WHAT CAN WE LEARN FROM ISRAEL AND BHUTAN ? AND WHY WE DO NOT WANT A GOVERNMENT LIKE BRASIL?

 Bhutan is a mountainous kingdom nestling in the Himalayas, where most of the people live in remote villages, most of which are not accessible easily.

In some cases, you may have to hike for a day or two or in some extreme cases, up to 15 days to reach some of these villages.

Yet majority of the Bhutanese adults have been vaccinated against the Covid virus.

They were eager to organize the vaccines and made arrangement with India which donated the necessary vaccine early.

The Government of King Wangchuk wanted its citizens to be protected, and they went out of the way, literally, to make sure that the vaccine reached remote areas, often by heliopter.

I have certain memories of Bhutanese Medical students who were studying in Santiago de Cuba, I remember one name, Dr Suresh C Mothey. One day I hope to see him in Bhutan.

Resolve the help the people of your country.

Make sure that you have a coordinated infrastructure for deliery of health care, regardless of the geography.

A population which are humble, loyal and understand the need for the protection

A population that does not believe in conspiracy theories, fake news and such.

Congratulations to Bhutan

A similar effort can be seen, CARE OF ITS OWN CITIZENS, in the State of Israel, the most vaccinated country in the world at the moment.

Even before the vaccines were approved, Israel made a deal with Pfizer and made sure that there were enough vaccines for all its citizen. An impressive 91 per cent of the elderly are vaccinated.

Israel's achievement in vaccination is so stupendous, that it is an inspiration. Even Saddiq Khan the mayor of London said: I would without hesitation call on Israel for help regarding Covid 19 Vaccine roll out!

Health workers went to remote villages and vaccinated people. A well educated populace, went to places of vaccination, using advanced technology in their cell phones and were vaccinated with lightning speed.

Once again, the desire of the government to protect its people, leads to people being protected.

Congratulations, Israel.

On the other hand, when a government or the leader is not that interested, and listens to claims which are not scientific and makes fun of wearing a mask or flout social norms, the average person in the street suffers .. Jair Bolsanaro of Brasil is the best example of the destruction of the public health of Brasil with close to 400 000 Brasilians who are no more, people dying while waiting to ge into the hospital, and refusing Pfizer vaccine, 70 million and with a vaccination rate down the ladder.. Brasil with its resources could have been a beacon for the developing world, instead has become a laughing stock with a President publicly taking Chloroquine tablets on TV and complaining that all these whining about death is for sissies ...Trump in the USA was no better, fortunately the wise American people saw the light and got rid of him and since Biden has been the president, the vaccination programme is the best in the western world of developed countries. The roll out of vaccines has been phenomenal and now every American over the age of 16 is eligible to get a vaccine.

PS Cuba and Bhutan has friendly relationships and Bhutan has diplomatic relationships with Cuba. The king of Bhutan in 1979 on his attendance at the NAM movement in  Havana, met Fidel and the friendship between the two countries blossomed. A group of 7 students arrived to study Medicine in Santiago around 1995, Dr Suresh Mothey among them. 

With a medical doctor from Bhutan (first picture) graduated in Cuba in 2012 after 7 years of university studies in Manzanillo, Cuba, at the celebration of the auspicious occasion of the 40th birth anniversary of H.M. King Jigme Khesar Namgyel Wangchuck, King of Bhutan. A photo from Bangkok, Thailand, pictured is the Cuban Ambassador at that time.

PPS

One of the least known facts is the International medical missions carried out by Israel. I clearly remember that Israelis arrived at the site of the earthquake in Haiti days before Americans arrived from Miami, just one hour away.

Cuba and Israel lead the world in International Medical Missions. So it is only natural that they care about their own people and educate the foreigners who come to study (22500 foreign students on scholarship studying in Cuba, mostly in Medicine) in the civic duty of helping their own .

OVER DIAGNOSIS AMONG AMERICAN HEALTH CARE PROVIDERS.. WHERE DID IT ORIGINATE ?

I am familiar with the health care systems in many parts of the world. The best, in my opinion, has been the one in FRANCE and the most chaotic is in the USA. The most humanistic one, for a poor country, is in CUBA. and I must commend ISRAEL, UK, Australia and NZ among the countries I am familiar with. 

USA has a broken system, and it is not correct to point the finger at any one but all people are responsible: The Fee for Service system without transparency, Insurance companies, Drug manufacturers and their peons, The Health administrators who are not normally conversant with Health Care, unlike in other countries. and the most important part, those instrumental in providing the Disease care, the Health Care Providers.

Even in that, it is so fragmented. You are not quite sure of the qualifications of the persons who are attending to you.

In the USA, with two years of extra education, Nurses can become Nurse Practitioners and persons with a Bachelors degree can be admitted to a PA Physician Assistant Programme of two years duration. Because of the system of fee for service, most of the Nurse Practitioners and Physicians Assistants work as Primary Care Providers.

Once again, it is the person and his characteristics that mark the qualities of a good care provider. 

In the wellness centre I am associated with, there are Massage Therapists, Fitness trainers and Physiotherapists. Every body agrees that as long as we keep the advise within the limits of our knowledge , there is less chance of false health information.

So it was interesting to read this publication from JAMA this morning.

Original Investigation 

Less Is More

April 5, 2021

Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing

Daniel J. Morgan, MD, MS^1,2; Lisa Pineles, MA¹; Jill Owczarzak, PhD³; et alLarry Magder, PhD¹; Laura Scherer, PhD^4,5,6; Jessica P. Brown, PhD¹; Chris Pfeiffer, MD, MHS⁷; Chris Terndrup, MD⁷; Luci Leykum, MD, MBA^8,9; David Feldstein, MD¹⁰; Andrew Foy, MD^11,12; Deborah Stevens, LCSW-C, MPH¹; Christina Koch, MD¹³; Max Masnick, PhD¹⁴; Scott Weisenberg, MD¹⁵; Deborah Korenstein, MD¹⁶

JAMA Intern Med. Published online April 5, 2021. 

editorial comment 

Key Points

Question  Do practitioners understand the probability of common clinical diagnoses?

Findings  In this survey study of 553 practitioners performing primary care, respondents overestimated the probability of diagnosis before and after testing. This posttest overestimation was associated with consistent overestimates of pretest probability and overestimates of disease after specific diagnostic test results.

Meaning  These findings suggest that many practitioners are unaccustomed to using probability in diagnosis and clinical practice. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse.

In this large study, USA based health care providers over diagnosed ordinary conditions the majority of the times, leading to extra expenses and investigations. It is a common scenario in the USA. and of course, now this lack of using probability of diagnosis has become the norm and there is a healthy Medical Malpractice Industry in the USA, which would consider this lack of a practice to be what a sensible man does, in the legal thinking. 

This over diagnosis was common among all sorts of practitioners pointing out to a medical habit or a taught form of behaviour and thinking.

It would be interesting to study when and how this lack of understanding of probability entered the practice of Medicine in the USA .. Hope they do not export this habit to poorer countries where there are no facilities or material support.

HIGHLIGHTS

• The U.S. spends more on health care as a share of the economy — nearly twice as much as the average OECD country — yet has the lowest life expectancy and highest suicide rates among the 11 nations.
• The U.S. has the highest chronic disease burden and an obesity rate that is two times higher than the OECD average.
• Americans had fewer physician visits than peers in most countries, which may be related to a low supply of physicians in the U.S.
• Americans use some expensive technologies, such as MRIs, and specialized procedures, such as hip replacements, more often than our peers.
• The U.S. outperforms its peers in terms of preventive measures — it has the one of the highest rates of breast cancer screening among women ages 50 to 69 and the second-highest rate (after the U.K.) of flu vaccinations among people age 65 and older.
• Compared to peer nations, the U.S. has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.
• 
  
  
  USA also has highest rate of spending money on Health (or Disease?) but do not have good indicators of health to show for it. 
• An analogy came to my mind. A few years ago no one wanted to talk about Climate Change and slowly people began to accept that there is a crisis. In the USA there is a crisis in the health care sector, but no one wanted to talk about it and murmurs are being heard that the system is broken. So there is still hope!

CUBAN SOLIDARITY, NORTH AMERICAN FRAGILITY AND JALALUDDIN RUMI ..

 While at the beginning of the Pandemic in 2020 and the various types of isolation that were to follow, many people, including me, welcomed the isolation and lack of intrusion when you don't need it and the chance to think and conceive ideas.

I had to cancel my trip to Europe which was to take place in April 2020, already having cancelled a trip to Cuba at the last moment (the suitcases are not unpacked even today!).  

By July it would be fine? Certainly, September? Ignored by the populist governments and leaders, the virus marched on, killing Indians in the Amazonas, energizing scientists to work towards a vaccine at electric speed..

By the end of the year, Island Fever starts seeping in. I had not seen my closest friends in Miami with whom I spend hours in conversation on a regular basis on my visits to Yuma (this northern land)..

Looking around, observing the effects, from an anthropological view, I could easily observe that the psychological effects of the Virus was universal and complete: 100 per cent of the people were suffering.

But there are some exceptions to the rule.. Cuban collective suffering in the island was similar to the other countries but individual cuban suffering was quite different from the country to the North and other compatriot countries.

During the early part of my stay in Cuba, I have the pleasure of meeting, I had the good fortune to meet Dr Jose Altschuler Gutwort, a historian of science and whose father was one of the founding members of the Original Cuban Communist party. (he was a jewish immigrant from Poland). Dr Jose said to me: If you are more concerned about yourself than the other people, you better go to the USA, it is the best place for such things, but if you are interested in other peoples rather than just yourself, you have come to the paradise, Cuba. I was quite impressed and many years later, completely came to understand the Cuban Solidarity with each other ..

My friend from Cuba wrote to me today: we may have trouble finding food but you know how the Cubans are, we help one another .

Remember what Dalai Lama had said: If you want to make others happy, be compassionate, if you want to make yourself happy, be compassionate.

After living in Miami for this year of Covid 19, for more than one year, and after meeting many ordinary cubans of Miami, I can assure you that the Cubans living in the island are far more happier than the Cubans living in Miami. 

Cuban Solidarity in the island .

Of course, the Doctors of Cuba show their solidarity with other developing countries. Can you think of a single other country which sent contingents of doctors to work in poor countries when Covid pandemic hit ? Cuban doctors and nurses have gone to at least 30 different countries to help the people.

While in Cuba, the people became more than resilient, in north america (Yuma in colloquial Cuban parlance) I can see people are falling apart. People are not nice to each other, i see them pushing ahead in lines at the supermarkets and just not being polite. Their ideas of entitlement has no meaning now and they view their loss of privilege, aided and abetted by racist governors and leaders and they begin hating every one to such an extent that in the last few months, there have been quite a few murder sprees for no reason in the land of the free ..

I thought of the happy people in the lands I normally travel to: Cambodia, Malaysia, Cochin in Kerala in India, Colombia, Argentina, Qatar, Israel.. and the happy Native people that I work with, including the Native people of USA.. Native Americans share very little, philosophically with those of the late comers and settlers. I also noticed that the covid 19 distress did not make them behave in an unfriendly fashion to their neighbours or relatives, but their lives continued blissful as before, now having more pleasure helping each other.

I respectfully thought of Wilma Mankiller, the once leader of the Cherokee Nation 

“I learned a long time ago that I can't control the challenges the creator sends my way, but I can control the way I think about them and deal with them” 
― Wilma Mankiller, Ex-Chief of the Cherokee Nation of Oklahoma 

I said to myself: I am not going to be drawn down by the Americans, Cubans and other immigrants around here . I will seek out those, regardless of how long they have been in Yuma, who are content, generous with their time and their thoughts and who have a compassionate nature.

this is the only way to enter the magical world that I know so well. I have seen the reality and I am not that fond of it. I have been doing vipassana meditation and i could feel the reality and understand it, but that does not mean I have to accept it. 

Reality is harsh and I will return to the magical world.

Mr Carlos, the elegant friend who loves linen suits, panama hats, and Rayban sunglasses.  we keep in touch through iMessage and Facetime .  He is a resident of Bruxelles but travels and of course neither Covid 19 nor the border closures are a problem for him, you will see why when you meet him. His last adventure was in Brasil when he fell in love with a Moça there, who broke his delicate heart..

Le Petite Poete de Côte Sauvage is a little poet that has been sprouting wisdom to me since age 3.

When it came time to say goodbye to her, the three year old philosopher said: I will not miss you, how can I miss you, when you are in my heart all the time ?

And the Little Philosopher of Cote Sauvage echoed:  if you shout, you will loose your voice

If you are not compassionate, it means I think in the mind of the little philosopher, happiness will not take root in your heart.

Tonight, reflecting my new mood, RUMI arrived, so you see, everything is related as they say in the Lakota Language, Mitakuye Oyasin..

How much I enjoyed reading the quotes from RUMI .. reflected in thoughts of a friend far away

A inspiração que você procura já está dentro de você.

Fique em silêncio e escute.

Rumi

At times, I feel homeless as I have to depend upon others for accommodation.. but as my younger brother Shimon in Israel said: you have rooms waiting for you in the hearts of so many people around the world.  Toda Rabah, Shimon.

Wherever you live, be compassionate..

Happiness will follow.. 

As always, for people in my heart..

SO PROUD OF CUBA, A SMALL ISOLATED, ASPHYXIATED BY THE GIANT TO THE NORTH, HAS ITS OWN VACCINE

 Cuban Revolution, considered to be a classical example of People's uprising against tyranny and Imperialism, happened in 1959. The Giant to the north so used to the kowtowing of the countries to the south of them try to choke the newly revolutionary government . That asphyxiation continues with a short respite during the Obama Administration. 

Blockade of Cuba has been going on for nearly 60 years, the initial purpose was to overthrow the government of Fidel Castro. Kennedy, Johnson, Nixon, Ford, Carter, Reagan, Bush I and II, Clinton, Trump all have come and gone, THE REVOLUTIONARY GOVERNMENT OF CUBA HAS NOT FALLEN ..

BUT the blockade has created enormous difficulties for ordinary cubans and it has gotten worse during the Covid Pandemic as the tourism was shut down and the US government stopped financial remittances by the Cuban diaspora in the USA from sending money to their relatives.

We try not to dwell upon the difficulties of every day life but this morning when I received this video from my good friends Annie and Luis in Barcelona, it did lift my heart a little bit .. I was standing line at a shop in Miami and I couldnt help myself dancing like I would do if I were in Havana..

Thank you, amigos Luis y Anna, nuestros queridos amigos, amantes de Cuba.

This video was made by Argentine musicians and actors and comedians, Ale Sanz and Rudy, part of the group, RS Positivo, accompanied by the pianist Humberto Spallina. and the cuban musician resident in BA, del valle.

For people who know the sociopolitical scene in this part of the world, names come of paying tribute.. Lula, and an array of Argentine politicians and also an indirect tribute to that great Argentine who became a cuban revolutionary, CHE.. tu querida presencia, denotes Che in the lyrics.

I listened to it again, and once again I felt good. In a very short time, millions are people are going to hear about this Cuban achievement, Soberania vaccine , and the lovely music.

Gracias hermanos argentinos..

MARVELS OF TECHNOLOGY: THE FUTURE WHERE ARTIFICIAL INTELLIGENCE MEETS HUMAN INTELLIGENCE

 This morning I received a message from an artist friend of mine from Teheran.

and included was a song

"I really love this song. I cant understand the meaning of that but I feel it can be about love."

I listened to the song, at first I did not even know what language that was being sung in. 

i listened to the beautiful song a couple of times, and each time I could distinguish words, even though I did not know the language of the song.

I picked up a word Zindagi, which is the same in Persian and Urdu/Hindi. Since she is from Iran, she would have known if the song was in Persian, so I assumed the song must be in Hindi.

In India, there is a culture of music in that many people will break into songs, and the worlds are universally remembered. Hindi is a North Indian language and most of my friends are in Cochin in Kerala where one hears a cacophony of languages with local language Malayalam dominating with Tamil being another.

I remembered the pharmacist who helps me, a young man who works in Bangalore and sent him the audio clip. He wrote back, very famous sir .. then i have to ask him the name of the singer and the name of the song. He knew it, and he told me that the singer was Arijit Singh and the song was tum hi ho.

Thanks to the Internet and You tube, the message had gone from Tehran to Miami to Bangalore. I also decided to send it to two friends in Cochin, Kerala

One of the friends I sent to, I knew she was a singer from her audio clips but an university student. 

Her reply:

Yes this song is from the film Aashiqui 2 (Hindi film) sung by Arjith Singh.   tum hi ho

and she sent a clip of her singing the song.

Another good friend of mine had this to say

Hindi. Language

I cannot live without you now.    title 

and you can guess the rest of the lines 

I hope somebody nice sent it to you.

This is how the world is connected .

A friend from Iran who does not know the song but liked the song sent it to me to find out where the song is from . I sent it to my friends in India and they immediately recognized the lyrics.

All in all, all of us felt good, an innocent sensation of pleasure and to know that we are all connected.. at this time eased by the technology.

I learned about a popular singer in India.

I talked about this with a friend of mine in Brasil. 

This connection around the world has really saved my sanity over the course of this past year.  I know i have to be a little bit more patient to see my friends from Cambodia, Thailand, Malaysia, India, Iran.. but each day is ONE DAY LESS..

But the priorities are 

Bauru, SP, Brasil; Israel; Quiberon, France and of course, La Habana, Cuba,

FATTY LIVER, WHAT CAN WE DO? DRINK SOME CUBAN COFFEE..

One of the simple pleasures in life is to sip a cup of Cuban Coffee. I walk to the nearest cafe, and order a Cortadito which is a Cuban style coffee with a little bit of milk. 

A question frequently asked by patients is that they have been told that they have fat in the liver and they should loose weight. If loosing weight was such an easy proposition as going to the store and buying a pair of shoes, we would have no Diabetes, no Hypertension and a slew of metabolic diseases.. But loosing weight, according to those trying to loose weight, is not easy.

The prevalence of fatty liver in the USA is between 25 and 33 per cent, let us say 30 %. The coffee culture in America is abominable despite the well off population trying to make Starbucks richer. Coffee sold in most places in the USA or "brewed" at workplaces is an insult to Ethiopia the birth place of coffee. 

But there is always a good cup of Cuban coffee for me. I do not suffer from Fatty liver but I can never resist a Cortadito.

I do recommend at least two to three cups of coffee per day for my patients with NAFLD," said Abdelmalek, professor of medicine and a gastroenterologist at Duke University, Durham, N.C.

Her thinking on this recommendation has been influenced by a meta-analysis of 16 studies including more than 3,000 coffee drinkers and 132,000 nonconsumers; the meta-analysis concluded that coffee drinkers were 39% less likely to develop cirrhosis. There was evidence of a dose-response effect: Consumers of two or more cups daily had a 47% reduction in the risk of cirrhosis, compared with the nondrinkers, while more modest consumption was associated with a 34% reduction. Moreover, the investigators found that coffee consumption was also associated with a 27% reduction in the likelihood of developing advanced hepatic fibrosis, compared with that of non–coffee drinkers.

"What's even more provocative is the evidence that coffee decreases risk of hepatocellular carcinoma," the gastroenterologist said.

Suddenly it occurred to me , what is the level of Fatty Liver in Cuba? 

During the Periodo Especial I am sure it was zero, but since then?

A cross-sectional, multicenter study was carried out in 6601 adults seen at gastroenterology outpatient clinics of nine hospitals in seven Cuban provinces from September 2018 through May 2019. Non-alcoholic fatty liver disease was diagnosed by abdominal ultrasound. The study included 1070 patients who met the diagnostic 

that is 16% prevalence , 

ie a 45 % reduction than the people of Yuma (estados unidos)

I can vouch to you that it is rare to meet a cuban who does not drink at least few cups of coffee per day, so following the logic and thoughts of the Gastroenterologist from Duke University, this reduction must be due to the habit of imbibing the good coffee in Cuba!

Thank you Cortadito

My sister in Havana can brew a mean cup of cuban cofffee and I add the milk into it to make it a Cortadito, whereas most Cuban seem to prefer the Cuba without milk.

EXCESSIVE EXERCISE IN THE ABSENCE OF NUTRITION ( NOT PROCESSED FOOD LIKE SUBSTANCES) MAY ACTUALLY DAMAGE YOUR HEALTH

 

When asked to accompany an European-Australian to go for a run around a football field, an Australian aboriginal person accepted the invitation and ran with him around the ground. When they came to the starting point, the Euro Australian wanted to run again, a puzzled indigenous australian asked him: will you come back here at the end of the run? Yes, said the Euro-Australian enthusiastically. Then, said the Indigenous australian, more relaxed now, I will wait there for you.

Most indigenous people do not understand "Exercise" while they know very well what it means to be active, the first one in their eyes, does not have a specific destination or immediate result whereas the second one, being active, you can get your tucker (food), go back to your country (land identified to them).

I am an Endocrinologist and I usually try to persuade sedentary people to move around a little bit. But more than once, among my own colleagues, I have come across the metabolic dysfunction caused by excessive exercise.

Excessive exercise training causes mitochondrial functional impairment and decreases glucose tolerance in healthy volunteers

• Mikael Flockhart
• Lina C. Nilsson
• Senna Tais
• Björn Ekblom
• William Apró
• Filip J. Larsen 3
• 
  

Published:March 18, 2021DOI:https://doi.org/10.1016/j.cmet.2021.02.017

Highlights

• •
  Here, we investigate the dose-response effects of exercise training in healthy subjects
• •
  Excessive exercise training induces substantial mitochondrial respiratory impairment
• •
  Mitochondrial impairment is associated with impaired glucose tolerance
• •
  Despite excessive training, markers of global oxidative stress were unchanged

Summary

Exercise training positively affects metabolic health through increased mitochondrial oxidative capacity and improved glucose regulation and is the first line of treatment in several metabolic diseases. However, the upper limit of the amount of exercise associated with beneficial therapeutic effects has not been clearly identified. Here, we used a training model with a progressively increasing exercise load during an intervention over 4 weeks. We closely followed changes in glucose tolerance, mitochondrial function and dynamics, physical exercise capacity, and whole-body metabolism. Following the week with the highest exercise load, we found a striking reduction in intrinsic mitochondrial function that coincided with a disturbance in glucose tolerance and insulin secretion. We also assessed continuous blood glucose profiles in world-class endurance athletes and found that they had impaired glucose control compared with a matched control group.

Graphical abstract

So, excessive training load we will leave to the athletes. We the ordinary ones, will be active, not sitting at the same place for hours on end, sleeping soundly and also calm your mind and mindfully walk  and enjoy the sunsets.

We live at a time when good nutrition is almost impossible to get. Half the americans get their calories from highly processed food. No amount of exercise will mitigate the damage done to your body by bad food.

Currently I am very content and inspired by an indigenous friend of mine and his able wife. He decided to change his nutrition, stick to that change and she expertly prepares the meals which they both enjoy together and the effect on his body metabolism has been nothing short of miraculous.

They send me photos of their blood sugar readings before, one hour and two hours after breakfast, lunch and dinner and I tell them that they have become members of the Century Club, maintaining their blood sugars around a 100 all day long.

Before Breakfast:

Breakfast

One hour after, above and two hours after, below.

Before Lunch, above, and the Lunch below

One hour after, above, and two hours after, below

Before Lunch and the Lunch 

One hour after Dinner, above and two hours after, below.

For a person who was in the Emergency Department (A and E) at the local hospital with sky high metabolic numbers, this is more like a miracle.

The miracle here is the FOOD as pictured, thanks to his expert chef wife. Congratulations to both of you, my dear friends.

When we started working together, I realized that I had to put aside certain prejudices of the doctor (medical education does make you prejudiced about other people's knowledge and wisdom) and embrace what the Indigenous Americans have taught me : Respect the person and acknowledge their knowledge.

In short order, we agreed that he can go off his medications, Metformin and Long Acting Insulin and also his medications for high cholesterol. These are what I call the Diseases of Civilization. 

Coming back to the title of the blog, exercise is necessary, but have an active mind as well, excessive exercise may damage your metabolism but in my opinion, the major aspect for your health is your Nutrition (way more than your exercise). 

and here is one example, of my Lakota friend and his wife, both of them have become members of the Century Club.

PS I am a member of another Century Club, a person who has travelled to 100 countries or territories, but I wanted to join the Century Club of Brave Thunder Journey. 

I am happy to report that my blood sugar during the day fluctuates only slightly around the 100 mg/dl mark. A proud distinction!

MY ADVICE TO MY PATIENTS 

PREPARE YOUR OWN FOOD