The Outside Blog

Skiing and Snowboarding : Science

Have Injury, Will Travel

AFTER DECADES of skiing and hiking, Anne Bujakowski's knee was toast, and she needed surgery—badly. So the 45-year-old Californian made a surprising decision: she flew halfway across the world for the operation.

"It was the best thing that ever happened to me," Bujakowski says of her 2010 knee replacement in Singapore.

Bujakowski had health insurance, but her employer, Snow Summit Mountain Resort, in California's San Bernardino Mountains, had just launched a program offering employees significant savings on copays and other costs by going abroad for surgery. Insurance paid for the Singapore trip, including airfare, meals, and ten nights in a luxury hotel while she completed her physical therapy. Her out-of-pocket costs? Nothing. In the U.S., they could have been as high as $20,000.

Traveling abroad for surgery is now a $40 billion industry, and it's growing by 15 to 25 percent annually. In 2013, some 900,000 Americans are expected to seek treatment overseas. The reason is obvious: skyrocketing medical costs at home. In the U.S., knee replacement surgery runs an average of $48,000. In Thailand, it's $10,000. A bilateral hip replacement in the U.S.: $100,000. In India: $14,000. Generally speaking, surgeries are about 80 percent cheaper abroad, and if your insurance has international coverage, out-of-pocket expenses are usually minimal and sometimes waived entirely.

Most people who travel abroad for medical care are uninsured or underinsured, with high-copay or high-deductible insurance, says Glenn Cohen, a professor at Harvard Law School who studies medical tourism. And a large number of them are younger, more adventurous patients, often because they have less-comprehensive insurance plans that don't fully cover the cost of, say, a blown ACL from skiing or a torn rotator cuff from kayaking, and also because they're more open to the idea of undergoing a medical procedure in a foreign country. According to a recent poll, 51 percent of millennials would consider going overseas for surgery, compared with only 29 percent of seniors.

Of course, the first question everyone asks is: Is it safe?

"Most overseas doctors are just as qualified or more qualified than the doctors in the United States," says Geoff Moss, vice president at Planet Hospital, a California company that brokers medical-tourism trips. "And the nurse-to-patient ratio is better. You get round-the-clock attention."

Over the past dozen years, companies like Planet Hospital have sprung up to help clients navigate the sometimes daunting experience of choosing a foreign hospital. The companies provide dossiers on surgeons and independent reports on facilities, send you patient reviews, and arrange follow-up appointments with a stateside doctor when you return home. Many take care of travel plans, from buying plane tickets to booking presurgery adventures. Most of the doctors they endorse studied in the United States or the United Kingdom and are fluent in English, and their hospitals are just as proficient in patient care.

Patrick Follett, 59, used Planet Hospital to arrange a hip replacement in 2012. For years, Follett raced mountain bikes, skied, and competed in triathlons. But his hip was so beat up that it eventually became difficult to climb stairs. After consulting with Planet Hospital, he drove from his California home to the Mexican border town of Mexicali and got a new one, selecting a hospital and a surgeon from a list provided to him.

Despite his trepidation—"It's a Third World country down there," he says—the Mexican hospital was "immaculate." Plus, unlike in the U.S., he didn't feel any pressure to speed through his recovery so he could be discharged. Most important, his new hip is working perfectly.

"I've been riding my bike like a madman," he says.

Stories like Follett's have some countries seeing dollar signs and beefing up their medical systems to meet demand, building shiny new hospitals and launching multimillion-dollar global ad campaigns. Inbound passengers at Seoul's Incheon International Airport are now greeted with a fully staffed information booth. The Czech Republic has its own medical-tourism website.

Meanwhile, various nations have earned a reputation for mastering certain procedures. Want a face-lift or cosmetic dentistry? Look to Mexico or Brazil, which have long catered to quick nips and tucks. Heart surgery? Think India or Japan, which have invested millions in cardiac hospitals. For those seeking orthopedic surgery for sports injuries, Southeast Asia and Eastern Europe are top picks.

Moss says that most of Planet Hospital's clients choose their country and hospital based on quality of care, but that doesn't stop them from viewing the experience as the trip of a lifetime, especially if they have a lot of sick days saved up. "I always hear, 'Before I have my joint replace-ment or spinal surgery, I want to see the palace, I want to see Phuket,'" he says.

There are risks—in particular, what to do if something goes wrong with the procedure. Rates of medical complications are difficult to pin down, but experts say that surgery at an accredited hospital can be as safe as surgery in the U.S. Still, they recommend that you bring a friend on the off chance that things take a bad turn (see "Tips for Overseas Surgery," below).

Demand for these trips should keep rising, even under the Affordable Care Act, which went into effect in October. According to the most optimistic forecasts, there will still be some 23 million uninsured Americans. And those who are newly insured may only be able to afford inexpensive plans with scant surgical benefits. Additionally, Cohen says the number of companies that, like Snow Summit, offer employees the option of undergoing surgery abroad should increase in the next few years.

So if you have a busted knee, a stiff hip, or a torn rotator cuff, take heart: you'll always have Bangkok.                 

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Tips For Overseas Surgery

1. Plan ahead.
Look at least six months out, which is probably how long it will take to get all your ducks in a row.

2. Consider a medical travel agency.
A good broker can arrange everything from preoperative consultations to postsurgy physical therapy. It can also help arrange follow-up appointments in the U.S..

3. Look for accredited hospitals.
Joint Commission International
inspects hospitals for high standards of care and lists facilities that specialize in procedures. Some might do only 50 knee replacements a year; you want the one that does 5,000.

4. Extend the trip.
Airplanes are a great place to pick up infections. Ask your surgeon when it’s OK to fly home, and don’t fly until at least three days after surgery. If you choose to spend two weeks on the beach afterward, tell your boss it’s doctor’s orders.

5. Buddy up.
Bringing a friend along adds to the cost, but a trusted ally can calm nerves, offer moral support, and, in the rare event that com-plications arise, be there to negotiate care and make alternate travel arrangements.

6. Seek Help
Medical travel agencies to help plan—and get you through—your surgery abroad:
360 Global Health

Med Retreat
Patients Beyond Borders
Planet Hospital

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The Long Road Home

On a thundery mid-August afternoon in Telluride, Colorado, Margaux Mange is hiking backward down a steep run on the front side the local ski resort, shaking a plastic juice container full of pebbles. "Beep! Beep! Blind man coming through!" she yells, as four wounded veterans from Canada and Australia scatter to the left and right. She shakes the pebbles faster, adding a rhythmic, maraca flair, yelling, "Ivan, come this way!"

"This is a lot harder than the military," says Therese Frentz who walks a few steps behind her blind teammate, Ivan Castro, an active Army Special Forces Captain. With soft, yet firm encouragement, Frentz tells Castro where to plant his two trekking poles in order to avoid tripping over rocks and slipping in the mud.

Today is another rigorous (if scenic) training day for the injured soldiers, who are preparing for The South Pole Allied Challenge (SPAC), a 221-mile, 20-day race across Antarctica. On November 28, three seven-person teams—four wounded veterans, two mentors, and one guide—from the United States, the United Kingdom, and a combined group from Australia and Canada, will be dropped off on the wind-blown sastrugi of the 9,800-foot Antarctic plateau and, pulling 175-pound sleds, will race on skis to the South Pole.

The U.S. team's guide and overall expedition leader—and the man responsible for loading everyone down with water jugs on today's grueling hike—is Inge Solheim, a Norwegian polar explorer who has led more than 15 expeditions to the North Pole and successfully guided a blind man to the South Pole.

"If I push them to the edge here, they will land in Antarctica with much better confidence," Solheim told me at the beginning of the hike. "I want people to find their weak spots now and not on the ice. This is not boot camp, but it is a unique opportunity for really good training. Our goal is to get everybody safe to the South Pole."

The women's teammates are Ivan Castro, 46, who lost his eyesight, his right index finger, and was riddled with shrapnel in a rooftop mortar attack in Yusifayah, Iraq in September 2006, and Mark Wise, 28, an Air Force academy graduate and commissioned Army officer, who was blown up by an IED in Kandahar, Afghanistan, in October 2009. He fractured all the bones in his face, blew out both knees, ruptured his eardrums, lost extensive tissue in his left shoulder and three fingers on his left hand.

The U.S. team's mentors, who couldn't make the Telluride trip but will be on the South Pole trip, include the Swedish actor Alexander Skarsgård, an accomplished outdoorsman best known for his role as vampire Eric Northman on the HBO series "True Blood," and Ed Parker, the co-founder of UK-based "Walking With the Wounded" (WWTW), the non-profit that organized the SPAC expedition as a fundraiser to help wounded service people, with additional support from U.S.-based non-profits "Soldiers to Summits" and "Soldier On," and Canadian non-profit "Soldier On/Sans Limites." Also on the all-star roster: Prince Harry, "Walking with the Wounded's" staunchest supporter and patron, will ski to the South Pole as the mentor for the UK team.

 

AS PART OF AN INFORMAL pre-expedition motivational tour, Frentz and Mange are in Telluride to take part in the "No Barriers" summit, a bi-annual four-day gathering of more than 500 people whose lives have been affected by disabilities—of any kind. The women are also here to train with their U.S. teammates and the Australia-and-Canada Commonwealth Team, a.k.a. "The Commies," all of whom have returned from war severely wounded.

They are also the first women, along with Kate Philp on the UK team, to participate in WWTW, which  uses expeditions to places like Mount Everest and the Poles as a kind of therapy to help wounded vets overcome the physical and mental ravages of war.

Frentz and Mange could pass for sisters, with long brown hair pulled back into tight ponytails and strong builds that indicate serious athleticism. In high school Frentz, 33, was a tennis and volleyball star in Wakulla County, near Tallahassee, Florida. Mange, 28, scored 76 career soccer goals for Alameda High School in Lakewood, Colorado, earning her a spot on the 4A division all-state team. But still, today's training hike to almost 12,000 feet has been rough. Since the women started 3,500 feet below, each has struggled to carry a 20-liter water jug in her pack, the sky has unleashed intermittent hail, and residual pain from traumatic, permanent injuries has flared.

In March 2007 Mange, now a medically retired Army Sargent who lives in Yuma, Arizona, with her Marine fiancé, was blown up by an IED in Baghdad, Iraq, while driving in a Military Police convoy. Her best friend, Sargent Ashly Moyer, who was in the tank behind her, died in the attack. The explosion left Mange with severe traumatic brain injury in the form of occipital and trigeminal neuralgia, the latter which is so painfully sensitive that even the light sensation of her own hair brushing against her cheek can set off brain-crushing headaches.

Frentz, now a medically retired Air Force Captain who lives with her husband, a park ranger, in Seminole Canyon State Park, Texas, was hit by the blast of a suicide bomber who stood just ten feet behind her in Baghdad's Green Zone in October 2004. The explosion left third-degree burns over 30 percent of her body. The trouble with hiking, or any outdoor activity for Frentz is that the scars are sensitive to sun and she abhors unveiling them in public, so even on this 70-degree day she is covered head to toe in a long-sleeved shirt and pants, and wears special gloves on her hands. To further complicate matters, the scar tissue impedes sweating, which makes it nearly impossible for her to thermoregulate, though on expeditions they were fitted with specially designed clothing from Helly Hansen to help accommodate the injuries. On top of their physical injuries, both women suffer from Post Traumatic Stress Disorder (PTSD), compounded by waves of depression.

"It would be so lovely to wear short sleeves and shorts," says Frentz as she hikes. "What a cooling thought."

 

OF THE 2,558,176 OF THE U.S. service members who have deployed in support of the wars in Iraq and Afghanistan (Operation Iraqi Freedom, Operation New Dawn, and Operation Enduring Freedom), 306,177 have been women. Of those women, 978 have been wounded in action. Of the 1.8 million total U.S. women veterans, one in five who are seen by the Veterans Affairs health care staff are diagnosed with PTSD. Many, many more cases go undiagnosed. If the wars continue, these numbers will only increase. The Office of Veterans Affairs projects that by 2020, women will comprise more then 10 percent of the veteran population.

"In previous expeditions we've had no women on the teams and focused only on physical injury," says WWW's Ed Parker. "But," he adds, "women get wounded just like men and there are four times as many mental injuries returning from war as there are physical."

Healing war wounds, whether physical or emotional, is a long, slow process. According to one study, it takes women veterans an average of seven years to fully acclimate to civilian life upon return from deployment. So after everything Mange and Frentz have already been through, why have they signed on for a relentless 20-day trek across a frozen landscape with threat of frostbite or worse?

"It's the ultimate challenge and I'm an adventure junkie," says Mange. But she admits there's more to it than that. "Everyone highlights the war amputees and no one focuses on the invisible wounds like traumatic brain injury. I want to help that cause." Dig deeper and there's an even more painful reason. "Every time I want to give up, I put my best friend Ashly in my head. She's dead. She can't go to the South Pole. I'm alive, and I can."

Frentz, the quieter of the two women, offers another perspective. "This expedition brings back the good parts of being in the military," she tells me. "I really loved the unit I was in and this reminds me of being part of a little family unit again, without the risk of a mortar landing on me." 

 "PTSD and other invisible wounds can be very isolating for women," says Dr. Erin Krebs, the Women's Health Medical Director at the Minneapolis VA Health Care System. "Avoidance makes those symptoms worse and prevents recovery. Women who do best with these kinds of injuries have accepted their new normal," says Krebs. "They have accepted that 'this is my new body, my new life, and I'm going to live the best life I can with what I've got.' Being brave enough to go out there and do this intense expedition relying on your team members, can be an incredibly powerful experience to help overcome these traumas."

Both women returned from the front lines, forced to cope with a new reality. Thera Storm, Therese's twin sister, who, along with the twins' mother, quit her job and moved from North Carolina to San Antonio, Texas, for six months to nurse Therese's burns, has helped her sister accept the loss of her past self. 

"Therese was a 24-year-old single woman who had burn scars all over her arms," says Thera. "She was feeling very exposed and vulnerable. Here I am, seeing the pain going on in her head, her mind, and her heart, watching her wonder what her life is going to look like."

Thera continued, "Therese has always been number one at everything she does and she has had to completely re-identify herself. It took this trip to the South Pole for Therese to start to realize that she can be the alpha female again. If anyone can make it in Antarctica, it would be her."

For Michael Mange, Margaux's father and her self-described "life coach" during her 27-month deployment, the South Pole is a natural fit for his daughter.

"After what I've lived through with her, I really don't worry about Margaux," says her father. "This is something that will keep her moving forward. She's with a great group of people and they are getting great training. All she needs to provide is the attitude and gumption." 

Jason Duvall, a research scientist at the University of Michigan School of Natural Resources and Environment co-authored a recent study that links outdoor activity to improved mental health in veterans. The study found that "one week after a multi-day wilderness recreation experience veterans reported a greater than 10 percent improvement in several measures of psychological well-being, a 9 percent increase in social functioning, and a nearly 8 percent gain in positive life outlook." In some cases the results lasted for a month.

"One of the things that was very surprising to us," says Duvall, "was that spending time outdoors seems to be most effective to those veterans who were most severely impacted by mental or physical wounds."

 

FRESH AIR DOES SEEM to be easing tensions on this weeklong training mission in Telluride. On a coveted rest day squeezed between an intensive gym workout involving hundreds of squats, bushwhacking elk trails above Telluride, and a 4,700 vertical-foot climb to the summit of 12,818-foot Ballard Mountain, and tackling the Via Ferrata (traversing a dizzyingly exposed cliff on Ajax Mountain while clipped into the safety of iron rings), the two teams are taking it easy in the 73-degree sunshine at Ridgway State Park, a reservoir of turquoise water surrounded by steep canyon walls.

For an idea of just what Frentz, Mange, and their expedition mates are in for; today's temperature in Telluride is 110 degrees warmer than the -40F average they will experience in Antarctica.

Paddling a solo kayak, Mange playfully rams Frentz and Castro's tandem kayak.

"Margaux!" yells Frentz, while Wise plays around with an adaptive device for his left hand that will make paddling easier.

Meanwhile, Solheim is doing a headstand on a standup paddleboard and Mange has moved on to splashing the "Commies."  

"These guys are, like, seven feet tall," she says of her competitors. "They can kick our ass any day, but we definitely have more heart."

A few minutes later Mange, Frentz, and Castro return to the beach and Mange and Castro swap out their kayaks for a standup board. They paddle, sitting down, into deep water where Mange slowly, patiently talks Castro through standing up. After he gets his balance, she stands behind him and the two paddle through the choppy water like pros.

Later on, I privately ask Castro what he thinks of his two female teammates. "Margaux is very young, bold, brave, and in great physical shape," he says. "Therese is exactly the same way, but she is very conscious about her scars. I keep telling her that beauty isn't only on the outside. One day she finally took off her long-sleeve shirt and I said, 'Man, you need to be proud of those. They're your battle scars.'"

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Sizing Up Sally Jewell

THE INTERIOR SECRETARY recognized the jacket and boots I wore to her office. Four months earlier she’d been selling them.

“They let you in here wearing that?” Sally Jewell said, giving the once-over to my North Face soft shell and Zamberlan hiking boots.

Jewell, the former REI chief executive who is now in charge of one-fifth of the U.S. landmass, 700 million acres of subsurface mineral estate, 1.7 billion acres of offshore territory, 401 national parks, 561 national wildlife refuges, 476 bureau of reclamation dams, 2,055 endangered or threatened species, and the maintenance of good relations with 566 American Indian tribes, smiled and led me into her working quarters.

“Holy shit,” I couldn’t help but blurt out.

The office of the Secretary of the Interior has long been one of the most formidable redoubts in the federal government. In scope the corner suite rivals the state of Montana—if Big Sky Country were carpeted in royal blue.

“I know,” Jewell said. “I’m still getting used to the size of it.”

The same could be said of Jewell’s new job, which the sinewy, silver-haired, 57-year-old executive took over in early April. In the 164-year history of the Interior Department, no incoming secretary has faced such a steep learning curve. Last December, she had nothing more pressing on her mind than the holiday sales figures at Recreational Equipment Incorporated, the outdoor-gear cooperative she’d run for the past eight years. Then came a phone call from President Barack Obama, who offered an upgrade she couldn’t refuse.

"This is the one job I would have left REI for,” she told me. “I’m not sure there’s another one out there.”

If the offer was a surprise to Jewell, it was equally unexpected to members of the capital’s chattering class, none of whom had Jewell on the list of likely successors to Ken Salazar, Obama’s first-term Interior boss. With zero political experience and an eclectic three-phase career (petroleum engineer, banker, outdoor retailer), Jewell gave everyone something to love—and to worry about. The American Petroleum Institute liked her oil-field experience. The Natural Resources Defense Council saw (it hoped) a nominee with “the heart of an environmentalist and the know-how of a business woman.”

For the outdoor industry, her appointment brought long-sought recognition of recreation’s place on public lands. Here was a cabinet secretary whose adventure résumé rivaled her executive CV. She’s climbed Antarctica’s Vinson Massif, and she summited Mount Rainier the first of seven times at age 16. “This is a paradigm change, not just for our industry but for America,” says Black Diamond CEO Peter Metcalf, who once shared a rope with Jewell on Liberty Bell, a classic climb in the North Cascades. “Secretary of the interior is traditionally a job given with a nod to industries like oil and gas or ranching. Today, much of the GNP on public lands comes from non-extractive industries like recreation, tourism, and ecological services.” Now, Metcalf says, “politics have finally caught up with reality.”

“You’ve got somebody who fundamentally gets the fact that there’s a huge economic stream” flowing from protected wildlands, says Adam Cramer, who heads the outdoor alliance, an industry group that lobbies for recreation and conservation. “Oil, gas, timber, and grazing aren’t the only ways to make money from the federal estate.”

President Obama agrees. “She knows the link between conservation and good jobs,” he said in announcing Jewell’s nomination. “She knows that there’s no contradiction between being good stewards of the land and our economic progress—that, in fact, those two things need to go hand in hand.”

In a nod to her passion for the outdoors, Obama said, “For Sally, the toughest part of this job will probably be sitting behind a desk.”

Hardly. The toughest part may be keeping Interior relevant at a time when the biggest environmental battles are being fought on the turf of rival agencies. Jewell has plenty on her plate, to be sure. In the next three years, her department will set new rules for fracking on federal land, oversee the first offshore Atlantic wind installations, decide whether to list hundreds of proposed endangered species, double the number of renewable-energy projects on public land, regulate offshore Alaskan oil exploration, and defend the Arctic National Wildlife Refuge (ANWR) against the ever present threat of oil and gas exploration. But the signature green campaigns of Obama’s second term are being waged by the Environmental Protection agency, where carbon regulation will be shaped, and, of all places, the state Department, which will help decide the fate of the Keystone XL pipeline.

Oh, and there’s one other thing on her to-do list. Interior secretaries traditionally bear the burden of establishing a president’s environmental legacy. Stewart Udall, the secretary under both Kennedy and Johnson, created the Canyon Lands and North Cascades National Parks and the Appalachian National Scenic Trail, and he oversaw passage of the Wilderness Act. Walter Hickel, Richard Nixon’s Interior head, saved the Everglades when developers wanted to turn it into the world’s largest airport. Under Bill Clinton, Bruce Babbitt gave the department a transfusion of environmental values and created the National Landscape Conservation System, which helps safeguard 27 million acres of BLM land. Even Dirk Kempthorne, George W. Bush’s second-term secretary, managed to create the world’s largest marine protected area, the Northwestern Hawaiian Islands Marine National Monument.

So far, Obama’s legacy is muddled at best. If he left office tomorrow, he’d be known for his ramp-up of renewable energy, for being not as bad as W., and for not much else. When I first spoke with Jewell, she was still emerging from senate confirmation mode: smile and speak only in vague platitudes. “I’m finding my way with a lot of help from the people here at Interior,” she told me. “My primary focus has been on listening. Listening to what’s been done before me, listening to the mistakes that others have made. Listening to the president and his agenda, and considering the role that Interior can play.” It wasn’t a bad early strategy: ears open, mouth shut. But before long, Jewell would have to stop listening and start acting. Because she faces one of the biggest challenges in Washington: creating an environmental legacy for a president who seems indifferent about having one.

When Obama took office in early 2009, environmentalists’ hopes were over the moon. The ruinous record of his predecessor was best summed up by Robert F. Kennedy Jr., who predicted that “George W. Bush will go down as the worst environmental president in U.S. history.” Much of the damage had taken place in and through the Department of the Interior, which, under Gale Norton, had become a den of corruption.

Bush’s appointees made oil and gas leasing their top priority, demoting conservation-minded managers, harassing scientists, cutting secret deals, partying with drilling executives, and encouraging greasy lobbyists like “Casino Jack” Abramoff, who scammed Indian tribes on casino deals, to roam the halls of Interior headquarters at 18th and C. In 2006, Inspector General Earl Devaney, charged with making sure Interior officials followed the law, summed up the situation under Norton: “simply stated, short of a crime, anything goes at the highest levels of the Department of the Interior.”

In 2007, Steven Griles, Norton’s right-hand man, was sentenced to federal prison for obstructing the investigation into the Abramoff scandal. Abramoff himself pleaded guilty to conspiracy, mail fraud, and tax evasion. Norton was later investigated but never charged over unrelated conflict-of-interest questions raised about leases won by the oil giant Royal Dutch Shell, for whom she went to work upon leaving Interior.

To rehab the department, Obama chose Ken Salazar, a Colorado rancher and an old friend from the Senate. The day Salazar was sworn in, White house chief of staff Rahm Emanuel walked up to Tom Strickland, Salazar’s deputy secretary, poked him in the chest, and said, “Clean up that mess.”

Salazar took out the trash. He immediately withdrew 77 oil and gas leases in Utah’s red-rock country—more than 100,000 acres—auctioned off in the final days of the Bush administration (and made famous by eco-activist Tim DeChristopher, who was imprisoned for false bidding) and revised leasing rules to prevent another Utah debacle. He issued a 20-year ban on new uranium mining around the Grand Canyon. He also moved quickly to appoint conservation-minded directors of the U.S. Fish and Wildlife Service, the Bureau of Land Management, and the National Park Service. Fish and Wildlife began moving dozens of stalled endangered-species listings through the evaluation process.

Job one for Salazar, though, was renewable energy. Solar and wind projects had been back-burnered by Bush’s BLM officials; for eight years, not a single solar project had been approved. Declaring Interior “the real department of energy,” Salazar replaced Bush’s “drill, baby, drill” policy with a shine-and-spin initiative. He fast-tracked 35 solar, wind, and geothermal projects—capable of generating 10,500 megawatts, enough to power 1.6 million U.S. homes—and approved offshore wind turbines along the Atlantic coast. When conservationists raised alarms about flyways turning into bird blenders and solar projects destroying desert tortoise habitat, Salazar responded with a siting process, called smart from the start, that identified appropriate zones for future renewables development.

That didn’t slow down oil and gas production. In Obama’s first three years, his all-of-the-above energy strategy produced more oil than Bush did in his final three years. The BLM approved about 4,000 drilling permits per year—down from the record number issued under Bush, but twice the permitting rate of the 1990s. Oil and gas data are notoriously susceptible to political skewing, but to get a real sense, look to the number of leases challenged by grassroots groups like the Southern Utah Wilderness Alliance. SUWA went bonkers during the Bush years, protesting hundreds of leases in fragile habitat. In 2009, 47 percent of all leases sold were challenged in federal court by environmental groups. By 2012, that number had fallen to 18 percent.

Like Obama, Salazar was just moderate enough to infuriate conservative critics and disappoint environmental allies. When Fish and Wildlife listed the polar bear as endangered in 2008, Kempthorne infamously slipped in a rule prohibiting the government from using the Endangered Species Act to regulate greenhouse-gas emissions, the very cause of the bear’s decline. Salazar froze Kempthorne’s order—but ultimately allowed the controversial clause to stand. After breaking up the inept Minerals Management Service in the wake of BP’s Deepwater horizon spill, he let Shell conduct oil exploration in Alaska’s rough and risky Chukchi and Beaufort seas.

Overall, environmental advocates seemed to give Obama passing grades: a B minus or a solid C. “I had high hopes for this administration,” says Jamierappaport Clark, executive director of Defenders of Wildlife and the head of Fish and Wildlife under Bruce Babbitt during President Clinton’s second term. “From an imperiled-wildlife and conservation stand-point, the first term has been disappointing. It’s hard to look back and see anything bold, aggressive, or earth-shattering.”

“Interior needs a visionary, not a mechanic,” SUWA legislative director Richard Peterson-Cremer wrote when Salazar stepped down. “The Obama administration has a real opportunity to change its course on public lands. The question is not whether it has time enough and space—it does—but whether it has will enough and steel.”

“I’VE BEEN TOLD that coming up to speed in this job is like drinking from a fire hose,” Jewell told a gathering of Interior Department employees in Portland, Oregon, in June. “Actually, I’ve found that it’s more like a water main.”

The line drew chuckles from the friendly, if skeptical, DOI bureaucrats. They’d seen secretaries come and go. Many of the department’s 70,000 employees were hired during the Babbitt years, and a few are old enough to remember the 22-month term of James Watt, the Reagan appointee who still holds the crown as the most environmentally destructive interior secretary in history. Billed as a meet-the-boss session, Jewell’s day in Portland was a chance for her to shake hands and make friends in the field offices. Unlike Salazar, who arrived with dozens of allies in the senate and installed his own “Colorado mafia” of well-seasoned appointees, Jewell had to build a network from scratch, working rooms like the Portland federal-building auditorium. There, 150 staffers spread themselves in agency-specific clusters: Bureau of Indian Affairs officials over here, Fish and Wildlife biologists over there, BLM folks in the back. “Anybody from the Park service?” Jewell asked. “No? Well, I guess it is the Friday of Memorial Day weekend. They’re kind of busy.”
a natural informality attends to her. Give Jewell a lectern and she’ll avoid it. Offer the choice between a hike and a backroom one-on-one, she’ll lace up her boots. She connects with personal stories, not policy. And so, in Portland, she spoke about her life.

Born in England, she moved to Seattle at age three when her father, Peter Roffey, took a fellowship in anesthesiology at the University of Washington Medical School. Eager to fit in, Roffey became REI member #17249 and bought his first tent from alpinist Jim Whittaker. Young Sally Roffey spent weekends hiking in the Cascades and sailing the family’s eight-foot dinghy on Puget Sound. “We used to camp everywhere we went,” she recalled.

At the University of Washington, she studied mechanical engineering and met her future husband, Warren Jewell, a fellow engineering student. After graduation, the pair took jobs with Mobil Oil in the roughneck fields of southern Oklahoma. She enjoyed the work, but it was the oil business in the seventies, and the glass ceiling hung low. “I wanted to work on offshore oil rigs, but Mobil wouldn’t allow any women on their rigs, except in Norway,” she told Interior employees in Portland. “I figured that was a long way to go for work.”

Then she heard that banks were hiring engineers to help evaluate oil and gas investments. She and Warren wanted to move back to the Pacific Northwest, so she talked her way into a job with Seattle-based rainier bank. The oil boom was showing signs of shakiness, but two rival Seattle institutions, Rainier and Seattle First National bank (Seafirst), continued to lay heavy bets. Jewell steered Rainier away from a number of bad investments, and when oil went bust in the mid-1980s, Seafirst collapsed. Jewell became known as the woman who saved Rainier Bank.

There are certain kinds of people who hire on as interns and, within a few years, end up running the place. Jewell’s rise was like that. By the late 1980s, she was overseeing Rainier’s entire loan portfolio, and when she left in 1992 to join West One Bank, a smaller regional operation, she was CEO of its Washington subsidiary within a year. Meanwhile, she was raising two children, Peter and Anne, both now grown and living in Seattle. her style wasn’t aggressive or brash; rather, say colleagues, she comes across as sensible and polite. “Sally is able to judge situations in a very sophisticated way,” says Seattle attorney William Gates Sr., who is the father of the Microsoft founder and served with Jewell on the UW board of regents. “She’s a person who very often has the right answer for the question under discussion.”

REI recruited Jewell to its board in 1996, attracted by her combination of backcountry experience and banking savvy. By 2005, she was CEO. REI was a foundering ship at the time, burdened by too much debt and knocked on its heels by an ill-advised foray into Japan. Jewell closed the overseas outlet, paid down the debt (the co-op now has none), and embarked on a slow national expansion, opening a handful of well-chosen, self-financed stores every year, including a 39,000-square-foot Manhattan base camp in 2011. Last year the company’s website and 127 stores reported revenue of $1.9 billion, making it the biggest consumer cooperative in the nation.

Meanwhile, Jewell pushed a triple-bottom-line ethos that emphasized environmental ethics and employee relations as much as profit and loss. That’s Jewell’s strong suit: getting the best out of people, but in a low-key way. “She was always asking questions, soliciting points of view,” says Camelbak chief executive Sally McCoy, who worked with Jewell on the industry-supported wildlands group Conservation alliance.

One of Jewell’s favorite books is Orbiting the Giant Hairball, Gordon MacKenzie’s guide to fostering creativity within a corporate bureaucracy. It’s an idea she’s pushing at Interior. “Did you know the engineers at hoover Dam are buying spare parts on eBay because nobody makes them anymore?” she asked her staffers. “If there’s something you’re doing as part of your job that makes no sense, tell me about it. Raise a holler. One of the things I told everyone at REI was: We’ve got to stop doing things that don’t make sense and concentrate on the things that do.”
Let me help you do your job better: that’s the message going out to the field from Madame secretary. “I’m a businessperson,” Jewell told her troops. “I’ve got 30 years in business and two months in the federal government.” a lot of people do outstanding work at Interior, she said. “I want you to know I’ve got your back.” she let that hang for a moment, leaving unsaid the second half of the sentence: and I’m hoping you’ll have mine.

To do what exactly wasn’t yet clear.

ON MOST WEEKDAY mornings, Sally Jewell walks to work under the haunting eyes of her predecessors. Along the hall outside her office hang large oil paintings of Salazar, Norton, Watt, and the rest, and in the lobby there’s a bust of Udall, widely acknowledged as the greatest interior secretary of the modern era.

In case Jewell doesn’t feel the weight, every once in a while a former secretary will pop up with some unsolicited advice.

Hello, Bruce Babbitt! 
In a bit of exquisite timing, Babbitt, the most influential secretary since Udall, issued a challenge to Obama 24 hours before the president nominated Jewell. “So far, under President Obama, industry has been winning the race,” he said during a speech at the National Press Club. “Over the past four years, the [oil and gas] industry has leased more than 6 million acres, compared with only 2.6 million acres permanently protected. In the Obama era, land conservation is again falling behind.”

Babbitt called for a one-for-one scheme that would protect an acre of public land for every acre put up for lease.

It’s an idea worth considering, but it also relies on a bygone metric. Environmentalism has expanded beyond its traditional protect-the-land-and-water paradigm. These days, the movement has become as much about energy and carbon, and that expanded focus has sent policy beyond the neat boundaries of Interior. The State Department is doing the environmental analysis for the proposed Keystone XL pipeline (because the pipe, which would deliver Canadian tar-sands oil to Gulf Coast refineries, crosses an international border), which effectively gives Obama the sole up-or-down vote. Interior has criticized state’s characterization of the pipeline’s wildlife impact as “inaccurate,” and in June the president said he’ll OK Keystone only “if this project does not significantly exacerbate the problem of carbon pollution.”

"Significantly"—that’s a word that allows a lot of room to operate.

Obama said this while announcing his climate-change initiative, a series of moves that bypass Congress and deal with global warming through executive orders. Interior plays a part—the president called for a redoubling of renewable-energy development on federal land—but most of the action will continue to happen at the EPA, which ran point on carbon under first-term administrator Lisa Jackson. The centerpiece of Obama’s climate initiative is an EPA-led clampdown on carbon pollution from power plants, which accounts for more than a third of U.S. greenhouse-gas emissions. It remains to be seen whether Obama has the will to follow through; the president backed Jackson on a number of clean-air initiatives, but in 2011 he caved on tougher smog standards after big polluters screamed job loss—as they’re already doing on the power-plant rule.

As if to underscore the centrality of the EPA—not Interior—to the president’s environmental agenda, senate republicans let Jewell’s nomination proceed while blocking Obama’s second-term EPA nominee, Gina McCarthy, for 136 days before confirming her in early July. a tough-talking Bostonian who ran Jackson’s clean-air team, McCarthy wasted little time in declaring that “we will act” to cut carbon pollution. She followed up on that pledge in September, when the EPA proposed new rules capping carbon emissions from new coal and natural-gas power plants. Similar caps for existing plants—where the real battle will come—are expected in 2014.

Jewell and McCarthy may end up playing good cop, bad cop for Obama on climate change—Jewell the gentle reconciler in a fleece jacket, McCarthy the brassy brawler straight out of The Departed. It’s a good match, because the EPA will surely draw more fire than Interior. Reducing emissions hits polluters in the wallet; expanding renewables offers the promise of profit. And Jewell’s confirmation led no one to believe that she’d pull back on oil and gas development. “We will continue to pursue the president’s all-of-the-above energy strategy,” she said at her senate hearing, and she hammered the point for months thereafter.

Inevitably, Jewell’s charm offensive has to give way to tough policy decisions if she wants to be something more than a caretaker. She’s not going to be the second coming of Udall—nobody will. What saint stew wanted, he got, thanks to a compliant Congress, an open checkbook, and a president preoccupied with Vietnam. Since Jewell took office, she’s confronted an insanely hostile Congress, a government shutdown that closed the parks, and a boss whose environmental commitment seems to come and go.

Is there still room for greatness at Interior? Bruce Babbitt thinks so. “Sally Jewell has the background, she has the national constituency, and she has the president’s confidence,” he told me over the phone from his office in Washington. Babbitt, now semi-retired, ticked off those qualities as if they were tools in a Jobox—here’s your hammer, there’s your tape and nails, get to work. “She has a fantastic opportunity to address a number of important issues.”

SO WHAT WOULD a Jewell legacy look like? “I don’t think about my own legacy,” she told me back in June. “I do think about a legacy for President Obama.” Exactly what that might be remained an open question.
 The answers began to come 111 days into her term, when the secretary pivoted from listening to leading. At a speech given at DOI headquarters and webcast to field offices nationwide, she laid out the top priorities. The more traditional goals included ramping up renewable-energy production, repairing the Native American education system, and addressing looming water catastrophes like the massively overburdened Colorado River. Jewell told staffers her agenda wasn’t “radically different than what you’ve been doing. Maybe a little tweaking, a little change.”

On climate, she showed that she can be bold. “I hope there are no climate-change deniers in the Department of the Interior,” she said to her team. “If you don’t believe in it, come out into the resources. Come out to Alaska, which is melting. Go in to the sierra,” which is losing its snowpack. It was a strong, clear message that raised howls among fringe denialists but provided cover to the scientists and biologists in Interior’s ranks.

We could use more of that straight-up fact facing, the courage to point at a cow pie and call it bullshit. Specifically, Jewell has a rare opportunity when it comes to oil and gas regulations. Interior’s proposed rules for fracking on federal land are a joke, modeled on a template put out several years ago by the American Legislative Exchange Council, the conservative bill mill backed in part by billionaire brothers Charles and David Koch. Jewell commands both the respect of the drilling guys—she knows how to frack a well herself—and the support of environmentalists; she’s in a unique position to give the regulations real teeth.

Ditto the rules for siting oil and gas leases on fragile lands. An early test will come in Utah, where the BLM has proposed 82 leases for the San Rafael swell, a recreationally important and biologically rich region often mentioned for monument designation. The leases, scheduled for auction in November, pin Jewell between her oil experience and her conservationist leanings. When I asked her about the skepticism with which outdoor enthusiasts usually greet drilling, she struck a decidedly non-Babbittian tone. “I think it’s important for people to step back and look at their own lifestyle and acknowledge that it’s difficult if not impossible to not be a user of fossil fuels,” Jewell told me. “Most outdoor recreationists drive to a destination. Some walk softer than others, but we all have an impact. It’s important to understand that and not vilify the industries that we rely upon.”

Other issues are also going to intersect oil and gas. She’s unlikely to halt the full delisting of the gray wolf, but her leadership could either cause or avert a legal train wreck over the possible listing of the greater sage grouse, a bird whose habitat of existing and potential oil fields could make it the spotted owl of the Intermountain West.

Much of the action during Jewell’s term will happen in Alaska: the ANWR stalemate will likely continue, and Obama shows no signs of slowing Shell’s push into the Chukchi Sea. But Jewell has real power when it comes to Bristol Bay, breeding ground for the world’s most productive salmon runs. It’s an airport-or-Everglades issue. One of two global conglomerates planning a gold mine there pulled out of the project this fall. Jewell and Obama could build on that momentum by creating a wildlife refuge or national monument on federal land. It wouldn’t stop the mine (which is on state land), but it would throw up roadblocks. “If you’re going to allow offshore leasing in Alaska, there ought to be offsetting designations of protected areas,” Babbitt says. “Using the Antiquities Act to protect Bristol Bay is a great opportunity.”

Those are the traditional big gets for Jewell’s term. But the question remains: What does she want her legacy to be?

THE KEY to Sally Jewell is that there’s no grand ideology at work. She’s neither neocon nor neolib. She doesn’t align herself with the Aldo Leopold school of conservation or the Bill McKibben carbon-fighting corps. Policy is driven by the personal and the pragmatic. She’s got to get on the ground and see what’s going on, paddle Rhode Island’s Blackstone River, as she did in May; handle an invasive boa in the Everglades (April); or circle Washington’s Squaxin Island, as she does every New Year’s Day in her kayak. She’s worked on the Alaska pipeline; she knows the benefits oil companies can bring, and she knows the environmental harm they can wreak. Most of all, she knows what outdoor exposure did for her as a girl, so she wants to spread the gospel of adventure among the next generation.

That commitment was on display on an early June morning in D.C., when the secretary of the interior went fishing with some kids on the Anacostia River.

“How many of you have ever been fishing?” Jewell asked. A few hands went up. “How many have ever been out on the river?” Fewer hands. Their parents and grandparents didn’t use the river because, back in the day, the Anacostia was a veritable sewer. Now that it’s clean—er, cleaner—the kids don’t use it because it’s not connected to a screen.

Once the kids were herded onto a tour boat, Jewell encouraged the youngsters to bait hooks, cast carefully, reel in, and see what they’d caught. She did her best work one-on-one, talking with young girls about the outdoors, and life, and siblings, and school, and whatever. Away from the microphones, the old silver-haired white lady actually forged a connection with a couple of young African-American girls. They spoke in low voices, with long, natural silences. As they baited a hook, one girl asked, “Doesn’t that hurt the worm?”

Jewell paused before answering. “Yes,” she said. “Yes, I suppose it does.”

It wasn’t a politician’s answer. The words seemed to startle Jewell even as they came out of her mouth. But they also earned the respect of the girl, who considered the information, then continued spearing the nightcrawler.

If there is anywhere that Jewell wants to have a lasting impact, it’s here, with the next generation. “This is one heck of a platform,” she told me in her office, “to help people understand about our planet, about our public lands, about the role they play in caring for our resources.”

Indeed, when she laid out her goals for the department in July, the last two were these: “celebrating and enhancing America’s great outdoors” and luring the millennial generation into the wilds.

That first part refers to the America’s great outdoors Initiative, a fuzzy, feel-good effort created during Obama’s first term. The idea was to connect an increasingly urban, plugged-in citizenry with its public land and waterways—but nobody on Salazar’s team figured out how to give it purpose and clarity. As Jewell receives it, America’s great outdoors can become whatever she wants it to be.

She can use it to lure more Hispanics and African-Americans into the parks, to expand the constituency of the outdoors. And she can use it to get kids to unplug. Last Child in the Woods, journalist Richard Louv’s exploration of kids’ increasing disconnection from the natural world, is a touchstone book for Jewell, and she’s determined to use her bully pulpit to fight the syndrome Louv calls nature-deficit disorder.

This is where Jewell’s true passion lies, and she’s already made it a top priority. There are easy fixes she can make: she can direct park and refuge managers to reconceptualize their most accessible areas to attract underserved communities. She can empower young Park Service rangers and reach the millennials where they live, on social media. But she has an opportunity to go even bigger, to create a signature program under her watch. To do that, she could revamp Interior’s partnership with the Student Conservation Association, which provides high school and college students paid, hands-on internships in parks and wilderness areas. SCA is one of America’s greatest programs, but it’s largely unknown outside of outdoor culture. It could become a public-service option as famous as teach for America or a brand as strong as outward bound. Franklin Roosevelt had the Civilian Conservation Corps; a supersized SCA could be Obama’s next-gen public-works project. With a one-month stint in SCA, you’ll hook a kid on the outdoors for life.

Youth and climate change: those could be the overriding themes of a great Jewell administration—and the foundation of Obama’s environmental legacy.

“We need warriors for that battle on climate change,” Jewell told me when I caught up with her again in July, at a youth summit in Seattle. The secretary seemed clear and confident in her message. “If I don’t get these young people engaged, they’re not going to care about and support the outdoors. I only have three and a half years. So I gotta get going.”

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The Single Fitness Stat You Need to Know

Elite endurance athletes and exercise physiologists have long known that VO2 max may be the single greatest determinant of athletic performance. But few recreational athletes have access to the kind of specialized lab equipment typically used to assess and train their number. Now a new study in the journal Medicine & Science in Sports & Exercise suggests a reliable, yet simpler way to find your VO2 max: An online estimator using your age, weight, sex, waist circumference, resting heart rate, along with data on the frequency and intensity of exercise.

While this tool may work for large populations, it has limited use as a training tool for individuals to track changes in performance and to set targets. But athletes aren’t out of luck. You can estimate and train your VO2 max without setting foot in the lab.

What is Maximum Oxygen Uptake?
The physiology behind your max can get complicated, but it is essentially a measure of your aerobic engine size and just how much blood and oxygen your heart can deliver to your exercising muscles. Because this number serves as the ceiling on aerobic athletic performance, increasing it allows you to perform at a higher level or at the same speed with less effort. For young and middle-aged people, a max of 30-40 ml/kg/min is typical, though this number can be easily boosted with training and weight loss. World-class runners, cyclists, and triathletes are typically in the 70-85 range.

Can Max Be Estimated?
Yes, and you don’t need a high-tech performance institute to do it for you. A number of equations can help you find these numbers on your own. I contacted Dr. Andy Coggan, a Senior Scientist at Washington University School of Medicine  and author of Training and Racing with a Powermeter, for input:

You can find literature supporting anything from just under 10 to around 12 mL/min per watt as the slope of the power vs. VO2 relationship (i.e., economy) in trained cyclists. In my hands, the average would be ~10.5 mL/min per watt.

This means that you can multiply by the maximum power output (watts) you can sustain for 4-5 minutes on the bike by 10.5 and estimate the oxygen consumption associated with cycling. Account for basal metabolic rate and you get an estimate of max that is within perhaps 5 percent. A simpler way to do it is just multiply the power output you can sustain for 4-5 minutes by 12 and divide by your bodyweight in kilograms.   

Things are a little more complicated with running because the oxygen running speed relationship is much more variable than the oxygen power relationship in cycling. However, if you know your best 10k time, you can make an estimate using this equation from Dr. Dave Costill, one of the true pioneers in human performance research.  Dave founded the world-famous Human Performance Lab at Ball State University and has arguably studied more elite endurance athletes (especially runners) than anyone else.

120.8 – (1.54 x 10k time in minutes)

Using this equation
30 minutes = 75
40 minutes = 59
50 minutes = 44
60 minutes = 28

Make Your Max Rise
Making your VO2 max rise should be one of your primary goals as an endurance athlete. And there are two ways to tackle it: from the weight side of the equation or from the power production side. If you reduce your weight, your VO2 max jumps. So focusing on a sustainable junk-food-free diet is the key to lowering this number.

Equally important but sometimes harder to nudge is your power output. Pushing this number up takes a focused approach, but it also requires a low time commitment, making this one of the best ways to boost your fitness while training indoors as the winter approaches. Three times a week, complete four to six intervals in the three-to-five minute range with up to equal rest. Runners should aim to hit these repeats at their best 5k times while cyclists should target about 90 percent of the power output they can sustain for 4 to 5 minutes.

The gains you’ll see are potentially dramatic. Consider the average recreational athlete in his 20s or 30s. He weighs 80kg and has a 10k personal best of about 46 minutes.  Using the equation above his estimated max is 50ml/kg/min or about 4L/min. With interval training the power side of the equation may increase 5 to 10 percent. If he drops 5 percent of his bodyweight, or about 9 lbs, he’ll suddenly be in the 56-57 ml/kg/min range—a whole new performance category with a 10k time of perhaps 41 or 42 minutes.

Michael J. Joyner, M.D., is a physiologist and anesthesiologist at the Mayo Clinic and a leading voice in the world of exercise physiology. Over the past 25-plus years, he's published hundreds of studies, many of which have focused on how humans respond to exercise. Dr. Joyner also writes at Human Limits. The views expressed in his posts are his own and do not reflect those of his employer.

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