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samedi 24 novembre 2012


I have never been a great fan of “Guidelines” issued by Professional Medical Bodies, especially for Chronic Diseases where a substantial profitability exists for Pharmaceutical companies.
The guidelines have changed at the whims of the “experts” who never apologize when their expertise goes wrong and kills many patients. Some mayvens insist on a HgbA1c of less than 6.5% in patients with Diabetes and as studies have pointed out, there is truly a chance of death of the patient if you are that enthusiastic! My healthy scepticism was founded early in my career, when I was training to be an Endocrinologist, I attended an International meeting where a flamboyant “expert” suggested that: Not putting your women patients on Hormone Replace Therapy amounts to malpractice. Few years and few deaths later, now the reverse is the accepted practice, unless you have a very serious reason to do so. I wonder which drug company he belonged to. As the Government funds dried up or the number of mediocre people practising “science” rose among the doctors, they walked into the den of wolves: pharamaceutical companies with money to burn as long as nothing too wrong was said about their products and of course, they would be pleased if you recommended their products as being superior to what is currently available.
The field of Diabetes Management (type 2) is undergoing such a convulsion at the moment. Most of these people who travel the country at the expense of the drug companies promoting their drugs have very little exposure to every day life of doctor and patient, if so they are very carefully screened and pampered patients who attend these trials for drug companies.
The Late Dr Howard Lessner who mentored me for a few months during my stay at Jackson Memorial Hospital, said to me once: Read only things you pay for, don't believe in materials that are sent to you free.
Currently my mailbox is full of stuff, published in a very polished fashion, courtesy of an Educational Grant from some drug company or other. There are lots and lots of very honest researchers out there in this world, so I really don't have to listen to people who take money from drug companies, the greedy ones from many companies.
I also tend not to read articles written by Medical Journalists who are used as proxies for medical researchers (who will have to expose their drug company connections). Most of the medical journalists are used by “throw-away” journals that are inundated to the offices of the practising physicians. So a report may appear as balanced but when you delve into it, the underlying interest becomes clear.
A busy practising clinician has no time to do such detective work and is at the mercy of so much medical information that my advice to them is, don't listen to the Pharmaceutical representatives or read it in a free journal or go to drug company sponsored dinners. Pay your hard earned money to get official journals of medicine and attend professional meetings of your society, avoiding once again drug company sponsored dinners.
We are inundated with information about the new forms of treatment for type 2 Diabetes, mainly DPP-4 inhibitors and Incretin mimetic or GLP analogues, which are at best only marginally better (at a extraordinarily high expense). I beg the doctors working in the developing world not to indulge in these medications as none of them have shown to hold a candle to minor changes in lifestyle. The presence of these drugs also give a false confidence to the practising physicians that they can do something, write a prescription, rather than counsel which they may not be good at. Also it is a form of “turfing”, getting rid of a patient who is not showing improvements as you would like. As such, using these drugs by Family Physicians is an admission that their treatment has failed or their knowledge about treatment of Type 2 Diabetes is sadly behind the times, incongruously as it may sound.
The following study just published a few days ago in November 2012 is of great importance to those of us who are actually working with patients rather than just going around talking about papers we have read in the journals, in fact talking about other peoples work and not based on your experiences to add to it.
Are diabetes management guidelines applicable in 'real life'?
Luciana V VianaCristiane B LeitãoMaria de GrilloEnnio P RochaJuliana K Brenner,Rogério Friedman and Jorge L Gross

A one-year, single-arm interventional study was conducted with type 2 diabetes patients in a primary care unit. Intervention consisted of intensification of lifestyle changes and sequential prescription of drugs based on ADA guidelines using the medications available through the publicly funded Unified Health System (Sistema Unico de Saude, SUS).


Ninety patients (age: 62.7+/-10.4 years; diabetes duration: 8.2+/-9.1 years) completed the trial. During the intervention period, increases were observed in number of oral antidiabetic agent (OAD) classes per patient OAD pills per patient ,insulin dosage  and number of patients on insulin but no improvement in or frequency of patients on target, defined as HbA1c <7 b="b"> Patients with baseline HbA1c <7 6.7="6.7" a="a" baseline="baseline" change="change" during="during" had="had" hba1c="hba1c" in="in" increase="increase" no="no" observed="observed" p="0.002)." small="small" such="such" the="the" those="those" trial="trial" vs.="vs." was="was" with="with">=7%.

It is interesting to note that the medication usage increased if you followed the ADA recommendations but not the measurements for the control of Diabetes. This study is the first of its kind to question the advice of the “experts”.
What is very important to note in this study is that the control of patients with Diabetes, from a mostly lower socio economic group was BETTER in the non ADA recommendation than ANY SUCH RESULTS in the USA, let alone from lower socio economic groups!
So you could re title this blog to :
Poor Brazilians get better medical care than well off Americans..
(the above is the reality. A1C less than 7% remain unchanged over the years)

I have looked into the Control of Diabetes Type 2 around the world, unfortunately just looking at only one measurement HgbA1c. What is amazing is the fact that regardless of the context:
War Zone in Basra
Private Practice of Medicine in Malaysia
Expensive Tertiary Medical Care in India
American Indian Health Services
Endocrine practices in Los Angeles,
33% of the patients do just well regardless of the treatment or place, even if you have no place to keep your insulin cold, or there is a possibility of death on a trip to the pharmacy or your insurance is paying 300 dollars to the Endocrinologist or you are getting all your medications free.
As an anthropologist, I can only add: an individual body cannot be separated from the society it lives in and the political forces that control that society.
If as a Primary Care Provider, you are not competent to do one or all of the above, please seek help from your colleagues.
On this day, I salute the doctors who work at the Veterans Administration Hospitals and Indian Health Services Clinics and Hospitals for their unselfish work to better the welfare of these two well deserving groups of people. It is not well advertised that some of the best diabetes care in America are in these two facilities

mercredi 21 novembre 2012


I was the first one to board the short AA flight to Havana in Miami. As I would explain to you later, I do not wish to be the first to disembark at my destination.
After an extremely productive week with the Lakota, where else to relax and rejuvenate the mind than my beloved San Cristobal de la Habana?
Called the Agency in Miami and they were courteous and accommodated me on this flight to HAV.
I arrived at the Terminal D of MIA, fairly new and was surprised there were no large lines at the CUBA check in counter, normally teeming with overweight Miami Cubans with their obese luggage! (Bultos).
Was able to greet one and all, including the Porter, who has worked at the same job for the past 13 years, he had migrated from Santa Clara many years ago. My ticket was handed over and my friend checked me in, with a joking tone, Sr Embajador!
Many years ago when direct travel to Cuba was much more difficult (had to go to the airport 5 hours before and your papers were checked by Treasury Dept. agents!), impatient Cuban Americans, with their luggage larger than ever “bultos”,”chorrizos” would object if any one was given any sort of preferential treatment. I did not particularly like the prospect of standing in line for hours, and my friend would call me over the head of the line, over the objections of loud Cuban-Americans. Then he would announce, he is the Egyptian Ambassador to Cuba! I would courteously bow to the people in line as befitting of an Ambassador under Hosni Mubarak. So the joke stuck.

This time he checks me in and writes Diplomatico on the ticket, so the lady who assigns the seat (from American Airlines) would know which seat to assign me.. Today it was 4B
That is where I am sitting now.
The reason for the rather quiet lines at the check in has something to do with Obama whose Treasury Dept. has issued over 140 licences for group travel by Americans to Cuba! There were two large groups of Americans, one Jewish and other not, who were going to Cuba, to learn about the Cuban culture. They all had paid over 2000 dollars for this privilege of being among the Cubans. Hotel, dinners, ballet etc. and meeting with some professors or artists.
I am happy that the Yanquis can see the truth and beauty of Life in Cuba, rather than depending upon the extremely conservative views expressed in the American Media, especially in Miami. It used to be rare to see Yanks on this direct flight. Since Obamas ascension, the rate has increased and in fact on this flight the majority of the travellers were Americans, rather than Cuban-Americans who can travel freely to Cuba. Cuba welcomes all people.. All nationalities. More immigration changes are on the way and before long you would be seeing, well off Cubans from the island taking this flight to come and visit their relatives or go shopping in Miami, like many other Latin Americans do.
I have some good friends in the Cuban Diplomatic Corps and I admire them for the tireless task on behalf of this Little Island. But I have never claimed to be a diplomat of any country, even though I am often mistaken for one.
The results are usually good.
Upgrade to Upfront and on long flights it does make a difference.
{60 year old Jeep with a Lada Engine fit for any Ambassador! was waiting for me at the Terminal 2 of Jose Marti International Airport in Havana, Cuba}

lundi 19 novembre 2012


Looking at the habits of healthy and happy people, all over the world, there are some common threads running through their lives.
Move Naturally. No need to be training for Marathons, but at the same time, don't sit in front of TV, Computer or iphone more than 30 minutes at any one time. Walk around, do the chores at work, home or play.
When you wake up each morning, make up a grateful list and wonder loudly to yourself that you have been put here for a purpose. Be positive about the day ahead.
Find your way to deal with the Stress. Stress has become a “natural” or “cultural” phenomenon. Anthropologists would tell you (Jack Goody) that Natural and Cultural are not the same. Find your own way to deal with stress: take a nap, socialize, pray…
Like the Okinawan centenarians say: 80 per cent full, never stuff your stomach to its capacity. Eat to satisfy your appetite and hunger. Avoid situations where you are searching “value for money” and eating low quality food.

Eat Less Meat, not only you would help yourself, you would help the global warming from less carbon emissions.
I am not a great fan of organized religion and certainly do not subscribe to the belief that one religion is better than another. Also I don't believe that Religion is necessary to achieve spirituality, religion is but one of the many ways to reach the universal concept of spirituality. But Happy people tend to have some faith, whether on rocks or trees or other symbols. Being part of a faith based community gives identity to oneself and reinforces the positive purpose of life.
All of us know that the power of love can transcend any other powers in every day life: maintain good family standards, put family first, be kind and generous with your time with your partners and parents.

Stay Social. As I told my good friend Marcos yesterday: Schmoozing is good for your health. Man by nature is a social animal and loneliness is not natural. Make time for your friends, reach out for them and spend time with them, uninterrupted by telephone calls, text messages and emails.
I had one such day yesterday with my good friends M and G and their lovely daughter M. The 24 hours spent with them included long hours of discourse on various subjects, some of which we had in common, such as Medicine, Israel, Travel, Food.. Our one day included
Jewish Cuban nouvelle cuisine at Books and Books in Lincoln Road.
Thai Food and the fusion Japanese cuisine now springing up every where in the USA.. Massaman curry was tasty indeed.
An Italian restaurant run by a jewish family from Casablanca, where I indulged in smoken salmon and bagel along with portions of Spanish Omellette..
Only in Miami! The diversity of culture, but a heavy overlay of either Latin America or Jews.
Our day had begun slightly after noon one day when we went to the Public Radio Station to watch a live performance of Aaron Lebos Reality, a jazz oriented group of excellent local musicians. Reminded me of a younger and latin oriented version of Claude Challe.

This being Miami, we were able to include a trip to the bay, skirting the many islands in the bay and enjoy the soothing breeze and rejuvenated local flora. An occasional Iguana could be spotted, enjoying the afternoon sun.
We spent long time talking, and realized the importance of friendships and I am glad that I have always believed in:  I am never too busy for my friends.

Looking forward to my next visit to the bayside home of MGM… with whom I had travelled to : Jamaica, Bahamas, Mexico, Panama, England, Wales…

jeudi 15 novembre 2012


The Young poet of Cote Sauvage, one day said to me:
The waves are coming to say Hello to the Earth..

It reminded me of my favourite woman poet, Cecilia Meireles, who is considered the greatest woman poet in the Portugese language.
O choro vem perto dos olhos
para que a dor transborde e caia.
O choro vem quase chorando
como a onda que toca na praia.

Descem dos ceus ordens augustas
e o mar chama a onda para o centro.
O choro foge sem vestigios,
mas levando  naufragos dentro.

There is a quest for love, but not of saudade. Nothing mystical but personal statement, separating herself from what she sees, nature does not lead to any self realization, but she emphasizes the present, the reality and the actual presence of the moment.
Our tears well up in our eyes
-only so can our grief overflow-
our tears well up, like the weeping
of a wave as it touches the shore.

Stern orders come down from the heavens:
the sea calls the wave to its heart.
Our tears bear the shipwrecked away;
Not a trace do they leave as they part.

About ten years ago, there was a used bookstore along the Miracle Mile in Coral Gables in Miami, now gobbled up by some shop selling yuppie Tupperware? I was aware of Cecilia Meireles from a poem I had read elsewhere in translation and when I saw a book of hers at this bookstore, I was more than happy.
I searched at the few places where my books are kept and I found my copy amidst my books in a warehouse and have carried it with me since then.
Search for love, but at the same time detachment, I made a note to myself, it is very yogic in concept. It would be nice to love without attachment like the real Yogis do, but how does Cecilia do it?
At the same time wanting solitude!
All of us who are in love are constantly reminded of our own mortal condition when love for another person is involved, you want to be free and at the same time but the human condition dictates the love that without love, there is an emptiness of silence. How to free yourself of this imprisonment? Cecilia thinks you can know the essence of love, the abstraction only when you free yourself.
Infinity and Solitude, which defines her poems, over and over again..
Porque pensar em qualquer coisa,
se tudo esta sobre a minha alma:
vento, flores, aguas, estrelas,
e musicas de noite e albas?
The escape is an escape into nature and to be one with its forces.
Why need I think about anything?
when everything rests upon my soul?
wind, flowers, water, stars,
the music of the night and dawns?

I tried to look up her books on line, there are some poems in translation but none of her books are easily available or amazon sells them for hundreds of dollars! Strangely enough the community library near the house here told me they could order and get it for me in a few days so that I can borrow it, so that it will be ready when I arrive for my next visit?
If you don't look, you cannot find, stop waiting for things to happen…I continued reading her poems from the second hand book I had.
When I was reading the following verse, something stirred in my heart.
Ir falando contigo, e nao ver mundo ou  gente.
E nem sequer t ever—mas ver eterno o instante.
In speaking to you and see neither world nor people,
Nor even to see you-but to see the moment in its eternity.
The present, the presence of it, I thought of Mindfulness of the Yogis and also what Kabat-Zinn had been talking about..
How come a Carioca born in the early part of last century at a time when women were restricted severely in Portugese society (that is why there are no great women writers in Portugese.. no George sand, no Emily Dickinson!) who went on to become to be identified with Modernism of Portugese Literature.
The title of the poem I read next caught my eye: Taj Mahal, Poemas escritos na India.
Here she accords timelessness once to something man made, not the timeless of sea, the sky, the infinity of space…
Tudo celeste, inumano, intocavel,
Substraindo-se ao olhar, as mais.
All heavenly, all untouchable,
fleeing from the glance and the hands.

Looking for her biography, I could read that she was fascinated by India and that she had translated Tagore and written about Gandhi. Many a critic agreed that the influence is much more oriental in her poems than the Lusitania of her ancestors.

A shepherdess of clouds, with empty face
I follow after figures of deceit,
keeping night watches on the eternal plains
which turn and turn beneath my unshod feet. 

(from 'Destiny,' translated by L.S. Downes)

It was good for me to discover this oriental influence on Cecilia Meireles, my favourite woman poet (favourite male poet will always be Pablo Neruda)


I sing because the moment exists
And my life is complete.
I am not gay, I am not sad:
I am a poet.

So, I send this message to the Little Poet of Cote Sauvage…On our next meeting, I will read a poem of Cecilia Meireles to you, in Portugese,