1 course while I was there and drove their ambulance for a while. While I was in Kotzebue, I heard they were looking for a health aide in Kobuk. I went and talked to the director of that program, and was denied the job immediately. He thanked me for applying but explained that it wasn’t open to outsiders. I persisted in asking multiple times, and eventually, they agreed to take me [up to Kobuk], show me the facility, introduce me to the native board, and we discussed from there. Maniilaq agreed to hire me on a 6-month trial. When that probationary period ended, the tribal council and mayor all sat me down in a tribunal, where they opened a review of my performance up to public comment. The mayor’s son showed up, as did a young 20-something woman who I had worked with. As soon as the floor was opened for comment, the mayor’s son broke out into very high praise of my work, and the young woman stood by my side in support. They hired me that day, and I worked in that community for a year. I absolutely loved Kobuk. They moved me to Deering the next year, which was good. More young people in that community and things to do. I spent 5 years as a health aide in Alaska. That time had some challenging moments but overall, a very good experience.
After Deering, I decided to work up on the North Slope as a health aide and made very good money there, rotating between a score of villages. Working there, they gave me full decision-making in cleaning out and organizing clinics. Providers should know, there’s a culture of respecting other’s things, even after that person is gone. This led to nothing getting thrown away! I had to show up and organize everything. Now, I would not recommend to any locums that they roll into the facility and make a dump run on your first day. That will ruin the working relationship every time, you must change nothing if it’s your first time at a village. Learn how the facility works, offer your support, and lead only by example.
A few years later, after PA school, I ended up in Bristol Bay as the medical director of the CHAP program. I made myself available to the 27 villages in the area as support and training for the CHAs in all of those villages. During that time, I worked on the CHAP training program with ANMC (Alaska Native Medical Center), writing protocols. I helped develop the current Community Health Aide Manual and even illustrated one of them. It was a very active program then, with lots of community health aides working.
In a typical Alaskan village, there are not very many paying jobs. There is the mayor, the mayor’s assistant, the schoolteachers, and the health aides. These jobs are important to the community, and the health aides take their work very seriously. I’ve met some very impressive health aides, 30-year veterans who never took time off and worked very hard for their community with the responsibility to each other and the trainees they were encouraging to stay. Those people loved working with physicians and were very respectful, and eager to learn new things. That relationship between health aides and the physicians, and especially the APPs, is important to maintain.”
The CHAP program is a necessary piece of Alaska’s medical system. Community health aides provide life-saving care on a daily basis to their friends and family. Like many rural programs, CHAP can only continue if it is supported and maintained by the new generation eager to serve. WMS is proud to staff medical providers in support of the community health aides. If you are a nurse practitioner, physician assistant, or physician hoping to work in Alaska someday, we hope you have the opportunity to work alongside these phenomenal medical professionals.