This memo is an effort at Consensus Building for the Rollout of our new Program to Entirely Eliminate Public Health Acronyms and Shibboleth Terminology (PEEPHAST).

A recent Gap Analysis of Public Health’s Capacity to communicate with our Partners showed that Lessons Learned have not developed into Best Practices as fully as we’d hoped in the Health Equity Plan. In fact, we’re getting considerable Push-Back about our terminology. This is causing pain in our Asset-Based Built Environment office.

In the interest of Transparency, the process to establish a Footprint for PEEPHAST will pick through the Low-Hanging Fruit from all the Silos we call Public Health programs.

A meeting of Stakeholders (who we hope, by meeting’s end will have become the Gatekeepers for PEEPHAST) has been scheduled at a place and time convenient to Staff. At the PEEPHAST meeting, we will Drill Down through the entire Skill Set in our Toolbox. Our Over-Arching goal is to find consensus that will make Champions for PEEPHAST of every one of you.

The agenda for the meeting is still under development, but it will be Robust, and there will be little time for Physical Activity Breaks. So please come prepared to work hard and remember: PEEPHAST for Public Health!

Note: consistent with our tradition of  Cultural Sensitivity in all areas, including the culinary, we have prepared two versions of this memo: one directed to Stakeholders, the other to vegetarians. Please pardon us in advance if you receive the wrong memo.

Spoken by a Public Health bureaucrat in Georgia State government as Swine Flu loomed.

“Don’t we just make the vaccine available, and let people decide for themselves?”  I asked in my naive, fresh-young-doctor way. It was 1976.

“Look, Sonny. Ah been in Public Health all mah life.  The State boss asked me and you to work on this here vaccine campaign, and the CDC says they want all folks vaccinated. Ah’m close to retirement. Don’t wanna look bad; Ah want big numbahs. But we got a problem with Them.”

‘Them,’ the Black Community (as it was called by some of us at that time), comprised 25% of the State’s population. And the statistics showed that, indeed, they were leery of this quickly produced vaccine. It was mostly Whites lining up to get the shots at the Health Departments and shopping malls. Where the TV cameras frequently prowled for evening photo ops.

The State officials in charge of the vaccine campaign fretted some, then decided to hold a brain-storming session. To, you know, solve The Problem. Think up something they hadn’t thought of yet. Which is to say, think of something that wasn’t just “the way we always done it.”

The brainstorming session encompassed two hours, three pots of coffee, and several good fishing stories to fill in the moments when people fell quiet.

We adjourned, coffee-charged and empty handed, with vague promises to meet again and solve The Problem. “Soon.”

“We’ve got to do something,” my boss told me as we walked down the hall to our office. “We got the dang CDC right here in our backyard. They aren’t going to be happy.”

That afternoon, a knight in shining armor called. The Health Officer of Fulton County (the County encompassing Atlanta) was on the phone. He had convinced Martin Luther King Jr.’s father to take the Swine Flu shot. The Health Officer himself would vaccinate “Daddy King” with multiple TV cameras rolling.

Everyone sighed a puff of relief and smiled. Surely the Black Community would follow Daddy King’s lead.

The day came. The sleeve was rolled up. The cameras rolled. The Health Officer – adequately serious of face – gave the inoculation. And Daddy King never flinched.

We began watching the vaccine statistics to see the ‘bump’ in shots given.

This memory floods back as I read a series of studies on vaccine acceptance. They are done as surveys, reflecting attitudes before the H1N1 vaccine is offered.

The summary of one, analyzed by race, shows a pattern that deja-vu’ed me:

46% of Whites were “worried about the (H1N1) vaccine”;

but a significantly higher percentage  of Blacks (62%) said the same.

Suspicion about a hastily produced vaccine appears to be as intact today as it was in 1976. And that distrust still varies across social and economic lines.

But it’s driven by emotion and beliefs, not by scientific fact and logic. We humans often do that.

As with this, which I heard recently:  “That 1976 Swine Flu shot killed people. Why risk taking the Swine Flu shot again?”.

Just because the H1N1 disease has the same nickname, “Swine,” doesn’t mean the same virus is involved. It’s not. So the two vaccines were made from different viruses, and are not the same. The 1976 vaccine has a tainted reputation from the concern at the time about increased incidence of Guillian-Barre disease. That association, by the way, has been studied for Seasonal Flu vaccine for over a decade, and no definitive connection between G-B disease and vaccine has been consistently shown since 1976. If there is an increased risk of G-B, it’s of the order of one case in a million shots; death from Flu, on the other hand, occurs at the rate of one death out of every thousand cases.

Or “I got sick with vomiting and diarrhea this morning. I’m sure it’s that restaurant where I ate 5 days ago.”

In my career, I’ve never heard anyone say “I think it was my mother’s cooking last night.” People’s belief systems don’t seem to admit that possibility, in spite of epidemiological evidence.

Or, more to the point, when people say “I don’t take the Flu shot. It’ll give you the Flu.”

Can’t happen. The virus in the shot is killed. Dead. What can happen is for a person to be incubating the Flu at the time of the shot. Then we make a mental association between the two events which doesn’t exist.

And, sometimes we are all just the victims of bad timing. As when, 33 years ago, the phone rang again, interrupting our enthusiastic survey of vaccination data, forty-eight hours after Mr. King had gotten his shot,. It was the Fulton County Health Officer.

“We got a problem.”

“Oh?”

“Daddy King seems to have taken ill.”

To this day, I don’t know what illness Mr. King had been incubating at the time of his Flu shot, but I do know that fear and other emotions still drive decisions. And I can’t help but wonder how many ghosts of 1976 Swine Flu Vaccine campaign haunt us, Halloween like, during this vaccine season, as we try to protect folks from the epidemic of H1N1 that has already begun.

Now, while everyone was still cringing after September 11, someone  with considerable sophistication (and apparently, inside access to advanced bioweapons technology)  sprinkled Anthrax spores through the U.S. Postal Service. So they (you know, “They”) shifted our focus from hijacked airplanes to something even scarier – laboratories.  Labs hidden behind hermetically sealed doors.  Labs dark at night, except for a single light illuminating the nefarious work of some twisted scientist.  Labs teeming with bizarre microbes most people don’t understand which – like everything we don’t understand – automatically makes them scary.

People demanded that Congress act.  Congress did act.  Congressmen who wish to act, really have only two options: pass a law making such activity illegal  (oops – too late – already done long ago), or throw money at the Problem.

So they backed up a fleet of dump trucks to our Nation’s treasury, and the Bio-Terrorism extravaganza was on.

Before we get to the Main Attraction, take a stroll with me past the carnival Sideshows:

“Federal funds have recently been released to your State!” the bold print blasted from one unsolicited letter. If they hadn’t been limited to paper and ink, the words would have been written in flashing neon, surrounded by an oval of glaring bare bulbs, accompanied by dinging bells and probably, a siren.

Another hawker tried name dropping:  “The CDC, FEMA, and Homeland Security all say that no one should be without – - -”

O.K. Now that they have our attention, what are they selling?

-  Biological Weapons detection devises that fit right into your pocket!

-   A pre-fab  steel plated “Safe House” for your family! (including the dog). This backyard bunker is featured in full, glossy, color, painted red, white and blue in a pattern you can guess.  Picture that next to the swing set.

-   Fever detecting thermometers shaped like credit cards which you can carry in your wallet or purse, wherever you go! Because everyone should know the instant they come down with Smallpox. “Free shipping on orders over 500.”

-   Consultants! Specializing in writing your required Plans and grant applications. So now you can use the cascade of Federal dollars to hire someone to obtain the cascade of Federal dollars.

-   Bomb scene investigation films! (Uh-h, isn’t that, like, too late?)

-   Seminars on how to put on Hazardous Materials suit and respirator. To be held in Honolulu.

And dozens – believe me – dozens more.

But the Main Attraction, from this Blog’s perspective, is the wholesale sell-off of Public Health.

The time-proven approach to providing Community-Based Health Care (which is what Public Health does) is to first diagnose the Patient. Just as your physician would. In the case of Public Health, the “patient” is your Community.  Is AIDS your biggest problem?  Are Teen Pregnancies more common than elsewhere?  Is your Community’s water contaminated?  Are you confronting an outbreak of hepatitis?

Every Community’s disease profile is different (just as each individual patient in a private Doctor’s office is different).  That’s why Public Health is best done at the local level, not by State or Federal governments.

So let’s say your Community has a higher rate of childhood brain cancer than similar communities.  That’s the Diagnosis.  If you were the Public Health Officer, having made the diagnosis, you’d next direct therapy to attack that problem.  “Therapy” in Public Health is not pills and surgery, it’s money and people organized in a creative way to address the problem.  People like nurses who can do epidemiological investigations of childhood cancer, and Environmental Health Scientists who sleuth out the culprits. Without either one of those tools, you can’t create a “Therapy” that fits your community’s specific Public Health problem.

But what’s evolved over recent years is a system where the Federal and State governments funnel money down to local Health Departments, specifically earmarked for certain programs.  Like addicts, Health Departments almost never say “no” to this money, even if the program attached to the money is not needed in that Community.  You can use the money to keep valuable employees on the job when their salaries are threatened. But those employees will need to change their program focus. So now you have nurses trained in Child Health suddenly working in Bio-Terrorism Preparedness or Environmental Health Scientists investigating cigarette smoking in public buildings. I am not kidding here.

And if a Local Health Department keeps this up for a while, soon it’s not out there “diagnosing” and “treating” the health ills of its Community; it’s running programs which were dictated to them from afar.  Programs they have to “sell” to the Community, since the Community doesn’t really need them.

What can happen as a result? In the 1960’s and ‘70’s, we discovered a handful of effective antibiotics to cure Tuberculosis. As a result, the rates of TB started to drop. So, funding for TB began to dwindle.  Less money for TB, more for sickle cell screening or for purchasing and installing specific computer programs. As the tool of money for TB withered, the tool of people skilled in TB investigation and management also shrank because their salaries dried up.  Thus, by the 1980’s and ‘90’s, most Health Departments had few or no Public Health Nurses skilled in watching for and managing TB as a Community Health problem. They were all doing some other (well funded) program.  Then, in the face of the double whammy of a new wave of immigration bringing more TB to the U.S., and AIDS epidemic devastating the exact part of the immune system used to control Tuberculosis,  drug-resistant TB erupted, creating havoc in our communities. It took several years for us to re-build the infrastructure to control it.  An infrastructure that Public Health once knew very well. An infrastructure that had been in place for over a century, but had been lost among the politically driven winds of diverted resources.

In the same way, Health Departments greedily gobbled up Bio-Terrorism money in the early 2000’s, and hired people to comb their Community for Anthrax, Smallpox and Tularemia.  Or, more accurately, to write Plans about how to comb their communities for those rare and exotic diseases.  Entrepreneurs made small fortunes selling Bio-Terrorism related trinkets.

And if  childhood brain cancer was out of control in your Community, it was suddenly getting a lot less attention as Public Health focused on the sexy Bio-Terrorism thing.

Now, when you go to your Doctor with a pain in your wrist, do you want him to give you a few samples of the latest, greatest, newest drug on the market for pain (drugs left at the Doctor’s office by salesmen, hoping for profits as your Doctor prescribes it after the samples run out) or would you rather have your Doctor diagnose your wrist problem and treat you specifically for that?

That’s what Communities should do.  Tell their Health Departments – who are the Community’s Doctor and who work for the Community – to stay focused on the local issues that are actually affecting people.  And tell their congressional representatives to fund Public Health, rather than the  categorical programs de jour which look sexy, like flashing neon.

Public Health should be your Community’s Doctor, not a circus.

Mrs. X lay in the back of an ambulance recently, IV running into her vein, rolling back and forth on the gurney. She was on a long trip to a specialty hospital, a couple of hours away.

Whatever was wrong with her, her kidneys were working just fine.  With each little road bump, her bulging bladder sent electrical shocks to her brain.

“I have to pee,” she told the Paramedic.

He braced himself with his hand against the wall, placed his feet wide apart for balance like a subway rider, and rummaged through a bunch of stuff behind a sliding panel.  He pulled out a large oval of plastic.

“Here.”

“What’s that?”

“A bed pan.”

Distain replaced the discomfort on her face.

“I need a bathroom,” she said indignantly.

“But…” the Paramedic tried to explain that they were still more than an hour from their destination medical center and that using the bedpan or holding it were her only options.

Not to her, they weren’t.  She was insistent.  Very insistent.  The Paramedic slowed down the IV.  While that move was scientifically logical, it was way too late.

The Paramedic braced himself again, one hand on either side of the rolling, sometimes lurching vehicle, and inched his way up to the front.  He explained the dilemma to his driver.

“Wadda you wanna do?” the driver asked.  “Stop at a Burger King?”

The Paramedic envisioned himself explaining that decision to a doctor, or worse, to his supervisor.

“That won’t work,” he said.

“I need to go now!”  Mrs. X’s voice was rising.  Probably her blood pressure was, too.  Not a good thing. Not while she was on his ambulance.

“All right,” relinquished the Paramedic.  He turned to his driver.

“We’ll be passing Memorial Hospital in a few minutes.  We can let her use the bathroom in the E.R., then be on our way.  An E.R. is safer.  And they’ll understand.  Radio them, would you?”

Then he inched backward, both hands and both feet braced, until he could sit next to his patient again.

“OK, Mrs. X.  We’re going to stop and let you – ”

“You need to talk to them,” the driver interrupted the Paramedic.

He started to roll his eyes, but controlled it in front of his patient.

“OK,” he said softly, confidently.

“Memorial E.R., this is Ambulance unit 24.  I have a 53 year old female we’re taking to University Med Center as a transfer from St. Joseph’s who – ”

“That’s correct.  St. Joseph’s.  We’re from the next County over, just passing through. The patient needs to go to the bathroom.”

“Well, no, we can’t go back to St. Joseph’s just for a bathroom stop.  That’s an hour back the other way.  We’d like to ask that you – ”

“She says she can’t hold it until we get to University.  That’s another hour and a half yet.  So if we could just – ”

“Yes.  Of course we have bedpans.  The patient was offered one, but refused.  Said she can’t use it.  So if we can just stop for a couple of minutes – ”

“Say again?”

Mrs. X tugged at the Paramedic’s pants and wrinkled her face in urgency.

“She has complications with her surgically implanted shunt.  So we’re taking her back to her surgeon at the Cancer Center.  She’s stable.  We’re within three minutes of your facility now, so could we PLEASE – ”

“No Ma’am.  I’m not shouting.  I just need you to quickly give me the OK to – ”

“Why can’t you let her use your bathroom?  She’ll just go, and we’ll be on our way.  I’ll accompany her.”

“You will NOT!” Mrs. X interjected.

“I’ll accompany her into the E.R.,” he spoke toward his patient, “and wait for her while – ”

“What regulation is it against?  She just needs to go.”

“But No! I mean, no.  She’s not here for care in your E.R., just to use the – ”

“What lawyers?”

“But – ”

“Look, we’ll assume all responsibility.  All she needs is – ”

“Yes, ma’am.  Understood.  Thank you.”

He slowly, with a bowed head, hung up the microphone.

“Well?” asked the patient.

“Well?” asked the driver.

He snapped out of it, became commanding again.  “Pull into the parking lot at the E.R.” he told the driver.

“About time,” muttered the patient.

“But don’t back up to the door,” he added.

“Say again?”

“Just park it!”  He lowered his voice, “like a visitor.”

“Better hurry,” her voice sing-songed.

The Paramedic took a deep breath.  “Mrs. X, we can’t use their bathroom.  But we can – ”

“What!!  What do you mean?”

“Regulations.  Legal concerns.  If you set foot in their E.R., they’ll have to process you as a patient.  Start all over, as it were.  It would take an hour or two.”

“Would they bill me?”

“Is the Pope Catholic?”

“All I need is – ”

“I know,” he interrupted her.  “I know.  But they’re afraid they’d get written up for some violation. Or maybe sued.  It’s either go through their E.R. as a patient, or – ”

“Would they let me pee first?”

“That’s out of my control, ma’am.  They’d probably want your insurance card first, then need to register you as a new patient, then – ”

“Gimme that bedpan and wait up front with your ears closed.”

When this epidemic first popped its head above the ground in Mexico, Paricutin – like, it was, of course, impossible to know if it would be a fizzler or The Big One or something, as was most likely, in between.

So we Public Health detectives watched the numbers like raptors following their prey, observing, tracking its path, trying to project where it would go.  Anticipating its behavior so we could pounce on it at the right place.

We are beyond that now.  Numbers have told us all they are gonna reveal.  They told us that the virus spreads efficiently from person to person.  That it will spread over the entire globe.  That, (darn!) it will continue to spread in places experiencing summer, like North America and Europe, which is abnormal Flu behavior, while simultaneously spreading in winter climes like Australia, New Zealand and South America (poor Argentina’s hit hard).

Now we have turned to question #2.  How will the virus behave in the human body? Like Seasonal Flu? Or something more aggressive?  To answer this question, we are now analyzing individual cases.

A 78 year old woman  became ill with Influenza-Like-Illness (ILI) on Monday, was hospitalized on Friday with bacterial pneumonia superimposed on confirmed H₁N₁ infection, and died on the following Wednesday.  She had underlying heart disease and emphysema.

Pretty much like Seasonal Flu.

A 39 year old rodeo athlete took a break from calf roping when he developed ILI on a Saturday. As he sickened, he consulted his physicians. He died at home the next Friday.

Definitely not like Seasonal Flu.

Ten people were admitted to the University of Michigan’s advanced care ICU during June for severe complications of the H₁N₁ infection.  Their chest X-rays showed “white-out,” i.e. lungs full of fluid.  A couple of them were coughing blood.  They all needed ventilators to breathe for them.  Two were placed on heart-lung bypass machines to try to keep their oxygen levels up.  Only seven of them survived.

Interestingly, bacterial pneumonia was not evident in any of these patients – it was the virus doing it all. And, of importance were their ages. The youngest was 21 and the average age was 42. The time it took for these patients to go from first symptoms to hospitalization was as short as one day.

Another interesting case is that of a sixteen year old from San Francisco who was found to have  H₁N₁ which was resistant to Oseltamivir (also called Tamiflu). Similar cases of resistant virus have been found in Europe and Japan.

It was only a month ago that every  H₁N₁ strain tested was sensitive to this drug – one of our major weapons in this fight.

A picture is emerging from these and similar case stories being reported from across the globe : the majority of cases of H₁N₁ are as mild as routine “Seasonal” Flu, largely a mild illness of a few days. Some ( the very young, the very old, and those with serious medical problems) get seriously ill, also like Seasonal Flu. But with this new virus, an unlucky few can get horribly ill with a viral pneumonia, with fluid in the lungs blocking oxygen uptake, and other complications (including blood clots and hemorrhage).  The mortality rate in this group is high.

And now the virus shows us that it is evolving very quickly, changing its genetic make-up to, at the very least, become resistant to our anti-virals. We do not yet know what other changes it is creating deep within itself.

This picture is typical of a genetically “shifted” Influenza virus – and it is a typical Pandemic pattern. Just read accounts of the 1918 and 1957 Pandemics and compare. The major difference from those earlier Pandemics will be the intensity (and professionalism) of press coverage. They’ll be all over this one. The epidemiologists will not be working alone.

First the numbers, now the Patients. The next interesting gauge of this Pandemic will be Society’s response. Watch for Public Health officials to close institutions. Watch for politicians to pontificate. Watch for comedians to mock the virus. Watch for religious gatherings to, contrary to their mission, discourage attendance. Watch for airplane ticket prices to fall. Watch, unfortunately, for counterfeit vaccine and Tamiflu to become available “ Now! For a short time only! ” on the Web. Watch for scary movies.

Wise old physicians and Public Health officials will shake their heads and wonder, as they battle this Pandemic, at how dramatically a mere virus will reveal the stuff of which we Human Beings are made.

Oh, oh.

But I had to take the call, of course.  It was 1976 and I had been placed in charge of the Swine Flu campaign for the state of Georgia.  Dealing with “the press” was part of the job.

“Doctor, we heard that someone up in the mountains of Georgia was found dead in a pig feeding trough last week.  Could we get a quote from you about him, seeing as how he’s the first victim of this Swine Flu of yours?”

‘ My ‘ Swine Flu ?

“Sorry,” I answered, trying to be firm. “But, that gentleman was a farmer who died of a heart attack.  It was NOT – I repeat, NOT Swine Flu.  But, thanks for the call.”

That was a long time ago, but today’s news awakens the memories.  However, there are differences.  We are not doing a mass vaccination campaign this time (there is no vaccine for the current “Swine Flu” strain) and we are at the end of the flu season, not the beginning.

So what do we do with this H_¹N_¹ Swine Flu?

First, we are doing surveillance.  Physicians country-wide are being asked to send samples from suspect patients with illness that looks like Influenza so we can find Swine flu as soon as it crops up.  So far, there are many parts of the world where no cases have been found.  But we expect it to continue spreading, and need to know when it arrives.

Next, we are asking that you follow these guidelines to prevent the spread of Influenza:

• Stay home if you are ill.    “At the first sign of the flu – - – staying home is the thing to do.”

• Wash your hands frequently, especially after blowing your nose or touching someone who is ill.

• Use alcohol-based hand cleanser (like we use at the hospital).

•        Use sneeze and cough etiquette, which means use a handkerchief or          Kleenex to cough or sneeze or blow your nose, or cough / sneeze into the elbow of your sleeve.

• If you have been exposed to a family member who is ill with flu, avoid any unnecessary contact with others until it is clear that you are past the incubation period (seven days) and did not become ill.

• The use of masks will not protect you. If you are worried about catching the Flu from crowds, avoid crowds.

Remember:              “At the first sign of the flu – - – staying home is the thing to do.”

         Mrs. G. had been here a long time – long enough that the road she lived on bore her last name.  Or, more accurately, that of her long dead husband.  So she probably felt that she, not the fox, owned the place.

But there he was again, just like the previous three mornings, wandering over her grass, not spooked at all when she tapped on the kitchen window.

“Shoo!  Go away!” she said in her loud voice, holding the phone receiver away from her mouth for the moment.

“Sorry, Dear,” she said into the phone, “I had to frighten away a pesky fox in the yard.”

“Oh, like most of them, he’s got a red coat and a grey trail.  Well, yes, it could be ‘she’.  I can’t tell from here.  What’s that?  You know my hearing’s bad, could you please say again?”

She watched the animal meander toward the woods again, at the far end of her grass, but it stumbled before it got to the trees, and, in struggling to regain balance, turned toward the house.

“That’s very sweet, Dear, but I’ve already told you, I’m quite happy  here, in this house your father and I built, on the land your grandfather claimed for ranching.  My hip is healing just fine right here.  I just couldn’t live in that city where you are – too many dangers like auto accidents and  – what are they called?  – ‘gang-hangers’.  And the TV said just yesterday: people cheat you in the stores there.  I’m just fine right here.

“But you can come any time and bring that cute red-haired grandson of mine.  He can play with some of my animals – the chickens, Fluffy the rabbit – - -  Shoo!

“What’s that?  No, no.  It’s that fox.  I want him to leave before he scares my cat to death.  You know, his hair is almost the same color as your son’s.  He’s very beautiful.  Just a little clumsy.  Think about July 4^th weekend, ok?”

She replaced the receiver and hobbled on her cane to the sliding glass door that looked out over the lawn.

“Here kitty.  Where are you?  Watch out for the fox,” she sang to her cat as she opened the door for her feline companion.

Suddenly, there was the fox, right at the door.  Startled, she stepped back, and almost lost her balance.

“Not on my new hip,” she thought, and protected the surgical work of that nice doctor from the city down in the valley by catching herself with her cane.

When she looked up again, that fox had just strolled right through the door, into her house.  What nerve!  There he stood, on her nice clean carpet, rolling his head left and right as if trying to see clearly.

“Stand up straight!” she admonished the animal, much to her own surprise.  What was it to her if he wanted to stand there with his legs too far apart for a self-respecting fox?

It slowly raised its head toward the sound of her voice and she saw something abnormal – and very distant – in its eyes.  A string of saliva dangled from its mouth, and fell onto her carpet.

“Look what you did!” she scolded him.  “Well, that’s enough.  Out you go,” and she poked at him with her cane to push him back out into the yard where he belonged.

Snap!  Its teeth chomped onto her cane so quickly, she nearly lost her grip. It began to shake the stick with its neck muscles and head, but she held on.

“You let go!” she yelled.

Saliva ran down the cane, dribbled onto the carpet, and sprayed into the air when the animal shook its head. After a few seconds of violent head shaking, the fox stopped moving, re-set its legs to regain its balance, and just held the cane tight in its jaws, its eyes focused somewhere far away.

“You don’t belong here!” she scolded it.  “And you’re acting very badly for a fox.  You get out!”

She disliked getting upset.

She pushed the cane hard, and it rammed into the fox’s throat.  It made a gargling noise and staggered backward, fell onto its side, but quickly, clumsily, struggled to its feet, and turned toward the open doorway.  It bumped head-first into the glass door, but a swat on its rump from the cane drove it left, and it staggered out into the yard.

Mrs. G. slammed the glass door closed and locked it.

She called me to report the encounter.  “I hear the Health Department is the place to report unusual things,” she said.  “Otherwise I would have waited ‘til my appointment with my orthopedist.”

“I’m glad you didn’t wait,” I told her.  “Close all the doors, and stay inside.  I’m going to call the Animal Trapper.”

It took the Trapper an hour to get up there, but much less time to find the fox and catch it.  He hadn’t wandered too far.  While it’s head was making its way through the delivery service to the laboratory, I was examining Mrs. G.

“Did it bite you?”

“Heavens, no.  I kept him away with my cane.”

“Did any of its saliva get on the cane?”

“Oh, yes.  All over it.  But I wiped it off.”

“What did you use to wipe it off?”

  I asked, fearing I already knew the answer.

“Well, these of course,” she held up her hands.  “And his drool made the carpet all wet.”

“Did you clean that up, too?”

“Of course,” she looked at me as if I’d asked whether she had been breathing today.

Her hands were the thick, hard hands of a woman who’d been splitting her own firewood and building her own chicken coops for 65 years.  Her palms had deep cracks, tattooed black by time and work.

When she came back to my office for her third rabies shot, she showed me a photo of her grandson.

“I’m thinking of taking my daughter’s invitation to move in with them.  I’ll miss the ranch but she said I could bring my cat.”

“Good,”

I said to keep her talking as I pushed the needle a bit harder than I have to for most people.  She had tough skin.

“Maybe it won’t be so bad in the city after all.”

*     *     *     *

If you were a rabies virus, just trying to find food and raise kids, some warm blooded animal would be your planet.  It would be in your own best interest – and your offspring’s – to keep your host planet healthy, so that you and yours could have a long life there.

But, if you were, in fact, a rabies virus, that’s not the way your genetic coding would have you play it.

You would take a boat ride on an ocean of saliva from, say planet “fox” where you’d been establishing your dominance, and you’d ride that saliva down into the wound made by the fox’s teeth.  Suddenly, you’d find yourself on (or “in”) a new planet, injected there with the saliva on your old host planet’s teeth.

Deep within the warm, moist interior of the new host, you’d slowly search for the tissue you like best – a nerve.  Small, thin, like a tiny wire, you’d attach yourself to it and make a home.  You’d reproduce.  Your offspring would crawl, slowly, up the nerve, to bigger, thicker nerves, all humming with electricity sending and receiving signals.

Unfortunately for your host, this propagation and up-the-nervous-system progression would cause damage in its wake.

Ultimately, your descendents would reach their “promised land” in this planet: the host’s brain.  There, a flurry of reproduction and associated destruction would wreak havoc on your host, and it would become rapidly ill.  Like climate change, the planet you and your descendents had colonized would become uncomfortably warmer (fever), and stop repairing itself and growing (i.e. stop eating).

Your host planet would be dying, carrying you and your rabies virus babies with it.  Your only chance to escape sure doom and extinction would be … to hop ship.  Find another host.  Another planet.

So, in addition to making the brain you inhabit sick, you would also make it – - – crazy.  Aggressive.  Then you’d scoot down the nerves into the host’s salivary glands, and get ready for the Big Flood.  Ready, like Noah, to ride the waters to a new land.  A new host.

And start all over again.

Well designed, don’t you agree?

We in Public Health traditionally say that the most successful parasites (including viruses in this global category of “parasite”) are those that don’t kill their host, but live long periods in a mutually balanced partnership.  Like Herpes virus or the Tuberculosis bacterium.

So the Rabies virus should be viewed by those of us in Public Health as one of the most spectacular failures as “parasite” since almost no host ever survives the full-blown infection.  But, with its creative answer to the problem, inducing the dying host to transfer the virus to a new, healthy host, you have to hand it to the little guy.  He’s definitely watching out for himself quite effectively, at the expense of his host planet. At the expense of us.

The good news was, I would spend the final three months of medical school in exotic South America, studying rare tropical diseases; the bad news?  The medical organization there was run by missionaries – no drinking, no smoking, no girls.

So I thought.

“Charlie,” the missionary doctor rasped down at me from his elevated position six and a half feet off the floor, “Get your jacket and Spanish dictionary – we’ve got a house call to make.”

He sucked so hard on his Marlboro that the room’s air whistled as it rushed between his lips.

“Where we going?” I asked, bracing for the toxic cloud of his exhalation.

“Over across the Ruta.  We’ll walk.”

The “Ruta” was the major highway that snaked through this sprawling grasslands and remaining islands of hardwood forest.  It was “major” only because it was paved.  All other roads including the town’s streets were either dirt paths or mud slides, depending on the weather.  A depression in the main street remained a puddle for days after a rain, and was home to a large pink sow who moved for no bicycle, motor bike, or truck.

The Ruta was also a steady source of emergency patients to our little hospital.  It brought us the chainsaw accident victims and women in labor from miles away where people were clearing the forest to create new lives as farmers. It aimed careless truck drivers and drunk motorcyclists into sudden collisions.  Although most were low speed collisions compared with the U.S. variety, they were ugly because motorcycles usually carried entire families at a time.

I could hear the Ruta at night, when the clamor of this frontier town surrounding the hospital ebbed. During brief silences in the cicadas’ songs,  it hummed with a low roar that crescendo-decrescendoed as trucks loaded with mahogany logs roared away from the frontier, and trucks loaded food, beer, cigarettes and other essentials of frontier life roared into town.  Lacing the edges of this low roar, like embroidery on a dishrag, was a tinkling of loud music, obviously blaring and shrill at its origin, but muted over the distance between the Ruta and us.  Aside from the initial drive into town two weeks earlier, I hadn’t been to the Ruta.

“What are we gonna do there?” I asked my mentor as I arose from my after dinner siesta.

“Told ya,” the lanky West Virginia physician said in a cloud of smoke.  “House call.” His long bones were so loosely hung on him that he lurched more than walked through the door into the fading light of dusk.  

“I didn’t know there were any houses over there,” I trotted to catch up to his ambling silhouette.  “Just stores and gas stations and bars, I thought.”

He stopped, turned, and showed me his teeth through a mischievous smile.  “Depends on your definition of a ‘house,’ doesn’t it, Charlie?  Come on.”

We found a dirt path that wound into the stand of palm trees, reduced now by dusk to shadows against a sky which glowed blue-black from a sliver of moon.  Insects buzzed so loudly on either side as we walked that my eardrums hurt.  Some bird up above let go with a fusillade of caws like a machine gun.  Then I thought: “Snakes” and looked down to find my feet, but they were swallowed into the darkness of the path.  I was walking by Braille.

Just as I took a breath to say something, he rasped, “You bring a flashlight, Charlie?”

“No.”

He clicked on his.  The path before us materialized from the darkness.

“You should, you know.  There are creatures out here at night.”

“Really?” I ran a couple of steps to get closer to the illumination.  “Doesn’t bother me.”

“Oh, good,” he laughed.  “I like that.  To be a doctor around here, best to be macho.”

A glow ahead silhouetted the tree trunks.  The distant cacophony of musical notes became louder as we walked.  It was connected to the glow, which also intensified as we approached.

When we emerged at the edge of the Ruta, the blaring of tin quality music smothered the droning cicadas.  Behind that noise was another: a gasoline generator, driving the turntable and loudspeaker system wired together somewhere.  Stark electric light bulbs, bare and swaying in the evening breeze from wires hung at roof edges, were as harsh as the music.

Four small square buildings of crude plank lumber and thatched roofs randomly sprouted at the other side of the Ruta.

“Where we going?” I asked.

“La Mariposa,” he pointed at one of the buildings which had a faint pinkish hue.  “The Butterfly.”

“Why?”

“Already told ya.”  He started across the road.  I followed him into the  glaring din.  The flashlight was no longer necessary.

Inside the one room building, the “music” was so loud it was unrecognizable as something produced by instruments.  There were four or five small tables of thick wood, about the size of card tables my parents utilized to play bridge in more genteel surroundings.  A bare light bulb dangled from the roof above, flooding the center of the room like a stage, and casting the walls into shadow.  We sat on crude wooden chairs at the table he chose.

From the shadows, a girl appeared.  Short black hair, ebony eyes, skin-tight top low cut to cover half her breasts (until she bent over), and a skirt that ended mid thighs.  She was barefoot, I noticed.  And her feet were broad – splayed actually – as are those of half the people here who live in such intimate connection with the soil.

“Cerveza,” the missionary requested of her, lighting another cigarette.  “Dos.”

She looked at me, smiled – or was it a leer? – and said something to him in Spanish too rapid for me to comprehend.

He chuckled.  “The joven is a doctor,” he told her.  “Recently arrived.  Be sure to be — nice — to him.”

She tossed her hair back in a maneuver meant to be sultry, I suppose, and walked away.  Wiggled away.  Jiggled away.

“Pay attention, Charlie.”

I whipped my head around to face him.  “Yea.  Sure.  Okay.  Attention to what?”

“To what you see around you.”

“Been doing that.  What did she say?”

“Said she hadn’t seen you before and wanted to know who you were.”

“What did you tell her?”

“The truth.  Here’s our beers.  Only place we can get beer this time of night.  All the stores in town are closed.”

For some reason, it had taken two girls to bring both beers.  For some reason, they also brought chairs and joined us.

“We’re not alone,” I said taking a sip from the bottle.  I was nervous, trembling a little for some reason.

“You noticed?” he guffawed.  The two girls giggled with him.

“Good,” he continued.  “You’re paying attention.”

The second girl was more attractive.  She was blonde, which is unusual here, and looked older.  Wiser.  More relaxed and sure of herself.  Her eyes, however,  were as black as the other girl’s, and burned into me.  She said something.

“What’s your name, Charlie?” the Marlboro man said.

“That’s really kind of a dumb question,” I blurted, “for a couple of reasons.”

He guffawed again.  This time with a head back, all teeth showing, spontaneous gesture.  The girls laughed with him.

“Yeah, I suppose it would be,” he said once he gained control of himself again,  “if it were me asking. But I was just translating for you.  Margarita asked.”

“Who’s Margarita?”

The blonde smiled broadly and lowered her eyelids demurely at the sound of the name.

“Blondie.  Tell her yours.”

“I am called Carlos.  Please I am to meet you,” I repeated the phrase I’d memorized best.  I had to scream it above the blaring cacophony.

Then there was more Spanish, half of it drowned by the “music”, the other half too fast for my primitive knowledge of the language.  It pinballed among the other three with occasional sentences aimed at me to which I merely smiled and/or nodded.

At first my mentor translated a few phrases, but he eventually abandoned English.  I had the tone of the conversation by then.  It wasn’t deep.  It wasn’t philosophical.  It was, unfortunately, mostly about me.

“Rosita thinks you’re cute.”

“Cute?”

“Yeah, you know, handsome.”

“Margarita wants to know if you’re married. They want to know what state you come from. Do you have any questions for them?  They are asking.”

Half way into beer number two, I became aware that the two girls were no longer sitting across from me and from him.  They were on either side of me.  They were laughing and tousling my hair.  Margarita’s bare thighs were rubbing against my pants.  Rosita was blowing big bubbles from her gum and we all laughed as she peeled the pink slime from her face, time after time.

“What are they saying now?”  I asked the hospital’s medical director.

He blew out a dense cloud of blue smoke that enveloped his brain-shaped skull.

“They gave you a nickname – ‘Choco Clinudo’ – ‘cause of your brown hair.  They think you’re cute.”

“Yeah, yeah.  I know.  They wouldn’t think I was so cute if I was broke, I betcha.”

“You’re right about that,” he said, taking another swig of beer.

Then, a flurry of fingers in my hair propelled by girlish giggles and squeals.  Their brown thighs jumped as they teased me.  “Hey, you’re messing me up,” I objected, grabbing their wrists and pulling them off me.

“They like you, Charlie,” he beamed, then threw back his head, laughed and guffawed and bellowed and let loose enjoying himself like I’d never seen him in the hospital where he played the role of American mentor to fledgling Latin interns and the dedicated nurses who actually did the work.

When he finished his laugh, he said something to them.  The two got up, shook my hand politely and said the “glad to meet you” phrase I understood. They dissolved again into the peripheral shadows.

“Let’s finish up and get home,” he said swigging the dregs of his beer.  “It’s late.”

“What about the girls?”

“We’ll see them again at the clinic,” he said.  “Thursday.  V.D. check day.  We need to test them every month.”

“So they come in once a month?”

“Not always,” he said reassembling his lanky frame into an upright position.  “These two have missed a couple of times, but they’ll be there Thursday.”

“How do you know?”  I waited for him to finish lighting another cigarette.

“Because,” he flicked off his lighter.  “I told them you’d be there.  Let’s go.”

We crossed the Ruta, dropped down to the palm tree thicket, and he flicked on the flashlight again.  As I followed him down the path, I raked my fingers through my hair to re-comb it, and snagged a wad of bubblegum with my fingernails.  My hair was deeply entangled in the thick, sugary wad.

“Shit!” came shooting out.  “Hey,” I called up to him, perhaps a little more aggressively than I should have.  “What exactly were we doing back there?”

His answer came floating back to me in a cloud of Marlboro smoke:

“Public Health, Charlie, Public Health.”