It’s over…

My last week was spent in Majuro, the capital of the Marshall Islands. It is much more westernized here and it was evident as soon as we first stepped foot on the dock. We were even working in a hospital with an inpatient pharmacy and air conditioning! Well except the pharmacy was the only room in the building that it didn't work. We did have fans and electricity though! And the American kind of electricity, the kind that doesn't require an adapter or a transformer. It's the small things….

It was interesting to see how they worked in this hospital pharmacy. The techs were allowed to fill and dispense prescriptions without the pharmacist's approval. Not much different than the last 5 weeks where we had Australian sailors and pretty much any spare body helping us dispense prescriptions, but it was interesting to see this in an actual institution. I had no doubt in the tech's abilities to do this job especially since their formulary was also severely restricted.

It is simply amazing how fast my time with Project Hope and the U.S. Navy passed. It was a wonderful experience and one I will surely never forget. I implore all of my pharmacy, medical, and professional colleagues as well as my friends to pursue such an opportunity to assist those in need if ever presented the chance. Participating in this medical mission trip has allowed me to work alongside specialists in their respective fields. It was also incredible to be able to interact with doctors from Canada, Australia, Chile, and South Korea as their kindness never ceased.

Jabwot

I had the pleasure of going to an outreach on the island of Jabwot. Our team was flown in by helicopter and my first impression as we flew over the island was that it was deserted. We soon found out that it pretty much was. We walked for fifteen minutes through a serene jungle, minus the occasional falling coconut, until we finally saw the village. Going in we were told to expect a census of 100 people. After checking everyone in at the clinic, we found there to be 54 people. Thankfully, all of the islanders received excellent care from a nurse that lived there and were generally in sound health.

After talking to one of the village elders I found out that the children have many opportunities to get off of the island and make a career for themselves. She had two sons in Arkansas and another in Hawaii. Though with 13 children, I guess some of them are bound to get around. We did see one patient who came in contact with a local predator. A fisherman had suffered a run in with a shark, was bitten in the wrist, and lost use of the tendons necessary for movement of the wrist. The doctor was able to refer the patient thanks to the Marshall's excellent referral system and follow-up care.

I was able to work right next to the two doctors and hand-deliver the medications so my job was done as soon as they had seen the last patient. The veterinary team unfortunately was up to their elbows in pig and dog neutering and soon enlisted our help. My first job, fend off the angry sow with a shovel while her male piglets were castrated. My second job, hold a piglet down while it was being castrated. Thankfully there was no third job. I figure the first two would look good enough on my resume.

Perhaps they'll let me pull teeth at the next site.

A good day

Today was a good day. We arrived in the Republic of the Marshall Islands and headed to the island of Kwajalein where an Army base is located. We didn't get hung up with passport or sovereignty issues and were allowed to take liberty on the island. I had Subway (it was a close call between that and Burger King) and the establishment across the way happened to have 50 cent Guiness Stout Bottles. The Pacific Fleet Band was there jamming out with some Michael Jackson and Jazz. The breeze off the ocean was the icing on the cake. Today was a good day, and it was much needed after the last two islands.

Kwajalein is a strategic military holding as it is home to a ballistic missile weapons intercept program, space operations support, and is one of five sites in the world with radar stations used to operate the GPS systems worldwide. The Republic of Marshall Islands is also the former home of nuclear tests conducted by the US, the most recognized atoll being Bikini Atoll. It is important to know that all the Marshallese located on Kwajalein were moved off this island to another, Ebeye. Refugees of the nuclear tests were also moved to Ebeye. One of our mission sites is located here and the population is estimated to be 12,000 living on a 0.5 mile patch of land. I've heard one of the commanders refer to it as a "little Tijuana."

Dr. Marks and I will not be participating in Ebeye MEDCAP but will travel on to Majuro in 3 days. In between, we are being flown out to two separate atolls for outreaches. Ailinglaplap and Jabwot await us with open arms, hopefully.

Kiribati – Betio Continued

On Thursday I had the great pleasure to meet Admiral Willard (http://en.wikipedia.org/wiki/Robert_Willard), a four star Admiral who commands the Pacific Fleet of the U.S. Navy. His accomplishments include commanding two different aircraft carriers, running the TOPGUN school, and has twice served on the Joint Staff among other activities. I was asked along with a representative of each partner nation to provide some feedback directly to the Admiral on our experiences and how they can be improved. Along with his wife Donna, the Admiral was personally responsible for organizing and planning this mission. It was a great honor to be able to provide a suggestion for improving it in the future, a proposal I'm sure will be considered for the next mission. After our meeting was concluded he gave us his personal military coin, which how I understand it, is an even greater honor.

We were asked to vacate the Betio Sports Complex for several days as they were holding an amateur boxing competition against rival Fiji islands. The two day event plus Sunday being a national day of rest turned into a 3 day weekend for myself. Dr. Marks and Phengphan each went to a different outreach site, an opportunity I will get to experience in the Royal Marshall Islands.

On Saturday I attended a health fair confident I could lend some support based off previous experience with APhA health fairs at the school. What I wasn't counting on was this fair being Kiribati style. Instead of having patients walk through the various stations and be screened, the I-Kiribati prefer to educate through song and dance. This made for an interesting afternoon as the Navy and USPHS healthcare providers were forced to come up with skits on the fly. Another important thing to note is the difference between the Navy's definition of time, if you're on time you're late, and the I-Kiribati definition of time, it'll happen when it happens.

On Sunday, the day of rest, some of the doctors and I went on a self guided tour of the Japanese defenses from World War II. We first passed the bunker the Japanese Admiral that commanded the island used. The building was pockmarked and overgrown but still rich with history. He died in the bunker on the 3^rd day of the invasion. As told, the bunker had gasoline pumped inside and was ignited via grenade, so deeply entrenched its defenders. Further down the road we found the Japanese artillery guns, still pointing ocean side. These gun batteries were huge and surprisingly still in great condition, though I doubt it would launch the coconuts stuffed down the barrel. The artillery shells were prepared in the pillboxes and bunkers behind the guns and transported via a rail system to the guns. Ironically, the guns were manufactured in the UK and sold to the Japanese prior to the war. All the directions on the guns are in English.

Tomorrow we start our five final days at the Betio Sport Complex before we steam ahead to the Royal Marshall Islands.

Kiribati - Betio

On Sunday morning we arrived off the coast of Kiribati (pronounced Kirabas as ti is an s sound in I-Kiribati) and were eager to get off the boat and ashore to begin set up for our first clinic at Betio Sports Complex (pronounced Besio). The islands themselves are surrounded by reefs and are nothing but spits of sand studded with palm trees. It appears the highest place on the island is about 5 to 10 feet above sea level.

We stayed on the boat all of Sunday due to a small issue between the U.S.A. and Kiribati governments concerning the Navy's sovereign right to not surrender a list of the crew linked to Department of Defense activities, i.e. the Navy and Merchant Marine crew. The issue goes from Kiribati customs agents to the Kiribati President and from our Commodore to the Commander of the Pacific Fleet, and wouldn't you know, an agreement is reached. So Monday we get on ground and instead of using the planned helo-ops, we end up having to take a 35 to 45 minute RHIB ride in. Once we arrive at the Betio Sports Complex the reason is clear; the ground is overgrown with both weeds and trash and the paved parts in are disrepair. Looking around one would think the place was 13 years old but a dedication plaque indicates it is only 3 years old.

The area itself is rich with World War II history everywhere you look. We drove past the battle-scarred Japanese headquarters, pillboxes and bunkers poke out from the ground, and the Japanese artillery guns, though rusty, still appear to guard the coasts. Even the RHIB ride in to Tarawa is historical. It is the same path the Marines took storming the beaches. Several boats are stranded on the reef just as the Marine's amphibious landing craft were stranded, forcing the Marines to swim and wade inland or face certain death under the Japanese counterattack. The water level is only 3 to 5 feet above the reef that stretches up to 500 yards from the beach.

Kiribati itself is another one of these "beautiful disaster" island nations. The scenery and people are genuinely friendly, but the conditions they live in leave a lot to be desired. The islands are small and narrow to the point you can see from one side of the island to the other just by turning your head. This leads to overcrowding and a collection of refuse. The only way they get rid of their refuse that I've seen is to burn it. The U.S. Public Health Service environmental health people have even told us of beaches that are littered with human excrement. One even joked that they don't even need to do thorough tests for choleform bacteria; they can just fill a glass up and then hold it up to the light for visual confirmation. The "Kiribati Salute" refers to checking the bottom of one's shoes for surprises.

Another interesting cultural difference is the children. They are everywhere and into everything. The children are very nice, curious to see us and what we are doing, and aren't afraid to invade your personal space. Another joke is that they seem to let their dogs and children run free, but lock the pigs up. Speaking of pigs and sustenance, due to the islands lack of space and rather dry conditions, they are only able to grow food in crops in small amounts and fishing predominates the food gathering. Kiribati is actually expected to be the first country to disappear due to global warming and the rising of the seas.

Shellback Ceremony

Dr. Marks and I began our shellback ceremony at 1800 with an announcement from Davy Jones himself! He heard about all of us slimy pollywogs, 47 in all, on board and was demanding we show up for physical fitness the following morning. The one and only King Neptunus Rex himself would be present with his court of trusty shellbacks for our physical test. The shellback ceremony is also known as the crossing the line ceremony. It is done to commemorate a sailor's first time crossing the equator and is administered by those who have been initiated.

Our first night we had to do a talent show in front of all of the trusty shellbacks. Possessing no inherent talents, I decided to "borrow" someone else's. Dr. Marks and I decided to copy Dr. Stolte's and Dr. Clements Thursday Night Live spoof from Phollies. We were imitating Craig (Will Ferrell) and Arianna (Cheri Oteri), the Spartan cheerleaders, from Saturday Night Live. We planned three cheers, my personal favorite being "Who's that pharmacist in my pharmacy" with Dr. Marks popping out and saying "It's me It's me." We also laced it with several jokes and references to what we have seen so far on this mission.

We were psyched, ready to get it over, and suddenly it was our turn to get on. We ran onto the flight deck with pom poms flying and executing perfect scissor kicks. All of our practice and hard work paid off. We got three lines into our skit and everyone stood up, and booed us off stage. Whew, that part was over.

We woke up at 0600 the following morning. I'm not sure if I am allowed to reveal the next part in its entirety, but here are some choice words. Water. Duck walk. Peanut Butter. Jelly. Calisthenics. New hairdo. Green eggs, bacon, oatmeal, and ham. Calisthenics. Oranges. Tuna fish and rice slip and slide. Calisthenics. Swab the deck. Leap frogs. Fire hoses. Bowline dragon. Row row row your boat. Make the baby laugh. Dunk tank. 2 hours later and I am now a trusty shellback.

Dr. Marks and I can now both say this with pride for having made it through. It's a great honor to be a part of this naval tradition as I imagine not many civilian pharmacists will be able to display their shellback certificates in their offices. This was another unique experience that this rotation has granted me with.

Good Samaritan Hospital

Our third and final clinic was at the Good Samaritan Hospital, donated and built by the Italians. Catholic nuns live, work, and run the hospital. Getting to the hospital itself is a nice 30 to 45 minute drive depending on how crazy the driver is. We pass through palm tree plantations which equates to 50 foot palm trees in neat rows as far as the eye can see. I hear the Solomons are the world's largest producer of palm oil. Supposedly it's also where one third of the world's tuna that is canned comes from. We also pass the island's only self-serve car wash, a shallow portion of the river the few automobile owners can drive through and splash water onto their car. This tradition was started by the United States Marine Corps back in WWII when they gained control of the islands. The hospital itself is set against a backdrop of mountains perpetually shrouded in clouds.

The view is quite soothing for the amount of volume we are seeing. Yesterday we had a personal best of 500 prescriptions! The pre-packed medications we gave the providers have certainly saved us a large number of prescriptions as well. We have also been very lucky to have a few of the Australian sailors as well as English medical students help us in the pharmacy. We are able to quickly train them to be autonomous in dispensing prescriptions. This is quite different from the U.S. where there are several checks and balances before the prescription leaves the pharmacy.

It's quite incredible what the nurses do here at the hospital. They are very well trained, love what they do, and this is a blessing for Guadalcanal. I imagine it is almost impossible to entice doctors to the island. It is one of the only islands where malaria is still an issue, healthcare reimbursement is next to nil, and the bustling city life is dirty and dangerous. The WHO lists the Solomon's as having something like one doctor per 155,000 people. The hospital is lucky enough that Sister Dolly, the head nurse, has two Cuban doctors as friends that will visit once a week. This it's self is boggling to me coming from America where Patient First's and quick-care clinics are starting to become as populous as retail pharmacies.

But now the Solomons are behind us and we are moving off towards Kiribati. The experience here has been very eye-opening and full of some life lessons. Hopefully Kiribati will be just as exciting.