samedi 31 mars 2012

OCCASIONAL PLEASURES OF INTERNATIONAL MEDICINE


International Medicine has its own rewards most of which are not quantifiable. The satisfaction of helping others and also abiding by the true nature of the human idea of sacrificing for others. and of course, there is a greater chance of meeting people of your own ilk, than in a medical society meeting in the country of your origin.
A friend of mine had given me some beluga caviar from Iran. i had hand carried it to Phnom Penh and it was resting in the freezer section of the refrigerator, as it should.

I suggested to Maurits that we have dinner at Le Rits and that he bring a nice bottle,which he did. a soft cabernet sauvignon. My country, Australia does not excel in too many things but it does in winemaking and oenology..
a very nice khmer french dinner
a bottle of wine from australia
caviar from Iran
and two like minded souls....
are there other things in life, how many are they?, with such sweetness?

Malacca to Phnom Penh: A Wandering Jewish Endocrinologist


The Wandering Jewish Endocrinologist, in anthropological parlance, The Other who has a Name.. in just a couple of days, so much happens, so much does happen in the course of the day..
The incredible hospitality of the Chinese Lady of Malacca and her gentle husband each with genealogy stretching for pages and who are so proud of their ancient Chinese connections.. regaling stories from the History of China and Asia..But her hospitality was so genuine...
Then on to Phnom Penh, Cambodia where another hero of our times, Maurits, is performing daily miracles. it is a pleasure to be with a person, who is intellectual, erudite and at the same time, more for others than for himself.. A selfish person has no story.. The Maurits Cambodian Model of educating Peer Educators is so successful and impressive..
You see me with Ren, the chief Peer Educator whose knowledge of Diabetes is on par with many of the Nurse Educators in the USA even though he was studying to be a tour Guide when Diabetes was diagnosed seven years ago in this young man..He is nothing short of superb in his knowledge, organization and communication. Maurits delegates authority well and at the same time demands the best of his co workers. Two sessions I attended were both inspiring.. 

Nga is an old friend from Vietnam and it was nice to see her to say Hello, she was on her way to Siem Reap with her family.. I became instant friends with her Niece..
In between all these there was a Secret Gift.. I shall share the bounties of that isolated country when Maurits brings a bottle of wine and we shall dine on Khmer-French cuisine..

It is nice to be part of this world in which so many humble and educated people are sacrificing themselves for the welfare of the downtrodden, oppressed and marginalized..

Food was not neglected during these exciting days, Malaysia as usual was excellent for food and Phnom Penh has not been disappointing either..

dimanche 25 mars 2012

AU REVOIR, FRANCE.. I WANT TO GO HOME

This morning the sun has risen and a bright morning is in store..
Just exactly one week ago, around this time, in Toulouse, a father took his two children to school..
the following was written that morning ..


on that morning, whatever their intentions were, an email from Spain, alerted me about the news. Rabbi Sandler ( a french jew, murdered along with his two children, in front of the very same school which he had attended as a child).
I felt suddenly so alone! It was so difficult to get through the day in which I had to counsel my patients about their every day problems..
My two brothers wrote to share the grief. Most compassionate, counseling messages came from a country where there is hardly any computers .. Cuba!
Each of my friends wrote.. I felt so close to them..
There was a total silence from elsewhere..
A thought occurred to me, I need to go home..
But where was HOME? It certainly is not France. Not Malaysia, Not Miami. I exist in the hearts of my friends, my brothers in Portland..also among some in Miami. But most importantly my HOME is where I have compassionate friends, who comfroted me through this grief.. Cuba..
Au Revoir, France; Good Bye, Malaysia, I am going HOME, mi isla Rica, mi CUBA...




Traditional days of mourning is over and I shall concentrate more than ever in the humanitarian side of my work, in memory of Rabbi Sandler, a Jew..he was born and educated in a country where he was murdered also for being a Jew...

lundi 19 mars 2012

19 March 2012 Toulouse, France and I am suddenly so alone

During this day of immense sadness, what comes to my mind is a poem by Pablo Neruda



“It was half past eleven in autumn and I was waiting for someone or another. Time tired of being there with me, little by little left and left me all alone.”
“Never before or after did I feel so suddenly alone. It was waiting for someone that did it…”

Grieving is always lonely but it is sad to be lonely on this tragic day ..
I thought of our revered RASHI  Rabbi Shlomo ben Yitzhaki (Troyes, Fr 1105 of CE), the greatest commentator on the Talmud.


Such incongruities... 
Why do they hate us, asked a young Jacobo Timmerman (Argentina, author of Cell without a number, Prisoner without a name). His mother said: Because they do not understand us.

Night is falling here in the Indian Reservation and I am going to light the candle and say the Kaddish

samedi 17 mars 2012

RELATIONSHIP MORE IMPORTANT THAN TECHNOLOGY


RELATIONSHIP MORE IMPORTANT THAN TECHNOLOGY WHEN IT COMES TO CARING FOR PATIENTS: A GOOD LESSON FOR THE DEVELOPING WORLD
When I try to talk to colleagues in the developing world about the non-technological aspects of medical care, they are often indignant, they want the latest technology and to demonstrate to their patients the virtue of having technology at their fingertips.
At the beginning of 20th century, the wags pronounced, Technology will eradicate POVERTY. Has that happened?
Doctors predicted technological advances would cure many of today’s diseases? Has that happened? Why is that in the developed countries they are not able to stop the epidemic of Diabetes which only increases year by year?
Photo: The Annual Pow Wow of the tribe in the Northeastern part of Nebraska,USA

The logic is much like a litigation lawyer who sues doctors and saying: we are the professions that are responsible for the high quality of medical care in America!!
What a twisted mind!
Or the various ads by the pharmaceutical companies who propose that they are in the business of taking care of HEALTH of the people, whereas they should honestly say, we are in the business of making money from the Disease of the people. It was interesting to read the falsification of the amount of money needed to develop a new drug, in a presentation to the American Congress so that the Pharmas can obtain sympathy from the well to do about the high prices they have to charge, without explaining why they are able to sell the same drug at other richer countries for a fraction of the price!






The logic is much like a litigation lawyer who sues doctors and saying: we are the professions that are responsible for the high quality of medical care in America!!
What a twisted mind!
Or the various ads by the pharmaceutical companies who propose that they are in the business of taking care of HEALTH of the people, whereas they should honestly say, we are in the business of making money from the Disease of the people. It was interesting to read the falsification of the amount of money needed to develop a new drug, in a presentation to the American Congress so that the Pharmas can obtain sympathy from the well to do about the high prices they have to charge, without explaining why they are able to sell the same drug at other richer countries for a fraction of the price!
Doctors are not good at Interpersonal relationships because they are never exposed to it in their education or careers. As American Indians would say, it is a good person that becomes a good doctor, becoming a good doctor is not a learned behaviour. Medical schools make you a good technician, and most doctors are mere technicians of disease, whose help we need from time to time, but not as advisors regarding our health and well being, because most of them are incapable of such, or even give us advice regarding something as common as Nutrition. See a Dietician, would say some. And when a doctor said to me, you must pay attention to your nutrition, I try to buttonhole him to explain what he meant, and when he knew that I knew lot more about nutrition than he did, even though he was in the business of diseases of the heart, he backed off.
Showing gory pictures to patients to change their minds about smoking is not cut it. But taking lessons on how to do motivational interviewing will help. We work in closed communities where we know all the members and there families and that the first four visits to see us, we are in the process of building a relationship. It is incredible how at the end of four visits they begin to feel better, the laboratory tests reflecting their well-being.
Mitakuye Oyasin, we are all related.
Without Relationships, no amount of technology or medications can help you, and you would be dying for the wrong reason!

dimanche 11 mars 2012

A country eats well and traditionally and is not Fat: the case of Morocco


GASTRONOMIC PLEASURES OF SOUTHERN MOROCCO
I distinctly remember, handwritten over a small Taco Bar/Resto in Merida, Mexico:
To eat well, is not a necessity, but it is a privilege.
Wherever you are in Southern Morocco, Marrakech, Essouira, Atlas Mountains, the cooking is uniformly good, whether at a posh resto or at a stop by the road, being invited for a hot cup of Mint Tea.
After a couple of days in Marrakech, happened to walk by the KFC outlet, and the smell emanating from there was nauseating indeed. There are hardly any foreign fast food outlets in Marrakech, I saw only one KFC and one Mc Do, no Starbucks… the Mint tea is so refreshing and the mint is fresh, not preserved, and a bargain at 10 dirhams (about a dollar usa). You can depend upon a good Tajine or Couscous and walking around the souk and the markets, they are full of local and seasonal vegetables. Didn't see any need for imported food, didn't even see packaged food. The central square abounds with fresh fruits, dates and other local produces, fresh orange juice to be had for 4 dirhams (40 cents American).
photos of various plates of food savoured during one week in Southern Morocco
I am an Endocrinologist, trained as an Anthropologist but you do not need that training to observe that childhood obesity is non-existent and that the people in general were not overweight. You saw some older women with some extra pounds but not once did I see an obese person. In a paper published by the Moroccan investigators and the Johns Hopkins School of Pubic Health shows
 Overall levels of obesity, identified by body mass index (BMI) ≥ 30 kg/m2, were 12.2% in Morocco and 14.4% in Tunisia. Obesity is significantly higher among women than among men in both countries (22.7% vs. 6.7% in Tunisia and 18% vs. 5.7% in Morocco) 

The absence of overweight women in the streets could be explained culturally in that; Muslim women especially the older ones tend to stay at home while men are in the streets conducting business. Morocco is a modern country and the teenagers and adolescents and young men and women were uniformly of normal weight. It is interesting to note from the paper that poor education was associated with obesity as well as migration to the urban area. One is six women was found to have a BMI over 30 where as only one in 20 men were found to be so. Most meals have high carbohydrate contents because of the liberal use of vegetables and the fat intake was not high, two thirds of the calories came from Carbohydrates.
It is interesting to note that
1/34 Moroccans in Morocco had Diabetes
(Or close to 3/100)
Where as 7 out of 100 women living in urban area of Sahraouian origin had diabetes and the figure goes up to 8/100 when Moroccans migrate to Holland, for example.
You don't have to be an Anthropologist to understand that the Diabetes can be caused by
Exile
Displacement
Migration
And the emotional stress associated with plus the lifestyle changes that follow.

So, please, KFC and McDO take your businesses back to your countries, leave Morocco and Malaysia (a penchant for these fast food is becoming ingrained) alone…
The main incomes for many Moroccans are from Tourism and also remittances from abroad. Spain with ¼ of its population out of work sends far fewer tourists and there is a sizeable Moroccan community there. I was told that the poverty level in Morocco has increased in the last two years…so you can expect the obesity and diabetes to increase or would this force people to eat more traditionally? In general, the former is correct, but with the general absence of fast food restaurants and the abundance of good food easily available, with the decrease in income, we may expect a decrease in rate of obesity and diabetes in Morocco. Inshallah!

Homage to an Indian Patient of Ours: Patience does produce results


NEVER GIVE UP ON A PATIENT OF YOURS AND IN FACT ON ANOTHER HUMAN BEING FOR THAT MATTER.

About ten years ago, when I had seen this patient, an Indian from the tribe with whom I have the longest continuous relationship, came to see me.
The appointment was for 3 pm and she informed me that she had just gotten out of bed, and that she really did not want to be there anyway. I knew her family well and knew that she had lived an outcast’s life because of other diagnoses she carried and she was on an array of medications prescribed by her Psychiatrist.
Her Blood Sugars were extremely elevated and reluctantly I chose to increase the medications to combat the high blood sugar knowing well that getting through to her and becoming a friend of hers would bring better results that more and more medications. With the other tribal members working in the clinic, we made the collective decision that I will see her, much more for a social visit rather than a Medical visit, each time I was in their territory.
No change in medications for Blood sugar did its trick. She kept about one in three appointments and when she came it was always, just after she had woken up and told me from the beginning that she did not wish to be there. Once our relationship became more in the joke pattern which is familiar to any one who works with indigenous peoples, I decided to write a letter to the Psychiatrist requesting whether he could find other medications which would not add to her Blood Pressure, Blood Sugar and Cholesterol Burdens. He agreed to do that.
About two years later, I noticed that she was keeping every appointment and was resisting, when I jokingly told her that I didn't wish to see her for another three months. She kept up coming and upon suggestion; she decided to enrol in one of the wellness classes run by Indians for other tribal members. The teachers who themselves are from the community talk about Nutrition with whatever they happen to have at their homes, learning to read the labels on food substances, plausible exercise patterns to follow.
Each November, we hold a three-day In-Hotel education, when we invite about 30 patients of ours for a combination of socialization, education and good cooking demonstrations and for a general good time. It is always held in a hotel in the nearby town, with a swimming pool and nice rooms facing the River Missouri.
I was surprised to see her there; this lady who had the habit of waking up only after the hour had struck three! More importantly, there was a glow in her face, she looked thinner and was more jovial than normal. She had been attending the classes and had made changes in her food habits and was doing a reasonable amount of physical activity. On my next visit in December 2011, she requested that I stop her medications as she felt that she was making such improvements. Sure enough, her biochemical profile was more than excellent!
BP 126/78
HgA1c 5.7%
Total Cholesterol 137 mg/dl
Random Blood Sugar 112 mg/dl
All these values are what a healthy person would have on his laboratory examinations. What all she had done, after years of our begging her and the appropriate forum and context of education, was to make no great changes but enough to normalize her metabolic abnormalities and with the loss of weight and wellness felt with regular exercise, her emotional situation also got better. She requested the Psychiatrist to take her off most of the medications, which he did as well.
Two months later, she was well, feeling much better than before, happy with her lifestyle and integrated well into her family and the tribe.
Ten years ago, if one of us had written: Non-Compliant Patient, see when necessary in the Clinic, what would have become of this patient?
Who is responsible for the “non compliance” (horrible word to use) among the patients? The Mid Level Providers such as PA, FNP or Primary Care Providers such as FP who do not have enough time for difficult patients who have been treated off handed for most of their time as patients in various facilities?
I know in my heart that whenever I see the term, Non Compliant in a Health Record, it is the Provider who is Non Compliant for the welfare of that patient… if he or he was compliant, she or he would have spent more time and effort… It does take time to get good results.

Perhaps that is why the Little Clinic catering for Indians in the northeastern corner of that state in the USA has good results with the OUTCOMES. It is not what is being done to the patient that matters (audits would show that measurements and education have been given) but what brings the results are: what actually did you sacrifice for that patient?

samedi 10 mars 2012

THE BOOKSELLER OF MOGADOR


THE BOOKSELLER OF MOGADOR
Until 1956, when Morocco became independent of France, the popular seaside town of Essaouira (very popular with Americans of certain regard such as Orson Welles) was known as Mogador.

It was an important port, with an island off the coast that the famed Berber King Juba II of Mauritania created beautiful Tamuziga where the current town stands, known by Hanno of Carthage circa 500 BCE as Karikon Teikos where he had established a dye industry. In the 11th century of the Common Era, el Bekri mentions Amagdoul in his ourvre Al Mamalik wa al Massalik. The Portuguese who were the first Europeans to visit these parts, even built a fort here, Castello Real, in 1505 called it Mogadouro. The Spaniards changing the orthography to Mogador, during their colonial incursions which resulted in Spanish Sahara and now the no man’s land of the Republic of Saharalui
The etymology of the word Mogador has been studied and has been suggested to be Jewish-Berber origin.
It became an important Jewish centre of Southern Morocco in latter years, with some great rabbis of blessed memory holding court, among them Rabbi Haim Pinto a Moroccan Jew of Portuguese origin. Many other well known Moroccan Jewish names were represented here for decades and centuries among them Cohen-Solal, Sebbag and as the town became prosperous, Jews from other Moroccan cities joined them and at one time over 4000 Jews lived here in complete harmony with Berbers and Arabs, and were prominent in every aspect of the life in Mogador.
Unlike in India where the establishment of the State of Israel was an impetus for the mass migration to Israel, In Morocco, it was fear of selves and properties soon after the independence of Morocco in 1956 that prompted a mass migration of Moroccan Jews: France, Israel, Canada, USA being the main recipients of the outgoing population.
It was to this city that I arrived at noon one day last week. It is situated along with its islets facing the strong winds from the Atlantic and the fragrance of the sea enveloped the town. Now very touristic, one can still see the ancient parts of the town and in fact the first synagogue, albeit in ruins, can still be seen.
I wandered around the town, now full of tchotchke shops selling souvenirs of your visit to Morocco and Essaouira, much like what the Jew Street in Jew Town has become in Cochin. But hidden amidst all this noise and calamities one could find gems.
I did find one.
Just two nights before on Moroccan TV, a documentary was shown: Edmond Amram El Maleh_Le Captif Amoroureux, which could be translated as A Prisoner in Love. It was a touching story, El Maleh, who became a prisoner of time, being in exile in France since 1965 and then beginning to write about his beloved Morocco, which was never far from his thoughts. In that documentary, an interview was conducted with a bookseller and antiquarian living in Essaouira, who was his friend, who also happened to be that last of the 6 or 7 Jews remaining there. Love of books and Literature keeps this man in his shop full of authors in various languages and genre (I saw Murakami’s Wild Sheep among his books), Most of the books are in French but there are books in other languages. He does not specialize in Jewish books or Jewish literature but in Literature. He has a fine collection of antiques among which can be found good examples left over from the magnificent period in which Jewish life flourished here.
I went inside his shop, the windows displaying the antiques, Jewish and non Jewish, and to the hall where books lined every possible space.
Excuse me; are you the bookseller interviewed in the documentary shown on Moroccan TV a couple of nights ago? I asked
About Amram El Meleh, he was a friend.
He was shy and possibly tired of the stream of tourists looking for tchotchkes and leave disappointed.
I said to him in French, I am a Jew from Australia.
He replied in English and he spoke good English, as he is a repeat visitor to London and New York and of course Paris.
Sudden warmth enveloped us as we talked about what we have In common, the history of Jews in Morocco. His family are recent to this country, so to speak, 1492, just 500 odd years as there were Jews during the Phoenician times, roughly 2500 years ago!
He asked about Cochin, I told him the story of how, during one Simchat Torah, there were not enough people to hold a Minyan, I undertook to round up a few Israelis, which I did so that we could have a boisterous, as usual. Simchat Torah celebration, Cochini style. The Halleguas, Yitzhak and Samuel were alive then, and as is the custom, we drank merrily while dancing around.
To show the extent of his knowledge, his next question was, Haven’t the Lubavitcher Hassidim come and try to conduct the services at the synagogue/ Yes, it is true, I said, wondering and admiring this bookseller from Essaouira keeping up with yet another vanishing Jewish community on the other side of the planet.
We talked for some more, and he said, I am sure we will meet again. I felt the same.
When you are here the next time, I will get a few people together and we can have a good chat.
I knew in my heart that I would be returning to Essaouira, to renew my acquaintance with one of the last Jews of Mogador, this bookseller and antiquarian.
I want to take something small with me, from the Moroccan Jewish community, for me to remind me of the glorious history and continuity of our people and that dispersed as we are, we are still loyal and faithful to certain ideals, which may differ from person to person, but in the end, it is am Israel chai.
He gave me a coin, the size of a 25 cent US piece, copper, with a fading Star of David on one side and an inscription and the date 1285, according to the Moslem Calendar, the coin is about 157 years old.
I shall carry it with me, on my upcoming trip to other parts of the world, thinking about this Bookseller, al Yahoudi, a Moroccan and a man of the world.
Nice to have met him…