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jeudi 27 février 2014


What does it mean, Genetic Memory? We inherit genes  from our parents, then learn our culture, our languages. Later on we go  on to live in countries which are not ours, learn languages which are not related to you, these does not seem strange any more. Less attention is paid to the fact that there are historical connections that has been made for you, which you have to become aware of. In my case it is Portugal.
Historic events that connects me to Portugal, will just mention place and year, mainly three and later on when I became aware of this Portuguese presence in my life, I explored it in different corners of the world.
Calicut and Cochin 1495

Malacca 1511 Birmania soon after

Kingston, Jamaica 1655

Portugese Synagogues in 
Amsterdam, London and Kingston as well as Curacao

Siriao, Birmania 1749 (there is an interesting story about a portuguese foot soldier sent from Malacca, who was brutal to the local Mon people, he declared himself King and later on was butchered by the local people who hated him so much!)
It must have been my father who alerted me as a child about Sultan of Ternate, Flores and the Portuguese! 

Later on, I was able to evoke this genetic memory in faraway places ..
Porto Novo, Benin ( Bruce Chatwin has a lovely book called The Viceroy of Ouida, which was later on made into a movie about a Portuguese slave trader from Brasil who lived in Ouida, Benin)
(The Portuguese Fort in Ouidah, which remained  in Portuguese hands until 1961)

Colonia, Uruguay
The Portuguese Museum in Colonia, Uruguay

Saudade do Brasil, entered with the song  Manha da Carnaval, remembered clearly listening to it for the first time  during adolescent years in Melbourne, which led to many visits to Brasil and also an exploration of its music, Porto Alegre and Elis Regina, Salvador do Bahia and Caetano Veloso

It was only in 1994, twenty years ago, one afternoon in Knightsbridge, a song was being played over the radio, Sodade by Cesaria Evora from Cabo Verde! What a great gift it was!
Si bo 'screve' me
'M ta 'screve be
Si bo 'squece me
'M ta 'squece be
Até dia
Qui bo voltà
Sodade sodade
Dess nha terra Sao Nicolau

If you write me letter,...
I will write you back
If you forget me,...
I will forget you...
Until the day...
You come back
the above lyrics are very reminiscent of a poem by Pablo Neruda, If You Forget me..As Luis de Camões wrote, himself an adventurer and a soldier, we spread ourselves with slashes of the sword and of love, therefore achieving the first genetic pool which begun in East Africa and went all the way to Japan.

Os Bayingyis do vale do Mu

Cristao as spoken in Malacca and Macao
Macao and Camilo Pessanha

Maputo and the introduction to  Mia Couto, the poet and writer
(Mia Couto, who won the 2014 Neustadt Prize for Literature.
“Some critics have called Mia Couto ‘the smuggler writer,’ a sort of Robin Hood of words who steals meanings to make them available in every tongue, forcing apparently separate worlds to communicate. Within his novels, each line is like a small poem.”)
Kavangos who spoke Portuguese in northern Namibia and of course Peri Peri Chicken in Southern Africa

Of course, there is the Cuba Connection, Cuba a small nation in the Caribbean with a deep love for Africa, that helped the liberation of both Angola and Namibia and 
which maintains a strong presence in Timor Leste where there is a Cuban Medical School and has graduated over 500 local doctors to serve the population. (graduation photo 2012 below)


Why is this?
A sensation of connection with a remembered past and historic past. 

A gentle people who greet you with a smile.

Sonorous language which gave us Pessoa, Pessanha, Saramago (Nobel Prize), indeed Camoes and Os Lusiadas, not to mention the copious literature from Brasil : Amado, Andrade Brothers, Mireilles. I had the chance to meet only one living Brasilian writer, Moacyr Scliar of Porto Alegre.
(the hugely popular Life of Pi was plagiarized from Scliar's novel about a Jewish survivor along with a Jaguar after their shipwreck on their way to Brasil!)

They seem to be very health conscious. The food courts have excellent quality health food (Vitaminos, Sandes, Farm, Prego) and healthier than food courts in many countries especially USA. 

All the MENU come with a salad and Zumo (freshly squeezed or made fruit juice)

Portugal is not an expensive destination, half as expensive as Singapore and one third as expensive as Paris, Bruxelas or Londres with very affordable hotels and public transportation. For the price of a single metro ticket in Paris or London tube, you can travel all the way to Sintra and back from Lisbon!

The best of course are the Portuguese people:
Sweet types from the countryside
Hardy types from Acores
Some colonial types from Africa with frowns on their faces
Lovely mixture of Africans from Angola, Mocambique and Cabo Verde, along with some from Goa and from Timor. and  I can feel Brasil everywhere! The current favorite FADO singer is from Mocambique!

Ethos reflected in FADO, which had influenced the mornas and coladeras of Cabo Verde as well as Musica do Brasil 


As Cesaria would sing:
Bô tém sofride
A mím também tém sofride más quê d'eu
Nos vida é um romance tristo de amor
Hora que tão sofre
O 'ta morre de dor
Nos vida é um romance tristo de amor
Hora que tão sofre
O 'ta morre de dor

Nha vida é um romance sem fim

jeudi 20 février 2014

WE ARE ALL LOOKING FOR A BETTER LIFE ...thoughts of Eastern Philosophers

We are all looking for a Better Life!
I spend time thinking about the three different philosophies that I have become interested in over the years: The Yogic philosophy of Patanjali, the Buddhist philosophy and that of the Native Americans.
At times, I am amazed, even though I should not be, of the similarities between the three different branches of the same tree. And after that, when I read Jiddu Krishnamurty, I feel that here is a man who has managed to merge all that into a humanitarian philosophy.

All talk about the hypocrisy of the outer world, and our eagerness to join it for morsels of happiness on an uneven basis and pathways of sacrifice within oneself to attain a greater contentment within. Another thread connecting all these ancient philosophies is social characteristics, which brings happiness to individuals and countries.
We don't think of countries adopting social attitudes that benefit humanity as a whole, starting with their own inhabitants. Bhutan and Cuba are two countries, which have taken Compassion, Solidarity and Relationships to a newer level over cross sections of their societies. Gross National Happiness in Bhutan and Solidarity in Cuba are two expressions of that national attempt at the betterment of its populations.

Buddha had explained that SUFFERING is the result of CRAVING through three poisons
If you look at the Kleishas or Structural defects of the Mind, delineated by Patanjali
Greed corresponds to ATTACHMENT

Yoga now in the west and emerging countries synonymous with EXERCISE, MEDITATION and RELAXATION, not to mention the entry of the train of charlatans, such as Hot Yoga among others.
The philosophy behind YOGA is much more than all these but as Patanjali had said: Yoga is complete control of human personality. It is a complete control over our whole personality: the body, the mind and more.
In search for a Better Life, we study, then study some more, to acquire knowledge to gain employment, we migrate, reassure ourselves of the reasons for doing so, we seek self purification through religion and its rituals. We are after that elusive SUCCESS which would then define ourselves in the societies we live in.
Most people in this world, alas, including the billion or so who scrape a living have no luxury over the poor objective of physical survivor. In this our minds are similar to the instincts of our mammalian ancestors.
When this survival attitude survives through the economic betterment of people’s lives as has happened in Malaysia and Singapore, the society tends to suffer because of the ignorance about the deep values of human existence. Greed, Hatred and Delusion are carried into the comfort of their new homes and relationships. Ignorance prevents them to examine the superficialities of their life.

Success is always measured in quantitative terms of the very same things that stand in the way of self-realizations
Career and Work
Relationships, personal as well as with the Society
And other societal forces
All the above stand in the way of success as a human being, we celebrate just one aspect of our lives: Work and Money.
Alain de Botton, the British philosopher talks of success in relative terms. American Indians would take a universal and spiritual view of what they consider to be success, where collective values supersede individual values. What you do for others is the measure of success in that society. Botton argues that you cannot be successful in everything, more successful in some and more unsuccessful in other areas, all measured values.
What is missing is the Gold Standard, as the Yanks would say or Yardstick as the Brits would say, how to measure our “success” through life. One such yardstick has been mentioned in connection with small tribal societies: you are successful if you do more for others.
In the absence of a yardstick or ignorance of such, life becomes a wanton waste in search of pleasures and false concepts which makes us go further in search of such pleasures or deep into false concepts.
In the words of a rich Asian, spending 1000 USD for a bottle of wine while having no taste for it, eat and Drink, since life has no meaning, you get old, get fat and die anyway. No need for discretions, caring of your mind or body.
When I was thinking about these matters this morning, I am once again amazed, even though I shouldn't be, at the similarities between the Philosophy of Patanjali and that of the Buddha.

I shouldn't be, as they are both products of similar milieu, 2500 years ago, in what is now North India. Both philosophers stress the capacities of ones mind to save oneself, not salvation though religion or God Figures. Buddha was never elevated to the status of a God, as happened to Mohammed or Jesus. Patanjali was all but forgotten during the long reign of Moslems over Northern India, followed by the British rule, until India became an independent country in 1948. The western Interest in Yoga has revitalized to some degree an interest in its philosophy. Westerners are also attracted to the Buddhist philosophy, as they become disillusioned with religious practices incompatible with greatly improved intellectual capacities, and a stagnant and non-evolving belief system out of touch with the modern world.
Whereas this modernity makes us search for an answer and both Patanjali and Buddha offer us the tantalizing possibility of a higher objective- a chance for ourselves to gauge our spiritual, physical and mental progress through life, without extracting any mental, spiritual, emotional cost from other human beings.
(I feel grateful for my long association with American Indians)
But most of us are happy to be attached to the colourful imitation of a pure consciousness, which we term EGO.
This is what makes the world a place of misery, says Patanjali. Buddha talks of the suffering in this world. The attachment to this outer world causes pain and suffering, according to both Patanjali and Buddha. Do not look for perfection in an imperfect outer world, that would be an illusion, but Patanjali takes us on the path to a higher consciousness through his Yoga Sutras, the philosophy of Yoga, more than exercise, more than meditation, much more than relaxation.
Dalai Lama talks repeatedly about the fallacy of thinking that the material world would bring you happiness. He stresses, if you want to make another person happy, be compassionate; if you want to make yourself happy, be compassionate.
Those who like Eastern Philosophers, the name of Jiddu Krishnamurthy is familiar. Here is one quote from him, relevant to this discussion.

Now, what is it that makes the mind superficial? Please don't merely listen to me, but observe, be aware of your own thinking when a question like that is put to you. What makes the mind superficial? Why cannot the mind experience something that is true, beyond its own projections? Is it not primarily the gratification that each one is seeking that makes the mind superficial? We want at any price to be gratified, to find satisfaction, so we seek methods to achieve that end. And is there such a thing as gratification, ever? Though we may be temporarily satisfied, and change the object of our satisfaction depending on our age, is there satisfaction at any time? Desire is constantly seeking to fulfill itself, so we go from one satisfaction to another, and getting caught in each new satisfaction, with all its complications, we again become dissatisfied and try to disentangle ourselves. We cling to persons, pursue teachers, join groups, read books, take up one philosophy after another, but the central desire is always the same: to be satisfied, to be secure, to become somebody, to achieve a result, to gain an end. Is not that whole process one of the primary causes of the mind's superficiality? - Krishnamurti, The Collected Works "Krishnamurti" by Pupul Jayakar

 (water lily.  Nicte Ha in the Mayan Language, flowers at night)

mercredi 19 février 2014


I have been extraordinarily lucky when it comes to travel. Starting at age 2 ½ that was not my decision, but seriously since age 19, when I began travel independently. My first Round the World trip was completed before the age 24. I have continued to travel, all through my life, during my university days, during my medical school days as well as a Junior Doctor (I did a Thursday to Tuesday RTW from Melbourne as the Hospital will not give me any more days off!) and now as a Consultant, with at least 20 major trips per year.  When Immigration Officers ask me why I travel so much, my stock answer is, I think I am lucky! I am grateful for a good medical education in London, Melbourne, Brisbane and Miami; I watched the recently become Young Consultants juggling to make money, while trying to do what ordinary people do. I decided to fashion a career melding my love for travel and my desire to help others through the little talent I have as a Doctor. I have since then been involved in Humanitarian Medicine, which suits me fine. A doctor without Border, having no affiliation to any group or institution, that is what I have become. Doing so, I have been able to practice my craft in far-flung places; memorable moments do exist, examining a patient from Tristan da Cunha at Funafuti, becoming the doctor to an entire family in Rapa Nui, in addition to the usual culprits, Jamaica, Venezuela, Myanmar, to name a few. 

Some say, travel extends your life, breaking out of the routine, it appears as if one week is longer than a sedentary week, weekends are prolonged without the anxiety of an approaching weekday. Being an early product of a globalizing world, I have felt that it was a prolongation of Innocence, a Peter Pan of Emotions rather than of the Body!
I remember how hard a time I had trying to explain to a WHO employee in Yangon, Myanmar about the definition of Innocence. In general people who are non-native speakers of English would interpret that word in its literal sense: physical purity or emotional immaturity!

Let me explain.
Recently I was at the Toy Museum where an afternoon party of 25, four year olds was taking place. I looked at them individually and I realized what the great sages had always said: Fundamental nature of human beings is pure, conscious, peaceful, radiant, loving and wise.
Then the questions, these children are everything pure in the human nature, who does the spoiling, why do they grow up to be nasty, cruel, unkind, violent, grizzly, cold, frigid and stupid?
Do parents do it? Trying to mould them after their own imagination?
Do the teachers and the classmates play their part in this destruction of humanity? Or is it the society with all its constructions?
(Text books in certain territories inculcate hatred of the other very early in life, while in some countries, in Vietnam for instance, the children grow up grateful to the friendly countries to Bac Ho!)
For many years into my adulthood, I could still savour the Innocence of my childhood, which taught me certain behavioural patterns.
Extend a hand, without worrying who would grab it to save themselves from drowning; it may lead sometimes to misunderstanding, but usually is beneficial to both parties.
Never Wait to Offer Help. When there is an opportunity, try to help, and do that with love and respect, if you can.
When I became a Consultant to the American Indians, I found resonance to these thoughts among their philosophy. I was satisfied to read Laurens van der Post describing his beloved San people, as men-children!

Walking along certain avenues of South Caulfield, in Victoria, Australia, flowers or vines overgrowing into the street, evoked in me a sensation, as if I was being transported into the crevices of the green overgrowth of the hills surrounding Melbourne.
The very first time, someone drove me to Crandon Park in Key Biscayne in Florida, as the car turned a corner, I was transported to the remembered sight of my first journey as an adolescent into the Malaysian Interior to Pahang. That sensation was reproducible, repeated in many a pacific islands.

mardi 18 février 2014



This was the story told to me by a good friend of mine in Indonesia.
He was recently at the class reunion from his High School Graduation, most of them now financially successful businessmen.
There were 12 of them; my friend probably was the fittest of them all, being dedicated to exercise and sports ever since his university days. Nine out of the 12 were either overweight or obese, a rate which rivals that of most corpulent countries such as USA, Mexico or UK and Australia!
While discussing health matters, my friend was told by a businessman: I just had a first class check up and also a PET CAT scan. To the query why they were done, it was said that they were done to make sure everything was all right. He had high cholesterol and high blood pressure and of course was overweight as well.

 My good friend began wondering, what is the need for all these tests? If the tests are done to see whether things are all right or whether things have already gone wrong, why not prevent from things going wrong? He asked himself. But the other gentleman was insistent and suggested that my friend contact the private hospital in Jakarta which offered these very modern technologies.
Why not prevent these diseases? My friend queried. Indonesia is blessed with abundant healthy food and why not eat well and healthy, fresh food, not preserved food or fast food, fruits and vegetables that are all available easily and cheaply. Usually the well off in Indonesia find they don't have time for eating well, even with myriad of household helpers they have at their disposal. Add to that high percentage alcohol drinks such as Whiskey, Gin and Cognac!
Another rich Indonesian businessman told me that he had gone to Singapore and ordered a 1000 USD bottle of wine and he couldn't tell the difference between that and a regular 20 dollar bottle of wine!

The gathered most of whom were in their early 50s, very rich by Indonesian standards who had made their money by hard work and manipulation, had one more thing in common: High Cholesterol and High Blood Pressure.
It is not a pattern unheard of in these emerging economies. People, who have been lucky in this upsurge of economy, make a lot of money, but the surging economies do not have prevention programmes and making money out of the ill health is also part of the surging economies. It is easier to get an expensive MRI scan in Bangalore, if you can pay cash for it, than be able to see a General Practitioner and no doctor wants to be one!
My friend told the gathering, I do exercise every day, and I don't smoke or drink, enjoy each and every meal and try to make sure that it is freshly prepared or not preserved.
He spends his well-earned money on good food for himself and not wastes it on 1000-dollar bottles of wine in Singapore in the company of European chefs who know epicurean fools when they see one, with other upstarts from the newly rich Singaporeans.

In addition to the futility of doing expensive tests looking for diseases which are entirely preventable, what about qualified people who can interpret these results, especially in light of the fact that many of the measurements are unique to the Asian population.
Poor doctor patient communication is not unique to the west but equally prevalent in Asia as well, if not more so. I will once again give the example of my friend who had to do some tests at the request of his insurance company.
The Doctor called him in and with a serious face told my friend, many of the results on these tests and measurements are wrong and I will need to send you a Cardiology Consultant to sort it out.
What are the measurements that scared the GP doctor?
My friend has a BP of 95/60 mm Hg, has a pulse rate of 60/min and on his electrocardiogram and CXR a suggestion of an enlarged heart!
But the GP doctor forgot to ask an important question, do you exercise? Instead he suggested that my friend exercise minutes a day at least three times a week and that he eat more vegetables and fruits.

My friend was flabbergasted! He walked out in disgust. He discussed this with me, I retook his BP and pulse and confirmed what I had known ever since we had been friends: My friend exercises up to 90 minutes per day, mountain biking, uphill biking, basketball, jogging, walking, strengthening exercises and swimming. In the past year alone I had been present when he ran the Bali Marathon and also the Singapore Duothlon, in both events placing very well in his age group.

While I was studying Medicine in London, I had the chance to attend Radiology sessions at Brompton Hospital for Chest Diseases and vividly recall a certain Dr Simon with his large hearing aid of that time conducting excellent teaching sessions. To us the students he would put up an X-ray and ask us questions, it was enlarged!
And we were told that the x-ray had belonged to one of the greatest marathon runners ever, Emil Zapotek of then Czechoslovakia!  I was lucky to have been exposed to such excellent teaching at the hospitals of London that all that information is still available at the tip of my memory!

The clinical entity of athlete’s heart has been defined with increasing precision using a variety of techniques. Henschen is credited with the first description in 1899, using only a basic physical examination with careful percussion to recognize enlargement of the heart caused by athletic activity in cross-country skiers.5 Henschen concluded that both dilatation and hypertrophy were present, involving both the left and right sides of the heart, and that these changes were normal and favorable: “Skiing causes an enlargement of the heart which can perform more work than a normal heart.”5
You see, how a small piece of critical information, the exercise habits of my good friend, was missing from the GP doctors’ questions and he comes to the wrong conclusions! And gives an entirely erroneous and incongruous advice!
So the machines however sophisticated, in these emerging economies cannot replace the lack of sophistication in the knowledge of the doctors!
It is absolutely normal and to be congratulated that my good friend in his early 50s has such an excellent cardiovascular profile: lower BP and slower pulse and extreme capacity of the body for exercise.
Yesterday while watching BBC world news, amidst the carnage of Syria and Central African Republic, there was an elegant advertisement to invest in Indonesia!

I thought to myself, how far removed from the reality are these images! 238 million people, most of who are yet to get themselves out of poverty, with a very narrow band of very wealthy businessmen and corrupt politicians, a country where the medical care to the needy is poor, on par with other poor countries like Laos and Cambodia. And like any other emerging economy, has up to date machinery so that a rich businessman can order for himself a PET CT scan, a luxury even by western standards!
Imagine an American or British or Australian, however rich he is, going to a doctor and asking them, perhaps even persuading them to do a PET CT scan because he has been told that it can detect diseases? No insurance company would allow the reimbursement and most self respecting western doctors would refrain from ordering an unnecessary, incongruous test.
There are many other very cheap ways to measure whether your body is inflamed and whether or not you are susceptible to a future heart attack or stroke.
Very simple and inexpensive!
If you smoke, your chance of a heart attack or stroke is increased!
Weigh yourself, measure your height and calculate your BMI, i.e. weight in Kg divided by height in meters, squared. If you are not a weight lifter or a marathon runner, if your BMI is over 23 kg/m2 then your chance of heart attack or stroke is increased, if you are an Asian; your chance of diabetes is increased in most Asians, especially in Asian Indians.
Two simple tests both of which will tell you about inflammation in the body: CRP and Cholesterol. If they are elevated, the idea is not to take Statin medications and continue your gluttonous eating habits but modify it to suit your race and ancestral eating habits.
Even after these expensive tests, the local doctors will tell you the same thing; Eat less and Exercise More, that is why the rich patient is there in the first place. Very few doctors in the West or the East are equipped to advice the patient on HOW TO EAT LESS and HOW TO EXERCISE MORE. It is almost as senseless as telling a poor Indonesian: Earn More and Spend Less. What the poor Indonesian wants to know is: How can I do it?
I decided to check up, pardon the pun, of the prices for these tests done by a popular hospital in Jakarta in Indonesia. For those of you criticising the American System of health care, they cost far less to a patient in the USA if they are ordered when it is needed.
The following set of tests taken together will set back an Indonesian a nice tidy sum of 1500 USD or more! Cash is preferred thank you!

 Includes the following examinations: this is the best money can buy, but cheaper alternatives are also available. What does it say about the mentality of prevention of the Hospital? The message here is the more money you are willing to part with, more tests we can do for you. Whether or not it would prevent anything is dubious!
    Doctor Examination (General Practitioner, Internist, Neurologist, Ophthalmologist, ENT, Dentist, Cardiologist (EKG, Treadmill), Obstetric and Gynecologist (female))
    Test: Eye Examination (Auto refractor, Tonometry, Fundoscopy, Ishihara test), Audiometry, Spirometry
    Radiology: Thorax AP/ PA, Panoramic, Mammography Digital (female), Abdomen US (Complete), MSCT 256 Angie Coronel Contrast + Calcium Score, MRI-MRA 3T Head Non Contras
- Complete Blood Count
- Diabetic Screen: Fasting Blood GLUCOSE, HbA1c (Glyco Hb)
- Liver Function Screen: BILIRUBIN, Protein, SGOT-SGPT, Alkaline Phosphatase, Gamma GT
- Kidney Function Screen : UREUM, CREATININE, URIC ACID
- Hepatitis B Screen : HbsAg, Anti Hbs, Anti HCV Screening
- Thyroid Hormone : T4 Total, TSH Sensitive
- Serology : VDRL-RPR, TPHA
- Tumour Markers : CEA, AFP
    Complete Urinalysis
    Stool Routine Analysis
    Consultation by Nuclear Medicine
    Pap’s Smear by Obgyn.(female), PSA-Prostate (male)
    Health Report

At the Manipal Medical centre (which is much more of a Meat market than a Medical centre), all the things included in Doctor Examination would cost less than 100 usd. MRI would cost another 100 usd
Add another 100 dollars for all the other laboratory tests mentioned, so the cost of these tests are 350 dollars maximum, doctors would be given 150 dollars for their work but the foolish but rich Indonesian businessman is paying 1500 dollars for the tests with of course a Health Report. As mentioned, the health report reflects the expertise of the doctor and as seen in the case of my friend, you may be referred for further tests and consultations.
You can spare all these. Come and see your classmate who graduated with you from High School, the humble man of Bogor. Listen to him, soon you would be spending your money to buy clothes that fit a thinner and healthier you, rather than paying into the coffers of the hospital making money for its investors!
Of course, there is a whole philosophy of who should be screened for what disease. In this case illustrated above, the only indication for screening seems to be MONEY, having money and willing to part with it.
My good friend, the humble man of Bogor has this to say:
Knowing my exercise schedule like I do, I think I am healthy enough, I don't feel anything, no signs of any sort of a medical problem, My BP is as 90/60 and the pulse is 60 per minute, blood cholesterol is not high and I eat well,
During my days of working with poor people of Jamaica, I learned a deep lesson, I told my friend.  It is foolish to go around trying to detect diseases among people when there is not enough knowledge to follow it up and offer adequate treatment. In the above case what if the PET scan, which is usually used to FOLLOW up treatment of Cancer with chemotherapy or radiation therapy in the west, what if, it lights up on a spot? What is the next step?

The West already wastes a lot of money on unnecessary tests and it is a pity that developing countries like Indonesia should copy these bad habits rather than copy habits of countries in the developing world, which are extremely good at prevention of diseases or adopt programmes that have been successful in the poorer countries. Several wonderful programmes in various parts of the world come to mind.
The following paragraphs are official criteria for screening for diseases. Urban Indonesia now competes well for Lifestyle associated diseases, such as Diabetes, Hypertension, Heart Diseases. Lifestyle associated diseases are prevented, not by tests and not by medications, but listening to good lifestyle related advice from such notably healthy Indonesians such as my friend, the Humble Man of Bogor!

When the prevalence of preclinical disease is low, the positive predictive value will also be low, even using a test with high sensitivity and specificity. For such rare diseases, a large proportion of those with positive screening tests will inevitably be found not to have the disease upon further diagnostic testing. To increase the positive predictive value of a screening test, a program could target the screening test to those at high risk of developing the disease, based on considerations such as demographic factors, medical history or occupation. For example, mammograms are recommended for women over the age of forty, because that is a population with a higher prevalence of breast cancer.
What criteria should be considered for an effective screening program?
  Life-threatening diseases, such as breast cancer, and those known to have serious and irreversible consequences if not treated early, such as congenital hypothyroidism, are appropriate for screening.
  Treatment of diseases at their earlier stages should be more effective than treatment begun after the development of symptoms. For example, cancer of the uterine cervix develops slowly, taking more than a decade for the cancer cells to progress to a phase of invasiveness. During this preinvasive stage, the cancer is usually asymptomatic but can be detected by screening using the Pap smear. Treatment is more effective during this stage than when the cancer has become invasive. On the other hand, lung cancer has a poor prognosis regardless of the stage at which treatment is initiated. Early diagnosis and treatment appear to prolong life little more than therapy after symptoms have developed. Screening to detect early stage lung cancer using currently available techniques would not be beneficial.
  The prevalence of the detectable preclinical phase of disease has to be high among the population screened. This relates to the relative costs of the screening program in relation to the number of cases detected and to positive predictive value. The expenditure of resources on screening must be justifiable in terms of eliminating or decreasing adverse health consequences. A screening program that finds diseases that occur less often could only benefit few individuals. Such a program might prevent some deaths. While preventing even one death is important, given limited resources, a more cost-effective program for diseases that are more common should be given a higher priority, because it will help more people. 
In some cases though, screening for low prevalence diseases is also cost effective, if the cost of screening is less than the cost of care if the disease is not detected early. For example, phenylketonuria (PKU) is a rare disease but has very serious long-term consequences if left untreated. PKU occurs in only 1 out of every approximately 15,000 births, and if left untreated can result in severe mental retardation that can be prevented with dietary intervention. The availability of a simple, accurate and inexpensive test has lead many states, including New York State, to require PKU screening for all newborns.
  A suitable screening test must be available. Suitability criteria includes adequate sensitivity and specificity, low cost, ease of administration, safe, imposes minimal discomfort upon administration, and is acceptable to both patients and practitioners.

There must also be appropriate follow-up of those individuals with positive screening results to ensure thorough diagnostic testing occurs.