Sunday, March 15, 2009

Wet Reserves and Dry Reserves

Wet and Dry Reserves
By William Hay, MD

There are still those who believe that the disease of alcoholism is a sympton and not a cause. It is an idea that remains prevalent in some psychiatric circles which believe that alcohol is a “self medication” of mood disorder.

That it is an immediate acute temporary central nervous system depressant is not questioned by those who believe instead that chronic use, that is alcohol abuse and dependence are primary illnesses.

In the 80’s I had the great fortune to go to work with Dr. Jack Hildes. He was the head of Community Medicine at the University of Medicine but more reknowned for beginning the Northern Medical Unit provided medical services to northern Canada. The Circumpolar Health Conferences which brought together the global care givers in the Arctic and Sub arctic areas was just one of the projects that Dr. Hildes was involved in initiating. He received the Order of Canada, the country’s highest award for his work in medicine.

Part of my work involved flying into northern Manitoba Indian Reserves, predominantly Cree or Ojibway nations, isolated from cities and towns by vast forests impermeable to roads except in winter when ice roads were built and supplied year round by planes.

The people of these reserves, some of my finest teachers and the warmest deepest humans a young man could care to encounter also had tremendous senses of humor and reserves of patience. They had long dealings with the white man and were never sure with good reason to wonder if any of his gifts weren’t yet another attempt to finally complete the genocide begun with the Indian Wars and following reserve movements.

“You’ll see the difference between the wet reserves and dry reserves when you fly into them, “ Dr. Hildes said. “You’ll also see the lead encephalopathies that come with gas sniffing by the children. “

I would fly north out of Winnipeg for most of the day in an old DC3 which I could have sworn had seen time in the war. I began going into the reserves I want to focus on when the snow was thick on the ground, up to one’s waist if you stepped off beaten paths. I wore a heavy blue nylon parka with a fur lined hood, down filled boots, and wore long johns under jeans and sweaters. I always had thick mitts and a wool toque and red scarf. I think the Northern Medical Unit paid for that parka which I bought at the Hudson Bay Store. My medical bag was a part of the packsack I carried with a light weight down sleeping bag I’d been taught in survivor training provided by the Northern Medical Unit was the best defense against a plane going down.

The DC3 was loud and usually I was the only passenger, though I once shared my window with a highly irritated infrequent flyer half german shepherd half wolf returning from a Veterinary visit to the city. He sort of joined me on take off and growled when I shifted under his weight. I don’t think he liked the view. The rest of the plane was filled with supplies. We were the sole passengers. He stayed on my lap till the co pilot came back to see if I wanted an instant coffee in a Styrofoam cup. He was able to convince the dog that I was perhaps not the sole reason for his predicament. The co pilot gingerly encouraged him to return to the floor. I had long ago completed my exam of the canine teeth and curled lip reflex so was most grateful for assistance.

“The Indians vote themselves whether the reserve is going to be dry. No one can bring in liquor after that. They don’t much bother the doctors and nurses and pilots since mostly they’re on the Hudson Bay lands where the store is. “ Dr. Hildes told me.

This reserve I flew into was a dry reserve. It could have been Little House on the Prairie. The streets were clean. All the children were well dressed. I attended the clinic and other than those illnesses peculiar to the region, like frostbite, and diabetes, the overall picture of health was no different really than that in the rural town I’d previously done family practice.

If anything the people were happier and there was a simple friendship network. Most folk went to church. The schools ran and after school hockey and other team games were important. There were volley ball games by the adults in the gymnasium in the evening and lots of good music with guitar and violin. Country and western songs were favoured by the Indians there. Johnny Cash was king.

I enjoyed my work there, doing home visits, getting my hot percolated coffee fresh from off the top of the big stoves used to heat the cabins. I’d see cuts and scrapes and listen to the chests of the old folk with my stethoscope. The nurses who did nurse practitioner work in the clinics served as doctor often. I as the doctor traveled to several different reserves by bush plane or ski doo and in summer by open boat with the evinrude outboards. The reserves were always on lakes or rivers having developed when the canoe was the main transportation. Trapping, hunting and fishing were still the main activities of the men though construction and some forestry was going on.

What was remarkable was the sister reserve. When the main reserve voted to go dry a few hundred folk decided they weren’t ready to give up alcohol.

“I remember being frightened around the men. When they were drinking with my aunt my grandfather told us to hide. There were 3 of us girls, all friends. We must have been maybe 5 to nine years old. The men would come stumbling after us. It was sexual. My aunt was raped. I heard her screaming. They were all drinking. Sometimes we hid under the bed but mostly we had to hide in the bushes.” She was a lot older when she was able to talk about those days.

“Henry was just hanging there. I found him out by the river. He’d been drinking. We’d all been drinking. I had my knife and cut him down before I went to get the others.” The young man told me that story back in the city in the psychiatry ward. He’d been diagnosed schizophrenic before there were cross cultural psychiatrists who recognized that PTSD was pretty well endemic in the wet reserves. Those whose lives were compounded with the Residential Schools experiences were worse.

I would walk across a bridge about a mile or so from the main reserve. The families who opted to stay wet had just moved a mile or so away. They just didn’t go over to the main reserve when they were drinking because that was the rules. The Indians in general were pretty good at following their own rules but not too particular about white man rules.

When I had clinics the folk would come from both reserves but when I began doing house calls with the nurses I really got to see the way it was. The nurses did all the public health. They were a dedicated rare breed of women, often from as diverse locales as Britain or Australia. Some Americans but mostly Canadians who faced all manner of hardship but lived to care for the people. They taught me a lot.

“Annie would have come to the clinic but she’s been feeling so poorly that she would have been ashamed not to be seen hardly able to walk. It’s her heart that’s bothering her and I’d certainly appreciate your seeing her, though, I’m sorry she’s in the worst part of the reserve and sometimes there’s trouble.” This was as much as I’d heard this nurse say in one go. She was a doer and native herself. Hardly five feet and a real ball of energy with a heart especially for the children.

In the wet reserve, the incidence and prevalence of all the alcohol related diseases was incredibly high. The contrast was extraordinary since the main reserve shared the same genetics and the only difference that could be seen was alcohol. Heart diseases, diabetes, pneumonias, liver diseases, skin infections, sexually transmitted diseases. All of them were over represented. The greatest tragedy was the children with Fetal Alcohol Syndrome.

When I came across the bridge and walked along the snow packed trail between the scrub spruce and fir I got to the first of the shacks. All around the outside of the shack was garbage. This was typical of all the houses here. The dogs who were everywhere go into the garbage bags and spread the waste. Nobody bothered to carry it the extra steps to the containers. They just threw it out the back door.. Pea cans, milk cartons, plastic plates, all strewn across the white snow.

Further on there was a shack which had half the wall missing. It had been abandoned though the rest of the building and the roof at least looked relatively new.

“What happened, “ I asked.

“Some men were there. They ran out of wood for the fire. They were drinking. They just took the wood from the walls.” She said as we walked and her breath formed white mist with the cold.

“How come you’re outside, Elvis.” She asked the little boy we found coming around the corner to the main street. He was kicking at the snow and shivering.

“They’re having a party at my place.” He said, looking down. Behind him the music from the house was loud and it was only 10 am. Hard to tell when the party on the wet reserves began. Often they went on for a day or two, binge drinking being the normal pattern.

“Come along with us, we’re going down to Annies. She’d like to see you.” She said to him, putting her hand on his hooded head and bringing him along with us.

Annie’s was at the end of the houses and just to the back of f the main road. She wasn’t able to get up and the public health nurse just opened the door telling her in her own language that she’d brought the doctor.

Annie was in her seventies lying in bed breathing poorly but smiling to see us. She was covered in blankets and when I went to examine her I found she was wearing four dresses. Her pulse were weak and her blood pressure abnormal. There were a lot of rales and crackles in her chest. Her heart sounds were tachycardic and hyperdynamic. I got under all the blankets to press her feet and watch the slow filling of the imprints of my fingers tell tale signs of edema.

She was in classic congestive heart failure and luckily I had some lasix along. I started her on this and went on to discuss the rest of the treatment with the nurse who would continue it after I left for the next reserve. I sometimes wonder today if I’d just treat confidently on clinical findings and not get ekgs and chest xrays which of course weren’t available within hundreds of miles. Even if I’d wanted them, mostly the old folk weren’t keen to leave and go to the city. Annie never did learn to speak English though you could tell she understood more than she let on.

When I stepped out of the cabin I felt good. The little boy had stayed with Annie and the two of them were happy drinking the tea the nurse had made while I was doing my examination. We’d had ours before leaving and shared cookies with the boy who asked so politely and shyly if he could have two. The nurse didn’t refuse him and Annie smiled sitting up in her bed.

I’ve always loved medicine and healing but these cases were the ones where you saw the results immediately. There was the community intervention with the boy and then the medical miracle of Annie. She was already perking up by the time we left and she’d be up and about doing her house work when the nurse visited the next day. I felt like the doctor hero for a moment because quite frankly often the work is drudgery with the results only apparent over time.

That’s when the 3 young drunk bucks appeared round the corner. They were stumbling drunk.

“Hey, look it’s a white guy” one said

“Kill the whitey, “ said the next.

“You’d better run, “ the nurse said beside me and next thing I’d gone from hero doctor to fleeing doctor running alongside this nurse who despite her short legs was going full tilt.

“Get to the chief’s house, the last one on this side, Go.“ she said. I continued to run while she turned and ran straight into the belly of the biggest guy in the middle bowling him over, the two of them sprawling in the snow.

The other two slowed up for only a second and then I heard, “Kill the whitey again” I heard a bottle break against a cabin wall and they were coming after me again. I ran faster to the chief’s banging on the door until this drunk little guy came out. The two guys had stopped short of his veranda.

“Who are you, “ he said. “I’m the doctor.”

“Go away boys, he’s the doctor.” He slurred. The guys didn’t move so the chief pulled me in. “You stay awhile here, They’ll go away soon.”

All around the cabin there were bodies in various states of inebriation and a couple of the women were lying on the bed half undressed.

“Want a drink,” he asked.

“No, thanks, “ He stood staring at me after that and sort of wavered forward and backwards

The public health nurse came in at that point and said it was okay to come out.

“What were you doing tackling the big guy,” I asked as we walked back over the bridge.

I know him from when we were children. He’s wouldn’t hurt me. He just doesn’t like white men. Drunk he’s violent. He just got out of the penitentiary for manslaughter.” She said as we trudged in the snow.

Violence, death from freezing in the snow, medical complications of alcohol, substance abuse with gasoline sniffing and a regular Peyton Place of STD’s made the wet reserve a kind of Dante’s Inferno compared to the Home Sweet Home Little House on the Praire main reserve.

I just always wished my colleagues who never diagnosed alcoholism could have seen this contrast. Maybe then some of the 40% of people who are in hospitals as a consequence of drinking and the 75% of people in the jails could get the kind of medical treatment which would address their primary problem and give them hope for a normal life.

Even when the reserves went dry the bootleggers would still fly planes full of booze and land them just outside the reserve limits. In spite of this and the Hudson’s Bay wanting to profit selling alcohol and the government always happy to benefit from the taxes made off liquor the dry reserve movement keeps happening. It’s the foundation of the empowering of the Indian movement that lead to the profound changes in the 80’s and 90’s in the Indians achieving self government.

As long as the Indians were drunk the government could manipulate them, Iguess.

Maybe if the country as a whole could take a lesson from the Indians we’d see some improvement in government, I thought. Certainly the denial about the profound medical and social costs of primary alcohol abuse and addiction would be addressed.

I’m just thankful that I had the opportunity to work with Dr. Jack Hildes Northern Medical Unit and see first hand what a people could do for themselves and how prevalent. extensive and ubiquitous alcohol problems and addictions are.

I recently heard one colleague call it the “great masquerader”. It presents as trauma, seizures or heart disease but it’s really just alcohol. Kind of like infections which spread through the body and give rises to rashes and fevers and many separate things that the good clinician recognizes for what it is. Alcohol does this in the body but its most profound effect for me is at the community level and in men’s thinking about alcohol and addiction. Pretty soon whole communities live in denial about drugging and drinking. Sometimes even the medical profession chooses to ignore the problem.

Maybe it will just go away. Maybe it won’t.

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