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The Books They'll Carry: Operation Veteran Admission
By Leander Schaerlaeckens
The sleeve tattoo on Vassar senior David Carrell's right arm tells the story of the last dozen years of his life. On his elbow, there's a tank sprocket—for the vehicles he commanded during his four combat tours in Iraq as a staff sergeant in the army. Around it are inked the initials of the 17 soldiers from his company that were killed over there. (Carrell needs to add two more, for comrades who committed suicide after coming home.) A skull with two sabers crossed up behind it represents the cavalry unit he deployed with. And there are the combat stripes, eight in all, one for every six months he spent in Iraq.
Carell is a solid man with tightly cropped blond hair and a heavy Texan drawl. When we meet in a Starbucks on Route 9 just south of Poughkeepsie, he's just come from his post-traumatic stress disorder therapy. He has nightmares. He has flashbacks. He ruminates and processes the things he's seen—the death and destruction and despair. "You just can't forget it," he says. "Before my feet hit the ground in the morning, I think about the war five times. While I'm brushing my teeth, that's what I think of. It's like having a movie in your head that's always on. If you don't keep yourself busy, it'll eat you alive." So he keeps busy. With the therapy, with a peer-to-peer veterans' counseling support group. With Operation Veteran Admission—but we'll get to that.
War will mark a person. But a particularly steep toll has been paid by the 2.6 million Americans who have served in Afghanistan and Iraq, the first major American wars fought by an all-volunteer army—and the longest and third-longest in the nation's history, respectively. These men and women took part in nasty conflicts, against insurgencies fighting with IEDs and suicide bombers. They came home with unprecedented cases of PTSD and addictions to a cocktail of psychotropic meds, reportedly misused by the armed forces to allow troubled soldiers to function in the battlefield. The shock from the explosions left them with traumatic brain injuries; the shrapnel with disfigured bodies. Some experienced sexual violence within the military. Almost all returned to a nation that said it was grateful but did little to back up its lip service. More than two million Americans came home to a wretched economy, soaring unemployment, a VA with year-long wait times for treatment and benefits, retirement payments that lagged many months behind. Veterans fell into homelessness.
Gradually, suicide grew rampant among them—a VA study found that male veterans under 30 are much more likely to take their own lives than the regular population. Their homecoming was disappointing. Their bodies were broken and their minds still at war. Finding a new way to be productive is key, but for many, that was and is an elusive goal.
Carrell has been busy though. When we meet, the thing that's consuming him is the paper on Nazi propaganda that's due later that day. At 34, Carrell, a husband, father of two teenagers, and owner of two dogs, three cats, five fish, and hamsters of a quantity he can't remember right now, is a junior at Vassar College after 11½ years in the army. He's a history major with a full course load. He spent 14 hours in the library yesterday, until very late, and he will be there longer when finals roll around. Luckily, the woman who runs the library lets him in early many days, before it opens at 8am. When we finish talking, he'll go back and work on another paper.
David Carrell '16 during a tour in Iraq.
This isn't how Carrell had imagined his life would go. He always figured he'd make the army his career, putting in the two decades required for a full pension. And certainly, after completing a 9-month, a 15-month, and two 12-month tours in Iraq, he'd proved his worth. There are easy deployments and there are hard ones. Some soldiers spend the entirety of their time in the theater of operations inside the various compounds, working a desk or logistical job, far from the action. Not Carrell. He was in Balad, Baghdad, Mosul, and Najaf, patrolling hard-fought neighborhoods, swerving the tank around the IED craters left when his peers and friends had been blown up. In some 1,100 tank missions, driving around in a big freaking target, he figures he made contact with the enemy at least 300 times. Sometimes every day for two straight months. The longest he went without getting shot at, he reckons, was 10 days. He spent four years of his life living in perpetual stress, playing Russian roulette every time the tracks rumbled out of the compound gates. He'd joined the army in the summer of 2001. His girlfriend Tori, who is now his wife, was pregnant. Carrell, a 20-year-old who had been moving furniture with his father in St. Louis, needed a job with benefits. His daughter was born on September 10, 2001. His deferred basic training was moved forward and his service began. His second child was born in April 2003, as he waited in Kuwait to invade Iraq three days later.
When he came home unscathed for a fourth time in 2011, he expected life to get easier. "I'd already put in my time," Carrell says. "All the hard work was done." After all those tours, he could have coasted through his last years in the army training soldiers. Having spent that much time in combat, he could have risen through the ranks quickly. "Four tours in Iraq is like a PhD in war," says Carrell. But when he saw an army doctor all of that fell apart. He'd gone in to get his back looked at. It had been bugging him for the longest time, but he'd always toiled through the pain—that's the warrior mindset. He figured he'd get a prescription for some painkillers and some stretches. The doctor told him his back was shot, that he wasn't quite sure how Carrell was still walking. Three discs had to be removed. His military career was over.
But soldiers don't just walk out of the military. Usually, they live on a base, amid colleagues who are also their friends. It's the only life they've known. And while it may be over, extending it for as long as they can is more comfortable than moving on. They hang around. The realization that they have to start over, that they have to remake themselves entirely, is where the trouble begins for a lot of veterans. Without a sense of direction, many spin around aimlessly.
Carrell knows the sentiment. "A lot of times, it's that you miss the camaraderie of it. And you're bored here," he says, pointing all around him, to the coffee shop and the strip mall and the busy road. "Being a civilian is absolutely boring. Because you wake up and you know what you're doing every day. You miss the adrenaline rush of getting called out to go secure a helicopter that crashed or something."
This is the trap for veterans. To spend the rest of their lives coming down from that rush, without doing much of anything. Carrell could have used the war as an excuse to hole up in his mother's basement for the rest of his life. Instead, he figured he'd take the almost total stress resistance he'd developed in all those years of dangling on the sharp edge, and put it to use. "If you're not getting shot at and there's nobody dying," he says, "there's nothing that can hold you back."
David Carrell, his wife Tori, and their children Lexus and David.
Recovering from his back surgeries, stuck in Fort Hood, Texas, through the long process of getting his medical retirement processed, Carrell got bored. He'd dropped out of high school as a sophomore but gotten his GED soon thereafter. He'd never been to college, but he decided to enroll in a six-week class in a community college. When it was over, his commander told him he didn't have to report back for duty—as he awaited his discharge—so long as he was taking classes. "I signed up for every class I could take so I wouldn't have to go to work," Carrell remembers. "Now I was getting paid to go to college."
He got his associate's degree, and was asked by an advisor if he was interested in attending Vassar College, which was looking to attract veterans on a partial scholarship. Eager to break out of the army bubble, he said yes. Then he Googled Vassar. He moved his family to the Hudson Valley and shrewdly figured out the finances. Tuition was about $50,000 a year. The GI Bill would pay him up to $19,000. And the Yellow Ribbon Program would match Vassar's scholarship of some $15,000. Put together with his housing allowance from the army and his partial pension, they could just about make ends meet. And Tori would even have time to go to Dutchess Community College, in hopes of transferring to Marist College the subsequent semester.
For Carrell, college has proved an excellent remedy for quieting his inner demons. "It's something to do and strive for," he says. "It keeps the stress level up. And if it isn't up, I'm bored and get complacent." A full course load at an elite college, combined with the constant logistical challenges of their crowded household, leaves much less time to think about the war. Moving forward at breakneck pace stops him from looking back. And that, he has found, is the trick to rebuilding a life. He's done well in college. Going back to school is supposed to be hard for veterans because they haven't been in a classroom in years and it's unfamiliar. "But I lived in unfamiliar territory for four years," says Carrell. It isn't a scary place to him. He isn't afraid to tell his professors they're going too fast, often to the relief of his classmates.
From Battlefield to Classroom
Having discovered the value of college, as a kind of therapy, as a vehicle for self-betterment, and as a relative bargain for veterans, Carrell began to wonder why more veterans weren't enrolled. That brought him to two realizations. One, veterans aren't made aware of all the funds and grants available to them to pursue higher education; and two, this lack of information funnels many of them into menial jobs. When Carrell left the army, he, like everybody else leaving the service, went through a week-long course that was supposed to prepare him to re-enter civilian life—how to find a job, mostly. But it's geared toward manual labor. Not once in that entire week did he hear the word college. "A lot of guys come out of the military and take the first job they can get, because they need a job, and they get stuck," Carrell says. "It dead-ends them." Outside of the military, where veterans' services counselors are perennially overworked, things aren't much better. "The Hudson Valley honestly sucks for veterans' education," Carrell says. "There's nothing for us. There's no push or support."
By Carrell's count, there are some 18,000 veterans in Dutchess County alone. At least 11,000 of those are eligible for the GI Bill—which will pay $19,000 yearly for four years—and the various tuition reimbursement, grant, and scholarship programs. Yet less than a quarter of them are in college or have been. That means tens of millions of dollars are going unused. So Carrell started talking to every veteran he happened to come across. Are you going to college? No? Why not? Do you know about all of these grants? "I just go up and tell 'em my story," Carrell says. "It motivates people to go, 'Shit, if this dumb redneck from Texas can do it, why can't I?'"
Soon enough, Carrell realized that his friend Josh Ridley '17, who is also a veteran at Vassar, was doing more or less the same thing. They had each helped some 15 veterans start the process of garnering the required paperwork to access all these funds—there is a prohibitive amount of red tape involved—and figured they might as well formalize their efforts into a real organization and call it Operation Veteran Admission (OVA). So they set up a website (veteranadmission.org) and got their 501(c)(3). They got on the radar of various local politicians, who now steer veterans to them, and joined their veterans' advisory commissions, made connections with local colleges—OVA only operates in the Hudson Valley at the moment.
Michael Finlay will be one of the first veterans to partake in Operation Veteran Admission, which will help him navigate the winding path through claiming his benefits and securing financial aid. Finlay spent five years as a nuclear machinist mate in the navy until he was honorably discharged in 2012. He, too, had planned on making a career of his service, slogging through the brutally demanding Navy Nuclear Power School, learning how to service and operate the nuclear reactors on submarines and airplane carriers. After two years of schooling, he began his first deployment by joining up with the USS Theodore Roosevelt in the Persian Gulf. But when he finally started doing the work, he didn't much like it. Truthfully, he'd joined the navy on something of a whim and now regretted it. He slipped into a deep depression.
David Carrell at the inauguration for the first round of Posse veterans.
Soon, it got so bad he had to be put on antidepressants. But sailors are not allowed to work on a nuclear reactor when they're on antidepressants. So he was temporarily reassigned to building upkeep duty, after the ship had returned to the Norfolk shipyard. That only made things worse. And the medication made him gain weight. He failed his second and third physical standards tests—strike one came after a surgery—and the navy discharged him.
"Figuring out a new direction to go, it's not easy," Finlay says now. "I kinda stagnated when I got out of the military. I wasn't sure what to do with my life. I was kind of lost." He spent three years adrift on unemployment benefits, partying and living with family. Meanwhile, he was the victim of domestic violence at the hands of his girlfriend, with whom he had two young children. They broke up and he took her to court to win custody. "It was a tough time," he says. "I didn't know what to do. I didn't feel like I really fit anywhere. Getting going was tough."
Finlay and his kids moved up to Fishkill from his home in Hastings, further away from New York City's temptations. Without the distractions and with kids to care for, he rediscovered his focus. But he didn't know how to put his life on track. He'd lost several important documents, including his discharge papers, which held the key to his benefits. He got in touch with local state senators, who passed him on to OVA. "It seemed like they really kinda got it, the sense of when you get out of the military, not really knowing what you're doing," Finlay remembers of his first interactions with Carrell and Ridley. "Just getting out is confusing. They seemed to know through hard experience how tough it was and really wanted to help. I was really happy to hear from them."
OVA guided him through the labyrinthine process of recovering his lost papers. They helped him apply for his benefits, for the GI Bill, and for the various tuition grants he was eligible for. They made him aware that he was eligible for treatment for the depression he had left the military with. And then they set about making a plan. If he accomplished little else, Finlay had discovered a love for cooking in his lost time after the navy. He decided he'd like to go to the Culinary Institute of America. OVA explained what it would take to get in. That he needed six months of work experience in a professional kitchen, and that it wouldn't hurt for Finlay to get his feet wet academically again. So he's looking for a part-time cooking job and enrolling at Dutchess Community College. "I'm still in the beginning of the process," Finlay says. "But if these guys hadn't helped me I'd have no idea what I was doing. I'd still be sitting here." Finlay hopes to eventually get his bachelor's degree in food science from the CIA. Then he'd like to become an executive chef and perhaps open a restaurant.
Getting a veteran through the process is a marathon. Carrell and Ridley have each been talking to a half dozen others, steering them in the right direction. They want to keep their organization as local and grassroots as possible. When I called Carrell a few months after we first talked to ask some follow-up questions, I caught him at a mall. He'd just spotted a man in old combat boots and asked him what he was doing for a living. He drove a truck, so Carrell told him about all the college money out there for veterans like him and handed him his business card. "We're just trying to help people get ahead," he says.
As for Carrell himself, when he finishes up at Vassar, he'd like to get an executive MBA from the University of Texas-Austin. He's not sure how he'll pay for it yet. His GI Bill is due to run out. But he'll figure out a way. And then he'll probably start another OVA chapter down in Texas. "You kind of get to continue your service by helping veterans," Carrell says.
Public radio's Marketplace recently featued the Veterans Posse Program in a series of stories. Listen and read more about Vassar's student veterans.
"Recruiting veterans to elite colleges"
"A veteran's college experience"
"A long road from the Marines to college"
Veterans David Carrell '16 and Joshua Ridley '17 cofounded Operation Veteran Admission, a program to help veterans enroll in college.
Writing Their Way Back
Veterans share their memories—and their pain—in a writers' workshop called "Voices From War," run by Kara Frye Krauze '93.
Meet AAVC's New Executive Director Lisa Tessler
Exploring Transfer: Encouraging Four-Year Degrees for 30 Years
Vassar Basketball Coach Leads Team to Silver in Maccabi Games
Angela Davis Speaks on Anniversary of Women's Studies
Meet Safety and Security Director Arlene Sabo
Glass Artist Dale Chihuly Presents a New View of Ulysses
Creative Capitol
Jane Smiley's Golden Century
Shaping the Civil Rights Discourse: Sherrilyn Ifill '84
Way To Go, Vassar!
Sporting the Oak: Courting Quietude
They Still Live On...
Remembering Bill Gifford

redpajama_set_name: RedPajamaCommonCrawl


Guardians of the Galaxy 20 was cover dated January 1992 and was on sale in November 1991, sharing the spinner racks with Aquaman #2, Daredevil #300, Elongated Man #1, New Warriors #19, Superman #63 and Wolverine 50.
Major Victory was written and pencilled by Jim Valentino and inked by Steve Montano and opens with a containment-suit-less Vance Astro leaping into the tense stand off from last issue and helping the Guardians of the Galaxy and the Commandeers turn the tide on the Punishers and the Badoon.
With the one of the two Badoon dead and the other running, the team give chase and ask Vance how he is free of the containment suit he needed to survive, only a day ago.
Krugarr the Sorcerer Supreme, used Hollywood's ionic blood and some magic to heal Vance and cure his skin so that it wouldn't oxidise on contact with the open air. The Guardians face off against the Punishers and cut a swath through them. Gabrielle of the Commandeers shoots Belle in cold blood for the betrayal that cost Inez's life and to save Nikki, Yondu uses a laser weapon from his artifical hand to kill one of the Punishers, being a Habaktu, Yondu feels ashamed about this use of a technological weapon and vows never again to use it.
The Punisher General flees and along with the surviving Badoon, makes it to the Ultimate Punisher tank. Before they can drive off in it, Hollywood lifts it over his head and throws it. Krugarr catches it and teleports them to the centre of the complex.
The scene shifts to space and the glowing form of Starhawk where Stakar tries to convince Aleta to give up her claim on their shared body by giving her a simulation of her old family. She is happy to see them and seems to forgive Stakar for his part in their apparent deaths, but then realises that since Starhawk re-inhabits his own body time and again, there is no Stakar and it's all Starhawk and she begins fighting for her body again. At the centre of the Bronx refinery, Charlie-27 rigs his cannon to go nuclear and take the refinery out, inside the tank, the Badoon tries to call the rest of the Brotherhood, but the Punisher General kills him and leaves once he realises that the Guardians will detonate the gun. Once he exits, Gabrielle shoots him in cold blood too and the Guardians escape before the gun blows, destroying the facility and ending the threat of Realiteevee.
There's a brief scene with Martinex on Mainframe's world trying to work out how his Galactic Guardians concept will work, while back on Earth, the Commandeers offer Vance's team use of the sub-basements of Avengers Mansion. Vance takes a second to point out that he recognises Hollywood as someone called Simon, clearly Simon Williams or WonderMan, who was an Avenger as well as an actor.
This pretty much brings the story to an end, with Talon being offered Guardians of the Galaxy membership and a nice little pin up page. Then we're shown what's coming next. Rancor and the Mutants of Haven find that their search for Wolverine will lead to Earth.
Notes: Thus ends the era of the containment suit and begins the age of Major Victory.
This was a sort of third act of the story, with the team given that last minute boost and that hero moment of Vance Astro flying into the action and changing the course of the battle. You can almost hear some kind of orchestral overture as he jumps in.
Gabrielle executes someone twice and is only brought up about it once. This highlights the difference between the Commandeers and the Guardians of the Galaxy. The Guardians are more of a super hero team, changed by their experiences and choosing to show restraint and mercy. The Commandeers however, are soldiers and very much still in this war. Gabrielle does what a soldier might do, but Vance's reaction shows that for him that feeling was a long time ago.
Rancor is back, not thrilled exactly, but there are half decent stories coming.
Talon is offered membership and stays with the team for the rest of this volume.
Did everyone get the Wonderman thing? I suspected at the time, but even when it's revealed there's no real mention of his name, just that he's called Simon.
Starhawk consolidates his control over Aleta and that will be brought back in the next issue.
Next time: The Return of Rancor.
Guardians of the Galaxy 19 was cover dated December 1991 and was on sale in October 1991, sharing the spinner racks with Aquaman #1, Excalibur #45, Human Target Special #1, Iron Man #275, Robin II #1 and Sensational She-Hulk #34.
The Gentleman's name is Talon was written and pencilled by Jim Valentino and inked by Steve Montano and opens with the Punishers surveying the devastation from the previous issue and the Guardians escaping through tunnels. The huge Punisher general kills the sniper who shot Vance Astro in the previous issue and demands to know about the man with the tale, commenting that they have an inside man and finding the Guardians will not be a problem.
In the tunnels, Charlie-27 demands to know more about this furred ally and gets knocked on his rear end for his trouble. Talon then and shoots Charlie-s hand with claws As a fight brews, Yondu steps forward to end it, once more being the voice of reason. The fight avoided for now, Talon points out that he has left Vance in good hands.
The scene shifts to Comandeers headquarters where Hollywood is joined by Krugarr and the astral form of the Ancient One, once known as Doctor Strange, who notifies Hollywood that some of his Ionic blood is needed.
Then we're back off to Courg. Martinex has evaded the knife and turns the tables on the Courgan native, who informs Martinex that all the devastation he can see is his fault. The Guardians drove off the Stark, but left the dead and disease followed. The Stark returned and massacred the people who survived the illness. The Courgan (who's name was Atur, I think) tells Martinex that the never considered the consequences of actions like this and a simple show of force does not solve the problem. Martinex is visibly shaken by this.
Back on Earth, the Guardians are enroute to the Realitivee refinery, people sort of pair off and there is a little bit of light hearted banter, including Tarin telling Yondu of her admiration of him. Yondu only responds with pointing out that he can hear a high pitched whine, like that of a homing device, one of the Commandeers is visibly shocked by this.
Meanwhile.. Deep in the heart of the Shi'ar empire, a museum curator shows a broken piece of a familiar looking claw to Rancor and her lieutenants from issues 9-11 who quickly kill the curator. There is another scene with Aleta and Stakar, trapped in a grey void along with their children while the Hawk God changes their body.
The Guardians arrive at the refinery, the only such refinery on Earth, nestled in the Bronx, far from the Punisher's turf. The Guardians find out that brains behind Realitee-vee are in fact the Brotherhood of the Badoon. They turn and see the Punishers behind them and from within the group Belle draws her gun against Charlie-27. Enemies in front of them, behind them and within them, Tarin calls for the Comandeers and Guardians of the Galaxy to surrender.
Above the refinery, Krugarr, Hollywood and another figure in shadow watch. The shadowed man points out that it's up to the three of them to save the rest. Hollywood points out that there's only 3 of them and their enemies are legion.
Notes: Another gripping part of this continued return to Earth story and it looks like it's heading for an exciting conclusion.
Belle is revealed as the inside man earlier than the next to last page, but only in retrospect.
Tarin's attraction to Yondu is brought up again, this time she tries to tell him about it.
An immediate rivalry exists between the military minded Charlie-27 and the free-wheeling Talon, which adds conflict to a team that is starting to get on a little bit too well.
Talon himself is an interesting character, secretive about his past, but a lot of fun and a lively addition to the story and eventually the team.
This issue takes us to the Shi'ar empire, the Shi'ar are bird-like aliens long associated with the X-Men and have been both friends and enemies to them, depending on who's in charge and what threat the X-Men and other humans pose to them. The Shi'ar scene tells us that the Mutants of Haven will make a comeback soon and am glad of it.
The Badoon are back, it only took 19 issues but they're back in their purple speedos and flying dogs.
Guardians of the Galaxy 18 was cover dated November 1991 and was on sale in September 1991, sharing the spinner racks with Black Canary #1, Conan the Barbarian #250, Doom Patrol #48, Excalibur #43, O.M.A.C. One Man Army Corps #1 and Quasar #28.
Punished was written and drawn by Jim Valentino and inked by Steve Montano and opens with a quick recap of recent events and then Vance gets shot.
The two teams (Guardians and Comandeers) find themselves under fire from the Punishers who shoot at them and a furred individual who fired some kind of dart at the lead Punisher, the main reason it seems that Vance's head wasn't removed, as it is, the bullet penetrated the adamantium sheath that has covered Vance's body since the early issues of this title. Taking the initiative, Charlie-27 orders everyone to fire back, his own cannon destroying the building that the Punishers were firing from, giving the team room to escape and seek medical aid for Vance.
Back in New York, a Punisher squad ambush Yondu, Old Redd and Inez and Inez is shot and killed by a smirking Punisher, who comments on it being worth a "Double Bonus". Yondu goes bezerk and summons a battleaxe from his new weapons stump and (partially off panel) decapitates the Punisher. While Nate & Nikki plan to take out a flying Punisher, a furry man with a tale lands in the window of a building in Greenwich Village.
The furry man (called Talon by the house's resident) tells the man inside that he needs help for the Guardians and Comandeers. Then back to action. Charlie-27 has caught up with the original shooter and batters him into the wall, while Nikki has taken out the flier and flies on a captured flying device and helps Nate, who is shot at and his eye is damaged. As Charlie is finishing punching Vance's assailant through the wall, a tank called the Ultimate Punisher arrives on the scene and Charlie quickly fires at it using his cannon, with zero effect.
The team retreat as Tarin comments on how badly the last two issues have gone, giving a nice segue into looking at Vance Astro, now lying in a vacuum chamber guarded by the Commandeer named Hollywood. Hollywood thinks about how Vance is quite conceited to wear Captain America's shield into battle, but says that if it was in his power, he would not let Vance die. Then as if answer, Krugarr the sorcerer supreme appears before him and announces that he is there to help Hollywood save Vance Astro's life.
As the remaining heroes gather together and wonder how to get out of all this, help arrives in the form of Talon, the cat man from earlier in the issue, who in a very Mad Max way points out that they need to talk to him to get out of there.
Notes: This is the first full appearance of Talon, who will stick around for quite a while and the welcome return of Krugarr.
This is a fun issue, very much a middle of the action story, with the heroes seperated and under threat, kinda reminding me of Empire Strike Back in a way.
Both Yondu and Tarin have prosthetics and it looks like Nate'll need one by next issue.
Yondu shows a great degree of savagery in his dispatching of one of the Punishers. Yondu is considered a primitive, or a barbarian, with his aversion to technology and his acceptance of lethal force in combat, but he's always been shown as a very civilised and calm person, so this savage beheading is very much out of character as Old Redd notices.
One thing that bothered me was that it's the 31st century, so why are people still using bullets? Even after the fall of human civilisation in the wake of the Badoon, howcome lasers aren't the norm?
Next Time: The Gentleman's name is Talon, the Punishers and some old enemies.


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A Dozen Scariest Places on Earth
Our world is beautiful, magical, and sometimes desolate, abandoned, and scarred. Let's take a look at a dozen scariest places on Earth -
(Centralia, PA -
abandoned town for decades
due to underground fire
that has not gone out)
What makes a place the scariest in the world? Well, it's a subjective evaluation, but the best bet is to think of places that people really don't want to be alone in at night. What makes them scary? Isolation. Deterioration. Dark history. Forbidden entry. See if any of these places scare you -
Catacombs - France
If you don't like caves, tight places, or the concept of creeping around tunnels under a major city, then the Catacombs in France are likely high on your list of scariest places.
With thousands of years of citizens having passed on, the Plague and wars, there were too many bones taking up vital land in the Paris area, and hence the bodies were interned and placed in catacombs beneath the city.
Suicide Forest - Aokigahara Forest- Japan
Does the idea of being in a beautiful natural forested park, but finding out it's a very popular place to commit suicide unsettle you? "Suicide Forest," as Aokigahara Forest in Japan has come to be known, has a reputation for people entering, but not exiting.
Many people have entered the forest, often times setting up camps with tents, contemplating their life path and deciding to end it there. The amount of agony and the weight of the depression likely permeate the very forest floor. If the idea of stumbling upon such a find creeps you out, then this forest is perhaps one of your scariest places on earth.
Transylvania - The Bran Castle
If you are a romantic at heart and love the classics, are fascinated with vampires and remote castles, perhaps the Bran Castle in Transylvania is your scary place.
Although Bram Stoker likely did not know of the castle or intend to focus the legend upon it, the very look and location of the castle make it a sought after hot spot referred to as "Dracula's Castle." Mood and atmosphere alone might make it a terrifying location to be alone. In the dark.
Chillingham Castle - UK
If you like ghosts, Chillingham Castle might be the Mac Daddy of all locations. With hundreds of years of dark history, it permeates the walls. In fact, they have rental apartments within the castle in case you ever wanted to sleep in a super haunted location!
I seriously miss that Scariest Places show every autumn. That was as fun and moody as it gets!
Capuccin Catacombs - Italy
These catacombs in Palermo shows the customs of the 17th to 19th Centuries of the people of Palermo. Citizens begged to be buried there and some to be mummified.
Perhaps the most famous mummy is Rosalia Lombardo, a 2-year-old who died in 1920. Her father was so grief stricken, he made sure she was mummified to remain two forever.
The corridor is lined with mummies of some of the town's most prominent men.
Doll Island - Mexico
A man who was tired of life in the town, moved out to an island on the canals in Mexico. After a little girl drowned in the canal, he was certain she was haunting his getaway retreat. He decided to leave her a doll, which later became a few more dolls, and more dolls, and pretty soon he was trading items for dolls to load up the island and protect the whole thing. Ironically, the man drowned in the same canal and now the island sits with its lonely hundreds of plastic dolls trying to ward off more spirits.
Humberston and La Noria - Chile
Deep in the rugged desert of Chile sits two neighboring abandoned towns that were once mining towns. In the 1800s the families living there were treated like slaves and had horrifying deaths. They say it lingers. Voices, footsteps, lights, and more are experienced by anyone who lingers after dark.
The bones of the dead are still scattered among the streets. It gets even creepier when you find out that near a church, a tiny 6-inch skeleton was found.
It was thought to be a premature baby, but it sure looked quite defined and quite abnormal. When DNA was studied, it was found to be human, but studying the bones and teeth discovered it was about the age of a first to third grader. How did it live that long? Well, my guess in that kind of uncontrolled mining area, it might have been an issue related to arsenic poisoning or lead creating an unusual birth defect.
Some say the dead arise from the grave after dark and their apparitions walk the town, taking it over. Coffins lie open and attest to the dead never resting.
Pine Barrens - NJ
You say "Pine Barrens" and most folks think about the Jersey Devil, a vicious flying monster that supposedly torments the area for over a hundred years. But, the Pine Barrens are full of weirdness.
There is a ghost called the Atco Ghost of a little boy who was hit by a car. The local legend tells of a place in the roadway you can stop and hit your horn three times and flash your lights three times and soon you see the boy cross the street.
An area that is abandoned called Ong's Hat is considered to be a portal to another world. The legend says that a machine called "The Gate" was invented which allowed passage to other realms.
If it isn't creepy enough that the island is one of the most remote ones in the entire world, it is left with enormous stone sentinels, the mysteries of which are still being uncovered, like the fact they had bodies beneath the soil and strange writing on them! The Rapa Nui said they couldn't translate the stone tablets found there with odd writing, but they did speak of the long-earred ones that they fought with, the ones who were originally there when the Rapa Nui showed up about 1200 years ago. Caves have exposed the bones of those who were cannibalized.
Pripyat - Ukraine
One of the worst nuclear disasters of our time, the Chernobyl accident led to the rapid evacuation of thousands of people. It left the country with many deaths and deformities from it and an ecological disaster beyond compare.
What it also left the area with is empty towns that some are coming back to in order to visit, with proper precautions for their safety. Abandoned towns are scary, but ones that might have wildlife affected by it, that have entire huge towns left in mid-action for decades, is pretty darned creepy.
And, then, there are legends of ghosts....
Ohio State Reformatory - Mansfield Ohio
The prison opened its doors in 1896 and closed them in 1990. During that time, it housed over 155,000 men. They offer plenty of ghost tours and extreme hunts in the building and with its very gothic baroque style, it is just the place to get you ghost fears flowing.
Sedlac Ossuary has 70,000 people's bones used to make this entire church in the Czech Republic. Everything is made of bone, even a communion cup.
Desert Submarine Base?
The town of Hawthorne, Nevada harbors a big 18-mile x 8-mile lake called Walker Lake. It also houses a guarded "Naval Undersea Warfare Center." This amazing lake has not one structure to support the locals enjoying a swim or some fishing, but does have some kind of base along its western edge. It has also been associated with some pretty amazing conjecture.
Haunted Caves and Scary Cave Finds!
Caves are more than the sites of mines and ancient hieroglyphs, the burial places of giants, and homes for bats. They can also be haunted. And, why not? In desperate times, caves were utilized for sanctuary and sometimes standoffs and, given the geology, they seem like ideal vessels in a feng shui sort of way, to retain and hold a kind of amplified haunting that is held captive in a cul-du-sac formation. I am utterly fascinated with the haunted cave phenomena. I cannot think of a better spirit vessel. Let's have a look at some more infamous haunted caves....
How To Make a Cheap and Scary Scarecrow Head
Simple components: Stryofoam head, straight pins, burlap (a yard will do), Elmer's glue, paint brush, paints (black, rust, straw color). Begin with what you need - styrofoam head (see link above and also Michael's store is carrying them), Elmer's glue, paint brush, black acrylic paint, straw colored acrylic paint, rust acrylic paint, and a yard of burlap. Carve out eye sockets to be big holes. Carve out mouth so it's a grimacing hole. Carve out cheekbone slashes like skeleton look. Mix 2 parts glue to 1 part water. Cut burlap into uneven pieces. Fray the edges by pulling on them and letting strings unravel. Dip into the glue/water mix, wring it out and place around the head. Use straight pins to pin it down on curves so it sticks. In a few hours it will dry hard. Now, take black paint and thin out with some water - about 2 parts black paint to one part water. Dip brush into it, now push brush into the pores of the bur
Theme images by Dizzo


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Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi
Wouter Bakker ORCID: orcid.org/0000-0001-6470-243X1,2,
Emma Bakker3,
Christiaan Huigens1,
Emily Kaunda4,
Timothy Phiri1,
Jogchum Beltman3,
Jos van Roosmalen2,3 &
Thomas van den Akker2,3
Medical doctors with postgraduate training in Global Health and Tropical Medicine (MDGHTM) from the Netherlands, a high-income country with a relatively low caesarean section rate, assist associate clinicians in low-income countries regarding decision-making during labour. Objective of this study was to assess impact of the presence of MDGHTMs in a rural Malawian hospital on caesarean section rate and indications.
This retrospective pre- and post-implementation study was conducted in a rural hospital in Malawi, where MDGHTMs were employed from April 2015. Indications for caesarean section were audited against national protocols and defined as supported or unsupported by these protocols. Caesarean section rates and numbers of unsupported indications for the years 2015 and 2016 per quarter for different staff cadres were assessed by linear regression.
Six hundred forty-five women gave birth by caesarean section in the study period. The caesarean rate dropped from 20.1 to 12.8% (p < 0.05, R2 = 0.53, y = − 0.0086x + 0.2295). Overall 132 of 501 (26.3%) auditable indications were not supported by documentation in medical records. The proportion of unsupported indications dropped significantly over time from 47.0 to 4.4% (p < 0.01, R2 = 0.71, y = − 0.0481x + 0.4759). Stratified analysis for associate clinicians only (excluding caesarean sections performed by medical doctors) showed a similar decrease from 48.3 to 6.5% (p < 0.05, R2 = 0.55, y = − 0.0442x + 0.4805).
Our results indicate that presence of MDGHTMs was accompanied by considerable decreases in caesarean section rate and proportion of unsupported indications for caesarean section in this facility. Their presence is likely to have influenced decision-making by associate clinicians.
The proportion of caesarean births is increasing worldwide, in both high- and low-income settings [1,2,3]. A worldwide ecological study representing 98% of global live births found no important association with maternal and neonatal mortality at caesarean section rates higher than 10%, in line with a systematic review by the World Health Organization and their statement on caesarean sections [4,5,6]. Caesarean sections may be associated with severe maternal outcomes like massive blood transfusion, admission to intensive care unit, hysterectomy, and death, and these associations are strongest in sub-Saharan Africa [7,8,9]. The risk of uterine rupture in subsequent pregnancies is increased, which is particularly problematic in countries with high fertility rates such as Malawi [10,11,12,13,14]. Therefore, it remains crucial to carefully select those women eligible for surgical intervention and prevent caesarean sections without medical indication, for instance by following evidence-based indications and performing audit of indications [2]. In addition, the World Health Organization advises to monitor caesarean section rates at a facility level [6].
In the Medical Doctor Global Health and Tropical Medicine (MDGHTM) programme in the Netherlands, participants are trained to work as medical doctors in low-resource settings [15, 16]. Their postgraduate training has a duration of approximately 3 years and focuses on acquiring basic surgical and obstetric skills, as well as knowledge of tropical diseases and public health [17, 18]. MDGHTMs are expected to critically assess labour progress and indications for obstetric interventions, and are prepared to provide clinical assistance and onsite training to other (associate) clinicians in hospitals in low-income countries. MDGHTMs often work in under-staffed rural areas in low-resource settings and combine clinical, managerial, and educational tasks [16, 19]. However, the impact of their presence on obstetric management in their work environment has never been systematically assessed.
The first objective of this study was to describe the caesarean section rate during the period of introduction of MDGHTMs in a rural hospital in Malawi, where hospital management was concerned about increased caesarean section rates. Second objective was to examine whether there was a decrease in the proportion of caesarean sections that were not supported by medical indications.
Study site
This pre- and post-implementation study was conducted at St. Luke's Hospital in Malosa. This 150-bed rural hospital is based in the southern region of Malawi, a landlocked low-resource country with a population over 17 million. St. Luke's Hospital is a mission facility run by the Christian Health Association of Malawi and works with a principle of user fees for services, but maternity care is free of charge for the catchment population through a government sponsorship programme. The hospital serves a catchment population of roughly 30 000 and offers comprehensive emergency obstetric care, with an average number of 2000 births per year. The monthly institutional caesarean section rate varied between 20 and 30%, which alerted hospital management and led to plans for further investigation [20, 21]. Services are usually provided by associate clinicians, in Malawi called 'clinical officers'. Clinical officers followed a 4-year practice-oriented training in general medicine and basic surgical procedures [22, 23]. The hospital struggled to contract a medical doctor, until April 2015, when an MDGHTM was employed in the facility, followed by a second MDGHTM from the beginning of 2016 onwards.
The labour ward of St. Luke's hospital has five beds with an average of two midwives per shift. Foetal monitoring is done by intermittent auscultation using Pinard's fetoscope or Doppler. Routinely, vaginal examination for progress is performed 4-hourly. Women are admitted in the labour ward when in active labour, usually from a dilatation of the cervix of at least 4 cm. Progress and foetal heart rates are plotted in a partograph, as enforced by the Ministry of Health (Fig. 1: partograph used in Malawi). Cardiotocography was not available.
The labour chart with partograph used in St Luke's Hospital, Malawi, adapted from the modified WHO partograph
MDGHTM
Since the late 1960s, the Netherlands Society for Tropical Medicine and International Health offers a training programme for doctors who are planning to work in low-resource settings. The programme, originally consisting of extra training in surgery and obstetrics followed by a 3-month course in Tropical Medicine and Hygiene on top of basic medical training, aimed to equip medical doctors with some extra skills much needed in low-resource settings where an all-round approach is required. The programme evolved into formal specialty training for MDGHTM, which officially started on January 1, 2014. The programme has now two possible pathways: 9 months of obstetrics/gynaecology combined with either 9 months of surgery or paediatrics, followed by the Tropical Medicine and Hygiene course and a 6-month placement in a low-resource setting.
St. Luke's hospital has a longstanding history with employing Dutch doctors. After a short period without any medical doctor present in the hospital, the hospital started employing MDGHTMs again from mid-2015. Next to clinical tasks, they take part in management as senior medical officer and fulfil a supportive and supervising role for junior staff. These doctors work alongside the clinical officers, but also have a leadership responsibility as head of the team.
Medical records were collected of all women who gave birth between January 1, 2015, and December 31, 2016. These records consisted of partographs and information on admission and follow-up. The partograph is a management tool for monitoring labour, containing all patient characteristics and keeping track of labour progress (Fig. 1). Women were included based on the presence of the partograph in their records. All basic characteristics were collected, including indication, type of health worker who made the decision for caesarean section, progress of labour, timing of the procedure, pre-operative interventions as artificial rupture of membranes, augmentation with oxytocin and trial of instrumental vaginal birth in the second stage of labour, and maternal and perinatal complications. Unless clearly stated otherwise, the health worker who was listed as the surgeon in the procedure was labelled as the one who took the decision. This is according to hospital routine. Files were analysed by one of the researchers present in the workplace, but if information was unclear, cases were discussed with one of the other research team members (WB or ACH).
Comparison to protocols
Staff of St Luke's hospital follow the National Obstetrics & Gynaecology Protocols and Guidelines, which include indications for caesarean section. For all of these indications, literature study and consultation of local clinicians was performed in order to provide measurable criteria (Table 1). Every caesarean section with an indication categorised in Table 1 was audited using these criteria. Cases in which criteria for any indication were not met, were labelled as unsupported indications. Cases in which it was impossible to assess whether indication met criteria due to missing data, were labelled 'unable to assess'. This was, for example, the case when the indication was foetal distress in absence of foetal heart rate recordings or if there was a delay between the last documentation and decision of caesarean section of more than 8 h. Cases that had indications not listed in Table 1 (the indications in this table are labelled 'auditable indications') were collected in the database but not audited. No distinction was made between elective and emergency caesarean section, since no system of booking caesarean sections was in place in the study period.
Table 1 Auditable indications based on national protocols
Primary outcome measure was quarterly caesarean section rate in the period under review. Caesarean section rate was defined as the number of caesarean sections divided by the total number of women who gave birth. Secondary outcome measures were frequencies of different indications for caesarean sections, percentage of unsupported indications over time, percentage of unsupported indications by clinical officers, and maternal and perinatal complication rates per period.
The database was checked for errors and duplicates. Data analysis was performed using IBM SPSS Statistics Version 24 and Microsoft Excel Version 16.24. Total number (n) and frequency (%) of demographic variables and clinical characteristics were analysed. Caesarean section rates, number of unsupported indications, and maternal and neonatal complication rates were calculated for the eight quarters of the study period.
Medical records of 3428 births were retrieved, of which 645 were caesarean sections (caesarean section rate 18.8%). Table 2 shows clinical characteristics of women who underwent caesarean section. Figure 2 shows a temporal trend of a reduced caesarean section rate per quarter during the study period (y = 0.0086x + 0.2295, p = 0.039). Medical officers performed 82 caesareans, clinical officers 513.
Table 2 Basic characteristics
Caesarean section rate per quarter
The commonest indication for caesarean section was cephalopelvic disproportion (CPD; 23.5%), followed by foetal distress (12.7%) and prolonged first stage of labour (of unknown reason; 12.2%). Nine percent of caesarean sections were performed because of two previous caesarean scars. All indications are listed in Table 3.
Table 3 Indications for caesarean section as described in case file
Of 645 caesarean sections, 501 had an auditable indication: 90 (13.9%) had indications that were not auditable (not part of the criteria listed in table 1) and 54 (8.4%) did not have a documented indication (Table 3). One hundred and thirty-two (26.3%) of the audited cases had an unsupported indication: documentation in partograph and file did not meet criteria for that specific indication. In 71 (14.2%), too little information could be found in the partograph to assess the indication properly. In 298 (59.5%) of the audited cases, partograph and file provided evidence to justify the indication (see Fig. 3).
Distribution of caesarean section cases
Fig. 4 shows the proportion of unsupported indications among the total auditable caesarean sections. There was a significant downward trend over time (y = − 0.0481 + 0.4759, p = 0.008). This trend was not only seen in all caesarean sections, but also in those performed by clinical officers (Fig. 5).
Unsupported indications per period
Proportion of unsupported caesarean sections by clinical officers
Looking into the different groups of indications, 93 (70.5%) of the caesarean sections with unsupported indications were due to prolonged labour. In these women, the partograph did not show signs of prolonged labour, although caesarean section was performed for that indication. Seventeen (12.9%) of the unsupported indications were foetal distress, 11 (8.3%) foetal malpresentation, and 11 (8.3%) two previous scars.
Maternal and perinatal outcome before moment of discharge, usually 3 days postpartum, remained relatively stable over time, although varying slightly per quarter. In the study period, four maternal deaths (0.6%), 15 fresh stillbirths (2.3%), five macerated stillbirths (0.8%), and six early neonatal deaths (0.9%) occurred in women undergoing caesarean section. Supplement 1 shows maternal and perinatal outcomes of caesarean section compared to vaginal birth. Stillbirth and neonatal death rates did not change significantly over time (p = 0.455 and 0.292 respectively, see Supplement 1). Plotting stillbirth and early neonatal death rates with caesarean section percentages (Fig. 6), no significant trend could be identified (p = 0.203) suggesting the decreasing caesarean section rate had no impact on these rates.
Combined stillbirth/neonatal death rate vs caesarean section rate and unsupported caesarean section rate
Our data suggest that the introduction of an MDGHTM could have had an effect on the caesarean section rate in the facility and on the proportion of caesarean sections not supported by documentation in medical records. There was a declining trend in both these rates over the 2-year study period. Introduction of an MDGHTM took place in the first quarter of 2015, and from the first quarter of 2016, there were two MDGHTMs working regularly in maternity care in the hospital. Additionally, from halfway the third quarter of 2016, there was one MDGHTM covering the maternity department daily. No other major changes occurred in the study period. Both caesarean section rate and proportion of unsupported indications decreased gradually. While medical officers took up some of the caesarean sections and thereby might have had an influence on the indications, remarkably the number of unsupported indications by associate clinicians decreased significantly as well. This is most likely attributed to supervision, training, and audit taking place throughout the study period, which were all part of the job description of the MDGHTMs. As part of hospital management, they fulfil a role as supervisor and head of the clinical team. In morning handovers, caesarean section indications were discussed and labour management was also part of maternal and perinatal morbidity and mortality audits. The effect on the overall caesarean rate could be partly attributed to this leadership role, but since the rate mostly decreased in the last two quarters, it could also be contributed to having an MDGHTM continuously in the maternity department to aid and supervise the midwifery team and thereby having a significant role in preventing unnecessary caesarean sections. Which element contributed most to the decline warrants further assessment.
A significant number of auditable cases (71, 14.3%) could not be audited due to lack of information. Indications for these cases might as well be considered unsupported, since no supporting information was found. Additionally, in 8.4% of all cases, caesarean section was performed with unknown indication. Therefore, our numbers of unsupported indication could be underestimated and stress the importance of evidence-based clinical decision-making to an even greater extent. Also, some criteria in national protocols give room to perform caesarean section at a rather low threshold. For example, a one-time foetal tachycardia can be interpreted as an opportunity to decide for caesarean section.
Reducing the number of unsupported, and possibly unnecessary, caesarean sections is important. It may save women from unnecessary risks of abdominal surgery. Furthermore, considering that a great number of procedures was done on young nulliparous women, preventing unnecessary procedures could prevent serious complications in subsequent pregnancies, especially considering the high fertility rate in Malawi. It seems a role exists for MDGHTMs, together with associate clinicians, to discuss indications for caesarean section and work towards optimal case selection. While this is a single-centre study, results are comparable with other caesarean section audits in similar settings, for example in Tanzania [24, 25]. However, the effect of MDGHTM was not studied previously. More research could provide better insights in this role, for example a qualitative study of health workers' perceptions in settings where MDGHTMs are employed, preferably accompanied by quantitative and qualitative data on decision-making in caesarean sections.
A surprising result was the high number of caesarean sections performed in preterm labour, especially in the range of 35 to 37 weeks (17.1%). Since there is no policy for determination of gestational age by ultrasound in Malawi, the first day of the last menstrual period is used to calculate gestational age. This might not always be reliable and can for example be influenced by depot contraceptive usage or long-term breastfeeding after previous pregnancies. In a significant majority, gestational age was completely unknown, but the majority of birthweights (76.5%) was above 2500 g, suggesting that the number of very preterm births by caesarean is limited.
A major limitation of the study was lack of documentation. Inclusion was done based on complete partographs. While case notes with complete unfilled partographs were not included, it sometimes still remains unclear whether a partograph contained all information supporting the decision for caesarean section. For example, a last foetal heart rate or vaginal examination prior to the procedure on which the decision of foetal distress was made, may have been forgotten to be documented, leading to cases being labelled as unknown. Furthermore, there may be underreporting of cases due to missing case files or partographs, which we believe would be on a random basis, but still may influence the calculated caesarean section rates. Poor documentation during labour not only provides a challenge for data analysis, it also burdens the clinician making the decision for caesarean section. If little is known about progress or foetal condition, one may decide more quickly to proceed to caesarean delivery. Proper and regular documentation assists clinicians in making correct decisions and thereby also attributes to prevent unnecessary caesareans. This is also the case with documentation of complications, which seem quite low based on our collected data. Complications can be missed due to lack of a structured patient file administration, whereby readmissions were not connected to previous admissions.
We cannot be certain that other variables in the hospital stayed the same during the study period, although our analysis was based on that assumption. Staff or policy changes may influence the decision-making process. Over the study period, there were, however, no major changes in management, protocols, or resource availability. Since the study setting is a single rural facility, small numbers or individuals could have influence on certain changes over time. The increase in caesarean section rates seen in the second and third quarters of 2015 remains unexplained, but might be influenced by staff changes. It is therefore also challenging to predict the sustainability of the observed effect. Supervision and training may have long-term effects, especially with the enrolment of surgical and obstetric training for associate clinicians [22, 23, 26]. Effectivity of task-sharing with associate clinicians has been studied previously, but not on the matter of indications and caesarean section rate [22, 27].
Ideally, interventions require to have a sustainable impact on quality of care. While most likely the tradition of Dutch MDGHTM in St. Luke's Hospital will continue for the foreseeable future, we hope that there is also a sustainable effect on clinical officers. We observed that senior clinical officers took the discussion of caesarean section indications very serious and this became a standard aspect of the morning handover meeting. With the start of a bachelor training programme for clinical officers in obstetrics and gynaecology, there will be more knowledge and experience on the obstetric level available, hopefully contributing further towards open discussions and thorough decision-making in labour. Alternatively, this could also be an opportunity for a Malawian trained medical officer.
Our study demonstrates the effect of MDGHTMs on caesarean section rate, as well as on the quality of caesarean section indications. Supervision, stimulating discussion, and audit are major parts of the work of MDGHTMs. Their background training in obstetrics is of benefit. We believe that continuation of training MDGHTMs in order to support health systems in low-income settings is important and more research into their effectivity is helpful.
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
MDGHTM:
Medical doctor Global Health and Tropical Medicine
NND:
Neonatal death
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Gajewski J, Borgstein E, Bijlmakers L, Mwapasa G, Aljohani Z, Pittalis C, et al. Evaluation of a surgical training programme for clinical officers in Malawi. Br J Surg. 2019;106(2):e156–65.
van Duinen AJ, Kamara MM, Hagander L, Ashley T, Koroma AP, Leather A, et al. Caesarean section performed by medical doctors and associate clinicians in Sierra Leone. Br J Surg. 2019;106(2):e129–37.
Ms. Elisabeth van Dorp and Mr. Misheck Kazembe for assisting with data collection. St. Luke's Hospital Management and staff at the maternity department for supporting the project.
This study received no funding and all expenses were paid out of the authors' own budget.
Clinical Department, St. Luke's Hospital, Malosa, Malawi
Wouter Bakker, Christiaan Huigens & Timothy Phiri
Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
Wouter Bakker, Jos van Roosmalen & Thomas van den Akker
Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
Emma Bakker, Jogchum Beltman, Jos van Roosmalen & Thomas van den Akker
Nursing and Midwifery Department, St. Luke's Hospital, Malosa, Malawi
Emily Kaunda
Wouter Bakker
Emma Bakker
Christiaan Huigens
Timothy Phiri
Jogchum Beltman
Jos van Roosmalen
Thomas van den Akker
EB, JB, and CH drafted the study protocol and involved WB in initiation of the project. TvdA and JvR provided advice during the study process. EK and TP provided local support and context. Data collection was conducted by EB under supervision of WB and CH. WB, TvdA, and JvR drafted the paper which was revised and approved by all authors.
WB and CH are both MDGHTM from The Netherlands who have worked in St. Luke's Hospital between 2016 and 2019. EB was a Dutch medical student in St. Luke's Hospital and has now graduated as medical doctor. EK is a registered nurse midwife from Malawi who was head of the labour ward department in 2016 and 2017. TP is a Malawian clinical officer in St. Luke's Hospital and holds a bachelor in Obstetrics and Gynaecology. JB, JvR, and TvdA are all consultant obstetricians/gynaecologists in Leiden University Medical Centre in the Netherlands. TvdA is also professor Global Health at the Athena Institute Amsterdam and JvR is professor emeritus at this institute.
Correspondence to Wouter Bakker.
All data were transferred anonymously into the database. Case files were collected month for month from the archives and kept in the office of the researcher during the data collection process. Name of involved health worker was not noted, only cadre. The study was approved as part of a larger study project by the National Health Science Research Committee of Malawi (approval number 1995) and fully endorsed by hospital management.
The authors declare that they have no competing interests
Additional file 1: Table 1.
Maternal and perinatal outcomes. Figure 1. stillbirth and neonatal death rates per quarter.
Bakker, W., Bakker, E., Huigens, C. et al. Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi. Hum Resour Health 18, 87 (2020). https://doi.org/10.1186/s12960-020-00516-5
Associate clinicians
Unnecessary caesareans


We don't mind a little love. See what our clients have to say about us.
Inside Out: When I met Jack Vanderlee from Jaw Drop Marketing, I was not looking or even thinking about working with someone regarding marketing. Our first conversation was not even about dentistry. It was about Banff National Park in Canada. (He lives in Calgary). Jack seemed less interested in my practice per se and more focused on me. It was then that I knew I wanted to explore working with him.
I called Jack and we spoke a few times and he came out to my office. I was expecting a meeting about advertising and marketing. But what I got was a day of Jack helping me define who I was, what I thought, and what my story was. All I could say was: Wow! Every other marketing person I ever met wanted to sell me something on who THEY thought I should be or was. This is your typical print media advertising, selling something. Jack helped me define who I was as a person, AND as a dentist. He guided me through a process of what I call Inside-Out. In my case, practice dentistry according to who I am, what I believe, what I stand for.
Our rebranding project (from Rose Dental to Good Health Dental) has allowed me to to love what I do – again. And that attracts those people to my practice, who resonate with who I am. Now they find me.
I've been working with Jaw Drop Dental Marketing for about 10 years now. Over that time, I have gotten to know the owners Jack and Astrid Vanderlee really well.
Besides this team's ability to provide remarkable, creative and effective dental marketing solutions, I experience an ongoing honesty and reliability that is truly rare today.
It has been an amazing experience working with Jaw Drop Marketing. From the very beginning, Jack was great at listening to what I was looking for and coming up with a proposal that gave me exactly what I needed. After that, his team worked tirelessly to come up with a very creative name, brand and a website. This initial phase of my marketing plan was done with great collaboration with myself and the Jaw Drop Team. It was a great experience and one definitely made easier with their creativity, experience and expertise.
Jaw Drop Marketing developed our new corporate identity (logo & tagline) and our strategic positioning in the Okanagan (BC) market place.
They were able to come up with a unique image and message for my practice. My website is 'breathing' exactly what I wanted, people can find me when they Google for dentistry services and my advertising campaign (billboard, print, radio) is on its way.
We have been in practice for more than 14 years in Noblesville, Indiana. Providing top quality dental care with a commitment to personal attention is key to our business.
Previously, I was working with another internet marketing firm.
They were prompt at cashing the cheque – but very poor at delivering a great product. After wasting $30,000.00 I felt like a complete marketing sucker. A friend urged me to try Jaw Drop Dental Marketing. Thank God I switched.
Jack (the owner / president of Jaw Drop Dental Marketing) provided a clear vision of what was possible and then customized everything to my unique situation. The entire Jaw Drop team implemented a precise, professional plan of attack to develop and implement my marketing strategy.
This company is knowledgeable, savvy, and exacting without compromise. They work diligently to develop a long term relationship of trust with their clients. I am thrilled with their results and eagerly await the future that our business relationship holds in store.


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Given Breath
"In his hand is the life of every creature and the breath of all mankind."
Posts tagged: #Joy
How could they?
How could they? How could they starve and gas six-million Jews? How could they rape innocent girls walking home from school, and kill wide-eyed children in front of numb mothers? How could they? How could they sell poor men like animals, and buy powerless women like meat? How could they ravish the virgin, once, twice, a hundred times and then leave her crumpled on the street, forever to feel like garbage? How could they? How could they reach into the warmthRead more
"What's stealing your joy?"
At age twenty-six, I was hired, miraculously, as the head women's volleyball coach at NC State University in Raleigh, NC. During the interview, the Athletic Director asked repeatedly if I knew what I was getting into (I didn't). Would I really be able to handle the many facets of a head coach position as I had exactly, uh, no experience in high-level Division I coaching? "What, Mr. Athletic Director?! Haven't I mentioned that I'm a seasoned twenty-six-year-old? I've lived longRead more
Above All: Guard Your Heart
We are walking and talking on a sunny trail, wrestling out loud with our first-world problems. First-world problems are those that arise in places like Austin, where there is plenty of food in the pantry, clear water flows freely from the shower, and there are three first-class hospitals within ten miles. Our problems seem petty in comparison to the despair in much of the world, but they are our problems all the same. A heart that is dead, or numb,Read more
Are We More Spiritual Than God?
I was asked this week about the Hunger Games. Did I read the book? Did my boys? Would I allow them to see the movie? My friend was wrestling hard. She had been given a verbal smack-down by a peer for allowing her young teens to read the books. How could she? She was feeling irresponsible and low – flailing in a pool of parental guilt. Full of empathy and understanding, I started to laugh. Why is it easier toRead more
What would you count as a loss?
A year from now, after all you are certain to face, what would you count as a win? More importantly, after all the energies you are bound to expend in the upcoming year, what would you consider a loss? I posed this question to a roomful of women at a recent retreat. We were identifying the current battles women fight on every front regarding fitness, food and the ever-more-difficult effort required to be fabulous every waking minute. The she-soldiers were aRead more
"Dead men tell no tales." It's the creed of good pirates everywhere. Celebrating a 7-year-old's birthday this weekend, we stepped aboard the Pirates of the Caribbean boat-ride at Disney World. DEAD MEN TELL NO TALES was scrawled on dungeon walls (in blood? Ooh!) and whispered ominously over the speakers. We rode slowly through caves of lust and loot and observed the bawdy behavior of 1970's, wildly politically incorrect pirates. I wondered how much my kids were taking in? Behind "It's ARead more
Whatever is good, lovely, excellent, or praiseworthy – think about these things: Given Breath is on Facebook
Every ten days (or so) a Given Breath post quietly makes it's way into the world. Would you like it to head your way?
Every ten days (or so) a Given Breath post quietly makes it's way out into the world. Would you like it to head your way?
Whatever is commendable, beautiful, true, or just- set your mind on these things: Given Breath is on Twitter


INDIANAPOLIS – Citizens Energy Group will close both northbound lanes and the easternmost southbound lane of Meridian Street before today's evening rush hour to repair structural failures in a 110-year-old clay sewer, brick manhole and connecting storm inlet.
All northbound traffic on Meridian Street will be detoured at 38th Street, redirecting vehicles to Illinois Street and Pennsylvania Street, and returning traffic to Meridian at 46th Street. Citizens crews will work around the clock until the work is complete, which is anticipated to last three days. Meridian Street is expected to open back up by the evening rush hour on Friday, February 8.


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Q: POST to /likes only works after GET - bug or by design? My app has permissions to "like" something on FB on a user's behalf. Using the Facebook C# SDK (5.4.1), here's what I wrote:
Facebook.FacebookClient fb = new Facebook.FacebookClient(AccessToken);
object o = fb.Get("1234567890_12345678901234567/likes");
dynamic parameters = new ExpandoObject();
dynamic success = fb.Post("1234567890_12345678901234567/likes", parameters);

The second line is superfluous and creates an unnecessary round-trip, as we're not interested in the other "likes" on the same object. However, without it, fb.Post fails and throws "The remote server returned an error: (400) Bad Request."
Is this a bug in the C# SDK, or a bug in the graph API, or is it by design?
Note that it's possible to POST to /comments without a previous GET.

A: Yes, it should be possible to do post commands without a get.  Strangely enough, my like code with the 5.4.1 does not require the extra GET directly before the POST for doing a like.  Maybe somewhere else in my app's flow I've already done some sort of GET via the API.  However, I'm going to investigate my DELETE problem with me/permissions that I'm encountering (http://stackoverflow.com/questions/8598614/facebook-c-sharp-api-return-400-when-deauthorizing-app) and see if a get to the me/permissions first will help resolve that issue.

redpajama_set_name: RedPajamaStackExchange


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Less is More set to record first album
March 7, 2014 Kurt Miller Arts/Culture, Features, Headline 2
A passion for music and a need to play have led to the beginning of quite the journey for Jane Finkel, Mackinac Island senior, and Brian Spencer, '13 alumnus. Less is More, the name of their alternative/folk band, is set to record its first album next week, as the two travel to Franklin, Tenn. over Albion's spring break.
"After graduating from Albion, I headed down to Franklin to complete an accelerated audio engineering and sound production program at The Dark Horse Institute," Spencer said. "My connection with that program has allowed us to head down there and record at a discounted rate, with some of the best equipment and resources that the industry currently has to offer."
The upcoming album has been in the works for the past two years, and according to Spencer, the album will spell out where the group sits mentally as they look to dive into the giant music industry.
"Music isn't something that either of us want to do," Spencer said. "It's something that we need to do. We love it that much. I think that distinction is very important. We are entering into an industry where examples of failure are all around us, yet here we are, unafraid and more driven then we were the day before."
Finkel and Spencer began working together during Finkel's sophomore year and Spencer's junior year, but it wasn't until two years later they started to write their own original songs.
"One of our earliest ventures was our 'Hey Ya' cover," Spencer said. "It was just an Outkast cover, but it was the first time our creative minds started swimming in the same pool. It was a very neat feeling to be on such a similarly creative and open playing field, right from the very beginning."
While their music and flow seemed to come naturally, one thing did not. Coming up with a name for the band. After the two struggled to come up with a name for a while, they finally came to a definitive decision.
"One morning my papa walked down with a shirt that said 'Less is More,' and it was at that breakfast table that we decided on our name," said Finkel. "It wasn't until we went to make our Facebook page that we realized it was also a toilet paper ad, but so far no one has walked into one of our shows thinking it was a toilet paper convention."
Since then, the two became a favorite at Cascarelli's on Monday nights while Spencer still attended Albion, and they recently performed at Crunchy's in East Lansing on Feb. 28. Their Facebook page keeps their fans up to date with new songs, gigs and more.
Dennis O'Dowd, '13 alumnus, had the opportunity to play with Less is More many times during his time at Albion.
"When they learned I had started playing the violin, they asked me to sit in on a few songs during one senior bar night," O'Dowd said. "I remember that at the end of the two songs I was in on, they all looked at me and Brian said, 'dude, could you do this like all the time?'"
Despite the group's willingness to incorporate guest artists when they perform, Spencer said he doesn't see any additions to the group being made any time soon, although it's not something him and Jane have talked about.
"I really love how Brian and I work together, and I'm not sure how another person would change the dynamics," Finkel said. "But never say never."
For now, Less is More is simply excited for their future, what it holds and they can't wait to begin living out their dream.
"Our dream is to touch somebody through our music," Spencer said. "Our dream is to sustain a living through playing our own creations for people that want to hear them. Ultimately, though, our dream is to help people as well as ourselves, through our music."
Their album is set to be released in mid-August at a release party on Mackinac Island, and they plan to go on tour shortly after in the fall with two of their good friends.
"Brittany Holt is a writer and will be documenting the tour through poetry and updating the Less is More blog," Finkel said. "Alex Essex-Carmona is a videographer, and he will be documenting the trip with short videos for our blog, and creating a documentary of our experiences. What could be more fun than working hard for what you love with people that you love?"
Photos courtesy of Less is More
Arts/Cultures
Brian Spencer
Jane Finkel
About Kurt Miller 37 Articles
Kurt Miller is a senior from Ann Arbor, Michigan majoring in Mass Media Communications and Economics and Management. He's passionate about all things sports and was a member of Albion's men's soccer team for four years. Follow him on Twitter @ShirtMiller.
Q&A with Andrea Walles
From visual to musical art
Hi! Quick question that's completely off topic.
Do you know how to make your site mobile friendly? My blog looks weird when browsing from
my iphone4. I'm trying to find a template or plugin that might
be able to correct this problem. If you have any recommendations, please
share. Cheers!
Less is More, Plus Two More | Meanwhile in Brooklyn...


Who is Responsible for Who Gets Paid?
Who to pay? It starts to feel a little like "Who's on first, What's on second and I-don't-know is on third" when we start to look at complicated mortgage transactions these days. We have mortgages, deeds of trust, lenders, assignees, beneficiaries, lender's servicing agents, trustees, securities, exchange securities, and more.
Here, as happens, title companies are charged with collusion in a complicated Ponzi scheme. I question how we legitimately know who should be paid in some of these complicated transactions. Should the check for a payoff go to the Lender holding the Mortgage or to the Servicing Agent, in hopes it will be properly credited? Did the title company know the scheme?