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.

Gallery of Pictures

Steve has taken the lead in writing about our adventures (and is doing a phenomenal job), since I am doing the SITREPs (Situation Reports) for Project HOPE, but I will add what I can to keep you updated. I have found that posting pictures to the blog is very difficult due to the internet capacity, so I am adding pictures to my own gallery which you can all access. Please go to http://gallery.me.com/alla.marks to view the first set of pictures from our mission. I will be posting new pictures whenever I can and will describe the picture above a little later in my blog to create some suspense and anticipation.

Tomorrow is our last day in Solomon Islands and we will be sailing to Kiribati on Wednesday (your Tuesday). Our first island has presented several challenges and accomplishments. We definitely have had to adjust to the heat, which is much more intense than Samoa and Tonga. We drink several bottles of water during our MEDCAP and sweat it all out. I found out the hard way, through an allergic reaction, that sunscreen with DEET, is not compatible with my face. So far, the mosquitos have not been bad, but Solomon Islands has the greatest prevalence of malaria, so everyone is diligently taking their doxycycline or mefloquine.

In terms of accomplishments, Steve and I have been on site every day of each MEDCAP (while other departments get work/rest cycles). The days are long, hot and busy, but very rewarding. We have had the opportunity to counsel on albuterol use with a spacer, discuss antibiotic options with the physicians, and instruct medical students from England and members of the Australian Navy as to how to dispense and counsel. I was able to assist a medical student in administering ceftriaxone IM to a patient, since she had never given an injection to an actual patient. Immunization delivery certification definitely came in handy! The team work during this mission is simply amazing. We have physicians, nurse practitioners, dentists, dental technicians, optometrists, and pharmacy staff all working together in a collaborative manner. Physicians actually ask us for advice (and even follow our suggestions) as well as step in after they are finished with clinic to help us get prescriptions out so we can pack up and get back to the ship. Pharmacy, of course, is the last stop for both medical and dental patients. The islanders are so patient...they stand in long lines to get registered, then to see a physician, then to get a prescription. If they want to be seen for more than one service, they have to get back in line to be registered again. Sometimes, it is very difficult for us in pharmacy, since we have such a small formulary of medications and we are only treating acute diagnoses or relieving symptoms. Simply giving acetaminophen to help with pain to a patient with tuberculosis or breast cancer definitely tugs at my heart, knowing that it does not resolve the cause of the pain. A lot of patients have serious chronic conditions that cannot be addressed by the Pacific Partnership, so they are referred to the local hospital without a guarantee that they will actually follow through or get the level of care that we are blessed to receive in the US.

Adjusting to military life is interesting. I, who am not a morning person at all, have started to work out before breakfast (served at 7am), since so many people do. Meals and meetings define your day. There is no training or preparation for hazardous physical activities. For example, yesterday we had to use Jacob's Ladder to get on the ship (pictured above) since the waves were too high for the regular gangway (which itself is extremely long and difficult to maneuver, especially with your heavy backpack filled with 6 bottles of water and MRE for the day). You have to time jumping off the RHIB onto the ladder as the swell rises then grabbing with both hands and climbing up one rung at a time without looking down. I am sure you can all appreciate the death-defying feat that Steve and I both accomplished (without falling into the water).

Well, it is rounding midnight and we are mustering at 0730 to go to the MEDCAP. Stay tuned for more exciting escapades.

A week on the H.M.A.S Betano

Dr. Marks and I had the great pleasure to stay on the Australian LCH's this past week. I was on the Betano and she was on the Wewack, sister ships who will be decommissioned next year. Let me just say, the Australians have been awesome and they welcomed us with open arms. Of course, there's a crew of sixteen or so on each ship and I think they were happy to have some new people to talk to.

On the Betano, we had a younger crew with a CO who knew how to have fun. The LCH's have very large tank decks for holding supplies and ours had been converted to a party deck after the first day at anchor. It was complete with weight room, pool (no diving), and a movie screen projected onto the side of a module. A module was what we slept in and it resembles an eighteen wheelers trailer, but much smaller. We were racked 3 high and I banged my head a few times on the bunk above before learning my lesson.

The Australians also were a great help at the clinics. They helped the dentists with extractions, pre-packed meds for us, handled crowd control, and all the while they did it with a "No worries mate." Afterwards, exhausted and sweat-soaked (I really want to drive in how hot it was), we would pile into the flatbed and head to the Auki Lodge to have a few refreshments, Solbrew, before heading back to the pier to catch a zodiac to the ship. From there we'd enjoy a hardy meal and cool down in the pool.

Sadly, the Australians will be heading back home after next week so we will lose a very large support arm of the mission. Cheers!

Visale and Auki

Our first week of clinic was quite the ride. The amount of sweat we shed was evidenced by the liters upon liters of water we had to drink to avoid heat related injuries. It's hot.

It's fair to say Dr. Marks and I were quite grumpy (Sorry Nicole!) at the beginning but we've adapted. We're getting closer to the equator and it will only get hotter. We're doing it the Solomon way – just sweat it out!

The clinic has been seeing 700 people a day through the combined services (optometry, medicine, dental) and we've been busy averaging 300+ prescriptions a day. We got smart very quick and had the Australian guys pre-pack all kinds of medicine to give to doctors to dispense to alleviate the burden on us. Even so, we average 200 people a day we still have to counsel in Pigin English. If you see Dr. Marks around school just ask her to show off her Pigin skills; she has learned a new language!

The islanders have shown up in full force and line up at 3am for our 9am clinics! Just about every other person has some sort of fungal infection and I've seen several cases of tinea corpus. Malaria is a problem here but we are referring those patients to the host nation for care. We're also quite lucky to be able to work with two pharmacists from the host nation. It is incredible how they've managed to deliver high quality healthcare with the extremely limited funds. They work 12 hour days and are on call during the weekends and JohnMac(enroe) travels across the Bay to get to the hospital.

The Solomon people are very friendly and intelligent. They live off the land and farm for themselves. The islands as a whole are very poor and they crowd our clinics because the healthcare is free and they may not have the funds to afford it otherwise. Besides betelnut, I've noticed another odd behavior of the Solomon people. They litter indiscriminately. As soon as they are finished with something it's either thrown on the ground or in the water. From afar, the beaches are beautiful, but as soon as you get close you'll notice trash is just below the water. Tomorrow we retrograde (pack-up) and head to the hospital in Honiera.