Friday, September 30, 2016

Grand Central Station: 10 Million Oysters!!!

©2013 Am Ang Zhang

©2013 Am Ang Zhang
22 million visitors a year.

10 million oysters a year at Grand Central Oyster Bar.

Other book I am reading:

The gene is, and is not, the determiner of our identity. It behooves us to accept this paradox and understand it. As we learn how our genome defines us, we also learn how we transcend our genome.

Thursday, September 29, 2016

National Coffee Day: Panama Fakes and Failures!

Panama has been associated with some fabricated plots. There were the John Le Carre book The Tailor of Panama that was turned into a film, the location shoot of the Quantum of Solace (in Panama, doubling as a country in South America), and the Canoeist faking death, just to mention a few.

Then there was the coffee scandal.
In 1996 in California, a certain  Michel Norton, owner of Kona Kai Coffee was sentenced to 30 months in prison. Apparently for an extended period of time (some reckoned a decade may not be an over estimate), cheaper and “lower grade” Panamanian and Costa Rican coffee were used to pass off as “Pure Kona Coffee”.

Cheaper, certainly, as you would not otherwise be doing it. But, INFERIOR? I think many would certainly dispute that. I do not think you can really use an inferior product to pass off as something superior and fool people for long.

 ©2012 Am Ang Zhang

So the Ambassador of Panama in Washington D.C. wrote to the 
New York Times:

To the Editor:
I read with amusement about the indictment of a coffee supplier on selling fraudulently marked beans to retailers (news article, Nov. 13).
Without making light of the charges, I am pleased that the coffee buyer for Peet's Coffee and Tea is uncertain that he can tell the difference between the ''cheaper'' Panamanian beans allegedly substituted for the more expensive Kona.
Panama's coffee is among the world's best. In fact, members of my staff have seen Panamanian beans for sale at high-end coffeehouses for little less than Kona. Perhaps we can arrange a taste test of Kona and Panamanian coffee for the sellers mentioned in the article. I am sure that no one will be more pleased with the results than my native coffee growers. 

Ambassador of Panama, Washington

The Cockroach Catcher was fortunate enough to have visited both Costa Rica and Panama. Costa Rica coffee is quite well known but few people realise that Panama produces coffee. I was determined to find out more about coffee grown in Panama.

Plants need to struggle to produce the kind of ‘poison’ against diseases, and coffee apparently is no different. This is well known for wine: vines grown in abundant sunshine may produce wine with a high alcohol content but does not produce enough of the ‘poison’ that humans love — we call the ‘poison’----- anti-oxidants.

Now even for the wonder malaria drug, Artemisinin, the plant Artemisia annua if cultivated with good fertilisers will not produce the anti-malaria ingredient at all.

Yes, plants need to struggle. Shade, and a misty atmosphere all work together to help the coffee shrubs struggle and help certain varieties of to develop health conferring properties, although the yield is lower than if you apply fertilisers and cut away the shading trees. 

David Cameron & The NHS: Politician & The Panama Canal

It is a common practice for politicians to ignore professional advice. As The Cockroach Catcher, his wife and friends cruise across this greatest of all human endeavour, he likes to re-post one of the Panama Posts.Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.Can we really learn anything from such a colossal failure.

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.

Extracted from the Official Website: Panama Canal Authority /French Construction

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 favour 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.

Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)

Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan.  But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind.  His own charisma turned out to be his enemy.  People believed in him beyond reason.

Could any of us learn anything from this experience?

Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.

Oct 16, 2010 ... Myrtilles Sauvage & Geisha Coffee. Years ago we spent a late autumn holiday in the French Alps. It was a wonderful time to be going on hikes ...

May 22, 2013 ... My friend's coffee plantation provides a beautiful setting for photography. The trees provide good shade for good coffee growing. 

Tuesday, September 27, 2016

Finland & Suicide: Settled Medical Science!

Medicine progresses and new discoveries are made though not necessary all that often. Compare with transistor and electronic technology medicine is the tortoise.

Yet, there are things we thought were a given at Medical School. Certainly, functions of well known Vitamins such as A, D & C. Vaccination against Smallpox. Endocrine conditions such as Thyrotoxicosis and Type 1 Diabetes. Stress and Peptic Ulcer is more or less a given. This is the phenomenon of “settled medical science”, next topic please.

We have at our school a wonderful teacher in endocrinology. Coming to think of it, a great one in haematology, GI disorders and I am not even venturing out to other specialties. Of course all our teachers were British trained and many became really the parents of medicine in Hong Kong.

We were so proud of our teachers that we have acquired a degree of arrogance about certain areas of medicine. We certainly know all there is to know about Thyroid, Diabetes and Thalassaemia. Peptic Ulcer is an interesting one as our Professor, Old Mac is not happy and decided that we should only call it Ulcer Syndrome, and as with other syndrome diagnosis, it implies that we still do not know. It has taken nearly another three decades before someone else proved that he was right.

 September 2012 ©2012 Am Ang Zhang

So in 1996, I was in Finland for a World Congress in Infant Psychiatry more or less during the longest daylight week of the whole year. Walking back with some Finnish Child Psychiatrists back to our University Accommodation at well past 11 at night when it was still bright, my Finnish colleagues jokingly said that in Finland, people started contemplating suicide after the Summer Solstice.

That Finland has the highest suicide rate of any first world country is well known and ever since the popularity of the diagnosis of SAD, it was naturally assumed that darkness in the Finnish Winter must have contributed to their famous suicide rate. I was back to Finland in 2012, this time for an extended Autumn holiday. Researching before travel uncovered some medical information that surprised me.

Extensive research in Finland[1] revealed that the highest rates of suicide started in May peaking at Summer solstice and tailing off symmetrically in July.

Our key finding of statistical significance demonstrates the increased suicide mortality on nationwide level in Finland during the period from May 14th to July 25th. This 76-day period covers symmetrically both sides of summer solstice. During this period there is only 1 to 4 hours of darkness during the night in Helsinki but no darkness at all in Oulu.

This is a high quality research that came out in 2011 in a country where suicide rate is high although in recent years, they have done much in terms of improving mental health care that has quite dramatically moved Finland out of the top few countries.

As I have stated earlier, there are subjects we studied in medical school and had the confident impression that our knowledge on some conditions were complete! Now let us concentrate on other newer conditions. Settled Medical Science indeed.

Feb 19, 2013 ... Adult A.D.H.D. & Faking: Real Psychosis & Suicide. Adult A.D.H.D. is open to faking and more so by medical students. In children, it was my ...

Jun 6, 2013 ... Stephen Fry has disclosed that he attempted suicide last year and only survived the “close run thing” when a colleague found him unconscious ...


Monday, September 26, 2016


Those of you who managed to catch the first Chapter "The Seven Minute Cure" will be wondering: Is the Cockroach Catcher famous as Barbados is for the British Celebrities? Some even arrives by Concorde!  Used to anyway!

Well, let the truth be told, Am Ang discovered Barbados long before the celebs.  He is still very fond of it though he tends to visit when the celebs have left and he can have the beaches to himself. His favourite beach is Accra Beach

There he has seen hatching turtles marching into the ocean, the few that remains of course.

In Barbados, the Cockroach Catcher also picked up golf, the only addiction where there is no cure, no rehab. None required anyway. 

There too he rediscovered his childhood love of snorkeling and he later marveled (in his book of course) at the way mankind took the better part of two decades to come up with a new snorkel design and lamented the sluggishness of medical progress.

Barbados is also the place that has the second highest number of centenarians per capita. Is it the fish they eat, the slower place of life or is it something that we have come to avoid, sunshine?

In the end genetics probably prevail; but one cannot let what is written in one's genes dictate one's life.

“There are two futures,
the future of desire and the future of fate,
and man's reason
 has never learnt to separate them.”

J. D. Bernal

The Cockroach Catcher    Chapter 3   Barbados and Retirement

Barbados, as everyone knows, is an island in the Caribbean. We had never taken a holiday in the Caribbean and it was a shock to friends and colleagues when news broke that we were moving there. 
      It may seem ironic given my love for my work that I could give it up so easily. The truth is that the unrelenting re-organisation after re-organisation in the NHS had finally taken its toll. I first arrived on this tropical island to accompany my wife to take up a two year posting with her employer less than a week after September 11. We had no idea where the world was heading and if there was going to be any world conflict Barbados seemed to be far enough away from where those conflicts might be. We first stayed in a hotel right by the sea on one of the loveliest beaches in Barbados that to this day remains our favourite. 
      We arrived in the evening, and in Barbados when the sun goes down it becomes pitch black immediately.  Imagine the surprise in the morning when I pushed open the door to the small balcony overlooking the beach and saw the loveliest blue sea that only the white coral sand and Caribbean September sky could conspire to provide.  Pure white coral sand tinged with pink and beckoning palm trees complete with gentle surfs was a sight too much to resist.

      There is a Buddhist saying:  Better save one life than build a seven-storey pagoda.  I felt that I had done my duty as a doctor, and could now retire and let the younger generation take over. It would be dishonest of me not to mention my frustration with recent changes in the NHS – no, not changes for the better.  The havoc on my physical health together with events of September 11 were the final straw.
      I remember bumping into one of the neurologists who retired a year earlier from my hospital. We more or less started at the hospital around the same time and most years we managed to meet up at Glyndebourne.
      Glyndebourne is one of those places that started life as a private opera house. The small and intimate opera house proved too small and eventually a new opera house with much bigger capacity was built in its place. Fortunately the gardens were left relatively intact and every year from late spring to late summer operas are performed every evening with an extended interval so that patrons can have a nice champagne picnic in the grounds. Most patrons continue with the Black Tie tradition and the few dissenters just look out of place. It was during one of the dinner intervals as I was ready to open a bottle of champagne when I saw the neurologist. When he learnt that I too was contemplating retirement, he exclaimed, “There is a hell of a lot of life after the NHS, you know.”
      It was not necessary for him to have said anything as my mind was already made up. On a sunny afternoon in the beautiful setting of Sussex countryside cows grazed on the other side of the ha-ha.  How many hours do they have to graze in order to produce a pint of milk for the coffee that we nicely dressed humans consume? Is there a lesson there somewhere?
      It is not that difficult to decide that there is more to it than to continue to toil under politicians all purporting to do their absolute best. We all started off with high hopes. Hope for a better health service. Hope for humanity and mankind.
      As my first guru and mentor in England put it when I called him with the news of my consultant appointment, “You now only have your retirement to look forward to.”  How right he was.

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Thursday, September 22, 2016

Tea Plantation: BOH Malaysia.

All Photos ©2016 Am Ang Zhang

BOH Plantations was founded in 1929 by J.A. Russel, a British businessman during the British colonial era in Malaya. He was optimistic of the tea plantation business due to huge demands despite of the world-wide Great Depression at that time. As a result of the potential, he applied for and was granted a concession of land for his first tea garden in Habu, Cameron Highlands.

Sunday, September 18, 2016

Blair & Gang of Four: NHS & The Complicated Plot!

Every day now, someone will write and say the NHS is being privatised. Well, it is more complicated than that and believe me Hunt is just a distraction. May and Stevens are the main plotters and Stevens was the original Gang of Four. 

Stevens can in a short time lose so much weight to re-join NHS with his American wife and young children from UnitedHealth. 

Be very afraid. 

He either loves the NHS so much that he wanted to save it or there is a more complicated plot. It is unusual for a chief to say hardly anything about Junior Doctors and as the FTs were struggling to provide a barely adequate service, some of Stevens Social Network Savvy left and right hand persons were getting so excited about all these very successful attempts to persuade punters (aka patients) to accept that you do not really need hospitals and hence specialists. 

No the NHS is not privatised. 

Its is worse, it is being chopped up and sold piece meal to the other punters who if they did not make enough money, hand it back and pocket whatever they have made. Hinchingbrooke, Vanguard Eyes and a number of others. This way it is going to be difficult to put back. It is like chopping a tree, grind up every thing so that is cannot be grafted anywhere else and the roots dug out with diesel poured in for good measure. Nothing will grow back. But the logo of NHS will still be there. Richer people scramble to get insurance that will not pay for everything. Different excuses will be used not to treat you: smoke, too fat, too thin, too demented, exercise too much, too little, too often. They just will not call it rationing but instead: catering for the individual. Juniors trained in this country scramble to the likes of Australia and beyond. Poorer quality ones will try to get in and eventually rules will change to admit them.


©2016 Am Ang Zhang
There is little doubt that the Plot to Dismantle the NHS is on course and going well. The problem with most of us is that we are so confident that the NHS will not be privatised and be run like the US system. Bearing in mind that in the US the State funds much of health care once you are over 65. Most of their citizens are heftily subsidized by the state through Medicare and the poor through Medicaid. That system allows insurers to make the most money when you are young and healthy knowing that you are off their hands at 65.

The current thinking is to keep the NHS as a Kitemark and allow privateers to become providers especially for profitable parts of health care.

In fact the way private medicine operates in England is that many so called private hospitals do not have the capacity nor the wide range to deal with the whole range of cases. In fact when I was still working, the new private hospital was so small it is smaller than our cottage hospital and anyone that needs more attention got ferried to the NHS hospital. No one will ever die in the new private hospital.

The other important aspect of the private / public divide is blurred by the fact that the consultants were nearly always the same ones. Keeping a foot in both camps is an advantage to the consultant as he knew that complicated cases will be dealt with. All of course for the good of the patient.

This was taken to a new level when BUPA for as far as I can remember BUPA will pay any insured if they chose to be operated in anNHS Hospital. Badmouthing of NHS is of little advantage to the likes of BUPA.

In some big cities, private hospitals take over most of the orthopaedic work as it is easy to price and unlike psychiatry, outcome is more predictable. Both private and NHS patients are treated there and as far as I can judge, the only difference is that private patients and relatives are offered high quality Cappuccinos and NHS ones, filtered coffees.

In places like Singapore, people preferred to pay for Primary Care for quick and easier access but chose State Hospitals for major surgery or complicated cancer treatment. It is not entirely free but as most are employed a system of insurance style funding leaves Singapore with a world class health care at a fraction of the cost of say US ones.

Singapore also managed to keep the State run hospitals at tip top quality but very reasonable cost.

This in fact was the problem with trying to privatise the suppliers to different NHS services. NHS hospital was too cheap and no privateer could offer services anywhere near.

So according to Colin Leys, the first step in privatising these supplies is by a very shrewd move:

To overcome this was the real aim of the Independent Sector Treatment Centre (ISTC) programme. ISTCs are small stand-alone clinics specialising in standard low-risk procedures, chiefly cataract removal anIf wd hip and knee replacements. The programme was set in hand in 2002 by a new Commercial Directorate in the Department of Health led by Ken Anderson, a Texan businessman.

….. The real aim of the programme was to put pressure on the existing British private health companies – chiefly BMI, NuffieldHospitals and BUPA’s hospitals – to restructure themselves into high-volume lower-cost businesses. This was done by giving very lucrative and risk-free contracts to a set of newcomers from overseas such as Netcare from South Africa and Capio from Sweden. The incumbent firms were, officially at least, disconcerted, and set about restructuring. The BMI hospital chain started separating its private patient work from its NHS work, aiming to make its NHS work cheap and fast, and was then sold to Netcare in 2006.  BUPA sold all its hospitals to a private equity company, Cinven, which set about the same task.

If we are honest, the actual doctors doing the work were the same NHS or Private and in essence there is much increase in spending but no real increase in work load. It is not important as the aim is paving the way for letting much of the work done privately whilst keeping the NHS name.

It is perhaps important to ask the question: how did this all started?

Well if we are honest, it probably started in 1991 with the introduction of Fund Holding. It was the best and the worst of the market system that I have personally seen as the system in no time created a two tier Health Care system. Our Trust lost much money from a Fund Holder that referred high number of cases but ran out of money. 

Labour's Gang of Four:

Milburn, Stevens, Penny and Corrigan in 2000 and the NHS Plan was published.

The NHS Plan, which was published in the same month, July 2000, was written by a team that included Stevens, Dash, Corrigan and Milburn. It mentioned the main elements of the shift to a market, but it disguised them as mere improvements in the existing system. 

Colin Leys again:

In my innocence, I dismissed this as a far-right fantasy. What I didn’t realise was that his vision was shared, to a greater or lesser extent, by a small number of people at the heart of government, especially Blair’s senior health policy adviser, Simon Stevens, Milburn’s adviser Paul Corrigan, and a significant number of senior staff in the Department of Health including, critically, its young director of strategy and planning, Dr Penny Dash, and Milburn himself. They all thought that to make the NHS efficient it should be reformed into a kind of healthcare market.

Interestingly the only one left to carry out overtly the plan is Simon Stevens. It fitted in with the revolving door pattern.

The players: the insiders: the 'policy community', corporate heavies, management consultants, think-tankers, freelancers and hired hands, including some academics and doctors. They can use the 'revolving door': company envoys can get jobs in the Department of Health, and ex-ministers and officials can get well paid jobs in the private sector.

Foundation Trusts:

But the central point about foundation trusts is that the contracts they make are legally enforceable, and if they run up unsustainable debts they won’t be bailed out by the Department of Health. This means that they become fully exposed to the risk of bankruptcy. The independent regulator, Monitor, can step in and impose new management on a foundation trust that is heading for bankruptcy, or let it close and get its work taken over by other providers. This means that the crux of all policy decisions in the hospital becomes financial. Foundation trusts don’t have to pay dividends to shareholders but in all other respects they have to behave like private companies. Milburn’s aim was that all NHS trusts should become foundation trusts by 2008.

But they couldn’t behave like companies unless their income was related to their performance. So Milburn also introduced payment by results. Each completed treatment was to be accounted and paid for individually. This involved putting a price on every procedure, a price that varies according to the different level of cost and risk posed by each category of patient. These prices were fixed. For the time being competition was to be on quality alone. But once a system of payment based on price per treatment was in place, price competition could then be quite easily introduced.

Unfortunately as far as PFI is concerned, FTs cannot go bankrupt. What a pity. Metronet did!

Smart move: Do not call it reform!

This is the brilliance of Simon Stevens. Without having to go through parliament a new wave of so called Vanguard schemes was brought in for the famous Five Year Forward View.

Simon understands Social Media and employed people that are good at it. Vanguard NHS is evolving like a parallel universe where everybody is so enthusiastic some of them should perhaps have therapy. The other universe in the meantime are facing a crises that was perhaps part of the plan. But with Junior Doctors striking for the first time in nearly 4 decades it makes you wonder if these Vanguard places really have Juniors doctors? 

Then there are catastrophic failures, first of Hinchingbrooke, then UnitingCare. Not to mention ISTC failures. They are just little hiccups and nobody seemed to say much about it.

The Department of Health created a commercial directorate to oversee the plan to privatise the NHS. A group of passionate market advocates were hired to transform a public sector institution into a target for private sector takeover. People such as Mark Britnell, who was the Department of Health's director general for commissioning when Labour was in office and who later joined KPMG – able to sell his experience in government to the world of management consulting – have now been outed as agents for the merciless dismemberment of the NHS. There was a revolving door between civil servants in the department and McKinsey, KPMG and Deloitte. Ex-ministers, such as Patricia Hewitt and Lord Warner, traded their knowledge of NHS privatisation with those who could benefit in the commercial sector.

Will NHS England revert back to just NHS? I doubt. But Simon can blame his American wife and young children if he wanted  to go back to Minnesota. After all there is Mayo Clinic there and they have never changed.

Or would J.C. Penny some day take on Simon?
Or would we some day read that: Big dreams, arrogance, infighting, and delusion all collided in the disastrous attempt to fix NHS England!