August 2006

Eugene: Final lessons from a veteran

On my last day here in Korea, I met with Dr. John Linton at Severance Hospital of Yonsei University. Dr. Linton is a physician who was raised in South Korea and was the first Caucasian to be licensed as a physician in South Korea. Dr. Linton has made numerous trips into North Korea as a part of humanitarian efforts organized by the Eugene Bell Foundation in the United States. Although the support work of this physician and the organization has covered a broad range hitherto, of note recently have been efforts to address the escalating TB epidemic in North Korea.

As a veteran in the field of North Korean humanitarian aid, I met with him to discuss my hopes and aspirations in the field. The more I discussed with him, the more I realized how I wasn’t clear about my vision for working in this field. When asked the simple question, "What do you want to do?", I had no answer.

I still have no answer.

However, my conversation with Dr. Linton helped me to identify important questions I have to wrestle with as I contemplate further work in this area. Of these, one question I need to ask myself is whether I want to work with North Koreans outside of their country (in China and Korea) or with the North Koreans in their native country. Both populations have needs that need to be addressed, and I wonder which I should try to serve.

I would like to say that our conversation made everything clear, but quite the opposite, I am now more confused than I was before. The same can be said about my time here in South Korea the past few weeks: the more I have learned, the more confused I am about what to do. Despite my confusion, I am more motivated now more than before in wanting to do something. We’ll see what exactly that is when the time comes.

Eugene: Home, sweet home

7.09.06

On my last day working with the NGO, I was invited to visit the apartment of North Korean family. The unit I visited was home for an older couple that had immigrated several years ago and had gotten married here in South Korea. The small apartment was on the 10th floor of a large apartment complex that houses a large number of North Koreans. The government owns units in these large apartment complexes and rents them out to North Korean migrants as they resettle in South Korea. These complexes provide a much-needed community for the North Koreans as they resettle in a foreign country.

I caught a glimpse of that community at work as I walked into the apartment today. As I came into the unit, I was invited by three older North Korean women who were huddled in a tight circle. They were old enough to be my grandmother, but had such energy and vibrancy as they chatted away with each other about just about anything and everything.

At one point, I remember chuckling to myself as they talked about how North Korean women decorate the interiors of their homes. They laughed as they remembered when they first picked up discarded furniture from the street. The furniture never matched, leaving the living rooms of these North Korean women a hodgepodge of clashing colors. To top it off, when the women finally had enough money to replace these used articles, they had to pay for the government to throw them out. One woman laughed as they told the others how she would avoid this fee by bashing up her old furniture and throwing it away in the regular trash.

For most of my time at the apartment, I observed the women as they conversed. I realized at that time just how important community is for North Koreans resettling in a foreign land. I was so thankful to have been invited to take part in it, although I sat in silence most of the time.

Eventually, however, my cover was blown, and they noticed that I was not joining in on their conversation. I was asked to speak up and was invited to ask questions to the women. At that point, I asked a simple question to the women gathered there:

"I know that in North Korean people are socialized to believe Americans are evil. Now that you are here in South Korea, what do you think of Americans? What do you think of me as I sit here before you?"

As the mood suddenly became very serious and contemplative, I realized that the women were preparing to give me an honest answer. Two of the women were very vocal in their response. They talked about how they have been learning more about the historical events surrounding the situation in Korea. As they learn more about the United States and its actions, they no longer think of Americans as the enemy. They also mentioned how they saw me as one of their own people. Although I am American by birth, I have a Korean ancestry. There was no denying that.

I did notice that not everyone was involved in the discussion, however. There was one woman in particular who never opened up to me from the time I stepped foot in the door. She never looked at me directly and didn’t speak to me. She didn’t answer my question and gave no input to what the others were saying. Perhaps she was not as prepared to accept me and to accept Americans.

As I left the apartment, I reflected more on the perceptions of North Koreans on Americans and on Korean-Americans, such as myself. Although the recent migrants have a better idea of the nature of their supporters across the seas in the States, the people of North Korea have no such knowledge. Whether I work with North Koreans in South Korea or in North Korea, I realize that accurate perception is critical. With all the confusing politics and propaganda circulating on both sides of the globe, this realization will be invaluable in my future endeavors with North Koreans.

Lena: Shocking moments back in America

So now that I'm back in America I've had a few moments that could be called shock. I think only one experience can really be classified as 'culture shock.'

When I walk down an empty street or an empty hallway and I pass someone, I can't help but greet them now. Likewise, if I bump into someone that I know, I feel like if I don't have at least a 10 minute conversation with them, I have been extremely rude. I find myself asking people over and over how they are, how their family is, how their summer's been, how's this and that and the other thing all are? I can imagine that it must sound repetitive and perhaps even nosy. This behavior may not sound that unusual to you, but this friendliness goes completely against my nature as an East Coaster.

Besides that I've only had shocking moments in which I have to remind myself that 'we're not in Tanzania anymore, Toto':

~My initial instinct before stepping outside in the evening is to apply bug spray. As my friends and I walked outside to warm up the grille, I asked, aren't you guys going to put on bug spray? Before they could respond, I realized that bug bites here aren't as serious because there is no risk of malaria (although perhaps people should be more careful with west nile floating around).

~I was filling up my water bottle with ice cubes before heading to the gym, when I found myself ready to dump them out. I had to ask myself why I would do such an irrational thing (because one of the things I appreciate most about being back is nice cold water, straight from the tap). That's when I realized that we are advised against ice cubes in Tanzania because they are generally made from contaminated water.

~Similarly, I was really excited when I got to run my toothbrush under the faucet to clean off the toothpaste, although I flinched the first few times. I had accidentally washed my toothbrush in Tanzania a few times. I must say, it was really nice to have a clean, non-gummy toothbrush to use the next time I brushed my teeth.

~I went out for chinese food and at the end of the meal I was shocked to see that the oranges they brought out with the fortune cookies were actually orange. Oranges in Tanzania are green on the outside and sort of yellowish on the inside. Interesting the Swahili word for the fruit and color is still the same. Once, I asked one of my professors how she could tell oranges, lemons, and limes apart because they're all green. She found this very amusing; you look at the texture of the peel of course, she replied.

When I finally stopped my malaria meds (which I had been taking every day for the past 2.5 months), it finally hit me that I am home for good.

Naresh: Papua New Guinea Picture Stories

Some pictures from the PNG trip in July

My favorite picture from the trip. These boys on the beach in Wewak simply lit up once they saw themselves in a digital camera - quite possibly for the first time

The airstrip in Ambunti, the only "town" in the middle sepik river valley. We halted at Ambunti while arranging a canoe and logistics for the upriver trip to the villages. The medic training was held in Ambunti for a week.

Signs of civilization after a six hour canoe ride. Villages were few and far between. One day we rode about four hours up the april river to get to a village and only barely got back around dark.. scary

The river was stunningly beautiful... much more rainforest and wilderness than the Amazon.

A typical welcome arch at a village designed for us. These were often accompanied by welcome songs, welcome dances and welcome speeches. Except when they weren't. There was also an odd correlation between villages that gave us welcomes and villages where we left tired from seeing every sick person around ;-)

Helena and a medic (Mary) helping a kid. A medical student, a local medic/interpreter and an premed would team up to help patients out, one-by-one, all with Kelly Murphy's guidance and supervision of course

A traditional welcome. These men in Siot village were hiding behind a large tarp and broke out in song and dance in their grass skirts much to our wonder and delight. We were truly touched.

Only in PNG ! Aggressive cockatoo climbs table to steal french fry from singaporean damsel in distress.

Eugene- A lesson in communication: The Ministry of Unification

North Korea has often been nicknamed The Hermit Kingdom by the outside world. Largely secluded from the outside world by purposeful policy of the military regime, the nation and its people are out of reach for outsiders. Recently, however, there have been notable advances in the communication and exchange between the North and South.

These advances are due, in large part, to the efforts of the Ministry of Unification in South Korea and its Northern counterpart. The Ministry of Unification is a department of the South Korean government that oversees numerous programs aimed at strengthening the relationship between the North and South. More specifically, there is a branch within the Ministry -The Office of South-North Dialogue- that is directly involved in improving communication and exchange between the North and South.

In a lengthy conversation with Chong-Ryul Ryoo at the Office of South-North Dialogue, I learned a great deal about the exchange between the North and South.

In Korean, "The Office of South-North Dialogue"

The Office of South-North Dialogue facilitates all official communication between North and South Korea. At the demilitarized zone (DMZ) between the North and South, there is an area called Pan Moon Jum. Under the auspices of the UN, this area is a physical space that literally spans the border and serves as a physical space for communication. The central Office of South-North Dialogue is in constant communication with this site at the demilitarized zone.

In addition to this site, there are two other sites along the DMZ that facilitate exchange between the North and South. There is a site near the Western border that abuts the city of Gaesang in North Korea. Gaesang houses a large industrial complex that is run by South Koreans and staffed by North Koreans.

In exchange for work, South Korea gives a salary of 60$/month for each North Korean worker at the facility. Since these funds are not given directly to the workers but rather to the North Korean government, some critics (including the U.S.) have accused this facility of providing funds to the growing military campaigns of the Northern regime. Whether or not this is the case, the facility does serve as a crucial site for economic exchange between the North and South.

Another site of exchange is at the Eastern side of the border, near the Gumgan-san mountain of North Korea. At this site, South Koreans are allowed over the border to travel as tourists to Gumgan-san. The tourists are strictly monitored and are allowed only on the permitted routes to and from the mountain. In a way, this site thus facilitates cultural exchange as South Koreans are allowed to enjoy one of the cultural landmarks of the North.

These three sites thus serve as gateways for exchange between the two nations. As a result, about eighty South Koreans are in North Korea at any given time. This number includes a small number of NGOs that have been allowed access to the North. Presently, about fifty such NGOs have been allowed access to North Korea.

This improvement in communication and exchange is in striking contrast to the present situation of other international parties. In contrast to the growing communication between North Korea and South Korea, communication between North Korea and other international players has deteriorated. North Korean policy towards international NGOs serves is illustrative of this contrast and helps explain why this difference arose.

Following a devastating series of flooding and drought in 1995, North Korea opened up its borders to numerous international NGOs. For the first time since the end of the Korean War, international spectators were given a view into the secluded country. Following the entry of these parties, some of the intervening nations began to speak out against particular issues that were reported back through the NGOs.

Of note was a report in 2000 by a German lawyer who spoke out against the human rights violations of North Korea. Shortly following this specific incident, North Korean began to close its borders to the outside world and also kicked out the parties that were already providing support in North Korea.

In contrast to this growing distrust for international support, South Korea has been able to maintain and even improve its dialogue and relationship with the North.

As I learn more about the health situation of North Koreans, this political backdrop will provide invaluable insight as I ponder the most effective ways to improve the situation in North Korea.

Naresh: A Medical Safari in the Sepik River Valley - PNG issue 1

Papua New Guinea: The Last Frontier?
A Two Week Medical Safari in the Sepik

The Papua New Guinea (PNG) Sculpture Garden in Stanford (near Roble) portrays a vibrant yet scary culture, especially by night. The images that stand out are distinctive: an impassive child in the mouth of a crocodile; A snake / kookaburra bursting forth from the mouth of a woman. My pre-departure conversations in India explained PNG as an island near Australia, comprised of many cultures discovered as recently as fifty years ago, beset by headhunters, pests and saltwater crocodiles.

However, modern day PNG presented scarier obstacles than totems of crocodiles devouring children. My two week medical safari only afforded me a snapshot of the cultures and problems of the Sepik River valley. Children covered with fungal infections, hordes of killer mosquitoes and crowds of rascals openly discussing us were only a few. PNG was unlike anywhere else in the world that I had traveled or worked in, including countries like India, Indonesia or Senegal. We traveled by canoe, managed medical problems including a 5 yr old suffering from acute cerebral malaria / meningitis and were afforded welcomes including tribal dances by the men and songs by the women...

Dr. Murphy, Medicine Man:

Kelly Murphy and Peter Lu (or Keli and Pita) have been leading the Stanford PNG Medical Project since 1996 where they venture into the East Sepik rainforest with Stanford medical students and undergraduates to provide medical care as well as train the local medics to take care of their patients. (Google Stanford PNG Medical Project for more information and articles in several magazine)

We traveled from village to village and setup medical camps for sick people in each place we stopped at. I will carry a few stories with me for a long while.

B was a young woman, possibly in her mid-twenties, who had boated in from the village of Saronapi in the dry season to our base camp in Siot. She had heard that a medical team was coming and hoped for a cure. When Kelly, Gideon (a UCLA MS2) and I went to see her, she could barely get down from her hut. Supported by three people, she slowly made it over to a place where she could lie down so we could examine her. It took her about fifteen minutes to cover the ten meters. Her right wrist was enlarged and her feet showed some edema.

Almost as soon as I put my stethoscope to her heart I could hear the characteristic high pitched diastolic murmur over the apex. The Mitral Stenosis murmur was so loud that I missed the regurgitation murmur Kelly heard in the background. A patchy twice-translated (vernacular – pidgin – English) history revealed what was most probably a post-partum infection followed by infectious endocarditis or rheumatic heart disease. Calcification and insufficiency of the mitral valve is a problem routinely corrected in India and neighboring Indonesia. Here it was a death sentence.

In the United States, B would have most probably not have had her fourth child in her early twenties leading to uterine prolapse (reported). She most likely would not have contracted the post-partum infection that might not have set in and damaged her heart valves. If it was Rheumatic, she might have taken the penicillin prophylaxis until she was eighteen.

We could do nothing now. We had no furosemide nor digoxin, drugs that would have helped her pass another day or two. We wrote down what we thought was her diagnosis and the drugs she needed on a piece of paper, and told her that possibly a medic at the Hauna hospital (two days by boat) or Mapoti (one day by boat) might be able to help. We also took down her information in case we could send her the meds from the USA.

The next day we saw an elderly woman with chronic TB and liver failure. She was completely wasted up to her diaphragm and then her abdomen was grossly distended with fluid from her liver failure. You could see and count her ribs on one side, and the distended abdominal veins (caput medusae) were all that was visible in the abdomen. Kelly didn’t give her too long to live in that condition, but asked her to come to our base camp if possible so we could drain a couple of liters of fluid to give her some comfort in her last days

I was shopping in the village for small shields two days later when I heard the wailing at the waterfront. A villager immediately told me that “she had died�. Thinking that the woman with TB must have died from the strain of travel enroute to her paracentesis, I rushed to the waterfront.

The wailing had a haunting musical quality to it. The village gathered there along with me as I saw all the women from the village carrying on a lament as the relatives of the deceased rolled down the muddy bank in distress and lay over the body wrapped in tarpaulin. Upon enquiring I realized that it was B. She had left the village in search of medicines at the outpost in Mapoti. While she was there she went into respiratory distress and arrest and was treated with two antibiotic injections. She didn’t survive the night.

I wonder if she would have had a few more days to live if she hadn’t made it all the way to see us and then go to the outpost in hope of help. We ran into her four children, all somewhat in grief, but also too young to comprehend exactly what had happened. One might say B was too young herself, in her mid-twenties.

D was too young to die as well. Only four, his mother brought him in (above) unconscious and running a fever of 105 F which had apparently been going on for a few days now. The boy was clinically dehydrated from diarrhea and was responsive only to painful stimulation. The medics tried to start an IV line under Kelly’s supervision, but veins in the hands were collapsed. Kelly found the femoral and we started him on dextrose.

Unfortuately for the kid, neither the medics nor us had any medicines in IV form. So we tried both oral and rectal administrations of Tylenol and Motrin, children’s doses to bring the fever down. With the fever not coming down, a decision was taken to move him out of the clinic into the balcony, and Joshua, an engineer with the team, setup the generator and the one fan that we had to blow over him.

Kelvin, an undergraduate and I started taking turns wetting the child down while the other students conducted clinic for the other sick patients in the village. Kelly was supervising the others though he was constantly preoccupied with thoughts about this kid and kept checking in. The fever slowly would down to 101F with aggressive wetting and wiping only to climb up minutes after we stopped wetting him down.

The medics went ahead and treated the kid with Artemesin for malaria and Chloramphenicol for anything else, both strong drugs with strong toxicities. Chloramphenicol especially has been discontinued for use across the developing world for its toxicities – particularly irreversible aplastic anemia in children. We had started the kid earlier on an oral dose of Azithromycin suspension as well. In between, D began having seizures lasting 1-2 minutes, which are not unexpected in kids when their brains are being roasted by fevers of 105.

Our diligence was successful in slowly bringing down the fever to 99 F by about 5pm, but D continued to seize at least once an hour even when afebrile. We began suspecting either cerebral malaria or meningitis – both with pretty bad prognosis given the conditions we were in. Kelly was willing to try one dose of dexamethasone to reduce any meningeal inflammation and irritation. Too much and it would depress his immune response, definitely not what we wanted.

Anticipating the mosquito attack around 5.30pm, we made ready a place in our hut by borrowing Helena’s mosquito net, setting up a tube light, the fan and the generator along with an ambu bag, toilet paper, thermometer, purell and other medical supplies. D was shifted to our hut just before the mosquitoes arrived.

From there on, it was a long night. The entire team took turns wetting D down and making sure that his temperature hovered around 98 F. He slowly began returning to consciousness and by 1am was alert and irritated. He rocked back and forth, obviously in pain and screaming and grasping anything in his reach and kicking over the bucket of water and whatever was available.

It was much easier to take care of him while he was unconscious. The medics wanted to give him some promethazine to calm him down, but Kelly vetoed the idea, since it would reduce D’s seizure threshold. D was continuing to seize even while awake, and we were all afraid for any brain damage post recovery. The ambu bag was used to stimulate his breathing after his seizures stopped and he was coming back each time, but it was a continuous challenge.

We gave him a half dose of lorazepam instead to sedate D a little, but it didn’t seem to have much effect for a while. Just as D calmed down, the medics gave him his second dose of chloramphenicol which woke him right up. Eventually, bit by bit, he fought back and we were able to start him on oral Tylenol, which was controlling the fever from then on. Around 4am, he began taking some oral rehydration solution, and by 6am, he was eating navy crackers and bland beef biscuits.

The locals had formed a crowd around D from 1pm the afternoon before and had waited below our hut until 1am during the night and had seen the kid unconscious and near death. They came back at 6 in the morning to see D smiling in his mothers arms and voraciously eating his crackers. I don’t think there has been a more dramatic testament to modern medicine in that village. Dr. Murphy, medicine man had won a battle. We had to move on that morning, so we left D in the care of the able medics, and went to the next village.

Patients with leprosy seemed to selectively migrate towards me, the Indian face in the crowd, and I got pretty good at spotting it and wrapping up their wounds and giving them the leprosy talk – protect your feet and you’ll keep them, etc.

We saw young kids with scabies, a baby with a large burn on the scalp that was secondarily infected, an unnecessary number of scalp and skin abscesses, a distal complete fracture of the radius and the ulna leaving the hand disconnected from the forearm, and an irreducible inguinal hernia the size of a softball in a guy in his mid-twenties. I also got extremely good at identifying different types of fungal infections based on their patterns – tinea versicolor, tinea imbracata (picture above) and ringworm were the most common, though we did see other varieties.

Almost every child in the villages had an enlarged spleen from chronic malaria, and I think I must have palpated more spleens in those two weeks than I probably will for the rest of my life in the United States.

Medically, Kelly got tougher on us as the days went by and expected us to present as we would back at Stanford, in the correct format and sequence. We began to formulate assessments and plans for the most common conditions that we would see over and over – children with fevers and chronic pains of all sorts.

All in all, the trip was a medically rewarding experience – I was able to leave with the comfort that even as I learned, I actually participated in helping people get better, especially children. However, the trip was an eye-opener beyond just medical care, which I’ll save for the next installment..,,

Naresh: Relearning Trauma in India

Last night my PI showed me a picture of an MVA and asked me if it was real or staged. The victim was riding a two wheeler without a helmet and was in a head down-feet up position underneath a truck with what appeared to be open wounds and large amounts of blood on his thigh and face.

My reaction was instinctive. Having driven around quite a few similar accidents to get to school, I told him i thought that not only was the picture real, but that accidents as gory as this were commonplace. But his question made me rethink my standards. If that picture seemed unbelieveable to someone used to dealing with trauma on a day to day basis, why did it appear ordinary to me, or to my friends whom I showed it to?

I've been relearning India this summer. The first is merely recognizing that while our trauma rates and intensities are higher than back home, the care, both pre-hospital and hospital based is inadequate. Part of this I'd ascribe to an attitude that i'm complicit with when in India - what are we going to do, its too complicated, he's dead anyway.. etc.

I remember calmly following traffic filing past an accident a few years ago when a motorist (again, on a motorcycle without a helmet) lay on the tar, blood gushing onto the street from the back of his head, eyes wide open and fixed at the sky.

Second, I'm learning that the trauma that we see in India is both more numerous and more intense/varied than the varieties back home. I was always under the impression that the speeds in the West were so deadly that if you crashed, you were pretty much dead - however, in India you were more likely to crash, but the speeds were low enough to just injure, not kill.

The reverse is true. We drive in such a clean, isolated environment protected by airbags and large bodied cars and child seats etc., that the worst trauma seen in hospitals back home comes more often from gunshot wounds to the face and the like rather than road traffic accidents. The guy who drives his motorcycle here has to contend with lack of a helmet (self-imposed), direct impact with vehicles and animals of all stripes and a lack of traffic rules (more like traffic guidelines, a la Pirates).

In addition to the devastating injuries sustained, the lack of application of western standards for a trauma work up is killing more people. One part to this equation is the care received in ambulances and hospitals. The aforementioned attitude, lack of training and supplies leads to dismal attempts at support and treatment.

We saw five head injuries at the trauma center in the General Hospital this morning. Of the five, only one was in a cervical spine collar (two sizes too large for him), presumably since he complained of some neurologic symptoms. The other four were being prepped for surgery (heads shaven, disinfected) just in case. The CT scanner was 100 yards away. The trauma ICU ward was being cleaned out during the day so it was not in use. The whole setup was a receipe for disaster. Yet if the head trauma patients dont make it past the night, the blame is laid on the seriousness of the injuries.

In some cases it is frustrating to note that the prehospital care is better than that available in hospitals. Stanford Emergency Medicine International, through my PI, Dr. Mahadevan, has been running an advanced prehospital course for Apollo Hospitals, India's premier (private) healthcare center in Hyderabad and Chennai. The facilities here are comparable to those at Stanford, 64 slice Helical CT, 24 hr MRI on demand, consultant radiologists, orthopods, cardiothoracic surgeons available 24/7/365 etc.

The Apollo hospital techs whom we train are competent to manage airways and intubate patients if necessary in ambulances. However, a few of them are promptly extubated as soon as they reach a private hospital in the name of protocol since there is no one confident to manage the airway there. It is almost a shame to say that some patients would be better off going for a long ride in the ambulance than being dropped off at a small private hospital.

All said and done though, its exciting to be in India at a time when Emergency medicine has still not taken off as a specialty, but people are recognizing its importance. It is very much like what I imagine the situation must have been in the US in the 1960s, with surgeons, anesthetists and physicians passing the ball on a patient's emergent care between each other in a way that didn't always produce good results for the patient. However awareness is developing and people are on the move ... more on Indian EM in a bit ...

Mike: Rural Surgery and Rural Kayaking

I've just returned from my final day of shadowing in the operating room up here in Sitka, Alaska (pop. 8,500), which is the rural healthcare hub of southeast Alaska and the town I grew up in.

My morning was abbreviated (giving me time to write this) because I knew the final patient quite well and didn't want to make her uncomfortable while she had her first child. It was a fairly illustrative finish to a really great summer of shadowing. Last night, a young fisherman got tangled in some lines, resulting in a long night of surgery, and ultimately an amputated leg. He lost a great deal of blood, so despite his loss, he's actually quite lucky not to have been farther out at sea.

Throughout the summer I've been trying to wrap my head around what it means to be a "rural surgeon". At times it seems like an endless stream of fairly straightforward proceedures and operations, cholysystectomies, appendectomies, hysterectomies, and colonoscopies. Then there are emergencies and trauma, the rates of which are significantly higher in Alaska than other states.

In both the routine and the unexpected, there is a distinct difference everytime you perform surgery in a remote location.

Unlike the central valley, where a population of 200,000 is considered rural, it is truly surgery in isolation out here. Every incision carries a great deal of wieght with the knowledge that there is essentially no backup if things go wrong. Further, if any complication happens a few days down the line, the patient is likely to be back in the remote village the came from, with little or no access to care.

I've been incredibly lucky to have as a personal mentor for the last four years a general surgeon with an incredible amount of experience in an urban, academic setting, and who has come north for his version of semi-retirement, which until recently was literally five years of continous, unshared call, and surgery nearly every day.

From what I gather, he basically embodies the impossible mold of what a rural surgeon ideally should be. Ironically, it seems to be a task that cannot be trained for in a rural location. The expectation that one individual can competantly perform general surgery (and I dont mean the ever-narrowing slice of the abdomen reserved for general surgeons in most regions), and also handle any trauma/emergency that might arise is truly overwhelming.

Beyond the technical issues, to treat rural, primarily Alaskan Native populations in a culturally congruent manner, and truly gain acceptance into the community requires traits that simply cannot be learned. There's got to be an award I can nominate this guy for.

Beyond surgery, I've been spending an incredible amount of time on the water sea kayaking (all but three days of the summer). Its an easy addiction to aquire when, thanks to my job as a kayak guide, I can be paddling within 15 minutes of any impulse I might have to do so. Sitka is situated on an island among islands, with the open north pacific literally right at our doorstep.

As a sport, sea kayaking is truly unparalleled. It combines endurance, meditation, incredible beauty, and a connection with the ocean (and its many temperments) that perhaps only surfers can appreciate. Of course you cant go camping on a surf board, or cover 30+ miles a day.

This summer has been an exceptionally rainy and cold one, which is a strong statement considering that we average over 100 inches per year. Despite the mist, I've been spotting more whales than usual this summer, which is something I will never tire of (aside from the mile-long sprints only to have them turn around and swim away right when you get there).

I had a particularly pleasant encounter with three orcas the other day, who seemingly came out of nowhere, bobbed around on the surface for a few moments, and dissapeared equally quickly. Considering they are the most powerful predator on the planet, I feel surprisingly comfortable around them. More so than the giant and curious stellar sea lions that they regularly toss around like rag dolls (the transient orcas anyway). I could easily continue my rant, but this is a medical blog, so I'll spare you further details.

Though nearly a month remains, I can sadly feel summer slipping away. I'm very excited, however, as eight fellow 2nd year med students will be joining me in about a week for a six day paddle, as well as several days of hiking adventures around the area. I am also very excited to return to warm, sunny Palo Alto, great friends, and whatever fun Dr. Regula has planned for us.

Though I could now check my notoriously bad spelling, I will forgoe the process as a friend and I are off to explore a group of islands I've so far neglected and he's honking in the driveway.

JoAnn: Giving Birth in EG

The other day, my Cuban friend Dr. Enrique told me that many doctors come to Equatorial Guinea with previous experience working in the developing world. He says they are usually shocked because what they see in EG is way less developed than anything they've encountered before. This is my first exposure to health care in the developing world, but after observing two births, it's easy to believe Dr. Enrique.

The post-partum room at the hospital.

The labor and delivery room at Malabo Regional Hospital is extremely basic. Three stainless steel birthing chairs are lined up against one wall. Running water only comes for two hours a day, so each morning the nurses fill up large plastic barrels (with no lids) and use a bowl floating in the barrels to dispense water throughout the day. Two metal carts in the middle of the room hold the surgical instruments used during deliveries.

The door to the delivery room is usually closed and a curtain hangs in front of it to give the women a little privacy, but other than that, the women are completely exposed. Also, the women often deliver naked, because there are no hospital gowns, and they don't want to stain their clothes.

At around 9am, a fifteen-year-old was escorted into the L and D room. This was her first pregnancy, and she was clearly in a lot of pain, but here pain relief drugs are reserved for only the most severe cases. Her cervix was completely dilated but her water still hadn't broken.

The nurse poked around with a probe of some kind, and soon the floor was flooded with a brownish watery fluid. Uh oh. Meconium. The baby had had a bowel movement inside the womb. This usually is not too dangerous, but it can be harmful to the baby's lungs.

In the US, the neonatologists would have been called to stand by and check on the baby once it was born. However, here in Guinea, the obstetrician hadn't even arrived, and mom was ready to start pushing. This girl's contractions were coming hard and fast, and the nurse told me that we would have to deliver the baby without him.

"Es su primero. Tendremos que cortarla," she told me. It's her first baby. We'll have to cut her.

In the US, episiotomies, simple procedures in which an incision is made in the opening of the vagina to make more room for the baby's head, are always performed by doctors, and usually only after a women has tried to push for a while and failed. Here it seemed like they do them with every first pregnancy.

After numbing the skin of the vagina with an injection of novocaine, the nurse picked up a scissors from the instrument tray. It had been sitting out on the tray for the entire time I was in the room (probably about half an hour) so if it had ever been sterile, I'm fairly certain it wasn't anymore. Then she began the episiotomy.

Right away it was clear that the scissors was not nearly sharp enough. She was cutting through the poor girl's skin with all the sensitivity of a five-year-old trying to cut through a stack of newsprint.

After the episiotomy and a few strong pushes, the baby was out. A little girl. The one nurse had to take care of both mom and baby, so she plopped the wet newborn on the instrument tray and spent about a minute making sure that mom wasn´t bleeding too badly. Then she used one of those little suction balls to clean out baby's nose and mouth. Finally, the shivering little baby was dried off, wrapped in blankets and handed over to me.

"Vestela, por favor." The nurse asked me to dress the baby.

It had been a while since I'd held a newborn and I was a little nervous, but after some gentle wrangling, I got the baby into her little sweater and pants. With that sweet little baby sleeping in my arms, I quickly forgot about the horrors of the delivery. A little angel. I carried over to meet her mom. For the first time in hours, the new young mother smiled. "What are you going to name her?" I asked. "Valentina," she responded.

Mom had to be stiched up after the episiotomy, so I took little Valentina out into the post partum room to meet her aunties. They were excited and proud, but there was a certain hesitancy to their celebration. Fifteen-year-old moms are pretty common in Guinea, but it's still considered pretty young. The aunts thanked me, and I headed back to L and D, because there was another baby on the way.

"Es un caso de Retrovirus," the nurse informed me. HIV positive.

International experts estimate that the rate of HIV infection in Guinea is between five and ten percent. The government has faced the AIDS epidemic with an attitude of denial and continues to claim that less than two percent of the population is affected.

Because the government refuses to acknowlege the problem, distribution of antiretroviral therapy for HIV-positive patients has been slow to catch on. Further, there is still tremendous stigma against HIV patients. The nurses treated this poor lady with palpable distain.

In the US, HIV-postive moms who receive good prenatal care almost never pass the virus onto their babies. They take antiretrovirals throughout the pregnancy, and the dose is upped right before delivery. The deliveries are done by C-section under "dry" conditions, with very little blood. Then baby is given a regimen of antiretrovirals, and fed formula to prevent transmission through breast milk.

Luckily this mom was on antiretrovirals, but the baby was a month early, so pre-delivery dosage increase didn't happen. Also, the whole dry C-section procedure is not done in EG, so baby was delivered vaginally, also by a nurse. This birth was not complicated, no episiotomy. I got to dress this baby, too.

I carefully looked her over for abrasions, or any places where blood to blood contact could have been made, and didn't find any. Depending upon mom's viral load (which I'm not even sure they have the technology to test) baby could have as high as a one in three chance of contracting HIV.

I took baby out to meet her family. They had been given a prescription for antiretrovirals for the baby. I talked with them about how important these drugs were, and they assured me that they'd fill the prescription. I'm sure they did that day, but these drugs are extremely expensive, and eventually, families reach a point where they can't afford the drugs. Extremely sad.

It's pretty sickening to know that the technology exists to prevent perinatal HIV transmission, but for political and economic reasons it's not happening.

Seeing these births was a bittersweet experience. On the one hand, new life is always cause for celebration. However, the incredible disparity and injustice in the world is pretty shocking. I don't know what the solution is going to be, but we've got to find one.

Eugene: The Korean CDC

As I have investigated the emerging issues regarding North Korea, I have learned that that the South has already begun a number of programs to prepare for future reunification and also to serve the increasing number of North Koreans that are entering South Korea.

Nonetheless, I have encountered very little from the standpoint of public health that the South has been pursuing in this regard. Has the South begun designing strategies on how to change the Korean healthcare system in the event of reunification? Are there plans for immediate provision of care following reunification? Does the South have knowledge on the pressing health issues of the North?

To find some answers to these questions, I visited the Center for Disease Control and Prevention (CDC) of Korea.

The Korean CDC was established with the following mission:

“Korea Centers for Disease Control and Prevention (KCDC) is newly established(in January 2004) to protect the public from various diseases and to foster safe and healthful environments. To this end, we conduct research to identify etiology and to find effective control, prevention, diagnosis, and treatment for communicable and non-communicable diseases.

Our primary goal for the 21st century is to confront emerging and reemerging diseases with more advanced and specialized surveillance system, protect the health of all Koreans and alleviate disease burden. In an attempt to achieve our goal, we build a close partnership with governmental agencies, international organizations, research institutes, private health corporations and academic society. At KCDC, we pledge to do our best to enhance the quality of life and the health of all Koreans.�

I met today with Dr. Young J. Hur, the Director of the division of Epidemic Intelligence at the Korean CDC. As a part of its work in South Korea, the division engages specifically with the public health issues of North Koreans in the South.

The 6,000+ North Koreans that have entered the South are not only informative indicators of how best to treat the growing population of migrants, but they also provide vital information about the health status of North Koreans. Considering the highly-restricted nature of this population, this information is instructive on many levels.

To learn more about the health of North Koreans, the Korean CDC screens each refugee as they enter South Korea. More specifically, a complete medical screening is provided for the refugees as they go through more general screening at Dae Dong Gong Sa during their first two weeks in the South. These screenings provide vital information for the government to best provide for the pressing health needs of this migrant population and also give a glimpse into the situation of their North Korean compatriots.

One of the research laboratories of the Korean CDC

Lena: Host family update

All my nervousness about moving off the compound was unwarranted. My host family was absolutely wonderful and they were very understanding of our cultural differences.

Here is a picture of the Shikobe family, with whom I've been living for the past 3 weeks:

Soon after we arrived, we had a meet and greet with the host families that we were to spend the weekends with. My host father was the only member of my family able to attend. Interestingly, although my host father is only 4 years older than my real dad, he has 4 grandchildren. In addition, he is retired; he worked at the center for 17 years and his wife still works here in the kitchen.

He was really excited to take me to see the house, so that same day, he drove me to the house. This being within our first week, I walked over to the right side of the truck, what I thought was the passenger side, and patiently waited for him to unlock it for me. He politely informed me that he would be driving and that I should probably get in on the other side of the car. I have to admit I was pretty embarrassed, but he handled the situation with grace and good humor.

The house was really nice, although you may not be able to tell from the outside. When I walked into the living room, I was surprised to find two very large teletubbies, prominently decorating the entertainment stand.

The first weekend that I stayed with my host family, one of my friends from the University of Nairobi came to visit. I was a bit uncertain about what to expect and how I would be able to balance spending time with my new family and also with my old friend. My host family made this weekend with my friend, Oposh, so much easier. They completely welcomed him into their home; he spent all day hanging out there with me and he ate all his meals with us. They helped us find him a guesthouse close by that was cheap and convenient. In the mornings they even sent someone to fetch him so he could join me for breakfast and the first night they escorted him back to his room, to make sure he could find the way.

There are definitely more mosquitos as I can hear them buzzing around at night, but I slept the first night in my net and I really didn't like it. It gets really hot and it just makes me feel clausterphobic. I just always keep tossing and turning, plus there is lots of noise outside from the animals and bugs.

Most of the family speaks pretty good English but for the most part I try to stick to Swahili, especially because my host mother doesn't really speak English. We mostly do a lot of mixing and occasionally my host father translates from English for my host mother. They both seem really nice and my host brother and host cousin got stuck with the duty of playing chaperone all weekend because I talked to one of my teacher's about Dan and she said, I'll make sure that nothing happens and she talked to my host parents. It's actually kind of nice, although a little weird.

My host father was going to make his son go running with me in the morning, but I snuck out without him this morning because I felt bad, plus I prefer to run alone. One of the little children in her school uniform starting trying to catch up with me this morning. I think most people were very amused by the fact that I was running when I didn't have to and several people said sorry as I ran by. Perhaps my shorts and bare legs were also a bit shocking.

I taught my host brother and Oposh how to play rummy, memory, and go fish and my host brother taught me a game similar to uno or crazy eights. My host parents went to church and also went to help prepare for a wedding, but I didnt't go in part because Oposh was around. Oposh helped me with the book I am reading for my book report and I definitely felt like I was back in primary school.

My mom from America sent me a care package with my favorite cereal: Cherrios. Because they came during the last week of my time here I brought them to my host family. I ate Cherrios with my host father yesterday morning. He sat and read the entire box the night before and was very impressed that they lower cholesterol. I told them that in America we eat it with cold milk, so they tried to chill the milk after boiling and he was very sorry that it hadn't completely cooled. He ate two bowls and I couldn't tell if it was solely for benefit, or because he actually liked them.

Eugene: The personal side of my experience

A couple days ago, I met a young North Korean girl who was admitted to the hospital for a hepatitis B infection. Her family lives at the southeast tip of Korea and traveled almost half a day to bring the girl to the hospital in Seoul. Since her father works, he had to travel back the same day she was admitted. This left the little girl all alone in a hospital.

The VP of the NGO and I went to visit her the day she was admitted. We gave her our phone numbers and told her to call whenever she felt lonely. The very next day, we got several calls from the lonely girl. Unforunately, I have to travel with the VP to a remote site outside of Seoul, and we were not able to get back to her until around 5.

Here is a picture I took with her the day we first met:

I have decided to bloop out her eyes for her safety. Anyways, she really likes giving the peace sign when she takes pictures and insisted I do so as well. She says it is a requirement. Of course, I quickly gave in to her request.

As we were going to visit her at the hospital today, we asked her if she needed/wanted anything. She asked for some slippers to wear at the hospital. The VP and I went to the market and bought her some princess slippers... take a look...

Guess who picked them out? :) They are sparkly pink with pretty little butterflies on them. She was a little embarrassed when we first showed them to her in front of the other kids in the ward... but I think that she really likes them :) She wore them out as we were saying goodbye.