Day Two

Today was the second day of the epidemiology course, which didn't require any teaching from me (yay!). Instead, my job was to sit in the back of the room and either: a) mess around on my iPad while Dr. Smoak evaluated the Ukrainian trainers; or b) have the translator sitting next to me talking pretty much right in my ear to translate what the trainers were saying so I could evaluate them. Needless to say, option a was more fun.

We have two different translators for this course, a really nice and fairly young Ukrainian woman, and a fat, old Ukrainian man who smells like a mixture of vodka, cigarettes, and the cheap mint breath spray he uses to cover up the first two smells. Needless to say, the woman is the ideal, but aside from her more pleasant aesthetic features, her translations are also much easier to understand. The man messes up numbers all the time (and numbers are kinda important when you're talking about disease surveillance and epidemiology/biostatistics) and tends to get lazy when he thinks it doesn't matter.

Translators aside, the students seemed to be doing fairly well with understanding the material, which, one can conclude, means that the trainers are doing fairly well. We've identified a few minor issues over the last two days (many of which might be semantics), which isn't bad at all. Hopefully this continues through the week.

First Day of Teaching

Today was the first day of actual work in Ukraine (I know... Sad). So after getting up, working out, and having a delicious breakfast (provided by the hotel), we got in an embassy car and made our way do another part of Kiev to start the class.  Most of the students were coming in from overnight trains, so things got off to a bit of a delayed start (around 10), but then it went well from there.

After all the introductions and whatnot, the Ukrainian trainers got to work. For most of this week, we're here to evaluate the Ukrainian trainers as they teach the material. This is the third module of epidemiology teaching (out of four) that the students (public health officials/epidemiologists throughout Ukraine) get. When the program first started, everyone was trained by Americans at all levels. Then they began training Ukrainians to do the first two modules, and now no Americans teach those. This will be the first group of Ukrainian trainers for the last four modules. No other country has their own trainers for modules three and four. 

I did get to try my hand at teaching through a translator near the end of the day, though. I gave the first lecture on cohort studies, and I think it went pretty well. Here's me teaching:

 

 

And then waiting for the translation:

It was 26 slides, but took about an hour and a half to get through, in part because I had to stop every sentence for the translator, and in part because the students had never had any material on cohort studies before. I think they did pretty well, though. Time will tell... They have a post-test on Friday.

Still Exploring Kiev

Today was more exploration of Kiev (and more shopping for souvenirs). We went to Maidan Nezalezhnosti, or Independence Square, which was where Ukraine celebrated independence from the Soviet Union in 1991, and also where the Orange Revolution was in 2004 (to protest election corruption). Today, it's pretty much just a central square of Kiev. They're also gearing up for Euro2012 (soccer), which explains this picture:

 

 We also passed by a theater with some interesting decorations to their buttresses:

Here's another picture from St. Michael's Gold-Domed Cathedral, which I also had pictures of yesterday. The church in the foreground is an old stone church from elsewhere in Ukraine that was moved to the cathedral grounds (I don't know why).

I also wandered up to Volodymyrs'ka Hill, which is a park close to Independence Hall. It's so named for the statue of St. Volodymyrs of Kiev, who was the guy who baptized all of Kiev, back in 988(ish). I think his statue is in the middle under the arch, but I'm not sure.

Here's another shot from Independence Square:

And, finally, some interesting characters that we met along the way:

Tomorrow begins the actual work of this trip. I'm going to be evaluating future Ukrainian trainers of epidemiology, and giving a lecture of my own. Should be interesting.

Arrival in Kiev

For those of you who didn't know I was going to be spending a week in Ukraine teaching epidemiology... Surprise! I'm in Ukraine for a week to teach epidemiology. After far too many hours of travel by plane, train, and automobile (okay, just plane and automobile, no trains involved on this trip...so far), I checked into my hotel in Kiev. And what a lovely hotel room it is.

 My preceptor for this trip, Dr. Smoak, has been here for a week already doing the first part of the training (two weeks total: week one is to teach them epidemiology, week two is to evaluate them teaching the same lectures back. That's the part I'll be doing), so after I unpacked and cleaned up somewhat, she took me out to see the part of the city where we are and do some souvenir shopping. Here is one of the churches (I don't remember the name, but I'm going to find out):

This church also had a memorial for the 1932-33 famine in Ukraine, pictured below:

To try to explain this famine briefly, without getting into complicated Soviet politics and history, in the Soviet system, there were common fields that all peasants were supposed to work, as well as small plots that individual/families maintained. In 1932, there was a pretty severe drought, and they discovered that people didn't really do anything in the common fields when there was work to be done on their own fields. So grain production was really, really far down. The Soviet solution to this was to take from the Ukrainian peasants who managed to produce anything, because they blamed the failure of the common fields on Ukrainian nationalism. In two years, millions of Ukrainian peasants starved to death due to the Soviet distribution policies, which was later determined to be a form of genocide. If you look at censuses that were done around this time (a few years before and a few years after), the Ukrainian region was the only part of the USSR that had a decrease in population. So the Soviets were selectively starving Ukrainian. They were bad people. But we knew that.

On a happier note, here's another church. Dr. Smoak said that this one had specific cultural/historical significance, but she couldn't remember what it was.
 

And, finally, a picture of the statue of the architect of Kiev.

That was my day/last couple of days. A bit hectic and definitely exhausting, which is why I'm about to go to bed. Tomorrow, possibly more walking around/souvenir shopping, and then Monday we have to go to work.

ACPM 2012

I spent Tuesday through Sunday in Orlando for the 2012 conference of the American College of Preventive Medicine, which has been a combination of a lot of fun and a lot of work (well, as much work as sitting in rooms in a conference center is).

The conference started on Wednesday (Tuesday was just a travel day) with a session on health economics and cost-effective analyses (yes, it was as exciting as it sounds). Thursday was a very long day, with a run in the morning before breakfast (a little more than 4 miles through Downtown Disney and surrounding areas), followed by sessions all day, poster presentation in the evening, and one more session that ended at 9:30. Long day. Here's a (not great) picture of my poster:

Friday was a slightly shorter day, mostly because I didn't see anything interesting to go to for one of the sessions and I decided to take a nap instead. The day also ended earlier, with the last session ending at 4:30 and my fellow residents and I deciding to go out to Universal City Walk for dinner afterwards. There were some big-name restaurants there, but it being a Friday night, the wait at some was rather ridiculous. We tried to go to Emeril's, but when they told us it was a 2-2.5 hour wait, we decided to hit Hard Rock Cafe instead. And because it was Hard Rock, we went to the store, where Derek decided to model the merchandise:

Saturday morning started with a long run, again through Downtown Disney and around the golf course. I actually got lost around the golf course, which made for a nice run, and amazingly enough, I made it back to the hotel with almost exactly the right mileage for the run (six miles). Here was my course:

Most of the sessions on Saturday (at least, most I attended) were part of the Uniformed Service Academy of Preventive Medicine offerings, which included a business meeting (terribly exciting), followed by a session on measuring behavioral health in the Army, then a session on vaccine surveillance in the military. In the evening was the awards banquet, which was a dress-up event. Derek and Raul only kinda understand the concept of dressing up:

Derek ended up getting an award for his oral presentation on degenerative disc disease, so we're very proud of him.

In all, it was a good conference, and I hope that next year I'm not too busy with work to go again.

82nd Civil Affairs Battalion, Ft. Stewart, GA

Again, I'm a bit behind on posting big news. Last Wednesday (as in, a week and a half ago), I received word that I will be becoming the preventive medicine officer for the 82nd Civil Affairs Battalion of the 85th Civil Affairs Brigade. For those of you confused about what the difference between a battalion and brigade is, here's a chart for you:

The 85th Civil Affairs Brigade is brand-new (activated 16 SEP 2011), which means my battalion (based in Ft. Stewart, GA) is brand new--as in, the stand-up date is SEP 2012. So I'll be coming into a brand-new position, which is kinda cool and really scary. Cool because I get to drive what my position is, scary because I have to drive what my position is. The whole, "Am I really smart/talented enough for this?" question that will, I hope, be answered soon (and answered to the positive).

Little bit of background as to the brigade and battalion. The 85th CA Brigade was stood up because the Army realized it needed more civil affairs assets, and decided to put that in the active component, instead of the reserves, where most of the other CA assets are (nine reserve CA brigades and one active duty to support special operations existed previously). There are 5 battalions in the new brigade: the 81st is at Ft. Hood (activated in 2011); 82nd at Ft. Stewart, one (forget the number) at Ft. Bragg, to be activated in September; and one at Ft. Lewis and one at Ft. Bliss to come in 2013. Each of the battalions takes a different part of the globe, with the 82nd taking Africa. The only other part of the world I think would be more interesting to go (in terms of health needs and diseases) would be the Pacific, and that's going to belong to Ft. Lewis, once that battalion exists. I've started convincing my friend Raul, who will be graduating next year, that that's the job he wants.

As far as what I'll be doing, here's the official guidance in the field manual for Preventive Medicine Services (Field Manual 4-02.17, in case you were wondering):

3-14. Civil Affairs Units
In CA units, assigned PVNTMED personnel assess the public health capabilities of a country or area, but
are not responsible for directly providing PVNTMED services to them. As such, PVNTMED personnel
are assigned to CA companies, detachments, brigades, and commands. The type and number of PVNTMED
personnel assigned is dependent upon the unit. Since the staff's role is advisory, it has no organic
equipment and must coordinate for support from PVNTMED detachments and the AO supporting medical
laboratory. If available, CA units are also supported by PVNTMED detachments.

That's what I'll be doing when I'm in the field, but in the meantime, I'm still waiting for my official orders to appear and trying to figure out what training I need to do before September, but I am excited about it. 

Executive Summary and Information Paper

It's been a week since the end of my POPM, so I've been a bit of a slacker about writing about the end of it. Sorry. Overall, it was a really good rotation and taught me a lot about the necessary steps in making policy (it's not a short nor simple process).

Most of my work during the rotation involved reading memos and proposed regulations and comparing them to current regulations to see how they fit (and that was an oversimplification of the whole thing). I also researched current issues that were coming in to POPM (things that people from outside the Office of the Surgeon General thought needed attention) and tried to make a decision about how important it would be. One of those issues was a report of twelve cases of swine flu (a different swine flu, not H1N1) in five states. After doing research, which mostly consisted of reading what the CDC has to say about it, I wrote an executive summary and information paper. Also easier said than done.

An executive summary is a short and concise summary of an issue, and there are very specific formatting rules for it, from the font and size to the fact that it has to be fewer than fifteen lines of information. Here's my EXSUM (we like acronyms):

(U) 12 HUMAN CASES OF INFLUENZA A(H3N2)v IN THE US.  (U) (DASG-PPM-NC)  Since August 2011, the Centers for Disease Control and Prevention (CDC) reported 12 human cases in five states of swine-origin influenza A (H3N2)v.  No cases have been reported among DoD beneficiaries.  Severity of illness is similar to seasonal influenza with three hospitalizations and no deaths.  The majority of cases occurred in children who have had contact with swine, with evidence of limited human-to-human transmission.  CDC provides interim guidance to clinical and laboratory personnel for surveillance and testing.  MEDCOM provided guidance to Army medical treatment facility laboratories on 13 Jan 2012 regarding typing and subtyping of specimens. Preventive medicine personnel will report all confirmed, probable, or suspected influenza A(H3N2)v cases in Disease Reporting System Internet and to local public health authorities.  Healthcare personnel should encourage beneficiaries to be immunized against seasonal influenza, as this may confer partial protection against influenza A(H3N2)v virus.     

If, after reading an EXSUM, someone wants more information, they request it and are provided an information paper, which, as it sounds, contains more information. It's supposed to be less than one page (again, very specific formatting rules), but can be longer. Mine was about a paragraph onto the second page, and I won't subject you to that.

So now that I'm done with POPM, I'm spending a little bit of time hanging out at WRAIR on what we refer to as "research downtime". Unfortunately, my research project happens to be at that exact place where there is nothing I can do to accelerate it, which makes my research downtime more of just, well, downtime. It's given me the opportunity to work out during the lunch hour, which is quite enjoyable, and get my poster ready to present at the ACPM conference in a couple of weeks. And get caught up on sleep, which after the commute I had to go down to Falls Church, was a bit lacking.

Pandemic Influenza Table Top Exercise

On Thursday and Friday (I'm only a couple of days behind, go me), I participated in a table top exercise about pandemic influenza preparedness. It had a tendency to drag on and get into the weeds at time, but was overall fairly educational.

One thing I didn't know before going into this is that we have definitions of pandemic severity, based on the case fatality ratio (below). In terms of pandemic influenza, the H1N1 (or swine flu) from 2009 was a category 1 pandemic (I feel like I need to back-up for a second and define 'pandemic'. It doesn't mean 'bad disease'; it means a disease outbreak that is spread around the world. An epidemic, on the other hand, is an outbreak that is in one area or part of the world. So H1N1 is a pandemic, because it's found everywhere, but obesity is an epidemic, because it isn't). Anyway, back to what I was saying: H1N1 is a category 1, because while there were a lot of cases, there weren't a lot of deaths. The 1918 flu, on the other hand, was a category 5 pandemic, and was the only category 5 influenza pandemic in history.

For the table top exercise, we were using a pandemic influenza modeling tool developed by the Innova Group, where you can enter in the severity of the pandemic (from 1-5), duration (typically 6-12 weeks for influenza, depending on the size of the geographic area you're talking about), the population size and age distributions, and expected attack rate by age (for example, children tend to have higher attack rates for influenza than adults). You enter in all that stuff, and then it spits out a bunch of reports about how many healthcare workers you need, how many gloves, the amount of storage space required for everything you're going to need, etc, etc. 

For this exercise, they modeled the Northern Region Medical Command, which is all the Army treatment facilities from the Canadian border through North Carolina, and a category 3 pandemic. The people running the table top were logisticians, not epidemiologists, so they didn't know all the right terminology of influenza surveillance or epidemiology and some of the things just didn't make sense. For example, based on the scenario, we knew there was a pandemic coming before the first cases hit the United States, which isn't the situation. With H1N1, it had been going on in Mexico for a couple of months before anybody typed the virus in San Diego and realized that it was a new influenza. So a little unrealistic, at least at the beginning of the outbreak, but it still generated a lot of good discussion about what we can do to prepare and how individual treatment facilities have to respond.

Overall, I don't know how much it taught me about policy (which is what I'm supposed to be learning on this rotation), but still educational overall.

Periodic Health Assessment

Today was a meeting of the Joint Preventive Medicine Policy Group (another acronym: JPMPG, pronounced jip-em-pig), which is a group of preventive medicine people from all of the services (Army, Navy, Air Force, Coast Guard, sometimes foreign militaries, etc), and the topic of the meeting was the periodic health assessment.

The periodic health assessment is done by each of the services, but each one is different, which in today's fairly integrated military, makes things a bit difficult. There's an online portion that each service member completes on his/her own time, and then there's a face-to-face with a medical provider (doc, PA, NP, etc). The problem comes in for the face-to-face... if a sailor goes to an Army clinic to do the PHA, there's no guarantee that that Army doc knows how to do a Navy PHA (or even knows which computer program to use). For the record, I don't know how to do Navy or Air Force PHAs, nor do I know what programs they use. As you can figure, that creates some problems on joint bases.

So the purpose of the meeting (which extends into tomorrow, but I won't be going to, because I'll be at WRAIR for didactics), is to figure out 1) what the purpose of the PHA is (that's an entirely different conversation, which I won't get into); 2) if the multiple different PHAs can be standardized into one form; and 3) what that might look like.

Easier said than done. There's a lot more to policy than meets the eye.

Proponency Office for Preventive Medicine at the Office of the Surgeon General

That's where I'm rotating now (today was the first day). Or, because the military likes acronyms the way normal people like breathing, POPM/OTSG (which we just call POPM, pronounced pop-'em).

To put it (very) simply, POPM is where medical policy in the Army comes from. Whenever there's a question about the way things are done in the Army medical department (AMEDD, back to the acronym thing), it goes to POPM, they check the research and what the civilian side and other services are doing and get the opinions of subject matter experts, and then make policy. Yes, that was very simplified.

Today I spent the morning doing the standard for a new rotation: in-processing. Fortunately, every Army prev med resident as rotated through POPM since 2008, so they know what they're doing (which is impressive; usually when someone should know better, they act as if it's never been done before and the wheel needs to be reinvented). Then the afternoon was taken by a teleconference about the new regulation for the Army program, which mostly turned into public health nurses bashing just about everyone else (including prev med docs). That took over three hours, and when it was done, they sent me home, because the snow was falling pretty heavily (not sticking, but still falling). Unfortunately, people around here become idiots on the road when there's weather involved (and I mean any weather... snow, rain, sunshine, hurricane, earthquake...). It's a little more than 15 miles from work to home, and it took me almost two and a half hours. I was not happy with that commute.