Medical Musings & Amusing Medicine

New year and "new" idea!

noreply@blogger.com (Unknown) — Thu, 05 Jan 2012 19:48:00 +0000

This last new year was probably the most uneventful one I've had in recent memory. In the last 5 years I've spent my new years' eves under the Sydney Harbour Bridge, in beautiful Cape Town, in snowmageddon Baltimore, in smog-filled Jakarta, and in a secure compound in Nigeria. This year however I spent it on a remote sheep farm in the Little Karoo of South Africa. I'm even a little embarrassed to say that I didn't even stay up for it!

It was on another night, when I happened to be struggling to sleep, that I conceptualized my personal philosophy on health and wellness. I wasn't on the farm this night so counting sheep was not an option. There are many ancient belief systems and contemporary ones that see the healthy human frame as being in perfect balance or harmony (or ease), and the unwell as being out of sync or imbalanced (or dis-eased). Similarly my approach to my patients is to explore their person to begin to understand the origin of the disharmony. This may be challenging in a 15-minute consultation which is often the case, but as I've begun to gain the confidence of particular patients through repeated visits, I have become more aware of the factors, events and behaviours that disrupt their homeostasis.

And with this word, HOMEOSTASIS, I would like to summarize my philosophy/approach to maintaing health. How-you-stay-as-is (homeostasis) is essentially the biological process whereby an organism maintains a constant internal environment. I'll elaborate further on some ideas relating to this concept with regards to how it may improve and furthermore maintain your health in subsequent posts. This isn't a new idea but is essentially a novel way of exploring the concepts related to maintaining your homeostasis.

Have a balanced year!

Cancer Hopes - Burzynski Clinic

noreply@blogger.com (Unknown) — Thu, 01 Dec 2011 00:07:00 +0000

If you have researched the Burzynski Clinic and Research Institute on the internet then I have no doubt that you have encountered very polarized opinions ranging from the avid supporter to the vehement sceptic. I would like to give you an overview of the treatment they offer and my personal perspective as to why Healtheon is collaborating with them.

The media and internet comments generally portray The Burzynski Clinic as an alternative cancer treatment facility. This is where the majority of the scepticism comes from I believe, as they have been lumped together with the likes of Gerson and other treatment modalities that truly have no scientific evidence. Burzynski has also been labelled as pseudo-science, in attempting to gain credibility in scientific eyes by publishing loads of poorly designed data. This is what formed the basis of my initial scepticism.

The buzz word in cancer therapy now is gene-targeted therapy. The largest oncology centres around the world are increasingly using gene targeted medication which is seen as the future of oncology, of which there are over 40 registered now I believe, in treating the various kinds of cancer that patients present with. Each medication has a particular indication for which it has gained FDA and other medicines control councils' registration (so for example x drug is indicated for colon cancer with x gene marker). This is exactly what the Burzynski clinic has been doing, but to a greater degree, and with more individualized therapy.

Through my visit to the clinic and laboratory facilities, in meeting their team, and witnessing their approach to patient consultations and treatment regimens, I gained confidence in what they are offering. The vast majority of patients who walk in their doors have already undergone surgical resection, chemotherapy and radiotherapy and have either had poor responses or have had relapses. The team of oncologists consult together regarding each individual case and decide upon an investigation and then treatment plan.

The investigations include prior biopsy results analysis, further imaging, and further genetic marker testing on new biopsies if necessary. If the particular cancer displays a certain gene marker known to current science, then the most appropriate medication is prescribed. The majority of cases I witnessed in the clinic were prescribed gene targeted medication from the largest pharmaceutical companies in the world that are routinely used in MD Anderson for instance (the 40 odd that I mentioned previously). It must be noted however, that the team assembled at Burzynski is very much on the cutting edge of gene targeted research and as such do take it upon themselves to prescribe these drugs off-label if it be in the interest of the patient. So for instance a drug that has been registered for colon cancers displaying a particular gene marker, would be used off label for a liver cancer that has also displayed that gene. Patient responses are then actively monitored through gene marker testing in ascertaining whether there is a response to the medication, and thus decrease in the pathologic gene marker.

This entire aspect of the treatment regime of the Burzynski clinic which can be seen as mainstream but cutting edge cancer treatment is not questioned, as it is what the largest oncology centres around the world are employing and at times trying to replicate. What has brought all the scrutiny and negative professional opinion is the use of Antineoplastons, which is the "broad-spectrum" gene targeting medication discovered by Dr Burzynski. It is this medication that continues to be used under clinical trials.

This medication is reserved for patients with inoperable brainstem cancers for which FDA trials were conducted previously and are ongoing, since no other treatment modality exists. For patients who have come in after exhausting "conventional" treatments, and those that do not display any gene markers covered by the specific gene-targeting medication that exist, special FDA compassionate permission is applied for in utilizing Antineoplastons as a "final resort", as there exists no other options. In these cases, permission is usually obtained and treatment is commenced. It is believed that these Antineoplastons can target over 100 of the cancer genes and is considered a broad-spectrum (shot-gun) approach when there are few other options. Burzynski believes in this drug and the research institute is continually trying to improve it, test it, and ultimately have it gain full registration. The documentaries have largely covered this struggle.

There was no instance in patient interactions where false hope was given. Each patient was treated with a respect and dignity that I generally fail to see in normal medical institutions. It is true that patients are usually desperate and often this is their last chance, but the impression that Antineoplastons are some miracle drug is not given and as such I am happy for us to continue working with the Burzynski clinic, moreso because of their overall approach to cancer treatment, and the results which they seem to be getting. I don't know whether Antineoplastons truly work or not but I feel that it is irrelevant in the sense that it is considered an experimental drug and is treated as such by the Burzynski clinic, which employs cutting-edge individualized gene targeted therapy essentially.

Why Invest in Health in Indonesia

noreply@blogger.com (Unknown) — Tue, 13 Sep 2011 23:55:00 +0000

What determines the health of a nation? How does one determine the burden of disease that the population has? Is it the average life expectancy? Or is it a series of statistics reflecting child and maternal mortality/morbidity? While the most accurate answer is likely a combination of these suggestions and others, child and maternal mortality statistics are frequently used to ascertain the state of a population’s health.

Indonesia is the 4^th most populous nation on earth and is the largest economy in Southeast Asia. Sustained year-on-year economic growth over the past 30 years, apart from a difficult period after 1997’s Asian Economic Crisis, has seen the country make major improvements in its health system. However, it is struggling to achieve important health outcomes, especially among the poor strata of the population. Indonesians are living longer with an average life expectancy of 68 years in 2009, contrasted to 32 years in 1953. During a similar period, Indonesia has reduced its child mortality rate by more than a third, yet maternal mortality rates of 4 mothers’ deaths out of every 1000 live births is about double that of the Philippines, three times that of Vietnam, and four times that of Thailand.

While child nutrition had improved up to the year 2000, it has stagnated since and is even increasing in some provinces. Key determinants of health such as female literacy and access to clean water and sanitation remain strikingly low among the poorest population groups. The significant geographical disparities may apply be highlighted with 25 out of every 1000 children dying before the age of 5 in Bali and Yogyakarta, while in Gorontalo closer to 100 out of every 1000 children fail to reach 5 years of age.

This can be explained by not only continuing, but also new, challenges that the country is facing due to demographic, epidemiological and nutritional transitions that are increasing the demand for healthcare. The aging population now has to deal with the disease burdens usually seen in both the developing world (communicable disease and malnutrition) and the developed world (chronic disease, diseases of lifestyle and cancers). This transition will demand a different, and more expensive, health system. Despite substantial increases in public health spending in recent years, overall health spending in Indonesia remains low and continues to be inequitably distributed between and within provinces, while World Bank analyses reveal major inefficiencies.

With the sustained economic growth forecasts for the region and the striking deficiency in healthcare as compared to its regional peers, there has been significant interest in foreign investment into Indonesia and its healthcare sector in particular. This interest has been stoked by a proactive 2010 government decree, which raised the foreign owner limit on certain sectors, including the health sector. Some investors have tipped Indonesia to rank beside the burgeoning BRIC countries of Brazil, Russia, India and China due to its big market potential and rich natural resources. However, bureaucratic red tape, corruption and overlapping regulations have continued to hobble foreign investment.

Personal leadership philosophy

noreply@blogger.com (Unknown) — Thu, 17 Dec 2009 20:00:00 +0000

During my Public Health studies at Hopkins I concentrated on Health Leadership and Management and found The Foundations of Leadership to be my most enjoyable course. This was my final paper reflecting my leadership philosophy which is bound to evolve as I do.

Introduction

The Collins English Dictionary defines a leader as “a person who rules, guides, or inspires others”, or simply as the “head”.1 Assuming a role of leadership may be considered both a privilege and an honor, but is also invariably a tremendous responsibility. In exploring leadership in terms of the innate qualities required, role of leadership and core values that should be engendered, and skills essential for successful practice, an amalgamation of various theories and philosophies as well as some personal insights have been utilized for the purposes of this paper. Specific leadership theories such as “great man”, trait or contingency theories were not specifically evaluated.

Innate qualities

The nature versus nurture debate regarding personal qualities of leaders is suitable to be delved into at this stage. The notion that great leaders are born rather than made may have some substance to it, as certain qualities felt to be essential to success in the role of leadership may not be easily acquired, if at all, during the course of one’s life. An essay by Robert Greenleaf, in 1969, first described the term “servant as leader”, which was later further developed in his book “Servant Leadership”. The qualities or characteristics described by Robert Greenleaf included listening, empathy, healing, awareness, persuasion, conceptualization, foresight, stewardship, commitment to the growth of people and building community.2 In essence these qualities are essential for this practical philosophy that supports people who choose to serve first, and then lead as a way of expanding service to individuals and institutions.

These basic concepts and qualities of a servant leader were expounded upon by Kathleen Patterson, where “the servant leader (a) demonstrates agapao love, (b) acts with humility, (c) is altruistic, (d) is visionary for the followers, (e) is trusting, (f) empowers followers, and (g) is serving.”3 The cornerstone of this model is agapao love, a Greek word, which according to Bruce Winston, “refers to a moral love, doing the right thing at the right time for the right reason”.4 An interesting paper by Jane Waddell, posits that the introvert’s ability to listen more than to speak is more compatible with servant leadership and as such introverts are furthermore “more likely to be perceived as being a servant leader by their followers”.5 Thequalities engendered by the concept of Servant Leadership are similar to the qualities of a Level-5 leader, a term originally coined by Jim Collins. “The most powerful transformative executives possess a paradoxical mixture of personal humility and professional will. They are timid and ferocious. Shy and fearless. They are rare – and unstoppable.”6 These qualities for the most part are not something that one can necessarily develop. They may not be something that you are genetically born with either, but through your upbringing and early life experiences, as your personality and values are formed, these qualities begin to define you.

Research by David Rooke and William Torbert suggested that “leaders are made, not born, and how they develop is critical for organizational change.”7 They defined 7 “action logic” ways of leading: Opportunist – wins any way possible (5%); Diplomat – avoids overt conflict (12%); Expert – rules by logic and expertise (38%); Achiever – meets strategic goals (30%); Individualist – interweaves competing personal and company action logics (10%); Strategist – generates organizational and personal transformation (4%); Alchemist – generates social transformations (1%).7

An important aspect of these qualities with regards to success in leadership is that they need to be authentic. In a paper by Bill George et al, the authors interviewed 125 leaders and analyzed 3000 pages of transcripts in an attempt to define the profile of an ideal leader. Their findings and conclusions rejected the notion of successful leaders having to be born with specific characteristics or traits, but rather that authentic leaders “reported that their motivation came from a difficult experience in their lives”.8 In becoming an authentic leader or person per se, one needs to begin to understand one’s personal self. “IQ and technical skills are important, but emotional intelligence is the sine qua non of leadership.”9 Understanding oneself, or self-awareness, is the first component of emotional intelligence. The next four components, as described by Daniel Goleman, include self-regulation, motivation, empathy and social skill. “Scientific inquiry strongly suggests that there is a genetic component to emotional intelligence.”8 With strong support to both sides of the debate regarding whether leaders are born or made, it appears that the answer may be a balance of both. Emotional intelligence does however appear to be of extreme importance in the mix of qualities, alluded to initially, that successful leadership requires, in that nearly 90% of the difference in the profiles of leaders analyzed by Goleman, in terms of success, was attributable to emotional intelligence rather than cognitive abilities.8

Role of Leadership

According to John Kotter, “leadership and management are two distinctive and complementary systems of action”.10 The distinction between leadership and management is a useful one in that it allows us to gain a better understanding of leadership and causes us to reflect on our personal roles as leaders, to critically ask ourselves whether we are really leading. A key distinction between the two has been elaborated upon by Jim Clemmer, where “we manage things and lead people”11 and by Joel Barker, where “managers manage within paradigms, leaders lead between paradigms”.12 While leadership is a necessary facet of management, the distinction is however apparent. A favored quote from Warren Bennis illustrates this point: “Management is getting people to do what needs to be done. Leadership is getting people to want to do what needs to be done. Managers push. Leaders pull. Managers command. Leaders communicate."13

The responsibility of a leader to inspire, guide and facilitate the professional growth of employees is one that cannot be overstated. The Pygmalion effect has long been recognized where “a manager’s expectations are the key to a subordinate’s performance and development”.14 A paper by Douglas Ready and Jay Conger explored the demographic shifts in the talent pool and existing talent development strategies currently employed in organizations, concluding that despite the wealth of knowledge and investment, virtually all companies examined felt incapable of filling strategic management roles. “Leaders have long said that people are their companies’ most important assets, but making the most of them has acquired a new urgency.”15 Of particular interest in this paper was the finding that the element missing from most talent development programs was passion and vitality. The authors subsequently proposed suggested measures that companies could take to build it into their cultures.

There are a myriad quotes regarding the role of leadership, which help define it further, but in my opinion, the essence of the role of the leader is to create and/or maintain the vision of the organization to create a sense of purpose, communicate it and empower individuals to embrace that vision and to uphold guiding values, while perpetually fostering individual and organizational growth and innovation.

The role of the leader in engendering creativity in today’s innovation driven global economy was explored by Amabile and Khaire, and five practices recommended: tap ideas from all ranks; open your company to diverse perspectives; protect creative persons from bureaucracy; know when to impose controls and when not to; create a filtering system.16 Peter Drucker argues that innovation rarely springs forth from moments of inspiration, but rather arises from disciplined analysis of opportunities that arise. He names seven practical situations that account for the majority of innovation opportunities: unexpected occurrences; incongruities; process needs; industry and market changes; demographic changes; changes in perception; new knowledge.17

Practicing Leadership

The practice of leadership may be considered to be similar to the practice of medicine, with “practice” being the operative word. Many regard medicine to be an art, requiring practice in improvement endeavors. It is not an exact science, and as such there is no formula for success. Should you wish to maintain your personal health, you would employ such best practices as regular exercise, healthy diet, and stress minimization for example, yet ultimate health would not be guaranteed. The notions of best health practices themselves have changed over time. Moderation in all things is the general philosophy I’ve favored in maintaining health and similarly to leadership practice, where employing best practices seeks to ensure the best chance for success and continuous improvement requires practice.

Creating the ideal balance of professional and personal life may be a life-long endeavor but “taking smart steps to integrate work, home, community, and self will make you a more productive leader and a more fulfilled person.”18 Stewart Friedman suggests designing relatively simple experiments that will produce benefits in all four domains, being work, home, community, and self. Ultimately he concludes itʼs about creating sustainable change that benefits you and the most important people in your life.

The job of leaders is “no longer to command and control but to cultivate and coordinate the actions of others at all levels of the organization.”19 Deborah Ancona et al argue further that the sooner a leader stops trying to be all things to all people (the ideal leader) and recognizes their limitations, the sooner they will be able to rely on others to complement their missing skills to the benefit of the organization ultimately. Having the ability to self reflect and understand one’s shortcomings is a general thread of thought presented throughout this paper, from qualities of humility, through “authentic leadership”, to the notion that the “best CEOs master the ability to reset their goals and reinvigorate their agendas every few years”.20 The ability to bring oneself to account regularly in order to recognize when something is failing, accept responsibility for the failure, analyze and understand that a reinvention is required, and finally to decide and take action is vital to ensure continuous improvement and to prevent stagnation.

Historically leadership has always relied upon a single individual, from kings and rulers of countries to CEOs of large organizations. These inherent imperfections of an individual leads to a concluding thought that perhaps the world needs to undergo a paradigm shift of sorts where reliance upon the judgment and sanity (thinking of some despots currently ruling countries around the world) of an individual becomes the exception rather than the norm. Collaborative leadership is an emerging theory of management practice, which centers around a leader recognizing that the skills and attributes required for solution to a problem lies across organizational boundaries.21

The proposed shift goes beyond this concept to one where no single individual has absolute power, but power is given to an elected/appointed group of individuals. Collective decision-making would potentially prevent grave mistakes in addition to protecting the organization/country from abuses of power. As with any system, there are potential weaknesses, such as the fact that collective decision-making would potentially take longer and be impractical where rapid decisions are needed. As such one would reserve non-programmed decisions to the larger collection, assigning programmed decisions to individuals. Under this model of leadership or governance, persons would only be able to assume their position of “leadership” within the group context and not as individuals, unless tasked as such by the collective decision-making group. How these thoughts shape my personal leadership style and future endeavors remains to be seen as they continually develop through ongoing practice, self-reflection, and correction.

References

1 Collins English Dictionary – English Definition and Thesaurus. 5th Edition. HarperCollins Publishers. 2000.

2 Robert K. Greenleaf. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. Paulist

Press, New York, NJ. 1977 (2002 reprint).

3 Kathleen Patterson. Servant leadership: A theoretical model. Doctoral dissertation, Regent University (UMI No.

3082719). 2003.

4 Bruce E. Winston. Be a leader for God’s sake. Virginia Beach, VA: Regent University School of Leadership

Studies. 2002.

5 Jane Waddell. Servant Leadership. Servant Leadership Research Roundtable. Virginia Beach, VA: Regent

University School of Leadership Studies. 2006.

6 Jim Collins. Level 5 Leadership: The Triumph of Humility and Fierce Resolve. Harvard Business Review. 2001.

7 David Rooke, William R. Torbert. Seven Transformations of Leadership. Harvard Business Review. 2005.

8 Bill George, Peter Sims, Andrew McLean, Diana Mayer. Discovering Your Authentic Leadership. Harvard

Business Review. 2007.

9 Daniel Goleman. What Makes a Leader? Harvard Business Review. 1998.

10 John P. Kotter. John P. Kotter on What Leaders Really Do. Harvard Business Review. 1999.

11 Jim Clemmer. Management vs Leadership. The Clemmer Group. Available at www.jimclemmer.com, accessed

December 2009.

12 Joel A. Barker. Future Edge – Discovering the New Paradigms of Success. William Morrow Publishers. 1992.

13 Warren G. Bennis. Leading Change: The Leader as the Chief Transformational Officer. In J. Renesch (Ed.),

Leadership in a New Era: Visionary Approaches to the Biggest Crisis of Our Time (pp 102-110). San

Francisco: New Leaders Press. 1994.

14 J. Sterling Livingston. Pygmalian in Management. Harvard Business Review. 1988.

15 Douglas A. Ready, Jay A. Conger. Make Your Company a Talent Factory – Stop Losing Out On Lucrative

Business Opportunities Because You Don’t Have The Talent To Develop Them. Harvard Business Review.

2007.

16 Teresa M. Amabile, Mukti Khaire. Creativity and the Role of the Leader. Harvard Business Review. 2008.

17 Peter F. Drucker. The Discipline of Innovation. Harvard Business Review. 1985.

18 Stewart D. Friedman. Be a Better Leader, Have a Richer Life. Harvard Business Review. 2008.

19 Deborah Ancona, Thomas W. Malone, Wanda J. Orlikowski, Peter M. Senge. In Praise of the Incomplete

Leader. Harvard Business Review. 2007.

20 David A. Nadler. The CEO’s Second Act. Harvard Business Review. 2007.

21 David Archer, Alex Cameron. Collaborative Leadership: How to Succeed in an Interconnected World.

Butterworth Heinemann Publishing. 2009.

Memory Foam: Friend or Fume?

noreply@blogger.com (Unknown) — Sun, 20 Sep 2009 14:02:00 +0000

My earliest encounters with “memory foam” was some 15 years ago when my aunt brought a memory foam pillow from the USA to South Africa, where I was living at the time. I remember being amazed at this apparent new technology that I heard had been developed by NASA for use in space. No one else in the country had such a pillow of what I believed to be cutting edge technology that would magically conform to the shape of your face. How cool is that? I don’t sleep comfortably unless I use my “memory foam” pillow.

Roll forward to today and the marvel of this product has worn off somewhat. Maybe it has to do with the fact that I am further chronologically challenged, have a small child now, and am studying public health, but when I opened up the mattress-in-a-box “memory foam” mattress, I excitedly purchased last week, I was suddenly overwhelmed by extremely noxious fumes that emanated from the strange foam that popped out of the box. Thinking to myself that this cannot be healthy for a small child and pregnant wife, I began looking closer at what I previously thought to be a technological wonder was exposing us to so intimately.

“Memory foam” is polyurethane foam with additional chemicals to increase its density and viscosity and as such is often referred to as visco-elastic polyurethane. It has the ability to react to body heat in a way that it moulds itself to the body shape in a few minutes. It was developed over 40 years ago by NASA as safer aircraft cushions but after the early 90’s, began to have wider commercial applications such as pillows and mattresses, especially in the medical setting to reduce pressure sores, and nowadays even in football helmets.

So upon further research into what chemicals are actually in “memory foam”, I found that there are about 61 different chemicals that may be found in such products. Several are of major concern, such as formaldehyde, which was what the debacle regarding the FEMA trailers post Katrina was about, benzene, a known carcinogen, and a variety of flame-retardants. PBDE (Polybrominated diphenyl ether) was a very common flame retardant that was extensively used prior to its ban in 2004, when it was found to have cause numerous hormone disruption effects, particularly estrogen and thyroid. PBDE was replaced however by other similar chemicals, often guarded by mattress manufacturers as their flame retardant trade secret, but one such chemical is BDE-99 or PentaBDE (Pentabromodiphenyl ether), which I fear we are being exposed to on a daily basis.

There are no human studies on the absorption, distribution, metabolism and excretion of PentaBDE, but animal studies seem to suggest that it is readily absorbed from the gastro-intestinal tract and widely distributed to all human tissues, and furthermore can cross the placenta to an unborn fetus. Now one may argue that few if any of us chew on our mattresses when we sleep, but polyurethane dust which is known to emanate from these foams can settle everywhere and we all know how often one places ones hands in your mouth after touching everything. Metabolism pathways for PentaBDE appear to occur mainly in the liver as further metabolite products in the pathway are subsequently found in urine and bile. Excretion of PentaBDE appears to predominate in fecal and urine but animal studies also found significant quantities in breast milk.

Having understood what happens to the chemical in our bodies however does not give us an indication of what effects it may have on us in the short, medium or long term. Unfortunately there is scant evidence of toxic effects in humans that do not permit any conclusions to be made. Extensive animal studies demonstrate numerous hormone and enzyme receptor interactions, which may result in liver and thyroid damage as well as developmental problems such as hyperactivity and changes in motor behavior and other brain functions. Chronic exposure has not been adequately studied, but it has been hypothesized that it has the potential for causing cancer through its interaction with estrogen receptors.

The ubiquitous nature of these flame retardant chemicals surely warrants further evaluation and restriction if necessary. I for one am not comfortable on my mattress anymore, especially in light of the fact that we spend a third of our lives in bed.

Speed: To thrill or to kill?

noreply@blogger.com (Unknown) — Tue, 04 Aug 2009 18:30:00 +0000

My childhood memories of things I aspired to acquire later in life revolved predominantly around a series of super-charged automobiles, each surpassing the previous, sometimes due to aesthetic beauty but always due to performance. There was the Diablo, the F40, and then the Bugatti Veyron. Today the fastest production car is the SSC Ultimate Aero with a top speed of 257mph. I recall paging through my dad’s old magazines to find a test for a car and flipping forward to find its performance ratings. I would avidly read up about its acceleration, top-speed and power to mass ratio. Once licensed to drive, I reveled in the thrill of driving rather too fast and too reckless. While I never had a major disaster, and thus lived to write this piece, in one piece, I did have several narrow scrapes which inevitably preempted a period of more responsible driving (lasting only until I forgot that I wasn’t totally invincible).

This brings me to the topic of this editorial. I started wondering some time back, perhaps in one of my many day dreaming moments driving one of those cars, where would I be able to drive 200mph anyway? The maximum speed limit anywhere in the USA is 80mph, in Texas (not surprising), with the rest of the states ranging between 60-75mph. Globally, only the Isle of Man and about 50% of the Autobahns in Germany have no speed limit at all.

Arguments have been made to raise speed limits in general, or even to abolish them entirely, most notably by associations such as the National Motorists Association (NMA). A study about the relationship between speed and motor vehicle accidents from 1964 involved 10,000 drivers, and clearly demonstrated a “U” shaped curve. The research found that any deviation from the average speed resulted in proportionally more accidents, but that a deviation less than the average speed resulted in more accidents, as compared to faster speeds. It is furthermore argued that the speed limits throughout the country serve as merely a moneymaking racket and have not been based on engineering measurements for traffic safety. The NMA further argues that higher speed limits would not result in more accidents and fatalities, but have quite the opposite effect and that raising speed limits would even save on gas consumption.

However, on the other side of this argument, and more clearly to reality which is ably supported by numerous research studies, it is argued that while slower speeds may in fact result in a higher frequency of road traffic accidents, there is overwhelming evidence that the road traffic accidents at higher speeds result in a much larger number of severe and fatal injuries. Motor vehicle accidents are one of the leading preventable causes of death in the USA. Joksch (1993) found that the probability of death from an impact speed of 50mph was about 15 times greater than from an impact speed of 25mph. Bowie and Waltz (1994) found that the risk of moderate or more serious injury was less than 5% when the change in velocity was less than 10mph and increased to more than 50% when the change exceeded 30mph.

The right of the individual in this case needs to be tempered with the right of the community to a safer environment. If there are speed limits everywhere, then why are the automobile manufacturers producing cars that easily exceed that. Even the cheapest car in the market, the Nissan Versa, has a top speed of 120mph. It’s like recreational drugs “legally” being sold without restrictions in a pharmacy while it remains illegal to use them. Traffic cameras can reduce speeding and thus dangerous accidents, but emphasis and policy needs to be leveled at manufacturers. Solutions may range from high-tech interventions that remotely limit the speeds of cars according to the road on which they are traveling to a broad policy, which is what I propose, that car manufacturers broadly limit the maximum speeds on the vehicles they produce (and thus engine sizes which will actually reduce gas consumption) to a safe acceptable level.

Perhaps the fact that I am now further chronologically challenged and am a parent myself that my wife complains that now I drive too slowly. It scares me that my son, from a few months of age, is fascinated with cars, their speed, and their crashing into each other. Where did this come from? It has to be that shorter Y chromosome! I do still get that urge to drive that red sports car sometimes; my wife jokingly tells me I can get one when I’m going through my mid-life crisis. Maybe if cars had their top speeds limited they would not only save many lives, but they may even save some marriages as mid-life crises would lose their appeal too.

Smoking Cessation

noreply@blogger.com (Unknown) — Tue, 14 Apr 2009 16:04:00 +0000

One of the tasks I would often be asked to support would be the creation of posters for the clinics. When I had a bit of time or a hint of inspiration then I'd usually create something a little more interesting.

The poster created which has become the topic for this post is smoking cessation. Tobacco usage has in more recent times become recognized as one of the major public health issues facing both the developed and now developing parts of the globe. Over 50 percent of the male population are smoking in China now. Thats over 250 million people! Tobacco related diseases are expected to be responsible for 10 million tobacco related deaths per year by the year 2030, with 80% of these in the developing world. At the moment, tobacco has been implicated as a risk factor for 6 out of the 8 leading causes of death worldwide.

You see, once the tobacco companies were restricted from advertising and their use in public spaces prohibited in the developed world, they concentrated all their considerable marketing muscle in the developing world. The largest business transaction ever in Indonesia was when Sampoerna, a local cigarette manufacturer was bought out by Philip Morris.

Anyway, the poster was quite well received. I hope it gives you some ideas or at the very least some information.

Living in Indonesia

noreply@blogger.com (Unknown) — Tue, 07 Apr 2009 11:08:00 +0000

As with all manner of animals, one of the primary survival instincts or needs for humans is to find shelter. The ability to feel comfortable and secure in

Indonesia

, being the shelter you have “chosen”, may be regarded as vitally important, as this safety and security may be the foundation upon which you justify your choices.

In the Universal Declaration of Human Rights, there may not be a specific reference to medical care being a basic human right, but in Articles 3 and 25(1), where “Everyone has the right to life, liberty and security of person…” and “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services…”, respectively, reference is made to security and medical care. These aspects are vital to your sheltering in

Indonesia

As with most things in life, the quality of security and medical care available in

Indonesia

may not be easily described as a matter of black and white, but should rather be looked at as a spectrum or range of quality in services. There are numerous historical reasons why security and medical care in

Indonesia

may be generally considered further along the spectrum, being further to the right or down, depending on your scale of reference, which in itself are beyond the scope of this article’s endeavours. Suffice it to say, that health statistics for life-expectancy, infant mortality rate, ratio of hospital beds per population and numbers of health care personnel per population, reflect the disproportionate gap between the various Indonesian regions itself, and between Indonesia and its immediate neighbours.

Case Study 1:

In exploring “Indonesian Medical Care”, being the title for this section, it may be useful to present a small case study or example to demonstrate what is meant. We are living in the information technology age, with widespread access to all sources of up-to-date knowledge. The internet has opened up a wealth of information, good and bad, to anyone with the ability to click a button. Thus, what typically occurs when a person becomes ill is that they tend to self-diagnose. This of course varies from place to place around the world, with some nationalities more adept to self-diagnosis and treatment, through using the internet or books for example, or by merely following age-old traditional remedies etc.

The old adage that “a little knowledge is dangerous” comes to mind, which was experienced during my medical education. The initial 2 years of my medical education generally covered the basic sciences of physics and chemistry, human biology, physiology and cell histology. The 3^rd year however was when things really became interesting, to me at least, when the various pathologies were studied. This was when chemical pathology, anatomical pathology and microbiology were covered.

This is the year all medical students periodically freak out as they firmly believe that they have some terrible disease, merely because they happen to share an overlapping symptom with the particular disease that they are studying on the day. The fact that the student is a 20 year old male student who stayed up late the night before drinking with his friends, and thus has a hangover, red eyes and body aches from being dehydrated, is self-misdiagnosed as having Reiter’s syndrome. This is a reactive arthritis that typically occurs in “reaction” to a previous urinary tract infection that typically presents with a conjunctivitis (red inflamed eyes), and an arthritis (painful knees, ankles and feet often), in addition to several other signs and symptoms such as painful urination, sores and rashes. Then there is another 20 year old female who becomes near panic-stricken as she believes she has Kuru disease. She has been stressing over exams, has not been sleeping well, and has been taking energy drinks to “boost” her productivity during the evenings. Little does she know that the headaches, body aches and shaky arms are as a result of sleep deprivation, stress, and energy drinks, and not as a result of Kuru disease. This was a fatal disease that was endemic in

Papua New Guinea

, and was transmitted by cannibalistic practices of eating the brains of diseased relatives.

In much the same way, contemporary patients often misdiagnose themselves, and cause undue stress on themselves and their families. A well informed patient is far more desirable than one that does not take interest in their health however, so the point of this anecdotal tangent is not to advise against the use of the internet and other information resources, but merely to recommend that when something is bothering you, and you are worried about your health, there is really no substitute for a medical consultation with a doctor, who will be able to hopefully put things into perspective and develop a rational diagnosis.

Thus when one becomes ill, a consultation with a doctor would be ideal. One would be faced with 2 options really, either find a clinic or find advice. For those that usually go directly to a clinic, the determining factor usually is that they have found something that closely resembles the level of care they would expect in their home country, or one that they would have confidence in. There are various clinics along the spectrum described earlier, and if you are not sure which one to go to, then finding one which has standardized treatment protocols and standards would be ideal. Alternatively, finding an information source for medical advice would be the ideal vehicle for the 2^nd option above, finding advice, as there are several websites that can successfully be used to guide patients with regards to a variety of health issues, particularly on a primary care level. Care needs to be taken with regards to which sources are used for advice since merely searching on Google will result in so much information which is almost impossible to sift through reliably to avoid potentially harmful or biased advice.

This brings me to the point of language. What we have observed as the most common reasons for breakdowns in medical service have been predominantly as a result of miscommunication. At a time when you are not feeling well, are worried because you’ve read up about some terrible disease, and generally are not in your comfort zone, as you are away from your familiar surroundings of your home country for instance, language barriers may become huge obstacles to your health outcome. In the vast majority of general practice consultations, the manner in which the doctor communicates with you plays an immense role in the confidence you have in them to “heal” you, and your general perception. If for example, you are not able to understand them as you only speak English, then a positive outcome is less likely.

In general, for routine medical care, local healthcare facilities offer good services. However, particularly for more serious medical conditions, when there is a discrepancy with regards to the standard of medical care available compared with the quality of healthcare you are accustomed to, it would be recommended that you consult the closest centre of medical excellence. This would ordinarily be in a larger urban area and may not be limited by geographical borders.

Case Study 2:

To expand on this case study further, were one to require emergency medical services as a result of an accident for example, the lack of established medical emergency services in Indonesia would be a major determining factor for one’s wellbeing. There generally is no organised pre-hospital training available in Indonesia, and as such there are no paramedics, at least none like those we visualise when we hear about paramedics in North America, Australia or South Africa. The ambulances witnessed on the roads in

Indonesia

are often transport vehicles and may not be able to deliver any adequate degree of pre-hospital care. Traffic congestion in the larger cities furthermore limits the responsiveness of these vehicles.

Having 1^st aid training, for family members, baby-sitters, drivers and employees etc. would be ideal in addressing the lack of emergency response services. Readily available Automated External Defibrillators (AEDs) are also useful equipment to have access to, as they may provide the life-saving shock within the golden 3-minute period from when a person goes into cardiac arrest. Having evacuation coverage is furthermore extremely important for the purposes of medical and security evacuations. Adequate medical insurance will be useful for general medical ailments, but may have limited abilities when it comes to emergency evacuations.

Conclusion:

Life in Indonesia may have its medical challenges, with its pollution, tropical diseases such as malaria and dengue, widespread hygiene concerns, disproportionate medical services, and pharmaceutical limitations, but the solutions do exist. Preparing your shelter for your stay is doubly important thus as the safety and security aspects need to be planned for and mitigated.

We need someone to give a Sex Ed lecture... Hey! Where did everyone go?

noreply@blogger.com (Unknown) — Mon, 23 Mar 2009 07:04:00 +0000

Many of the initial posts on this blog will be referring to incidents or projects in the preceding 3 years, and won't be in chronological order. I've only just now become blog-literate and as such it may take quite a number of posts to get everything up to real time.

As you may have gathered already from the title of this post, I was asked to speak to the International School here in Jakarta. Twice a year, an International SOS doctor would visit the grade 9 and 10 (I think is the equivalent) to give lectures on Sexually Transmitted Disease and Contraception. As you can imagine, these aren't topics that doctors would be jumping at the opportunity of delivering. Nevertheless I accepted the "assignment" as it would get me out of the office, but immediately regretted my situation once I reviewed the material that had been traditionally used.

It was pretty bland, and used a scare/gross-you-out sort of tactic that strongly reminded me of what I didn't miss about purely clinical medicine. They grossed me out too!

Anyway, I set about completely redesigning the presentations and figured the only way I'd be able to present these topics to these kids, who probably knew a helluva lot anyhow, was to incorporate humour, graphics and diagrams where needed. Previous presentations were either too graphic, in response to requests from the school to "scare" the students, or too text-based and boring, in response to criticisms of the graphic nature of the presentations. You can never please everyone!

As it turned out, the presentations went really well, and the students were that much more comfortable to be able to ask questions in an open discussion afterwards. I've been back 3 times since to that school and have actually enjoyed giving these lectures; the questions these teenagers come up with never ceases to surprise me.

The Contraception presentation can be found here while the STD presentation may be found here.

Getting Started

noreply@blogger.com (Unknown) — Mon, 23 Mar 2009 06:13:00 +0000

So I finally decided to start my own blog, and populate it with interesting material that I've been creating for International SOS and stories/images from some of the sites I've visited.

To get the ball rolling, lets start with a simple poster designed for the World Blood donation day. International SOS has 3 very busy clinics in Indonesia to support its members and also to provide general medical assistance to the communities. There is a Blood Donation drive annually that is held at the clinic, and I was asked to design a flyer come poster to advertise the subsequent day.

I found so many interesting posters out already and couldn't find a way to integrate all the wonderful ideas until I thought of incorporating the posters I liked into the overall design. You'll see what I mean when you look at it. Anyhow, it was really well received, and in fact one of the editors of a chamber of commerce magazine liked it so much they printed it in their monthly magazine.

A month in Equatorial Guinea

noreply@blogger.com (Unknown) — Mon, 28 Jun 2004 09:16:00 +0000

In 2004 I had the amazing opportunity of working in Malabo, the island capital of Equatorial Guinea. I found some photographs of my trip recently and decided to post some of my experiences and memories. I've pre-dated the post back to 2004 to maintain a timeline even though I'm actually writing this January 2012.

This was to be my first locum contract with International SOS who had only contacted me 2 weeks previously (May 2004) with the plan that I'd work in Nigeria in August sometime. It just so happened that there was an attempted coup-de-tat in Equatorial Guinea and the hired mercenaries included some South African ex-soldiers. So I was asked to urgently fly in to provide medical cover for the Marathon LNG plant there since most of the South African doctors needed to return home to get a police clearance, which can take months.

I arrived in Malabo via Zurich (I had to fly from Windhoek to Johannesburg, then to Zurich, and then back down to Malabo! Windhoek is geographically closer to Malabo than Johannesburg or Zurich). I was greeted by the immigration security and ushered to a back room, which was probably the only back room in the tiny airport. A security officer in military attire sat at a table with his back to me while I stood in the doorway surrounded by a few other guards. He proceeded to question me about why I was there, why I had visited South Africa so many times, why I had my visa granted in Paris instead of South Africa among a few other questions. He then opened up my computer and found a directory with photographs I'd taken from home and recent travels to Istanbul and Israel and then asked me who each and every person was. I approached to try point out people and had taken no more than a couple steps when he abruptly put his hand up and said I need to stay back. He never turned to me so I never saw his face through this entire interrogation. The paranoid and aggressive state of the immigration personnel was to reflected by the military and police throughout my stay.

The clinic I worked in was in the camp across the bay from the "city" of Malabo, which is at the foot of an apparently extinct volcano. The clinic was staffed by another South African doctor (who managed to get a police clearance quickly), a Mauritian paramedic, a Filipino nurse, and several Equatoguinean nurses. It was a small clinic that was to be superseded in about 6 months by a much larger clinic for the next phase of construction. The camp itself was amazing with a typical Texan style built-environment consisting of large suburban like streets and 3 bedroom villas, a beautiful fitness centre and pool overlooking the bay. I spent my working hours each day seeing a few patients with cuts and bumps and coughs and sniffles. Thankfully nothing major happened.

One morning I needed to perform a safety and hygiene inspection of one of the offshore drilling rigs. I had to get up at 4am to drive to the port to leave at 5am. I hadn't had any breakfast and became the sickest I've ever been due to the bumpy boat ride through the choppy early morning ocean. I was so relieved to get onto the rig which felt like solid ground. After a light breakfast and probably the first cup of coffee I've ever had in my life, I felt semi-functional and was able to conduct the inspection.

I spent almost my entire time on that camp, as I was on call most of the time. I did venture out on one occasion to Malabo with a friend of a friend, Nabil, who I managed to track down after 3 weeks of trying. He is an American Baha'i who grew up in Ecuador and after working in Israel for a time, heard about the only former Spanish colony in Africa, Equatorial Guinea. He decided to explore the country and in fact he eventually found his wife there. I believe he is no longer living there though. He picked me up at the camp and we proceeded to drive around the bay to Malabo. I tried to take some photographs along the way but was quickly warned that since we were driving past the presidential compound, should any of the military see my camera it would be surely confiscated and I might be in worse trouble. Even in the "city" itself, I managed to take only a couple photos before being aggressively harassed by some small kids who were demanding money or they'd call the police. After a great evening with Nabil and his then-fiancée, we went to a small restaurant and had pizza, while he described all the difficulties he had had in trying to work there.

This was my first foray into West Africa but I was markedly taken aback by the dilapidation of Malabo, particularly considering the documented wealth of the country. One could see some older colonial structures, but everything was covered in a layer of black soot like dirt. The vast majority of the cars were all in pretty bad shape and were all imported from Spain apparently, decades ago. I do regret not spending more time in Malabo and among Equatoguineans as my stay there felt quite superficial in the compound across the bay.

(click on images for larger view)

Beautiful Villas in the midst of squalor

Wisteria lane?

Nice pool overlooking the bay

That is Malabo across the bay

The extinct volcano dominates the island horizon

Fascinated by the massive trees (you can tell I'm from a desert)

Fishing boats

View of the LNG plant from the clinic window

My consulting room

The emergency room

Paramedic and ambulance driver

Nursing staff and ambulance driver

Massive ambulance straight from the US (no crouching needed at the back)

LNG plant at night

Streets of Malabo

The "best" pharmacy in town

Typical Malabo sidewalk activities

The town centre circle and monument

Nabil and his fiancée Priska

The drilling rig had 2 platforms

This flare burns off excess gas from drilling

All suited up in appropriate PPE