Today was another day of more of the same of what I did yesterday, sitting in the back of the room with the translators as I evaluated the quality of the teaching being done by the Ukrainian trainers. It was a little more challenging than yesterday, though; for one, I was doing most of the evaluating, instead of Dr. Smoak, and two, the material is getting much more challenging.
The most time-consuming part of the day was one outbreak exercise, a look at a Legionella outbreak in Louisiana from 1989. The exercise starts by stating that a hospital, noticing an increase in pneumonia cases way above the normal, calls the state health department for help. Unfortunately, the exercise then gets into a long and detailed description of what Legionella pneumonia is, and then goes back to give a table of all the pneumonia cases by month in this one hospital for the last four years. So that confused both the students and the trainer, who assumed that the table was all Legionella cases, not pneumonias of various types. They spent far too much time analyzing the table, trying to get seasonality trends and whatnot for Legionella based on it. I pointed out the distinction to the trainer, who, after the break, set them straight and explained that the purpose of the table was to show that it was the sudden jump in pneumonia cases that got the hospital's attention, and at this point, they didn't realize it was Legionella.
The next hang-up in the case is a perfect example of the difficulties of working with a translator (especially when that translator is the old guy who doesn't translate very well). The exercise notes that there are several water towers, cooling tanks, and paper pulp processing plants in the city, and asks if we should check each one for Legionella. The students discussed this, and to me, it sounded like they wanted to. The trainer also seemed to be going back and forth, from what I was hearing. He asked at the break what we would do and why; I explained that it would be premature to sample everything, because Legionella lives in all sorts of water tanks, and that the purpose of the case-control study that the exercise is about is to find what the cases have in common, and then you can focus your testing, instead of testing every water tower, air conditioner, etc in the entire city. Well, the translator mistranslated that explanation, and after the break, the trainer said that we should test everything. So I very quickly jumped in and redirected and reminded them that this is why we were doing a study. This is also a difference between Soviet epidemiology and Western epidemiology; whereas we are very analytical (doing studies, performing statistics, etc), they tend to be more descriptive and immediately reactive. There were new paper pulp processing plants in the town and new cases of pneumonia; therefore, the paper pulp processing plants are the culprit and we should test to confirm. Fact is, because Legionella is everywhere, they probably would have found it, and completely missed the true source of the outbreak, and people would have kept getting sick.
It turned out (and this was a real case), it wasn't the pulp plants or the water towers; it was the produce misting devices at the grocery stores. I didn't really think about it until reading through the case, but I remember the mist at the grocery stores when I was younger, and then places just stopped having them. Turned out, they stopped having them because this town in Louisiana noticed that people were dying of Legionella because of them. What would happen was the Legionella bacteria would grow in the water tanks, and then be released with the water when it would spray the produce. The people nearby would breath it in, and if they were unfortunate, get Legionella pneumonia (and if really unfortunate, die). The worst part was, the mist did nothing to keep produce fresh longer; it was just to make the customers think it was more fresh and to attract them to the fruits and vegetables.
Anyway, that whole exercise took about three hours today, and I don't know how much the students really got of it (hopefully, if nothing else, that this is why we do studies instead of go with our first instincts). After the case was over, Dr. Smoak and I took the trainers out to dinner. We went to a restaurant (or, as it appears in Ukrainian, pectopah) called Praga (and I can't write what that looks like in Ukrainian, because my keyboard doesn't have those symbols). It was quite scenic; here was the view from our table:
After dinner, I ordered hot chocolate for dessert. In Eastern Europe/former USSR, hot chocolate is pretty much a bar of chocolate, melted in a cup. It was delicious.
Tomorrow is the last day of teaching, and like today, I'll be the one doing most of the evaluating (we have another long and challenging case). And then Friday the students graduate from Module 3 and I finish buying souvenirs (probably chocolate), and then Saturday, on home.
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