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lundi 3 octobre 2016


My good friend Gordon with his wife recently visited La Habana, my current home. We had known each other since our days as Junior Doctors at Repat Hospital in Melbourne, which we recollect as the golden days of our training for the real life Medicine. Gordon has gone on to become to practice the art of medicine, taking into consideration, the aspirations and abilities of the people to whom he ministers, successfully I may say, watching the outcome of patients.
One thing we both shared from the beginning was our dislike for rules and regulations in the practice of medicine imposed by professors and peons of the industry, with their illogical algorithms and constructed numbers as gate keepers for treatment. Many years later, many of these algorithms, evidence based treatments belly flop and the professors move on to other computer generated models, we plod on, dealing with every day people, in my case, the poor of the United States, the marginalized Native People of that continent.

We had long discussions about health of the society in general, and I was able to share with him some new information from Israel about nutrition and microbiome and level headed dietary advice in the midst of the jungle of experts in all sorts of fields. Australia did take a lead in defining Glycemic Index by defining the increase in blood sugar of a thousand different edibles that one comes across on a daily basis, but they forgot one important aspect: The Patient. In our lifetime, the demography of Australia had changed and as the Israeli research shows, a slice of bread may result in blood sugar excursions which is not consistent from person to person and that without knowing the microbiome of the person, it is hard to give nutritional advice. During his years of practice to a stable population in a Melbourne suburb, Gordon had made many discoveries which in the future may be scientifically proven but certainly intuitive and in tune with the explanatory models of the patients.
He had always been like this. I remember many years ago his attempts to get the management of Qantas, the national airlines of Australia, at that time an International player in aviation, to give passages to doctors on their long haul flights to Europe, but turned down. I had been called many times by the flight attendants to look at people who do not well traveling and should not be traveling in cramped conditions in the economy class but could offer some comfort and alleviate the suffering. I couldn’t help but chuckle when I read that ANA the popular airline of Japan with a wide outreach to other continents has introduced a concept of ANA doctor on board and would allow qualified practitioners to register as ANA doctor on board while traveling, to be called upon in case of need.

Gordon is a man ahead of his time when it comes to health care delivery to his patients, because he is unbound from conventions of Australian medical systems and the egoistic, self-fulfilling, and often unnecessary arrogant attitudes of the doctors at the Consultant levels. I am a GP, he would announce proudly.
While talking about the laboratory abnormalities with no current evident explanations among the American Indians (such as high alkaline phosphatase which is an enzyme in the liver, bone and guts; lower to non-measurable levels of CPK, an enzyme in the muscle), Gordon talked about Melanoma in Australia, a very prevalent cancer among its population, coming in at number 4. But Australians of darker skin colour are spared of this high prevalence and Australians of Asian ancestry tend to have a lower incidence. Darker skin does protect us from the UV radiation, associated with the Melanoma formation. Discussing these matters, accompanied by the excellent Mojito at the roof top bar facing the ocean in La Habana, I told him of a study done in Cuba where genetic mapping was able to point out the racial admixture from the past, to such a degree that most people who looked white had some black or Amerindian ancestry and most people who looked black had a fair bit of European genetic presence.
Right now, we treat patients as if they are a number and that studies done on people who are different from them in looks, socioeconomic status and race, are doled out as if we expect to get good results from it. The failure of modern medicine in USA or Europe or Australia to control chronic diseases to any great degree or prevent diseases and its complications over the years show that one medicine does not fit all and that we need to individualize our treatment, taking into consideration the explanatory model of the patient, the socioeconomic status and the current and future expectations of the patient and in fact a patient oriented rather than a disease oriented medical care.
We could reel off diseases which affected people of pure European or mixed European ancestry much more than Africans or Asians, such as Type 1 Diabetes, many of the autoimmune disorders and the higher than normal prevalence of metabolic diseases and mortality from Diabetes and Cardiovascular diseases from immigrants from South Asian region or origin. Malaysians or Cambodians don’t too well in Australia the statistics say, of course it does matter whether you are a Chinese Cambodian or a Khmer Cambodian!
On top of it all is the widely accepted, and slowly recognized metabolic explanation that Diabetes and Cardiovascular and cerebrovascular and degenerative diseases are inflammatory in nature and that the microbiomes may have a causative role in them.
So we could easily put out a pamphlet and jovially dedicate to our fun times at Repat Hospital... The Repat doctors medicine for your DNA... We laughed out loud to the amazement of the usually ebullient Cubans present at the roof top bar as the sun was setting over the US embassy into the sea...  

If you wish we can give you a couple of articles to show you how relevant was our laughter laden conversations were in La Habana, the moveable feast of a city. (The first article was published after our conversation in La Habana took place)
Here is one about Asian Americans, first of all, they are a heterogeneous group. For example, migrants to Australia from South India are racially different from those from the North. In South East Asia, the Chinese are the healthiest (perhaps also the wealthiest, which may have something to do with it). People who have undergone trauma, such as the Khmer under Khmer Rouge have epigenetic changes that give rise to illnesses.
The Burden of Cancer in Asian Americans: A Report of National Mortality Trends by Asian Ethnicity
Caroline A. Thompson, Scarlett Lin Gomez, Katherine G. Hastings, Kristopher Kapphahn, Peter Yu, Salma Shariff-Marco, Ami S. Bhatt, Heather A. Wakelee, Manali I. Patel, Mark R. Cullen and Latha P. Palaniappan
DOI: 10.1158/1055-9965.EPI-16-0167 Published October 2016
Background: Asian Americans (AA) are the fastest growing U.S. population, and when properly distinguished by their ethnic origins, exhibit substantial heterogeneity in socioeconomic status, health behaviors, and health outcomes. Cancer is the second leading cause of death in the United States, yet trends and current patterns in the mortality burden of cancer among AA ethnic groups have not been documented.
Methods: We report age-adjusted rates, standardized mortality ratios, and modeled trends in cancer-related mortality in the following AA ethnicities: Asian Indians, Chinese, Filipinos, Japanese, Koreans, and Vietnamese, from 2003 to 2011, with non-Hispanic whites (NHW) as the reference population.
Results: For most cancer sites, AAs had lower cancer mortality than NHWs; however, mortality patterns were heterogeneous across AA ethnicities. Stomach and liver cancer mortality was very high, particularly among Chinese, Koreans, and Vietnamese, for whom these two cancer types combined accounted for 15% to 25% of cancer deaths, but less than 5% of cancer deaths in NHWs. In AA women, lung cancer was a leading cause of death, but (unlike males and NHW females) rates did not decline over the study period.
Conclusions: Ethnicity-specific analyses are critical to understanding the national burden of cancer among the heterogeneous AA population.
Impact: Our findings highlight the need for disaggregated reporting of cancer statistics in AAs and warrant consideration of tailored screening programs for liver and gastric cancers. Cancer Epidemiol Biomarkers Prev; 25(10); 1371–82. ©2016 AACR.

One could sense that Gordon is a genuinely caring practitioner of our art of medicine. He has all the qualities which has been catalogued for the “hard working doctors” who may have forgotten the human elements while caring for the diseased. (Pun intended)
Published in Cardiology December 2015
FRIDAY, Dec. 11, 2015 (HealthDay News) -- Seven behaviors should be implemented to improve the art of medicine, which can help improve relationships with patients, according to an article published in Family Practice Management.
Thomas R. Egnew, Ed.D. from the University of Washington School of Medicine in Seattle, reviewed the literature and delineated seven behaviors that promote more consistent practice of the interpersonal aspects of medicine.
Egnew describes seven behaviors that include focusing on the patient, ideally taking a moment to prepare before entering the office, and establishing a connection with the patient, preferably before opening the electronic medical record in the first few minutes of the consultation. Other tips include assessing the patient's response to illness and suffering, use of communication to foster healing, use of the power of touch, use of humor and laughter, and showing empathy.
Anyone who knows Gordon will readily admit that he possesses those qualities in good measure!