Category: Health

Don’t ignore these 5 signs of diabetes in children

Dr. Marshall, Auburn Reporter

Diabetes is one of the most common – and increasingly prevalent – chronic diseases in children. For parents, the challenge is recognizing the symptoms in their child.

Since the onset is slow and the changes are subtle, diabetes often isn’t recognized until a child is very ill, usually in conjunction with another illness.

So how do parents know if their child has diabetes? Keep an eye out for these five common signs:

• An increase in thirst or urination.

• Lethargy.

• Increased appetite with sudden or unexplained weight loss.

• Vision changes.

• A fruity odor to the breath.

A doctor should be consulted for any of those symptoms, because the symptoms may have other causes besides diabetes. If the doctor suspects diabetes, a diagnosis can be made by looking at the results of one fasting blood sugar test or two random blood sugar tests.

After a child has been diagnosed, many parents realize in retrospect that the symptoms of diabetes had been present for quite some time.

What is diabetes?

The two main types of diabetes in children are type 1 (previously known as juvenile diabetes) and type 2 (previously known as adult-onset diabetes).

In the past 10 years, in conjunction with the childhood obesity epidemic, there’s been an increase in the number of children who develop type 2 diabetes.

Diabetes is when the body is unable to convert blood glucose – sugar – into energy. Insulin, produced by the pancreas, is needed to do that.

In type 2 diabetes, the body is producing its own insulin, just not enough. Type 2 diabetes is closely linked to being overweight. Other risk factors for type 2 include being older than 10, having a family member with type 2 diabetes, and being from a high-risk ethnic group, such as African-American, Pacific Islander and Native American.

The most important prevention tools for type 2 diabetes are a healthy diet, exercise and maintaining a healthy weight. Parents should check with a pediatrician to make sure a child’s body-mass index is below the 85th percentile.

With Type 1 diabetes, there’s no way to prevent it and there’s no cure. The body attacks the pancreas so it doesn’t produce insulin. The only treatment is to replace the insulin through an injection, which is a lifelong process.

Diabetes can occur at any age, but it is most commonly diagnosed in toddlers and at puberty. Each year, about 15,000 U.S. children are diagnosed with type 1 diabetes, and about 3,700 are diagnosed with type 2 diabetes, according to the most recent estimates by the Centers for Disease Control and Prevention.

Treatment options

Many children with diabetes are on insulin pumps and some are on continuous glucose monitors. Pumps provide a constant infusion of insulin and allow insulin to be given through a small catheter that is inserted every three days, eliminating multiple injections. Continuous glucose monitors are the size of a quarter and check sugar levels every five minutes.

Families can meet with a diabetes educator specialized in pediatrics to help them through the process. The MultiCare Mary Bridge Pediatric Endocrine and Diabetes Clinic offers testing, treatment, consultation and education for infants, children and adolescents. The pediatric professionals, child-friendly environment and advanced technology provide the ideal setting to evaluate and educate children and their families.

In addition to the services offered in Tacoma, the team makes regular visits to specialty clinics in Puyallup, Olympia and Silverdale, so that children can get care closer to home. Diabetes educators also coordinate services with community resources and direct support groups.

A diabetes education program can offer:

• Individualized education for children and families.

• Comprehensive group classes.

• Brief, age-specific programs.

• Phone consultations available for families, school nurses and other care providers.

Diabetes education and self-management training is generally covered by most insurance companies, including Medicaid. Contact your insurance provider for coverage information specific to your insurance plan; financial assistance may be available.

Untreated diabetes can have serious, lifelong consequences for a child. Short-term risks are hyperglycemia (high blood sugar), hypoglycemia, (low blood sugar), diabetic ketoacidosis (increased ketones in the urine) and coma. Long-term risks are primarily vascular and nerve damage, resulting in blindness, kidney failure, amputations and increased risk of heart attack or stroke.

Since children don’t necessarily understand the long-term consequences, it’s a parent’s responsibility to make sure children get a proper diagnosis and take their medication.

With the technology and treatment options available, children with diabetes can expect to live long and healthy lives.

Dr. Barbara Marshall is a pediatric endocrinologist at MultiCare Mary Bridge Children’s Hospital & Health Center in Tacoma, which also has children’s health centers in Puyallup, Olympia and Silverdale. For more information about diabetes programs, call 253-403-3131 or or 1-800-552-1419.

Watermelons: Good fun, and good for you

Sally Birks, The Herald

What’s 92 percent water and has a healthy glow?

No, not the human body. It’s watermelon.

Yes, that green giant weighting down the picnic tablecloth is the new darling of health food fans.

Watermelon gets its ruddy inner glow from high levels of lycopene, an antioxidant; it contains citrulline for good heart and cardiovascular function; and it’s low in sodium, the National Watemelon Promotion Board says.

Plus it’s great fun to see how far you can spit those big black seeds.

And if you’re handy with a melon baller, you can carve some pretty cute and edible centerpieces, such as this easy golf ball, fitting for Father’s Day.

Select a small to medium very round melon. Cut ¼ to ½-inch off the stem end so it will sit flat. Then cut out a 3- to 4-inch round circle off the top.

Wield your mellon baller to make shallow round divots like the dimples in a golf ball. Next peel off thin layers of the rind to expose the white part.

Scoop out the red flesh and make little round balls to fill the golf ball.

Buy another watermelon or two and you can complete Dad’s dinner with chipotle maple citrus watermelon wings — that’s chicken, not a carved melon in flight — and watermelon popsicle wedges.

And P.S.: A watermelon won’t grow in your stomach if you swallow those little white seed coats, despite what Gramma says. We can’t guarantee that you won’t get a tummy ache if you eat down to the green, though.

Recipes

The watermelon chicken wings are a little tangy and a touch spicy, but you can control the action. And the refreshing popsicles are an easy way for kids to grip their treat.

Find lots more recipes on www.watermelon.org.

Chipotle maple citrus watermelon wings

Watermelon glaze:

  • 2 cups watermelon puree
  • Juice from 3 fresh lemons
  • 1 tablespoon lemon zest
  • 1/2 cup maple syrup (can use light version)
  • 1/2 teaspoon cinnamon
  • 1/2 teaspoon ground chipotle pepper, or to taste

Chicken:

  • Chicken wings or drumettes
  • 2 cups pineapple juice
  • 1/2 cup soy sauce
  • 1 tablespoon minced fresh ginger
  • 3 cloves minced fresh garlic

Watermelon glaze: Simmer ingredients together in a heavy saucepan for 20 minutes or until sauce is thick. Makes 2 cups. Keep warm.

Chicken: Place the chicken in a large zip-lock bag with rest of the ingredients and seal tightly. Allow to marinate at least 2 hours or up to 12.

Grill until cooked and arrange on a warm platter.

Pour the glaze over the chicken and serve immediately.

Watermelon slice popsicles

  • Watermelon slices, cut to triangular wedge shapes, about 1/2 to 1-inch thick
  • Popsicle sticks
  • Insert a popsicle stick into the rind. You can also freeze the sliced popsicles for a chilly, refreshing treat.

National Watermelon Promotion Board

How removing trees can kill you

Photo: Flickr/rogersanderson
Photo: Flickr/rogersanderson

Jason Kane, PBS Newshour

The trees died first. One hundred million of them in the eastern and midwestern United States. The culprit: the emerald ash borer, a beetle that entered the U.S. through Detroit in 2002 and quickly spread to Iowa, New York, Virginia and nearly every state between. The bug attacks all 22 species of North American ash and kills nearly every tree it infests.

Then came the humans. In the 15 states infected with the bug starting, an additional 15,000 people died from cardiovascular disease and 6,000 more from lower respiratory disease compared with uninfected areas of the country.

A team of researchers with the U.S. Forest Services looked at data from 1,296 counties, accounted for the influence of other variables — things like income, race, and education — and came to a simple conclusion: Having fewer trees around may be bad for your health. Their findings, published recently in the American Journal of Preventive Medicine, suggest an associative rather than a direct, causal link between the death of trees and the death of humans.

Geoffrey Donovan, a research forester at the Forest Service’s Pacific Northwest Research Station, joined the NewsHour recently to discuss why.

NEWSHOUR: Geoffrey Donovan, thank you so much for joining us. It’s an interesting premise. What made you want to study this?

DONAVON: Well my basic hypothesis was that trees improve people’s health. And if that’s true, then killing 100 million of them in 10 years should have an effect. So if we take away these 100 million trees, does the health of humans suffer? We found that it does.

Researchers have shown this in other ways in the past. There’s been some famous research showing that people recover faster from surgery and take fewer drugs if their hospital room has a view of trees. Other research — including some of my own — has shown that mothers with more trees around their homes are less likely to have underweight babies. It’s been shown that if you put people in a natural environment, it can reduce their blood pressure, heart rate and other measures of stress. Obviously we also know that trees can improve air quality. And that’s why I looked at these two causes of death. I didn’t look at pancreatic cancer or something like that. I looked at cardiovascular disease and respiratory disease because both can be affected by air quality and stress.

NEWSHOUR: So the emergence of the emerald ash borer presented a new opportunity to study the effect?

DONAVON: Exactly. This is what we call a natural experiment. If the emerald ash borer were to come around your house, you would probably never see it because the beetle itself has no direct effect on people’s health. All it really does is serve as a tree removal agent. It just gets rid of the trees — kills them with no other effects, almost like the trees were beamed up into space or something.

That’s a really unique opportunity. Imagine if you were trying to look at the effect of trees growing on someone’s health and I got 100 people, I put them in 100 identical houses, and I planted trees in front of 50 of those houses and then waited. It would take 40 or 50 years before you found anything because trees grow really slowly. It’s hard to see significant changes quickly. On the other hand, trees die really quickly. That’s why you have this unique opportunity to see a big change in the natural environment in a short amount of time.

NEWSHOUR: And what did you find?

DONOVAN: Increased rates of death from cardiovascular and lower respiratory mortality in the counties with emerald ash borer. And interestingly, what we found was the effect got bigger the longer you had an infestation, which makes sense because it takes two to five years for a tree to die typically.

We looked across space and time and saw this repeated over and over again in places with very different demographic make-ups. So you’re seeing it in Michigan but then you’re seeing it in Ohio, you’re seeing it in Indiana, in New York, Maryland and Tennessee. So it’s happening again and again in very different places. Places with high education, with low education, with great income, with low income, with different racial makeups.

NEWSHOUR: So what’s the takeaway message here?

DONOVAN: I put it in terms of a question. Maybe we want to start thinking of trees as part of our public health infrastructure. Not only do they do the things we would expect like shade our houses and make our neighborhoods more beautiful, but maybe they do something more fundamental. Maybe trees are not only essential for the natural environment but just as essential for our well-being. That’s the message for public health officials.

For ordinary people: Get involved in planting trees. In most cities, either the city itself or nonprofits will help with tree planting efforts. Also, spend time in the natural environment. I think people intuitively know that. There’s a reason that we like to go walk in the woods or that we like to spend time in the park.

The only thing that’s new here is we’re trying to quantify it. If you talk to a painter or a poet or a writer, do you think they understand that trees are part of our well-being? Look at things like the tree of life metaphor in the Bible. Look at how often trees get painted as symbols of well-being or used in literature. The idea that trees and humans are linked is as old as humanity. So I think you need to look at my research in that context.

NEWSHOUR: Geoffrey Donovan, thank you so much for joining us.

DONOVAN: Thank you.

Heroin use, deaths up increase in state

Donna Gordon Blankenship, Associated Press

SEATTLE — Heroin use and related deaths have increased significantly across Washington over the past decade, especially among people younger than 30, according to a new study released Wednesday.

Young people are finding it cheaper and easier to get heroin than prescription opiates these days. Both kinds of drugs offer a similar high, and a similar addiction danger, said Caleb Banta-Green, author of the report and a researcher at the University of Washington’s Alcohol and Drug Abuse Institute.

The data from Washington mirrors a national trend, but the most up-to-date national research is a few years behind Washington, according to Tom McLellan, CEO of the nonprofit Treatment Research Institute and President Barack Obama’s former deputy drug czar.

A National Institutes of Health study cites national numbers from 2009 that show a national rise in opiate addiction and overdoses. The authors of that study, which was published in February 2013 in the Public Library of Science journal, predicted heroin use would likely increase as a result.

“The state of Washington has by far the best and the most comprehensive and the most up-to-date statistics, way better than the national government,” McLellan said.

Banta-Green found the largest increases in heroin use and abuse in Washington state were outside of metropolitan areas, where drug treatment and awareness are lowest.

Overdose deaths from heroin or related prescription drugs more than doubled in Cowlitz, Snohomish, Grays Harbor, Chelan, Lewis, Mason, Thurston, Benton and Kitsap counties between 2000 and 2011.

“It’s a big change,” Banta-Green said, adding, however, that he’s not surprised by the data.

He attributed part of the increase to new state rules that make it harder to get pharmaceutical opiates because of better prescription tracking.

Washington is ahead of the nation in that trend, Banta-Green said. He expects other states also may see an increase in heroin use after they tighten their prescription rules.

“This is a state manifestation of the broader national picture,” McLellan agreed.

Since 1997, doctors and pharmacists have done a better job nationally of treating pain, but the unfortunate side effect of that medical improvement was the more prescription pain medication was getting in the wrong hands because of theft or resale, he explained.

The diversion of drugs has led to an increase in overdoses, especially among young people, and has also led to more interest in heroin, McLellan said.

Washington is also setting an example for the nation with new pharmacy rules that allow pharmacists to distribute overdose response kits, including a medical antidote to heroin, naloxone, without a prescription from a doctor. So far, only one pharmacy in Washington is participating in the program, but Banta-Green expects that will change.

“What we are seeing and the pharmacy work is leading the country, for good and bad,” he said.

Banta-Green used three sources of data for his study: police drug evidence testing, treatment statistics and county death certificates. Here’s what he found:

— The number of pieces of police evidence that tested positive for heroin totaled 842 in 2007 and increased statewide to 2,251 in 2012.

— Drug treatment admissions for heroin increased statewide from 2,647 in 2002 to 7,500 in 2012. The majority of 18- to-29-year-olds seeking drug treatment for the first time in 2012 were being treated for heroin use.

— The number of accidental deaths statewide involving heroin and prescribed opiates doubled from an average of 310 a year between 2000 and 2002 and 607 a year from 2009 to 2011. In King County, almost three-quarters of drug-caused deaths involved heroin or a prescription opiate between 1997 and 2012.

Banta-Green believes the pharmacy program and a relatively new 911 overdose Good Samaritan law, along with increased awareness, could turn at least the overdose statistics around.

Washington passed the Samaritan law three years ago to encourage people to seek professional help when someone is overdosing. The law gives the person calling for medical help immunity from prosecution for drug possession charges.

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Online:

Report on opiates: http://bit.ly/1a4rr0w

Stop Overdose: http://www.stopoverdose.org

Arctic melt spurs global spread of disease

By Kieran Cooke, Common Dreams

A cow grazing on the lush pasturelands of Cornwall in southwest England and a seal swimming in the ice cold waters of the Arctic might not appear to have much in common. The link between the two is tuberculosis, with a strain of the disease threatening cattle populations in Britain and elsewhere now showing up among seals in the high Arctic.

Dr Claire Heffernan, a trained vet and a specialist in global health and disease interaction between animals and humans, says that as the climate warms in Arctic regions, more and more diseases from Europe and elsewhere are spreading there, threatening both animal and human populations.

“In the past diseases might not have survived in the cold temperatures and the ice of the Arctic but as the region warms a new dynamic is introduced” Heffernan told Climate News Network.

“We need to fundamentally alter the way we look at disease in the context of climate change. We should recognize disease as a harbinger of a warming world.”

Dr Heffernan, a senior fellow at the Smith School for Enterprise and the Environment in Oxford and director of the livestock development group at the University of Reading says a wide variety of diseases have recently become evident among Arctic animal populations.

Toxoplasma, a parasite common in European cat populations, is now being found in polar bears in Greenland. Erysipelas, a disease of domestic pigs, is being found in Musk Oxen in the Canadian Arctic: the animals have also been found to have contracted Giardiasis, an intestinal parasite of humans. Meanwhile West Nile virus has been found in wolf pups in the Canadian Arctic.

Transmission

Such diseases could have been transmitted in a variety of ways, says Heffernan. The spread of Toxoplasma, for example, might be the result of people flushing cat faeces down toilets in the US and Europe which are then carried by tides to the Arctic. More people are visiting the region. Tourists defecating in the wilds might be the cause of the spread of Erysipelas.

“The Arctic is like a Heathrow airport in terms of bird, seal and other migration patterns so that’s another way disease is easily spread” says Heffernan.  “And the disease pathway is not all one way – they can also be transmitted from the Arctic to elsewhere in the world.

“The point is no one is really joining up the dots between climate change and the spread of disease. There’s a whole new disease transmission cycle appearing in the Arctic which we just don’t understand.”

Impact on humans

Human disease levels in the Arctic are a continuing concern says Heffernan. Rates of TB among the Inuit of northern Canada are far higher than in the general population.

Major economic change and development now taking place in the Arctic means previously nomadic people are moving to towns in search jobs. Ice melt is also forcing more into settlements. With people living in close proximity to each other, disease tends to spread faster. Infant mortality in the Arctic, much of it due to diseases curable elsewhere in the world, is considerably higher than elsewhere.

“In 1930s there was a temperature spike in the Arctic which led to an outbreak of malaria” says Heffernan. “In subsequent years chloroquine was used to combat it. But what happens now, with temperatures rising and the prevalence of chloroquine resistant malaria?”

Anthrax alert

Early in the last century there were periodic outbreaks of anthrax in the Russian Arctic, resulting in the deaths of thousands of deer and cattle. Some Russian scientists and officials have warned that burial sites of those anthrax infected animals are now being exposed.

“As the Arctic melts, ancient pathogens can suddenly escape” says Heffernan. “No one knows for certain how many livestock burial sites there are in the Russian Arctic – I’ve seen estimates ranging from 400 to 13,000.”

In recent years there have been several anthrax outbreaks affecting both cattle and people reported in the region, particularly among communities of the indigenous Yakut, who often live near to such burial sites.

With Arctic temperatures rising at more than twice the rate of the rest of the world, Heffernan says there’s an urgent need to link disease and climate change and tackle health issues.

But there are a number of problems preventing concerted action: the Arctic is governed by different states with different laws. There’s not even a common agreement among Arctic nation states on the region’s boundaries. There’s a dearth of trained medical staff and research across the region. When it comes to statistics, the Arctic is something of a black hole with health data subsumed into more general country wide statistics.

“There’s very little biosecurity work going on in the Arctic” says Heffernan. “Yet we have the means to control so many of these diseases. There must be urgent, concerted, joined up action.”

Kids’ bike helmets, child safety kits available for free June 8

– The Marysville Globe

SMOKEY POINT — The Marysville Kohl’s and Arlington Pediatric Dentistry will serve as sites to help make kids more safe on Saturday, June 8.

Arlington Pediatric Dentistry in Suite B-105 at 3710 168th St. NE will furnish parents with John Walsh-endorsed free child safety kits from 10 a.m. to 4 p.m. on June 8.

The free child safety kits in Arlington will include FBI-certified fingerprints and Next Generation PALM Prints, as well as a digital photograph and a child safety journal.

The Kohl’s at 3713 116th St. NE in Marysville will host a free kids’ bike helmet giveaway from 10 a.m. to 1 p.m. that same Saturday.

The free bike helmets in Marysville will be available for children aged 1-18 years, while free multi-sport helmets will be available for children aged 5-18 years.

Due to limited quantities, a limit of one helmet per child will be enforced, and the helmets will be dispensed on a first-come, first-served basis, with no appointments necessary.

The wearers must be present and fitted to receive their helmets.

For more information, log onto www.makesurethehelmetfits.org.

Volunteers Needed: Mountain Stewards Protect Mt. Baker ecosystems

Everett, Wash., May 31, 2013—Want to help keep Mt. Baker pristine? Mountain Steward volunteers are needed this summer to teach day hikers, backpackers and climbers to care for and protect this delicate alpine ecosystem.
 
Forest Service staff will train volunteers July 13 and 20 in low-impact recreational skills, natural history and back country management. Mountain Stewards commit to work three weekend days during July 13-Sept. 22 on the three busiest trail systems: Skyline Divide, Park Butte/Railroad Grade and Heather Meadows/Artist Point. An optional training is offered Aug. 3 for those who want to volunteer at Heather Meadows.
 
Apply by June 28. Find applications online and email to brichey@fs.fed.us,  fax to 360.856.1934 or mail to Mt. Baker Ranger District, Mountain Stewards, 810 State Route 20, Sedro-Woolley, WA 98284. Call 360-854-2615 or brichey@fs.fed.us for more information. Volunteers must be 18 years or older with hiking and outdoor recreation skills.
 
 

Do You Hike? Want to Help Get Rid of Noxious Weeds?

Become a Weed Watcher
Renee Bodine, Public Affairs Officer, Mt. Baker-Snoqualmie National Forest Service
Everett, Wash. May 31, 2013– Uncontrolled, weeds like oxeye daisy can monopolize alpine meadows, English ivy will cover forest canopies and Japanese knotweed will choke creek-side vegetation. The Mt. Baker-Snoqualmie National Forest and Washington Department of Natural Resources have teamed up with the Mountaineers and King County Noxious Weed Program to train volunteers to find invasive plants on trails.  Hikers are needed to monitor trails for infestations in theMt. Baker-Snoqualmie National Forest’s designated wilderness areas and in the Middle Fork and South Fork Snoqualmie valleys of King County.  Classes will train Weed Watchers how to identify invasive species, record and collect data with GPS units and control some weeds.  The volunteers will choose which trails they want to “adopt” in a particular area this summer.
 
June 9, 10 a.m. – 4 p.m. -Wilderness Weed Watchers Training
Darrington Ranger Station, 1405 Emens Avenue North, Darrington, WA
 
June 15, 10 a.m. – 4 p.m. -Wilderness Weed Watchers Training
Glacier Public Service Station, 10091 Mt. Baker Hwy, Glacier, WA
 
June 23, 9 a.m. – 4 p.m. – Upper Snoqualmie & Wilderness Weed Watchers Training
Snoqualmie Ranger Station, Back Conference Hall, 902 SE North Bend Way, North Bend, Wash. 98045
 
To join the Upper Snoqualmie Weed Watchers contact Sasha Shaw at 206-263-6468.   Volunteers can register to train for the Wilderness Lakes Wilderness Weed Watchers on the Mountaineers website  and contact Sarah Krueger  for more information at 206-521-6012.
 
The National Forest Foundation provided a grant to inventory weeds in the Mt. Baker, Noisy-Diosbud, Boulder River, Henry M. Jackson, Clearwater and Norse Peak Wilderness Areas.  Learn more about noxious weeds, workshops and events from the King County website.
 

Health Care Is Spread Thin on Alaskan Frontier

Jim Wilson/The New York TimesA plane arriving with a patient at the airport in Bethel, Alaska.
Jim Wilson/The New York Times
A plane arriving with a patient at the airport in Bethel, Alaska.
 
By KIRK JOHNSON
May 28, 2013 The New York Times

 

BETHEL, Alaska — Americans in some rural places fret at how far away big-city medical help might be in an emergency, or at the long drives they are forced to make for prenatal care, or stitches, or chemotherapy.

Dr. Ellen Hodges only wishes it could be so easy.

She oversees health care for a population of 28,000, mostly Alaska Natives, here in the state’s far west end, spread out over an area the size of Oregon that has almost no roads. People can travel by boat or snow machine at certain times of the year, but not right now: the Kuskokwim River, which wends through Bethel to the Bering Sea, is choked with unstable melting ice in late May, magnifying the isolation that defines everything in what may be America’s emptiest corner.

"Jim

“If you have a road, you’re not remote,” Dr. Hodges said.

The complex machinery of health care is being reimagined everywhere in the nation through the combined prism of new regulations and shifting economics, even here on the continent’s frosted fringe.

The grandly named Yukon-Kuskokwim Health Corporation, for example, where Dr. Hodges is chief of staff, is scrambling this spring to install a new electronic medical records system. That is a hallmark of the federal health care overhaul, compounded out here by the fact that computers run by generators in far-flung villages are subject to brownouts and fuel shortages.

Cost controls are also the way of the medical frontier no matter where you look. In other places, such constraints may be driven by insurance companies; here, by sequester-driven budget cuts to the federal Indian Health Service. The agency is the 50-bed hospital’s main support in treating the tribes and villagers who have lived for thousands of years in the boggy crescent of lowlands where the Yukon and Kuskokwim Rivers carve their paths to the sea.

The 56 tribes in the region voted in the mid-1990s to bundle their health care money from the federal government to finance the hospital. Grants supplement the work.

But the one thing that shapes every care decision, from the routine to the catastrophic, is the map. Triage in medical decisions, logistics and money is all filtered through an equation of time and distance on a vast and mostly untracked land.

Is air transport justified for medical reasons? Too slow to make a difference? Too dangerous in bad weather to attempt? What should a health worker on the ground — in most villages a local resident trained by the hospital — be told to do, or not do?

“There are judgment calls that you never have to make in the lower 48,” said Dr. David Bielak, 31, a family medicine practitioner who started coming here last fall in temporary stints from his home near San Jose, Calif.

And many of those decisions, often based on telephone descriptions from a villager, can be weighty. None of the more than four dozen communities served by the hospital have a doctor in residence.

“It’s the middle of the night, and you get a call from a clinic way up in the middle of nowhere where something very, very strange has happened,” Dr. Bielak said. “A lot of it is dark: a lot of alcoholism, suicidal ideation, a lot of abuse.”

A lack of running water and sewer systems in many villages in turn compounds the struggle to make, or keep, people well in a place long marked by poverty and isolation.

Take a glimpse, for example, into Alexandria Tikiun’s world: At age 25, with four children at home to care for, she is a community health aide, the closest thing to an M.D. in her village, Atmautluak, population about 400.

The aide system itself is uniquely Alaskan. It was developed in the 1950s, during an outbreak of tuberculosis, when the first health aides were trained to dispense medicine. Now, in sessions here at the hospital, Ms. Tikiun and 150 other aides, mostly women, learn medical skills that include trauma response, pregnancy testing and vaccination, all based on a book that they call their bible, which walks them through a kind of algorithm of step-by-step questions leading to treatment protocols.

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This article has been revised to reflect the following correction:

Correction: May 28, 2013

An earlier version of this article misstated the number of tribes that voted in the mid-1990s to bundle their health care money from the federal government to finance a hospital. It was 56, not 58.