 called Disparities of Culture, Outcomes in Vitality Research that an acronym has discovered, and that looks at racial, ethnic, disparity in the chronic disease risk in burden and how to use better screening treatment and outcomes. So she does that at Palo Alto Medical Foundation as well as volunteers with doctors.border. That will be our talk for today. So thank you for that introduction, and thank you all for coming today. And I'll be speaking for about 45 minutes, and then we'll have 15 minutes for questions afterwards. I'll just give you a little bit more of my history, so you kind of know where I came from and how doctors at Outborders have been into my life. So I did the seven-year integrated pre-medical medical program at Michigan, and then I came out to Kaiser San Francisco for my internal medicine residency. And then I applied for preventive cardiology fellowship at Stanford, and I also applied for an individual NRSA. It's called the National Research Scientist Award. It's an F-32. They still have them. They're called Ruth Kirschstein Awards. And so I had planned to just go directly from internal medicine and to preventive cardiology, but I kind of wanted to fit in Doctors Without Borders. And so I deferred. I got in, and then I deferred both of those things, both the NIH Award and the fellowship. And I'm really glad I did that. Sometimes when you're at this stage in your life, you just kind of feel like you need to be moving forward. But it was a very valuable experience that I'll talk about today. And there's not a day that goes by that I don't think of it. And then a little bit of my personal history in that, because I know that we all have personal lives that fit into our careers. And so I went and volunteered in East Timor right after I got married. So after my residency, we got married that summer, and then we went to both of us. My husband and I went to Doctors Without Borders in September. So you'll see some pictures of him in my slides as well. So feel free to ask questions as we go through. I will try to remember to repeat the question, because we are being recorded. And then I'll also leave some time for questions at the end. Does anyone have any questions before we begin? One's in the right place at the right time. OK. So Doctors Without Borders is a French organization that's called Medicine Sans Frontier, or MSF. I kind of had a little bit of conversation with people. And the experience that I'm going to be talking about is over a decade old. And things have changed, but not all that much in MSF. And I'm part of a return volunteer network for MSF. And I'm not aware of Stanford faculty who have gone more recently than I have. But if you are, I would love to hear about that and connect with them as well. So MSF was founded in 1971 in the wake of the Biafra crisis. So the Biafra War was a war that happened in Nigeria in 1971. And I know that one of the global health speakers in December, it was December 7th, because I went online and looked at the videos. A guy named Burt Patanod spoke about the evolution from the Red Cross to MSF. And I know not all of you were there at that talk. But can anyone sort of briefly summarize how MSF is different, the main way that MSF is different from International Red Cross? OK. So the International Red Cross, it's very important to be nonpartisan with the Red Cross. So the Red Cross did go into the Holocaust. They witnessed all of those atrocities. But they did not comment on them, because it would limit their access to the Holocaust victim. So the main difference with MSF is that witnessing is a very important part of their process. And they have a French word for it called timonage, or witnessing. And this happened in the Biafra crisis, where doctors, as part of the International Red Cross, went in. And they were mostly young French doctors. And they were witnessing what they thought was a genocide, and there was debate about whether it was actually a genocide or not, and said, look, we can't be muzzled as you're asking us to be in the Red Cross and not say anything to the world about what we're witnessing. So we're going to break off and create our own organization called Medicine Sans Frontières. And a big part of our mission is going to be reporting on the things that we see. So that's sort of the main difference. And in all of the places that you go, you will see all of these different aid organizations. And there is even a group that's broken off from Medicine Sans Frontières called Medicine Dumond, MDM, Doctors of the World. So each of them have a little bit different flavor of how they practice humanitarian aid. But one thing that MSF is well known for is being able to mobilize quickly in a crisis and get on the ground and do things effectively, which is what I experienced when I volunteered with them. So the MSF charter, so there are some things that are similar to Red Cross. So neutrality and impartiality. So Red Cross will also be neutral and impartial when they go into different situations. And they're also, both organizations are independent from all political, economic, or religious powers. So it's very important to realize that different governmental organizations have different aid portions like USAID, but they all have different agendas. And so it's very important to remain impartial when you go into humanitarian aid because often you're in the middle of two sides of a conflict and you need to be able to provide care and show that you're not taking sides and providing that care. So MSF makes that a very important part of their charter. And then again, the witnessing and being able to report on this is what distinguishes MSF. So they're neutral. This is a picture from the Democratic Republic of Congo. So they aid both sides of any conflict. They're impartial. So this is a picture from Liberia in 2007. And you can see that they have a picture here with a gun, with an X through it. So basically soldiers and people who are part of the conflict can come as long as they check their guns at the door. And they're independent. So it's really important to realize that MSF doesn't get any funding from any governmental organization. They get most of their funding from people who write $5 checks in December. So 80% of their funding is very small amounts of money from lots of different people. And it helps them not be conflicted or biased in the care that they provide. So MSF has medical programs in more than 60 countries. So the countries that they have medical programs in are the ones that are slightly darker. And there's more than 27,000 field positions. So that's people that are in these countries in the field. And there's 9% international staff. And that's a little misleading, because when you say international, it means that the people who are in the country. So when we went to East Timor, we hired East Timorese staff. So that makes up 9%. And then what they call the people who go from a different country into East Timor are expats or expatriate staff. They did more than 7.6 million patient consultations in 2010 around the world. There were 150,000 deliveries. So this is an important thing to remember if you ever think about doing humanitarian aid work is that the demographics of the developing world are quite different than the demographics of where you're training. And that you're gonna be taking care of a lot of pregnant women and children. And it's good to brush up on that. And I'll tell you about my own experience with that. And there are 58,000 surgical interventions. So we're talking a little bit before. So the minimum time commitment for an internist to go into MSF is six months. But they have some specialized surgical missions that you can go for as little as two weeks. But you have to have those surgical skills. So the annual worldwide budget is 1.2 billion. 91% of funding comes from individuals. Almost 80% comes from individuals. And the rest comes from corporations and foundations. And at least 82% of the overall budget goes to program activities. So this is really important sometimes when you do donations, they give you a pie chart of how much actually goes to the program. And they say that you should look for programs that are 70% and above that go to the activities. And MSF is 82%. And I can attest to that. I know that being residents, you're probably not, don't have the best expense accounts. But even when we wanted to go buy things when we were doing our training like potato chips or beer, it was kind of all on our own nickel. And we were volunteers, we weren't getting paid. So you really have to have a commitment to do that. So who volunteers? Medical doctors, as we talked about, and I said the minimum time commitment is six months. And it's important to realize that general surgeons, anesthesiologists, and doctors only make up 20% of doctors without borders volunteers. The other 30% are nurses and midwives because there's a lot of OBGYN. And then there's also a small proportion of nutritionists, epidemiologists, public health professionals, mental health professionals, administrators, logistic professionals, WOTSAN or water and sanitation experts, and FNA, finance and administration. So they really have a whole team that goes out there and they create this little business in these remote areas and they take everything with them. So I think sometimes it's a little bit of a mismenomer to call it doctors without borders because it's only 20% doctors and there is this whole other team and you'll find that in order to practice medicine, I mean you realize that you have a lot of support in order to do it. And I'll tell you when we went to East Timor we didn't know what side of the road to drive on, we didn't know what currency to use, there was no water, there was no shelter and there was a lot of things that need to be in place before you can practice medicine. So we live in a really rarefied environment here as you can imagine. So the question is what percentage do you think are paid staff? So when we were actually out in the field we were technically paid, we were paid $700 a month while we were there and of course they provided shelter, they provided food while we were there. So what I was referring to earlier was that when we were in a training period we went to like a training thing we weren't paid. And then the local staff that we hire there are paid at local rates. So people are paid and this was a decade ago so maybe it's $800 a month or something now but and you can compare that to maybe your own resident salary, yeah. It's not much and really what it's designed to do is be able for you to pay for storage for your staff while you're away and that's about it. So the activities of Doctors Without Borders and what they're really known for and what they're very good at is responding to emergencies. They're just incredible. I mean they have land rovers that are packed with everything that you need and if there's an emergency they load them onto planes and they can literally drive off the plane with everything you need to provide medical care for a population in need. And they provide medical support to populations without access to healthcare. They're very good at responding to chronic epidemics. They have a lot of cholera programs and TB programs in Russian in Russian jails and again bearing witness. This is something that wasn't on the previous slide but they had when we were in East Timor they had three people that were there just to write press releases every day so they would come around and talk to all of us and find out what the stories were and every day there would be 30 press releases that went out from East Timor. And then also we were there the year they won the Nobel Prize so that was even more PR than maybe they were usually used to. Okay, so now I'm gonna move into talking about my specific experience in East Timor which was in 1999 and does anyone have any general questions on Doctors Without Borders before we move to that? Okay, so East Timor is a small little island nation that was formerly part of Indonesia which is depicted here. Here's Australia, here's India, there's Malaysia and Singapore and you can see that there are many, many islands and it may sort of not be intuitive why this small island, so this is half of that other island so this whole island is called Timor and T-I-M-U-R that means East Timor Timor means East Timor and this is the country the capital is Dili there's also a little part of East Timor over here in West Timor so it might not be entirely clear why this little island is separate from Indonesia and we have to kind of go back to colonial times to figure that out. So most of Indonesia was colonized by the Dutch this teeny tiny little part was colonized by the Portuguese and they had obviously different customs than the rest of the islands and when the Portuguese left in 1975 so the Portuguese left and said okay East Timor you're on your own and they left because they didn't wanna support this little colony. At that time the Indonesian army basically just came over and took over East Timor because they didn't have an army to defend themselves or anything like that. So then for 25 years there was low level resistance and then there were lots of things that as often in these conflicts there's a socioeconomic reason for why there's conflict and East Timor for instance had the fewest roads of any place in Indonesia and then having been influenced by the Portuguese they were a Catholic country and the Indonesians had different policies so they would come in and do forced sterilizations and that type of thing and it's not something that sat well with the Catholic country. So there was this low level resistance for a long time and there were people who went to the UN and asked year after year can we vote, can we vote, can we see if we can be separate from Indonesia? And then finally in 1999 the UN granted them a vote and Doctors Without Borders was in East Timor even before the vote. So any questions on that conflict at all? Okay, so they decided that they were gonna take a vote but all along the Indonesian military and I'm sort of telling this like a story but I don't mean to take sides in any way I'm just sort of portraying the conflict the way it was. The Indonesian army did fund what they called militia so they funded people in East Timor so it wasn't the Indonesian army that was out there the face of this conflict but they had paramilitary so who they called militia so here are some militia members they have stones and machetes and they're there to threaten the people at the time that they wanted to come and vote so this is all pre-voting that was the pictures on the street and this is people here with their voting papers standing in line to vote despite all of this terrorizing there was still a large proportion of the population that turned out to vote 80% of the people in Timor who were eligible to vote voted which is a lot less than voted yesterday I'm sure for us. So this shows that there was violence during that time so this is a ballot box people guiding the ballot boxes but these stones and things that you were seeing in the previous pictures were thrown in here to really instill fear in the people who were coming to vote but despite that people did come out to vote and then this is a picture in Jakarta so this is the Indonesian military in Jakarta and these are students who are protesting the Indonesian occupation of East Timor so this is what happened after the results of that vote came in the militia sort of went on a rampage they burned down buildings they turned over buses they went from home to home and asked people to leave so they could burn down their homes and sometimes it wasn't such a polite ask to leave it was at gunpoint they went to beaches some people estimate that over 100,000 people were killed in this aftermath of a massacre and we when we were there on a daily at first almost weekly basis after that finding mass graves and bodies washing up on the shore so this is a picture of people trying to carry their belongings and go to the refugee camps which were set up in West Timor and also Jakarta so this is pictures of people getting on boats so they were put on boats with their belongings and here's a small child I apologize for the quality of these pictures they were taken before digital imagery scanned in and you know so they don't look so great and this is another picture of the militia and it was difficult to go out we as part of MSF always had to travel in convoys you always had to have walkie-talkies with you and I'll tell you the MSF interview that I had was the hardest one I had I'm sure you've all had wonderful interviews in your life because that's why you're here but you know most interviews go pretty well people ask you why you want to do what you're doing and you give a good answer and it's generally a positive experience in my interview for MSF they said you know why do you want to do that this I gave them my answer and it was always you know sort of a challenge and they said to me what do you do when you're stressed out and as many of you do I said well I go for a run and they said well what would you do if you couldn't go for a run and I said well I don't know I maybe do yoga or something like that so but you know the questions they asked were very pertinent because I couldn't I mean you can't go outside for six months so this is so they were very prescient in asking you those questions about how you would handle stress and it was very stressful so this is a picture of a burned down house this is where a house was and the tree that was burned down there this is an overturned bus this is another house that was burned down these are pictures of more cars that were burned and another house and more cars and it's interesting because you know we didn't really see a lot of this actively happen but it was because we had such security measures in place and we weren't allowed to go out after dark you know we kind of happened upon these things the next day when we were out going to the clinics then we were in and more pictures of the cars and being burned out so this is a picture of a fountain that was right near the Dilly Airport where we flew in and there were no commercial flights obviously so we took the UN planes in so this is just some pictures of the graffiti so this is a little bit in Bahasa so it says autonomy so it's like the word autonomy but it's spelled O-T-O-N-O-M-I yes so they were saying that they wanted autonomy from Indonesia and so this is the acronym for the Indonesian Army TNI and then it's also referred to as the militia so this says TNI or militia is I'll let you read the rest and then the group that we went in with was called InterFET so it was the United Nations International Security Forces for East Timor and so they write we love InterFET thanks for your security so this is the first clinic that I had there this is a soccer stadium and they chose a soccer stadium to set it up because it's a place that's easy to defend and so you can see here's the refugees here and we had one clinic or sorry one tent to see people in and one tent where we sutured lacerations and that type of thing in the back and you can see the soldiers and sandbags in the corners of that soccer stadium and we were there probably for the first two months living in tents those are UN soldiers so the UN each country sends soldiers so we actually had soldiers from all over the world that we worked with but most of the this particular UN army was Australia because they were so close and so this is where people waited so I know we all have hard days here but there were 250 people waiting and they all knew exactly how long you were taking with each person because they were watching you there wasn't a lot of privacy there wasn't even a lot of water to wash your hands between patients and this was before the days of hand sanitizer I didn't have a lab, I didn't have x-ray I didn't have anyone else to talk to to ask if you think this spleen is big or not or do you think this conjunctiva is pale and do you think they have malaria and I only had 20 medicines in a box in a blue box and I went from arguing about whether I should give someone a third or fourth generation cephalosporin and an ICU to have to figure out what they've got and I've only got Bactrum or Penicillin to give them and I hope that worked and it's really interesting because we think of all of these wasting diseases and I often wondered why they called them wasting diseases but if you don't have any diagnostic material it's hard to tell the difference between TB and cancer and HIV and there are people who would just go and treat everyone as if they had HIV but just hoping that it would work a third of the time and you can do that type of thing in East Timor because there's no regulation or that type of thing so this is pictures of some of the refugee that moved through the clinic so this is a little girl among her belongings this little boy was waited a long time in the clinic area that we were in so we also saw people as they came back from the refugee camps from West Timor and they often came at night or at very untoward times but we were able to mobilize and set up clinics at two o'clock in the morning so this is a picture of me and we always wore these MSF shirts so you could be recognized as a member of an aid organization and not a member of some other organization so you can see that people are taking their belongings down this is a truck that's unloading the boats and we set up, so this is all MSF we set up big spotlight so people could see what they were doing in the middle of the night when they were unloading and we gave everybody, so these are plastic buckets so people could do personal hygiene and then they got a tarp so they could provide themselves some shelter and then this is a little bag of rice that's on top of that and it's very interesting when you think about logistics because while MSF does a great job for instance we got everyone these tarps but the first time we handed out these tarps we realized there was no hardware store to go get nails to nail down the tarps or hammers or any of that type of thing so we put in a quick call to Darwin which was an hour away by flight in Australia to get those things in order to provide people shelter so this is a picture of my husband and he worked with a Belgian gentleman named Jacques who was a MSF veteran he left, Jacques left his pregnant wife at home and came and volunteered with MSF until she was about to deliver and it was their first child and my husband is not in medicine he was an engineer and then did sales and before we left was basically trading stocks and when we went there so what he did was logistics so he set up the clinics and made sure the water was clean and right now they're setting up a generator for those lights that you see so my favorite story about going to MSF was there was no telephones right because they cut all the telephone wires when you left and this was before cell phones and they had a sat phone, a satellite phone and we each got a five minute call on a satellite phone when we got there which cost about $50 at the time so I used my five minute sat phone call to call my mom and my family and tell them that I was okay and we were moving forward and my husband uses five minutes to call Charles Schwab and sell all of his options so yeah, we were living very different lives so this is a picture of one of these tents that we set up in the middle of the night to see returning refugees this is a picture of me this is a picture of my interpreter so I had to have an interpreter to speak Tetum which is the language that was spoken in East Timor which was different than Bahasa Indonesia which was spoken in the rest of Indonesia and you see here that there's a television crew this is a German television crew and this was a time in 1999 so we went in September and they won the Nobel Prize in October so there were a lot, lots of PR that happened that at that time mainly because of the Nobel Prize and also because East Timor was sort of a hot conflict at the time but you realize when you're in these humanitarian aid situations that a lot of the organizations are vying for attention from these television crews so whoever gets on the cameras and who is in front of the world news they're the organizations that are gonna get the $5 checks that are written so it's interesting that you're in sort of this non-profit world and yet there is still some competition in a way for something, in this case media attention so this is a picture of the water supply so they ran a water supply and it's covered by a tarp and then this is what it looks like underneath the tarp so the thing that we worried about a lot with something like this was malaria exactly and there was a lot of endemic malaria there this is, so we had three clinics at the time that I was there for in six months so the first clinic was the two tenths this is the second clinic this is a school gymnasium this is the gymnasium of a school where people are staying that's where they're living this is the rice that they're consuming and then there were two classrooms back here which was the second clinic that we were in and I'll show you a picture of the third one here in a minute so as things are stabilizing we're able to get a little bit more solid surroundings I guess so this is back to the soccer stadium so now the soccer stadium is being used mainly for these tent camps so this is a picture of the house that we eventually moved into after we left the camping conditions and the soccer stadium and you can see the MSF logo there and there were 20 people that were living in this house with one bathroom and we didn't have a flush toilet but it was a western style toilet where we poured water down and the most treacherous thing about that house is that there were lots of cockroaches so this was our honeymoon suite where we stayed and so this is a foam mattress on the ground with mosquito netting which was very important as you can see so a large part of the violence afterwards meant that we still had like sort of a dresser but like there was no mirror in there because that was all broken and then there were some pictures from our wedding and some raid which was very important for all the cockroaches this was our dresser where we stored our clothes and so you can see that things were pretty primitive and we had it so this was my headlamp for the night time things so this is a picture of the first market that opened up after all this violence so trade did start to happen and they sold fruits and vegetables here and then this man is also selling something else can anyone see what that looks like? We'll get a little bit closer so one of the things I told you were endemic was TB and we all know how difficult multi-drug resistant TB is and this is something that's just being sold in the market so people have a cough maybe they're coughing up blood maybe they had TB before the conflict and they knew that they had to continue treating it but can you imagine just having your patients go to the market and buying maybe a little isoniazid maybe a little tetracycline or whatever they can afford so you can imagine how multi-drug resistance becomes a big problem very quickly so this is a picture of the last clinic that we had and it was a very nice clinic my husband participated in building this and we had a real waiting room and two exam rooms and then we had sort of a pharmacy as well so it was really getting to look like more real life and then at the end of six months they really, so I told you I always work through an interpreter and I know probably in many cases that you work through interpreters here as well and you may know that those interactions aren't sometimes as good as having interactions in a language that you're comfortable with and that's something that MSF has recognized and they told me that it was better for me to train an Indonesian doctor in how to use my little blue box of medicine than to continue to work through an interpreter so usually in a acute conflict they'll have lots of ex-patriot staff that go in so there were 20 ex-patriot staff when we went in but now in East Timor there's only two ex-patriot staff there'll be a medical lead and a logistics lead and then the rest will all be national staff but they'll be working with resources provided by MSF and there can be some conflicts in that handoff as well I mean you have to realize that you're working in an international situation and as I was working with the Indonesian doctor for the trade-off she was handing out penicillin for every URI that came through and then we had to talk about how most of these things are viral and that penicillin would lead to a lot of drug resistance but was that education that needed to go on but you can imagine that that might be hard to maintain as there's more and more handoffs that go on so this is a picture of, so this is me here, this is my interpreter and this is the picture in the last clinic so you can see that it's a little bit, we actually have some gloves finally these are some MSF books that they have handbooks on how to handle different situations and then the family that we're taking care of in the back so it did get a lot better in a very short amount of time but there was still, at the end there was still untayet forces so this is just a regular day in East Timor and you have a soldier with the gun aimed at looking out for any potential conflicts and still tanks in the street and that type of thing and this is just another picture of that and then it was very cute actually they had a picture of, so you can see this is a this is TIM team, Visita, so the visitors versus our team or us and so they at one point had a soccer game of the soldiers and the people from East Timor so it was nice to see some of these more normal activities coming back this is a picture of East Timor it's a beautiful country if you ever get a chance to go there you probably have to fly through Australia to get there there's a beach here at the end we used to call it Jesus Beach because it had a picture or a statue of Jesus similar to Rio de Janeiro and we went, we used to go there on Sunday afternoons which was the only time that we had off we worked all day Saturday, half day Sunday and but then there were alligators there but we didn't go there anymore so so this is a picture of Zanana Goosma who was part of the resistance for that 25 years and then after the conflict was over and they were able to elect their first leader he was the first president of East Timor and this is a picture of the plane that we flew out on and then since I've been back I've done various return volunteer network stuff with Doctors Without Borders and then Doctors Without Borders has lots of other initiatives including one for orphan medications and so they had a traveling exhibit this was a few years ago it was called It's a Different World Without Medicines and it was set up here at Town and Country so they have lots of good projects that you can get involved in even on a local level so that's the end of my slide so I'll take any questions if there are any I think that for internal medicine doctors 15 months or specialists is that the same? Specialists within internal medicine? The thing about specialists is that you have to practice as an internist and even as an internist you kind of have to practice as a family practice doctor so the story I didn't tell you is also when I went there I had a one week overlap with the doctor before me and I told you I'm coming from congestive heart failure and heart attacks and stuff like that and then I go and then I forgot you had to weigh kids before you dose them antibiotics so fortunately I had this one week overlap where they taught me those things but yeah it's great to have those skills the other thing that's a little hard about doctors without borders is that they kind of work off of the European system of training so I don't know if you've talked to people who have trained in Europe but when they're at the end of their internal medicine they almost have as much clinical practice as we do after medical school because we have those two years after medical school but they only really get a lot of contact with patients during their internship and so that's why they require three years after medical school in order to volunteer with doctors without borders but three years after medical school for us we're pretty well differentiated into our specialty so I don't think that's such a good model for us but they do require three years so you can't almost go after medical school which I think would be a really good time or maybe after a year of internship or something like that is anyone thinking about doing it? a little bit, yeah it's a great experience I know that you guys don't take sides but do you ever, like do you ever get looked like in a place like this that had a very recent conflict would you ever get blowback from the side that maybe doesn't like what you're doing if you're helping the people that they're opposed to in some sense? Yes, and you have to be very careful about not even appearing to take sides and that's what the logistics people are very good at because you're there to do your job see patients and do what you can but there are people around you who are just all day long talking to everybody talking to the militia talking to the people who are there and saying look, please come to our clinic we're not associated with the army and we're not associated with the government we're not associated with the Indonesians and there needs to be a lot of PR and marketing that goes on, which I didn't appreciate as a physician I wouldn't have done that I probably would have just put my head down and done my thing and sort of let the chips fall where they may which is sometimes not such a good idea and I'll give you an example so I really coveted the, so the French army is also quite amazing logistics wise they can, they set up a surgical hospital in like a week in East Timor and oftentimes, I told you my struggles with not having a lab or a, you know to even microscope to look at things and sometimes I would go there to use their facilities because I thought it would help me take care of patients but they were very clear at Doctors Without Borders that I couldn't wear my shirt when I was going in there I just had to go in as a separate person and this is probably the biggest mistake I made in East Timor but one time, you know, again got my little blue box of medicines and a truck pulls up like a, you know kind of a big U-Haul moving down kind of thing and in the back, and there was no windows in the back and in the back there were about 20 people and they opened up the back of the truck because someone had directed them to this there was a clinic here and everyone is bloody and you know, I look around there's lacerations, there's what I think is a hemothorax and I'm like, I can't do anything here all I've got is, you know this is my blue box of medicine so I get in the back of the truck with my interpreter and I'm examining people trying to figure out, you know, what happened and then I ask through the interpreter what happened, what I thought was that they had been attacked and that, you know they had been tortured and put back in here and sent over here so I get in the back of the truck and I ask through the interpreter what happened here, you know why is there so much damage and I tell them to drive to the French Army Hospital which is like a mile away and then they say through the interpreter oh there was a car accident and I said, oh, you know it seems so weird, everyone seems so tossed around and then they said, oh they said, oh yeah and I said, why do they have this car accident if they run into anyone and it didn't really look like there was a lot of damage on that car and they said, well the brakes don't work up to this car so, you know, if you're ever in that situation it's called the domino effect you know, you've got to figure that out before you get in the back of the truck but fortunately we somehow made it to the French Hospital and got everyone taken care of but yeah, you really have to know your limitations and MSF was very good in counseling me to not look like you have associations with other army and military and government but sometimes I felt like I needed it to do more than what I could which was frustrating do you get to choose where you go or is it assigned to you? so it is given to you as an option so, and that's hard too because you get, so I got done with my residency and I was waiting for an assignment, right but conflicts like East Timor doesn't come up you know, you get done with your residency on Friday and you can't start on Monday so you're waiting around which is very difficult for us and also it was difficult for me and my husband to get placed together it could only be in an acute situation because as I said, as it gets to be more stable they would only send one expatriate staff so we had to sit around basically waiting for an emergency and we were given I think one option before in Africa but it was, I think only one of us could go so we said no to that one and then East Timor itself or sorry doctors that borders themselves would not have sent us to Sri Lanka which was also an active conflict at that time because I have a Tamil heritage and that was part of the conflict so they don't wanna send you into some place where you could be perceived as part of the conflict so then East Timor came up and even in fact for East Timor I showed you the picture of East Timor and there was, we were told initially that we were gonna go to a place called Laquisha which was sort of, it had a hospital and they said I would start a TV program and I was very comfortable in that situation because I thought okay well I can do that coming from intramus and residency but then when we got there they said no we change your mind, you're gonna go to Dili which was really a lot more conflicted because the other one was more inland and I was so stressed out I remember making that decision in Darwin that I was literally like dipping chocolate in coffee because it was like the two things that I used to manage stress but we decided to go and we were fine so but it's definitely a decision you have to and my husband's parents thought I was crazy like taking their son to this place but we survived and most people do, the thing that people have who have died before, most of in Doctors Without Borders is actually car accidents which you know it's what happens here as well So the question is how has the experience in East Timor changed how I practice medicine here and I will say that there's not a day that goes by that I don't think of it and realize how fortunate we are to practice medicine the way that we do here and it really definitely puts things into perspective I remember I was in my preventive cardiology fellowship on 9-11 and I was seeing patients and sometimes our patients here can get a little impatient if they have to wait half an hour and it was on 9-11 so that morning things are happening and I'm half an hour late to my second patient and they were irritated by this but I remember people would wait the whole day in a soccer stadium to see me and they knew I was working because they saw me see everyone before them but definitely I think what I take from it is that we're very fortunate to even be able to practice medicine the way that we do here and that really puts every day into perspective because my worst day here is better than my best day at Eastern State so if there's no more questions I will wrap it up, thank you so much The preceding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University please visit us at med.stanford.edu