Wednesday, October 21, 2009

SARS, Freedom & Knowledge

Thirty years ago, I saw mountains as mountains, and waters as waters.

When I arrived at a more intimate knowledge, I came to the point
where I saw that mountains are not mountains, 
and waters are not waters. 
Thirty years on,
I see mountains once again as mountains, and waters once again as waters.
 Adapted from Ching-yuan (1067-1120)

In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.
         For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease.  The alarm was first raised by its first victim, Carlo Urbani.  He was an Italian physician employed by the World Health Organisation (WHO) and based in Hanoi, Vietnam and he gave the disease its current name. It was as if this newly mutated virus knew what it was on about. Get the doctors as they would be the first who could deal with you. Urbani died. So did some of the medical staff that attended the first few patients.
         Doctors often thought that they would be immune, a God given right I suppose.  Not so this time! The virus obviously knew what it was doing.
         Our knowledge base was in total chaos. What we knew was obviously not good enough. Nor were the most up to date antiviral drugs. Even then in some places they were sold out as rumours spread. There were rumours too of vinegar and certain dietary items giving protection to certain ethnic groups, notably Koreans. The lack of knowledge about this new infective agent led to the great proliferation of myths that were soon spreading like wild fire on the Internet. Anyone with cold symptoms was treated as if he was carrying the plague. It was the plague, the new plague.
         Without any sound knowledge authorities took draconian measures – any measure anyone could dream up.  Some worked well if only to raise public awareness. One actually caused more harm and unfortunately deaths. That was the restriction of movement in one of the tower blocks in Hong Kong – a true quarantine. In the absence of insight into how the infection was spread, more people were infected. Some broke the law and fled the buildings before the quarantine. Unfortunately 321 people were infected and 42 died. Eventually someone was sensible enough to move them to another quarantine site.  Otherwise there would have been more deaths.
         Canada's hasty decision to declare its virus free status when so little was known about the virus proved costly and further eroded the public's trust in governments and people in positions of influence. Clinicians’ view no longer seemed to hold any sway where commercial interest was more important.
         Except in Canada, one advice was almost universally adopted – the wearing of a mask.  During this time, I was in correspondence with many of my medical colleagues and relatives in Hong Kong and Canada. One thing was clear: even the most difficult child complied and wore a mask. To this day one still needs to wear the appropriate mask to visit someone in hospital in Hong Kong, on top of having a dollop of alcohol gel to sterilize one’s hands. Many clinics require patients and staff to do the same.
         Now this must be the clearest lesson to every parent in every land. Where life and death is concerned, there can be no compromise.
         So it started me thinking about my practice, specifically Anorexia Nervosa and other difficult cases that I have encountered.  Take Anorexia, it may have been unnecessarily classified as a mental illness, given that it is the result of the parents giving the individuals concerned too much right and freedom for self determination.  If a child can be made to wear an uncomfortable mask, why can parents not make a child eat?
         The answer may lie with our view of freedom. Many parents of Anorexia Nervosa sufferers are highly educated, and some hold high positions in big corporations and even in Health Authorities. Many are professionals. Many have a great respect for individual freedom and self-determination and unfortunately they get caught in a bind of not being able to be authoritarian as far as their own children are concerned. It is not difficult to see why many parents of Anorexia Nervosa sufferers are not prepared to give up being a modern parent, and until they do, we psychiatrists will have to soldier on with the difficult task of treating what need not necessarily be an illness, let alone a mental one. 
         My second thought is that when something as familiar as chest infection can turn out to be a deadly new plague called SARS, we need to examine again the relationship between our existing knowledge and medical practice. We have to keep an open mind. What we know from the past should be an aid, not a hindrance.

Otherwise we shall never see the mountains and waters for what they really are.                                               

                                                                                                           From The Cockroach Catcher

Recent political decisions on Swine flu would seem to indicate that not much has been learned from the SARS experience in Canada and Hong Kong.

Wednesday, October 14, 2009

Cockroach Wine Catch: Bodega Septima Gran Reserva 2006

It is fun discovering different wines from around the world.

The house of Codorniu is well known to most visitors to Spain as the wine maker of some fine "bubblies" outside of Champagne.

Then they founded Septima in Argentina.

“Septima was founded by Codorníu in 1999 with the purchase of 470 acres in the Luján de Cuyo area of Mendoza at a stunning altitude of 3400 feet, concentrating on Cabernet Sauvignon, Chardonnay, Malbec and the Spanish Tempranillo grape. The winery acquired additional acreage in the Valle de Uco in 2007. Mendoza native Rubén Calvo is winemaker. The ‘high and dry’ climate is the key to the success of the venture. Big swings in day and night temperatures make for excellent color and flavor development; the stony humus soil cooperates to keep the vines in place in what is otherwise a harsh arid climate. Irrigate this soil to the optimum degree, add state-of-the-art modern equipment both in field and winery, and you have a recipe for success.” Elliot Essman, Style Gourmet.

In Panama, because of trade agreements with South America, you can get South American wines for nearly half the price you will need to pay elsewhere in the world.

In New Zealand  you could be paying more than $50 (US$ 38) for a bottle!

Jancis Robinson gave it a gold medal!

Elliot Essman continued:

“The Septima 2006 Gran Reserva is a blend of 58% Malbec, 33% Cabernet Sauvignon and 9% Tannat; these grapes were sourced from three different vineyard blocks, vinified separately and aged twelve months in French and American oak. In color the wine is a profoundly deep ruby. The nose has violet and rose flowers, nutmeg and black pepper spice, brambly red berry fruit, and chocolate. As in the case of its single varietal cousins, this blend is superbly balanced. The medium-body and smooth mouthfeel was the first quality I noticed; the acid is firm, the tannins round. Flavors, none of them too pushy, swirl around each other in turns: red cherry, blackberry, chocolate, sweet cinnamon. The finish is lengthy, showing restrained but lasting acidity and tannin with ripe red fruit and vanilla-laced chocolate at the end. Despite excellent flavor, however, it is the elegant feel of the wine in the mouth that catapults it into a league far beyond its $25 asking price.”

For under $13 in Panama, it is a steal and if you can get it for under $25 anywhere else, it is still a bargain.

Tuesday, October 13, 2009

Panama Canal: Diseases & Failures.

We learn little or nothing from our successes. They mainly confirm our mistakes, while our failures, on the other hand, are priceless experiences in that they not only open up the way to a deeper truth, but force us to change our views and methods. 

C.G. Jung
Jung was referring specifically to psychotherapy with those words. But why should this principle not be applicable to politicians?


Panama Canal © 2008 Am Ang Zhang

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.

In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.

The engineer was no match for a career politician:

“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”

“The resolution passed with 74 in favor and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”

The French failed in a spectacular fashion.

Diseases like yellow fever and malaria played their part as a sea level canal involves a good deal more digging.

The discovery of yellow fever being carried by mosquito must be credited to one Cuban physician: Carlos J. Finlay.

For twenty years of his professional life, he stood at the center of a vigorously debated medical controversy: the etiology of yellow fever. Finlay believed that it was waterborne and carried by common mosquitoes: Stegomyia fasciata.

Finlay's advice and experiences proved invaluable to the United States Army Yellow Fever Commission. When the Commission decided to test the mosquito theory, Finlay provided the mosquitoes and Walter Reed of the Commission wrote triumphantly after the success of the experiments of inducing yellow fever by mosquito bites, ‘The case is a beautiful one, and will be seen by the Board of Havana Experts, to-day, all of whom, except Finlay, consider the theory a wild one!’ The US experiments vindicated Finlay's two-decade-long struggle.

Reed acknowledged that ‘it was Finlay's theory, & he deserves much for having suggested it.’

William Crawford Gorgas wrote of Finlay:

"His reasoning for selecting the Stegomyia as the bearer of yellow fever is the best piece of logical reasoning that can be found in medicine anywhere."

The discovery by Major Ronald Ross that malaria was transmitted by mosquitoes (Anopheles)had tremendous impact on the Panama Canal.

Crude oil was used on stagnant water to prevent the mosquito proliferation and nets were used to protect workers. Quinine was extensively used to treat malaria. A lock canal was eventually built by the Americans.

Some say that a large part of the eventual success on the part of the United States in building a canal at Panama came from avoiding the mistakes of the French. Knowing the causes of diseases must have helped.

David McCullough in his book "The Path Between the Seas" wrote: "The fifty miles between the oceans were among the hardest ever won by human effort and ingenuity, and no statistics on tonnage or tolls can begin to convey the grandeur of what was accomplished………It is a work of civilization."


Confucius & A Tale Of Two Cities

1859 Chapman & Hall
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity.”

Charles Dickens A Tale of Two Cities

Confucius taught that one must look after oneself, then family, then nation before one can rule the world.

So perhaps our leaders and MPs are just following ancient Confucius wisdom.

In The Telegraph:

“Mr Brown used his expenses to pay his brother Andrew Brown £6,577 for cleaning work at his Westminster flat between 2004 and 2006.


“An inquiry was launched into Miss Smith's expenses claims after it emerged that she had designated her family home in the West Midlands as her second home for expenses purposes, while listing a room at her sister's London house, where she lodged, as her main home.

For once London and Paris may not be all that different:

The Independent:

The possible – or even probable – appointment of a 23-year-old Paris law student to run Europe's largest office development has generated a storm of protest and mockery in France, including an 8,000-name petition on the internet. According to his critics, the student has only one qualification to become the next political boss of the lucrative, prestigious but floundering La Défense business district west of the city centre. The student's name is Jean Sarkozy, the son of the President of the Republic.

That which has come to be, that is what will come to be;
and that which has been done, that is what will be done; and so there is
nothing new under the sun.
Ecclesiastes 1:9

Reischauer Lecture on Confucius: Family, Nation, and the World

Oh dear: Blue Peter

Saturday, October 10, 2009

Noctors, Piano, Golf & ADHD

My friend just returned from a month at Spring City Golf & Lake Resort in Kunming, Yunnan. He showed me the score cards.

One golf course was designed by Jack Nicklaus and the other by Robert Trent Jones Jr.

“You have to go. The weather is perfect, and so are the courses. You can play 18 holes and not sweat. The ball goes further at this altitude and the caddies are just wonderful.”

Kunming happens to be my birth place. It is north of Vietnam and is well known for its biodiversity and superb year round weather.

China, which just celebrated 60 years of Communist rule, is now embracing golf in a big way. Most golf courses are designed by big name western golf designers or golf champions turn designers. It must indeed seem ironical, as golf is seen by many as a game for the elite. Venezuela has just banned golf for that reason.

Changes in China since the early 80s have been phenomenal. First it abandoned the “Barefoot Doctors” that was started by Mao when doctors and intellectuals were seen as the elite and sent to remote villages to farm. “Barefoot Doctors” with minimal training cannot really deal with more complicated medical cases. It is a shame that we in England do not seem to have learned from the bad experience of China and the politicians have been pushing ahead with reforms in the NHS with the result that “Barefoot Doctors” known as Noctors (Dr. Crippen) are taking over.

At the height of the “Cultural Revolution”, the piano was seen as the definitive sign of bourgeois decadence.

Petroc Trelawny wrote in The Spectator that Fou Ts’ong (one of my favourite Chopin pianists) was forced to seek exile in London, where he later heard his parents had fatally poisoned themselves. Liu Shih Kun, who came second in the Tchaikovsky Competition when Van Cliburn won, was imprisoned by Madame Mao. He survived and has now established a number of piano kindergartens across China, in response to the craze created by Lang Lang’s performance at the 2008 Beijing Olympics. Many Chinese parents now want their children to learn the piano. The BBC reported that an estimated 30 million children in China are now learning the piano.

Is the piano China’s answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants? With the advent of unproven modern approaches to education at all levels, very few subjects require memory work. Yet in the last decade or so, memory work has been shown to be beneficial to “brain power”, leading to a whole new approach to neuroplasticity. Learning a musical instrument is one way to give the brain the right amount of training.

For now, just as the west is abandoning classical music training as part of the school curriculum, parents in China are paying for their children to have piano lessons. By some reckoning, North America probably consumes 90% of Ritalin and similar stimulants, whereas China is probably consuming 90% of the pianos produced. One factory in the south of China is currently producing 100,000 pianos a day.

Some will argue that such pressure on children is not good. Yet we have to look at Michael Phelps, whose parents abandoned drug treatment for his ADHD in favour of swimming. The modern Chinese parent may indeed have stumbled upon something similar to Michael Phelps’ swimming in dealing with problems of concentration. Many parents actually believe that the discipline of learning the piano is helpful in building a more rounded person, although some may have aspirations that their offspring might be the next Lang Lang.
As China now moves into a new era, the piano practising child may have something else to practise: golf.

The Independent reported that it is the new game that is the game of choice for China’s new elite.

My friend told me that when he was at the Spring City Golf & Lake Resort, a nine year old just won a junior tournament. The boy was only 9 and he scored 71 on his final round playing from the red Tee
He may well be the next Tiger, a piano playing Tiger.

A Book Review: Knowledge, Ginkgo, Software & Brain Fitness

Monday, October 5, 2009

Curiosity & Nobel

The Nobel Prize in Physiology or Medicine 2009
5 October 2009
The Nobel Assembly at Karolinska Institutet has today decided to award The Nobel Prize in Physiology or Medicine 2009 jointly to Elizabeth H. Blackburn, Carol W. Greider and Jack W. Szostak for the discovery of "how chromosomes are protected by telomeres and the enzyme telomerase"

Associated Press, European Pressphoto Agency, Associated Press
From left, Jack Szostak, Carol Greider and Elizabeth Blackburn.

"This year's Nobel Prize in Physiology or Medicine is awarded to three scientists who have solved a major problem in biology: how the chromosomes can be copied in a complete way during cell divisions and how they are protected against degradation. The Nobel Laureates have shown that the solution is to be found in the ends of the chromosomes – the telomeres – and in an enzyme that forms them – telomerase.

Telomeres/NIH File Material

"The long, thread-like DNA molecules that carry our genes are packed into chromosomes, the telomeres being the caps on their ends. Elizabeth Blackburn and Jack Szostak discovered that a unique DNA sequence in the telomeres protects the chromosomes from degradation. Carol Greider and Elizabeth Blackburn identified telomerase, the enzyme that makes telomere DNA. These discoveries explained how the ends of the chromosomes are protected by the telomeres and that they are built by telomerase.

"If the telomeres are shortened, cells age. Conversely, if telomerase activity is high, telomere length is maintained, and cellular senescence is delayed. This is the case in cancer cells, which can be considered to have eternal life. Certain inherited diseases, in contrast, are characterized by a defective telomerase, resulting in damaged cells. The award of the Nobel Prize recognizes the discovery of a fundamental mechanism in the cell, a discovery that has stimulated the development of new therapeutic strategies." Nobel Press Release

Carol Greider told Associated Press that the research was aimed at understanding how cells work, not with the idea for certain implications for medicine.

“Funding for that kind of curiosity-driven science is really important,” she said, adding that disease-oriented research isn’t the only way to reach the answer, but “both together are synergistic.”

It was comforting that Nobel chose to reward this kind of research as any breakthrough in Medicine and indeed Science could only come from fundamental research. It would not be a discovery if you knew what you were looking for.

The New York Times noted that:“Though Americans have once again made a clean sweep of the Nobel medicine prize, two of the three winners are immigrants. Dr. Blackburn was born in Tasmania, Australia, and has dual citizenship; Dr. Szostak was born in London. Dr. Blackburn came to the United States in the 1970s because it was ‘notably attractive’ as a place to do science.”

PDF, Telomeres

Nobel Posts:
Kandel & Doidge: Neuroplasticity & Memory.
Nobel: Kandel and Lohengrin
Chinese Shared Nobel Prize in Chemistry
Papaya and Nobel Prize