Ambushed!

International work, medical or otherwise, is dangerous. Maybe only a little more dangerous than normal American life, maybe quite a lot. A long-term Christian missionary doing really, really good work was gunned down in Haiti just today.

noyau-goat-3
About as remote as it gets.

I myself have done relief work in Haiti. One of the places I worked is located in the hills of a village-esque area called Noyau. This place is about as remote from civilized life as I can recall being in my life.

After an hour of 4WD driving on extremely-rough dirt switchbacks up a mountainside, we pulled on packs and hiked for another hour+ to reach the area of our clinic. If something went wrong out there, the time required to receive aid would exceed 4 hours easily. Assuming emergency crews had access to a 4WD vehicle, which is doubtful.

I recall thinking, as well over 100 Hatians stared at us zipping ourselves into our expensive tents and sleeping bags at the end of a clinic day, how honorable they were as a people. They had hiked for many hours to find our clinic, and often the only thing we had to offer them upon their arrival was a few TUMS tablets. Frequently their medical problems were either too complex for us to help with, or, more commonly, we simply didn’t have the medicine or procedural ability they needed.

But they could have robbed us. Selling our nice North Face and Sierra Designs gear would have fetched an impressive price in Port au Prince. Furthermore, they could have kidnapped us and held us for ransom. Now we’re talking real money. Until they talked to my wife, who would probably say something like, “Take ‘im. Never does the dishes anyway.”

We were totally vulnerable in that village. But the reason, I believe, nothing bad happened was simply because most Hatians are good people. Honorable people. Honorable, even, by my wealthy American standards, where respect for property and life is alive and well. They let me keep my nice tent, even though they couldn’t be sure of their next meal.

Similarly, while working in the Galatsia camp on our 3rd day in Athens, I ended up in an extremely vulnerable position. Again, we came out unscathed largely because most people are, quite simply, good.

Prior to entering the camp, I asked one of my team members with military training to effectively serve as our “security.” He took his role seriously: identifying sight-lines, exits, areas of risk, areas of relative safety. He developed rudimentary emergency plans, identified key leaders in the facility and communicated escape plans to our team.

But for some reason, when I was asked to leave our clinic to go see a patient reportedly too sick to walk to us, I didn’t think to ask our security guy to come with us. In “medical mode,” it’s difficult to think in “safety mode” too. Our task is to meet needs, not protect ourselves, and the thinking between the two is often very different.

wpid-wp-1444825879926.jpeg
See all the people? That lady in blue is an aide worker. Behind me was a large room, a courtyard, and a line of police. I thought we were going here.

I also believed we would be going to one of the large rooms with lots of people, located near the entrances, near the police, organizers, aides and managers.

That’s not where we went.

Led by the sick woman’s husband, we walked down corridor after corridor. Branching off from each of the primary hallways were other halls, down which I saw a half-dozen young Middle Eastern men, crouched against the wall, all looking at me. The halls were strewn with trash, cell phones hanging by cords from every available outlet. I heard yelling, some laughing, but mostly saw numerous drawn, emotionless, bored faces. There was no joy.

I went with our clinic organizer (a Persian woman who organized the whole medical clinic, speaks numerous languages, and knows what she’s doing) and, as luck would have it, the pastor of the local Calvary Chapel we’re working with who saw us wandering away and followed. So at least I wasn’t alone.

hostages
This happened in the Philippines just last month. However improbable, we could have rounded the corner and found guns and flags, not a patient.

But after the 3rd corridor, and up a large flight of stairs, then outside the building and then back into it and around a corner, I knew that if someone wanted to do us harm, they would have succeeded. We’d followed this guy like ducklings.

But he didn’t harm us. All the man wanted was to know if his wife would be OK, and if it might be possible to get her on her feet by that evening, in hiking condition. He intended to continue his journey into Europe as soon as he could.

I diagnosed viral gastroenteritis and told him she may be ready to roll by that evening, but giving it another day or two would be better. He clearly intended to leave that night, despite what I’d said.

Later, of course, we laughed about this. Our team leader, Sahar, laughed at me for being so worried.

But the truth is that there is no way to do this work without incurring some amount of risk. Usually the risk is small, thanks largely to the fact that although there is terror and violence in the world, most humans on this planet are good, fairly honest people. Most are just trying to make a better life for themselves and their children.

As are we all.

Galatsi

On day 3 we left our makeshift clinic in the 2nd Evangelical Church of Athens to work in one of the main refugee “camps” in town. But it isn’t a campground. It’s one of the main stadia used in the 2004 Olympics, located in the Galatsi suburb of Athens.

The story of how this stadium came to be used for refugees is emblematic of the refugee crisis in generally. The stadium has been shuttered for years, no lights, no electricity. But with thousands of people suddenly camping in parks all over Athens, the people of the city were understandably upset. Furthermore, anti-immigration groups were organizing and preparing potentially-violent opposition to the influx.

So the Minister of Immigration apparently decreed that refugees would be moved to the Olympic Stadium. Only then was the mayor of Galatsi notified of the dictate, while also being told that he was, in fact, in charge of the stadium.

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Queuing up for lunch. The food I saw was a step up from David Copperfield-esque porrige, but not by much.

On balance, it’s a good plan. There is lots of room there, the people and tents are out of the parks and off the sidewalks. The Greek Army (I think) has been tasked with feeding the refugees 3x per day, an endeavor equal to any reasonably-trained Army. It also protects Greek political leaders from human rights criticisms, since the people are being cared for while not upending entire neighborhoods.

There is both massive influx and efflux of people from the stadium every day. Nobody intends to stay for long; the Greek government does not plan on operating the facility indefinitely either.

We were given an emergency medical license under which I could function as a de facto Greek doctor on days when I worked at any of the camps. We were asked, really more like begged, to work at the Galatsi camp because over 1000 people were there, with hundreds requesting a doctor.

Here are some observations from that day:

  • 5
    Lots of people, all trying to help. Not a lot of organization.

    We worked out of a small room, filled with donated medicines, even some supplies. It was better-appointed than I expected. It was cramped, sweaty and regularly filled with people for myriad reasons. A hazy notion of ‘organization’ came and went throughout the day.

  • We infuriated the Greek doctor, a pulmonologist, who is overseeing the medical room in the camp. We had been “begged” by the ministry of immigration to come work that day. She was never notified. So our presence was a surprise to her. She wasn’t, however, working. Nobody was. She showed up, yelled at us about attending a strategy meeting in a few days, hung around for a bit, then left.
  • The Greek Government is doing better with this crisis than reported. There
    greecemap
    Areas around Greece where people are helping with the refugee crisis either directly or by collecting donations, etc. Click this pic for an interactive map.

    were police on the campus (until later in the afternoon, when they apparently lost interest and wandered away). There were GIANT piles of clothes in the “clothes section,” and everyone had food at mealtimes. The camping areas were dry and were clean if the refugees cleaned up after themselves (some did, some didn’t). But the same Greek Government has relied heavily on individual donors, NGO’s and privately-funded clinics like ours’ to make this some sort of controlled chaos.

  • Before we started, I watched a T.V. reporter van pull up next to a nice black car, out of which stepped some guy in a suit. The camera started rolling as the guy stood next to a reporter-looking person. There was a quick interview, then some panning shots of the facility. Then the guy got back in his car and drove away. I found out later this was some politician getting time on T.V. “working” at the camp. This is happening on the local Greek news, with dignitaries, including local doctors, posing as helpers in this crisis.
  • The majority of refugees in the camps and on the streets are from Afghanistan and Iran, not Syria. In general, the Syrians have more money and are staying in rented apartments. Usually, those apartments are being sub-let (for a substantial profit) by other refugees. It’s a dog-eat-dog environment.
  • 4
    Quite a few meds. No smokable opium. No opium t all, in fact.

    I saw a patient with back pain who was smoking opium for pain control. He said he didn’t want narcotics for his pain, but also said nothing else worked for him. As our clinic absolutely has no narcotics of any kind, we offered him some non-narc alternatives. He left, unhappy, then returned later, forcing his way through the scrum outside to “complain” about our “service.” Apparently narc-addiction and the behavior it engenders knows no social or ethnic boundaries.

  • Our clinic lead, the Persian woman who organizes these clinics (a refugee herself 15 years ago), wisely did NOT allow advertising when we started our clinic day. Just by word of mouth alone, we were nearly overwhelmed with a shouting, occasionally-pushy mass of people that formed outside our “clinic” shortly after we opened for business. HUGE credit to a great team in front of me to help control and direct the traffic outside.
  • The Mayor of Galatsi, and manager of the camp, is not a happy man. The Greeks dislike him because he’s helping refugees invade their country. The refugees don’t like him because he oversees a camp perpetually under-resourced. The political class over runs him, taking their own photo-ops and garnering the credit for the work being done there. When I met him in the camp, he half-shook my hand, then tersely told me to “get to work.” Can’t blame him.

I was worried to work here for a host of reasons, but I’m glad I went. I wish we could spend more time in the camps. Getting patients to our clinic at the church was a big challenge. No problem here.

Medical Case

image

A 44 year old man came to our clinic today with a description of chest pain, mostly on the left side. He says it’s been ongoing for about 4 months.

He arrived in Athens about two weeks ago, with plans to head to Germany in another week. He was seen last week at a Doctors of the World clinic in town for the same problem.

He says they gave him the above EKG, told him he was having a heart attack, and sent him out the door with 10 pills of Prilosec and instructions to go to “the hospital.”

Due to money restrictions, lack of transportation, minimal confidence in, and maximal confusion from, his interaction with his Greek-speaking doctor, he did not go to the hospital. He instead came to our clinic 4 days later, worried he was dying from a heart attack.

How would you handle this?

Lentils or Needles, Your Choice

church
The Church (not abandoned, as I first thought) were our clinic is located.

We saw around 15 patients on our first day. If I this was a video game (maybe all of life is?), by the end of the day my strength bars would have been around 2/5.

Today we have nearly 30 people on the schedule, plus a smattering of missionaries who seem to filter in with loooong lists of medical questions.

The missionaries are amazing. Most consider themselves to be “married” to the mission field, and are here by themselves, living on donations. And not just for a week. For years.

If you’re looking for “underserved” medical communities, no matter your own personal faith persuasion, here’s one. Most Christian missionaries donated their health and bodies to their work long ago. They see a doctor when they can (read: every 5 years on average), but it’s never a regular thing for them.

One question from a missionary yesterday, “We’re so excited. We’ve been given permission to use an old elementary school from the Greek government. People have been defecating and doing drugs in there for the past 5 years. All we have to do is clean it out, and it’s ours! Do I need Hep B vaccination? I think I had one of those shots. What about that HiB thing? Oh, and what about tetanus. Can’t remember when I last did one of those. And should I wear gloves? Maybe a face mask?”

Afghan migrants arrives on the shores of the Greek island of Lesbos after crossing the Aegean sea from Turkey on a inflatable dinghy, Thursday, Sept. 24, 2015. More than 260,000 asylum-seekers have arrived in Greece so far this year, most reaching the country's eastern islands on flimsy rafts or boats from the nearby Turkish coast.(AP Photo/Petros Giannakouris)
Afghan migrants arrives on the shores of the Greek island of Lesbos after crossing the Aegean sea from Turkey on a inflatable dinghy, Thursday, Sept. 24, 2015. More than 260,000 asylum-seekers have arrived in Greece so far this year, most reaching the country’s eastern islands on flimsy rafts or boats from the nearby Turkish coast.(AP Photo/Petros Giannakouris)

Another story: 12 year old girl with dizzyness. She left with her parents from Afghanastan over 6 months ago, running from the Taliban. The family took a number of cars overland from there to Tehran for around 20 hours. They then hiked from Tehran to somewhere in Turkey for days, eventually finding their way to a huge refugee camp there.

Then the family found a smuggler who, for most of their remaining money, agreed to put them in an inflatable raft for a trip to the island of Lesbos, which is officially “Greece,” and would allow them to begin the process of obtaining refugee status.

They were required to get from the refugee camp to the coast on their own. Upon finding the launch site a few days later, according to the mother, they found that the raft was about 8 feet long, and she counted nearly 30 people in it.

They were turned back by the Turkish coast guard 5 times before they succeeded. Each time they were turned away, they were “towed” back to the Turkish coast, which effectively half-sunk their raft because the front end kept getting pulled under the water. Although some had life vests, many did not, and nobody knew how to swim, so the affair was terrifying.

This young patient started her period 8 months ago. She has had to learn how to be hygenic in refugee camp conditions. She can’t understand why she feels so weak and tired all the time. I asked her how and what she eats.

“We got cookies on the road from Tehran to Turkey. They were good.”

“Do you eat the food in the camps.”

“Ew. It’s always bean soup, and they never cook the beans.”

I smile and look at the mother, she is looking at me, rolling her eyes. “Lentils, usually,” She says through my translator Sahar (and Superwoman). “But I can’t get her to eat anything. She’s my pickiest kid.”

Here I am, a billion miles from my homeland, from any Caucasian, from my life, and this mother is dealing with a UNIVERSAL problem of parenthood.

“I have the same problem in my house,” I say smiling. The mom laughs.

I then look at the daughter, “You are probably dizzy because you are losing lots of blood every month. It makes people feel weak, tired, cold and dizzy. The best way to take care of it is to eat. Cookies are not food.”

I look at the mom, smiling again, but shrewdly. “But I don’t know for sure if this is the problem. I need a,” (imagine the audio slowing down here for emphasis), “BLOOOOD TESST.”

The girl’s eyes widen. “Uh huh,” I confirm. “With a NEEEDLE.”

Cute, 12-year old crestfallen face. “So I’ll make you a deal,” I continue. “Lentils or needles, your choice.” Mom laughs again, getting it.

The daughter, I hope, got it too. The mother and I were able to make light of this, but it could get serious. The girl’s arms at the biceps are thinner than my wrists.

There are more stories from only this first day. To depict them is like trying to pour the entire Mediterranean Sea into a rain drop. It just can’t be done.

This world, these sorrows, these tragedies…they can only be know by walking, even for a moment, with those that are living them.

Tomorrow We Leave

We leave for the refugee clinic in Athens tomorrow.

I intended to blog the step-by-step story for how we arrived at this point. But THAT didn’t happen.

Here are some specifics:

wpid-wp-1443899443776.jpeg-We intend to see approximately 30 patients per day for a week, working half-days on Monday and Friday. I suspect we’ll end up seeing many more than this.
-We will be working in an abandoned church in downtown Athens. We’re staying in a Youth Hostel a short distance away.
-We have access to labs, Xray (maybe?) and some medications but I’m not sure which ones.
-I’ll be using an antique oto/opthalmoscope manufactured by the Riester Company, which was based in, you guessed it, Germany.
-We plan to see Afghan, Iranian, Iraqi and Syrian refugees. There could be many others.
-On the last day we will likely go into a refugee tent camp and set up our medical clinic there.
-Donations continue to roll in, to date over $6000.
-I’m not without a sense of concern. It isn’t lost on me that Americans aren’t the most popular people in the world today, especially in the lands where these people are coming from. On this, the night before our departure, I’m keenly aware of all that I leave behind, and all I hope to see again soon.

Your thoughts and prayers are most appreciated.

Donations

Sansum Medical Research Institute

I used to work at a non-profit medical research institute. There, we didn’t “earn” a single dollar. Everything was given to us through some version of a donation. So I suppose I shouldn’t be so amazed and slightly mystified to receive the thousands of dollars sent our way for the relief trip to Athens.

True, our costs are estimated to run in the $6-10,000 range, and we’re still around $3,000. So it would be nice to get closer to our goal. But even if all the money stopped tomorrow, this has been a humbling experience. Things went from what seemed like a good idea that aligned well with my interests and lifelong training, to something more important. Quickly.

I’ll explain:

I spent a loooottttaaa time in that building. Still miss those days!

The medical school I attended is located in Israel. Called the Medical School for International Health, the curriculum strongly emphasizes International and cross-cultural medicine. It’s a small school, but is comprised of people who love, love, global, cross-cultural experiences.  I’m one of them. These are “my” people. Aside from my wife and children, to this day, I love nothing more than being somewhere, far, far from my familiar world, surrounded by languages I don’t understand and histories and stories and traditions and beliefs I have yet to learn. Being at MSIH put me in the lives of people who love the same thing. I’m not sure I ever felt more at “home,” and I was approximately 6,940 miles from the suburbs of Colorado Springs, where I grew up.

A refugee relief clinic in Athens, thus, is a natural thing for me. I’m wired for this. It’s what I’d do full-time if I didn’t have obligations to children and student loans. But, as evidenced by my parents’ one single excursion out of the U.S. to visit me in all the years I’ve lived overseas, this international stuff isn’t for everyone. In fact, especially relief and refugee affairs isn’t really for most of ANYone. It’s a briar patch kind of thing: This is what I do. But I don’t expect it’s what you do.

So I am amazed to see that what started off as something I care about, has become something you care about too. To those of you who have sent money, and prayers, and follow this blog, thank you. It’s humbling, and a little disquieting, to know that the work we’re doing isn’t being met with ambivalence around the world.

Indeed, it has been quite the opposite.

Bread Between The Legs

English: Candida albicans
We call these ‘branching hyphae’

Yeast infection: Yuck-central to the average vagina owner. Discharge like milk curds, funky smell something akin to old toes floating in rotten vinegar, and an intense itch that you can’t actually itch because if you try, it hurts. Cool, huh?

When you’re talking about this fun experience, what you’re largely talking about is overgrowth of a specific type of yeast called Candida albicans, which is actually a fungus. Pretty gross.

Truth is, there’s probably a few of these little guys hanging around the average human vagina all the time and it’s no big deal, but too many of ’em and you’ve got a problem.

Candida albicans
Same as the above pic, just the DANCE version.

Of interest, Candida is kept at bay by another creature that you want hanging around in your vagina called, as a group, the lactobacilli. These guys don’t fight candida, they’re much more suave. They simply produce an acid (“lactic” acid…get it?) as part of their normal life cycle that subsequently keeps the vagina acidic. This makes things real tough for most other creatures, except for the odd Bear Grylls of the Candida world who eat acid for breakfast.

Yeast infections result when the acidity levels in the vagina drop. It’s hard to predict when and how the pH will change in that region of the world, but often it does.

Historically, yeast infections were easily treated with anti-fungal creams or a single pill of the drug fluconazole. But the “easy” part is going away. Increasingly, I’m seeing patients who have recurrent yeast infections despite the usual treatment.

Often, these patients have a history of heading to the doc for “that pill.” And often, docs (or the “provider”) just fire the pill at them and everyone calls it a visit. It’s quick for the patient, saves the doc time, everyone’s happy. Unfortunately, the happiest of all in this equation is the yeast.

Fluconazole
Fluconazole

Fluconazole works by blocking an enzyme. That enzyme facilitates reactions that create the yeast’s cell wall. With the drug around, their cell walls get floppy(er) and don’t hold together as well.

But that doesn’t mean the bug is dead. Fluconazole isn’t some flaming thunderbolt from Mt. Olympus that blasts yeasts back to the Elysian (bread) Fields. The drug is fungastatic, not fungicidal. The weakened yeast is then susceptible to other bugs our our immune systems. Like a mob boss of the pharmaceutical world. It doesn’t do the killing, it just arranges, eehh, ‘tings.

These days, fluconazole isn’t as tough as it used to be. It doesn’t work like it did, often not with the strength it had. So tossing this pill at a yeast infection is a bad idea. Real bad.

Certain types of yeasts make poofy bread and good beer and they keep Jewish people busy (some would say crazy) during Passover. So they’re not all bad. But it’s an organism that we could do without. Fungal infections, when they become systemic, have always been tough to treat; more so than bacterial. And systemic anti-fungals have always been tougher on the body than antibiotics.

Under these circumstances, the best approach to recurrent yeast infection is NEVER to just go get another pill. You should firmly request that your doctor not only get a wet prep (which is merely looking for the presence of yeasts on microscope slide), but also order a culture of the yeast should any grow on the prep. From that culture, not only can the species of yeast be determined, but it can also be tested for sensitivity to fluconazole and other anti-fungals to see if the right drug has been chosen.

Recurrent yeast infections are beatable, but not if you’re lazy about it. For reasons that most men can understand, yeasts really, really like the vagina. If you don’t like ’em there, you’ve got to put more than just a little effort into getting ’em out.

Reader Q: Why Did You Sign with the Army?

Hi Dr. SW101,

Enjoyed reading some of your blog posts both older and the newer army related ones today. Lots of smiles and chuckles, Thanks.

Laughter? In response to this blog? That’s TERRIBLE. This was supposed to be serious stuff. Like taxes. This is information. Data. Recommend re-read.

I’m curious to know why you signed up?

I signed up for the Army for one major reason and one minor reason.

The major reason was the craven want of money. I wish it was something more patriotic, but the primary motivation was an offer of a loan repayment grant and monthly stipend during my years in residency. The Army required nothing in return during my training years. Faced with sneaking my 6-member family into a 2-bd apartment that allows only 4 people, I took the money. Instead of the apartment, I was able to put my family in a cute 3-bd home on a quiet corner two blocks away from my training hospital.

The second reason was patriotic. Despite my vehement opposition to the war in Iraq, and moderate opposition to the war in Afghanastan, I was fully aware that primary care was severely lacking in the U.S. Army at a time when young Americans were throwing themselves into war. Irrespective of how I felt about those conflicts, I remain an American. News of my countrymen dying or suffering partially due to lack of good medical care was something I couldn’t tolerate.

I have always been taken with depictions of how our nation pulled together and sacrificed during the second world war. Back then, those war efforts were truly a national affair. Virtually everyone gave to the effort in some fashion. And, I think a huge reason for the wealth and power we have enjoyed for the past 60 years are a direct result of those sacrifices made by our Greatest Generation.

Pretty Sure I Woulda Deserted

“Earn this,” CPT John Miller, dying from a mortal wound during the Battle of Ramelle, implored Private Ryan in the Spielberg movie. The message, as I took it, was our generation (and the Boomers before us) must understand that great sacrifices were made to allow us to live on the top of the world as we have as Americans. It remains our mandate to earn that sacrifice; it was made before we even deserved it.

So I signed.

I saw posts about officer training and an earlier one about trying to figure out the military scheme as a civilian. What got you in? 

I think you’re referring to how I got into the Army as a civilian. If so, the answer is website: http://www.usajobs.com. Everything runs through this site. I applied to this site in the winter of my senior year of residency, and forgot about it. Literally. When I was called by the clinic here in Germany for an interview in MARCH the following year, I had no idea why.
If you want to get a job overseas, however, this is one of THE best routes. You can’t work for the State Dept as a doctor until you’ve been in practice out of residency for 5 years. You can’t get a job with any of the aid organizations unless you know someone AND don’t need money. So, this is a good option because the pay is steady, only slightly beneath the national average, and comes with perks that don’t usually accompany private-sector jobs.
There’s lots of archane goofiness that come with Army medicine. There’s lots of unusual quirks that are a result of non-medical “commanders” decreeing all kinds of demands from on-high.
But, in reality, every managed care organization functions like this these days. I wouldn’t put Army medicine behind or beneath any of the major HMO’s (in principle, I haven’t worked with any of them). I think Army Med is about on-par with most of American medicine…approximately 18th best in the world.
Also wondering why Olympia was your first choice? You’ve said elsewhere that Ventura is probably the best FM program in the US. I’ve heard of a number of graduates going to Tacoma Family Medicine and lots of interest in Alaska, too. Can you comment on them?
I am very proud of my FP training program, and maintain the belief that it is one of the best programs on Earth, and THE best on all outlying planets. I firmly believe that Providence is one greatest healthcare organizations anywhere.
But in all honesty, I have to say that Olympia is not the best. Just MY best.
English: Statue of Father Junípero Serra. Vent...
Father Ventura, surely a surfer
Ventura is better. Better than anywhere else I know of (and I practically got a PhD in FP residency research during med school). The hands-on experience they allow there, assuming times haven’t changed, is second to none. The faculty are top-notch; some are dual-certified, etc. Facilities suck, too, which is great. I can think of no better means of preparing an FP to deal with a crappy, under-funded, under-supplied environment where the only thing you have to give to patients is your training.
I was told I had a shot there. What they told me likely sounded MUCH like what they tell EVERY short-white coat wearing minion worshipping at the altar of VCMC during their exit interview. But I still like believing I coulda made it in there. I never ranked them, however, because my large family would have needed to live in a box on the beach to afford the cost of living in Ventura. And, truth be told, since I could have reasonably placed that box at the point at Fairgrounds (read: KILLER surf spot), residency would have been AWESOME for me. Just not for my kids waking up with sand fleas in their eyes and facing yet another breakfast of seaweed and/or Wonderbread bologna plus peanut butter sandwiches at the local Rescue Mission.
One nuance Ventura is the dual FP/MPH program at Dartmouth which is as good as it gets if policy and health system design is your calling. Love it or hate it, the Obama Health Care plan wisely referred to the health resources utility research out of Dartmouth. Although barely ranked, I am of the opinion that Dartmouth is actually one of the best – if not THE best – MPH program in the country because the research and work they do is prescient, unassailable, repeatable, tested and longstanding.
Tacoma is a great program, but they have nothing on Olympia. Their city smells weird, their facilities aren’t any better than ours, and we do rotations at the Peds ER up there anyway. So I recommend ranking them 1/2 with the top choice going to the town you like best.
Alaska is probably a lot like Ventura. Sans wicked right point-break and unfortunate box.

Yesterday O’Clock

Special Forces Sniper
This guy was dead asleep in his underwear exactly 33 seconds ago.

Doing Army stuff is awesome.  Except that it starts so early, the time is best described as “yesterday.” 

It’s not uncommon to hear (through my ears), something along the lines of “Formation at Yesterday O’Clock, soldiers!  Then we head to the range for M-16 qualifying.” 

I assume he means we will be qualifying with the rifles by the light of Orion’s belt, since that will be the major source of target illumination for the next 5 hours.

My particular training class has a group of Army Rangers in it, along with some Special Forces guys too.  They all decided to hang up the guns and take up stethoscopes as P.A.’s and pursue things in life, like hobbies and families.  As you might expect, these guys can handle Yesterday O’Clock better than anyone. 

It’s a bit mystical, really.  In our tent of 30 men, someone starts to stir at the ungodly prescribed hour, and everyone just organically follows suit.  Soon every guy in the tent is methodically working step-wise to primp themselves (Army-style, more on that later) for another dimly lit Army morning. 

Everyone except the 4 Rangers.  They stay there, still as statues, enshrouded in their sleeping bags while the tent becomes a kicked anthill of activity.  The minutes tick by, the spectre of arriving to formation suffusing the humid tent’s air. 

Maybe these Ranger guys so easily stare down scary things like being late to formation because they’ve stared down much scarier things, like death via hot shrapnel.  Whatever.  Fine. But here in our little AMEDD training world, being late to formation is scary.  And being late is easy, because it’s scheduled so freaking early, it’s yesterday o’clock.

As the appointed “time” (more of a philosophical concept, this early in the morning) approaches, a frantic rush ensues.  In desperation, we huff out to stand in our little box of humans, also called “formation.”  And guess who’s standing there, looking sharp and ready to plant a spear in a saber-tooth bear? 

The Rangers.  2 minutes ago these guys were lined up on their cots like 3-toed sloths on an ativan drip.  The rest of us have been running around for 45 minutes. 

“Where you guys been?”  One of them asks, as I run up, wild-eyed and still priffing with my uniform.  “We’ve been here since yesterday.”

Smarching

Sprinkler03
Me, spinning in formation

“1st Platoon!  Atten-SHUN!”

We all throw our shoulders back and stare straight ahead into nothing.  And we don’t move.  Leaders mill about, thinking about things, looking over their retirement accounts, playing Tetris on their phones. 

But we, the little people, just stand there.  Sweating.  Sweat runs in what feels like lightning patterns down my face.  Down my neck.  My back.  My rear…and down my legs.  I stand there taking a sweat-shower.  Spin me around fast enough and I’d fling so much water in every direction I think I could personally ease the drought problem in Texas.

“SMAAAARCH!”

Well, he actually say ‘march,’ but, really, you just can’t call it that.  No nuance.  We aren’t marching.  We’re walking around in 104 degree F heat, with sweat pouring from our bodies on par with your average Bangladeshi monsoon.  So we’re sweating.  With a little marching thrown in. 

It’s smarching.