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Sunday, May 27, 2007

The Fidelity Of Cuba


Dr. Lester CN Simon

Arguably, one of the most unacceptable ways to mount a revolution in this country, in this century, is to see a major problem coming and disregard it until it literally erupts in your face on the front page of The Daily Observer. A major revolution in medicine is brewing in Antigua and Barbuda and Cuba is at the heart of it.

The first Antiguan and Barbudan Cuban trained medical doctor went to study in Cuba in 1980. Two more medical students followed in 1982 and one in 1984. With varying numbers trained over the ensuing years, a maximum of 20 Antiguan and Barbudan medical students left for Cuba last year. Remarkably, not a single scholarship to study medicine in Cuba will be offered this year. Poor planning or, correctly, no planning whatsoever has resulted in doctors returning from Cuba with no jobs available for them.

The yawning gap between the demand for jobs and the surplus of doctors will widen. Allegedly, 12 additional Antiguan and Barbudan doctors will return home this year from Cuba and about 6 or 8 will add to the rising dam next year. The gravamen of the problem is that the internship done by our doctors in Cuba is considered inadequate for our purposes. Two different health systems are in unprepared conflict.

Internship is the immediate period after you graduate, during which you gain first-hand, practical experience working under supervision as part of your training. Interns from the University of the West Indies (UWI), work for 18 months on hospital wards and in the community as part of a firm. The intern is the first person to see the patient admitted to the firm. Internship is a trying, eye-opening period with many sleepless nights.

The Cuban system has a 10 month internship but the intern has to compete with medical students and senior doctors to have as much direct access to the patient and as much hands-on management of the patient as the UWI trained intern. For the Cuban national, the internship is quite suitable because after internship, the Cuban doctor fits into a tightly knitted network of referrals and gains tremendous experience. When our doctors return home, they enter a completely different system from their Cuban counterparts.

In many countries, such as Jamaica, an intern gets a legal, provisional registration until successful completion of the internship, when full registration is offered. Thereafter, attendance at conferences and other forms of continuing medical education are requirements for yearly continued registration.

After observing the Cuban trained Jamaican doctors in practice and a fact finding mission to Cuba, the Medical Council of Jamaica, the registering body, mandated that Cuban trained Jamaican doctors must do a one-year, UWI style internship and pass an examination afterwards to be legally, fully registered.
Partly because we do not have a history of training doctors here and because some aspects of medicine here are marching backwards as others advance, we have only one type of registration: full registration. Any doctor, local or visitor, no matter how inexperienced, can legally open a private office after registration.

Because of the humongous demand for, and supply of medical scholarships, the exponential increase in the number of medical students in Cuba has resulted in a falling off of the quality of training. Quite simply, there are too many pairs of eyes, ears and hands to benefit from a patient during the Cuban internship. Some eager students will go the extra mile to see, hear and feel all that is available but the average student will not be able to do so. The best student might become frustrated by inadequate provisions for the unique, practical demands of the increasing numbers of overseas students returning to a different health system.

Many CARICOM states are following Jamaica and are making provisions for some form of additional, more hands-on type of internship and a common exit examination before full registration. This revolution requires dedicated specialist doctors in many fields to guide young doctors, a modern medical library and, inter alia, the foresight and will to turn our problem into a golden opportunity and devise and activate a health plan to solve our health needs. In the while, we cannot be overzealous and take all that Cuba generously offers if we know we cannot handle the consequences of excess. This is a lesson we learn at Carnival time.

While we are looking at our local doctors trained in Cuba, we must also look at the other doctors who have been fully registered. These doctors practise medicine under a life-long registration with no legal regard for continuing education as a requirement for continuing registration. Some registered-for-life doctors look askance at our Cuban trained doctors. They are so anti-Cuban, they lack fidelity (and a sense of humour).

Many students want to study medicine. It is a noble profession and it appears to attract a lot of money. Unbeknownst to most prospective doctors, the money that was once associated with being a doctor was old money and the new money came on top of a parental, grandparental or even great grandparental deposit. These days, the obverse is that the extended family is dependent on the doctor’s financial withdrawals. The immediate fancy car, fancy house and bags of money right after graduation is a disillusion-in-waiting.

We cannot allow our returning doctors to become frustrated, despondent and depressed. They will eventually leave. And guess who will fill the void, amigo? We must push the medical registration board, the medical association and the government to get off their backsides, enact tiered registration and devise a plan in which public and private health facilities can network to accommodate our returning doctors.

President Castro said that a doctor is like a shepherd, a priest, a missionary and a crusader. Inarguably, it is obscene to train young doctors and leave them out in the cold. History will not absolve us of the medical negligence of our best and brightest minds whilst we celebrate diversity. !Venceremos! We shall overcome!

Thursday, May 17, 2007

Stick Em Up! With Stick?


Dr. Lester CN Simon

Having a gun pointed in your face can be a life encapsulating moment. It’s amazing what you can see in microseconds. The first time my face encountered a real gun was some time in the sixties in Montserrat. A group of us, relaxing after a drama production, was listening enchantingly to war stories told by a World War II veteran exhibiting his captured Luger pistol. He had shown us at least three times that the gun was not loaded. When he suddenly pointed it in my face, my entire life went flashing by in vivid technicolour.

The second and last time a gun bumped into my face was when I was reluctantly leaving a night club in downtown Kingston in the seventies after a squad of policemen barged in. It was really a case of fools rushing in where angels should fear to tread. On this occasion, I did not see my life flashing by, probably because it had become much too complicated. Or maybe the jaw-dropping go-go dancing I had seen in the club, called The Keg, on lower Orange Street, had already taken me through my life’s journey when the police interrupted.

During the many sleepless nights of my medical internship in Jamaica I tried, unsuccessfully, not to get accustomed to the Pavlovian link between the sound of gunshots and the sound of the telephone summoning me from my bed to the hospital. Wary and weary of guns, I tried hard to confuse the sound of gunshots with the sound of backfire from a car. But Jamaica had many good auto mechanics and many more active gunmen.

When the last comptroller of Customs of Antigua and Barbuda was brutally murdered, I thought at first that it was an outside job. My protective instinct initially prevented me from admitting the obvious for fear of what could happen to any citizen, including me, my family and friends. But the crime scene was too much of bloody mess to be a professional, outside job. For that same reason, it took us less than ten seconds on boarding the Computer Challenger yacht in Barbuda, to suspect that that too was a local killing.

Since those two local murders, the numbers of guns, deaths and injuries from gunshot wounds have shot up. Some people do not like to hear the truth but guns were rampant during the tenure of the last government and guns are more rampant now. Could it be that forces other than politicians are facilitating the entry of guns into a once halcyon Antigua and Barbuda? We have a nasty, satisfying habit of blaming politicians for everything. And please do not say that the last government still has operatives in strategic places. The alternative might be too hard to countenance, but it may very well be that people other than politicians are facilitating the movement of guns.

Any teenager knows that the vilest goings on can take place right inside the church, in schools, hospitals, offices of professional business persons and such places. We all know that unsuspected professionals can do unsuspected, evil things, professionally. That was why I laughed hysterically one time in Jamaica when we were held back in a road block to allow a speeding public vehicle, escorted by outriders, to run through. Someone jokingly remarked that it was alleged that that was the best way to transport drugs and guns.

Despite the sordid gun stories I heard and witnessed professionally and otherwise in Jamaica, the most heart wrenching one was right here at home. A hard working police officer noted how difficult it was to fight the war on drugs because someone always seemed to know when a police raid would take place. One week later he was almost as distraught as the mother of a young man who was killed on or near a basket ball court. The good officer, convinced that the mother knew the killers, could not fathom why the weeping mother, aching and boiling over for the loss of her son, refused to say a single word about the suspects.

It reminded me of the time fifty years ago when, despite my protest of innocence, I received a thorough lashing for allegedly pouring water into a tall, family sized Jergens lotion bottle, with few precious drops of lotion remaining. Later, it was discovered that someone else had done the watery deed. Moreover, one person witnessing the rain of licks on my backside knew the guilty one. To this day, no one apologized to me or even put my licks on credit for the next occasion when I was really guilty. To this day! How then, did they expect me to run to them and inform them on what was really going on in the outside toilet when pairs of boys and girls would seemingly and seamlessly disappear?

Now, I know that sometimes you have to take the wrongly inflicted licks and say that the national toilet is really full of feces (for want of a four letter word). Something rotten is going on here. Almost all of the murders are committed by our own born and bred Antiguans and Barbudans. I repeat, almost all of the murders are committed by our own born and bred Antiguans and Barbudans. In the while, we prepare for an invading, imaginary army from outer space and blame the immigrant army of Caribbean nationals. Foreigners do commit crime, as we did in the Virgin Islands. Frankly, if most of the gun crimes here were committed by hardened criminals from overseas, all of us would have been stiff, tone dead long time.

The pen is indeed mightier than the sword but words know their targets. Bullets are worse than stray animals. We cannot wait until people in high places get shot and killed to use the national resources we already have to put a stoppage to gun crimes. If we were to do that, we would be admitting two very awful things: that some lives are more important than others, and worse, much worse, that, like little Bo Peep’s sheep, the guns have finally found their way back home, bringing their tales behind them.

Monday, May 7, 2007



Dr. Lester CN Simon

One of the secret joys of growing up and growing old should be made public. It is the quiet realization that the words of wisdom that members of your family, neighbours, friends and even perfect strangers, uttered to guide you along, are universal concepts that you have discovered to be true. It is now your sacred duty to pass them on.

Too much of a good thing can be bad for you. If you do not take kindly to advice from elders and others, you should read on and take counsel from hard scientific facts.

Pathology literally means the study (logos) of suffering (pathos). It is concerned with the causes of disease and well as the mechanisms underlying the causes of disease and how they lead to the signs of illness and the symptoms of patients. Television has presented the pathologist as someone who deals exclusively with matters related to the dead. Some pathologists, known as forensic pathologists, do that almost exclusively. Most general pathologists spend much more time and effort working in a lab overseeing technologists and examining and reporting on all sorts of specimens from the living. Indeed the motto of the Royal College of Pathologists is that pathology (including forensic pathology) is the science behind the cure.

The Newsweek magazine issue of May 7, 2007 carries an article by Jerry Adler in which he writes that doctors are changing the way we think about heart attacks and even death itself. The remarkable thing here is that the rethinking doctors are doing is based on a fundamental concept that would have made my dearly departed maternal grandmother smile knowingly. In fact many Antiguans and Barbudans are intimately familiar with the concept that, under certain circumstances, too much of a good thing can be bad.

When parts of the body are injured, they may adapt, suffer or die. A particular form of suffering occurs when the tissues of the body are deprived of blood. The flow of blood to and through the tissues is called perfusion. If loss of perfusion is massive and sudden, death can occur. If the loss of perfusion is not massive and it is gradual and prolonged, adaptation or suffering can take place. The decrease in perfusion is called ischemia (holding back of blood).

The news celebrated in Newsweek is based on the seemingly contradictory concept that when normal blood flow is restored to ischemic tissues that were chronically starved of blood, the suffering tissues can be injured more severely by the return of the formerly vital blood flow! This is called reperfusion injury. There are many mechanisms at work here. One such mechanism is that compromised tissues in their accustomed state of deprivation or chronic ischemia cannot suddenly adapt to the high concentration of vital chemicals that the renewed blood flow is bringing in. Do you see members of a united political party smiling?

In retrospect, we should not be surprised by the concept of reperfusion injury. We have all been suddenly awakened from deep, lovely sleep and had to snooze for a while before getting up. Or we recall being in the dark and suddenly exposed to very bright light. Worse, some may recall getting used to the blues of a lost relationship when all of a sudden the ex-lover reappears out of the blue bringing old tidings of great joy and new tales, fears and tears of rekindled injury.

One of the lessons from the remarkable research into reperfusion injury is that we may be treating some forms of heart attacks incorrectly. Many heart attacks occur because the heart is starved of blood beyond its ability to compensate. When we try to jolt such a weakened heart back to life we may be doing more harm than good. Instead of the jolting, heavy handed approach of almost literally beating the heart back to normal, we should reduce the demand on the heart and adjust the way it functions so that it can be coaxed safely and gradually back to normal. This slowing down, or slow waking up approach may require
lowering the body temperature to decrease the amount of energy required and using other practical methods currently under research.

But my grandmother knew all of this high science and technology long ago. I am sure she smiled in heaven and begged pardon for me when I got into trouble in biochemistry class at university. The lecturer was going on and on about the structure of large, complex protein molecules and how scientists used an enzyme called papain to break down these complex protein molecules into smaller, “digestible” pieces to study them. Unable to contain myself, I busted out laughing and disturbed the entire class.

My excuse was that I had recalled Granny cooking cow heel with green pawpaw on Saturday evenings for soup on Sundays. Green pawpaw is a natural source of the enzyme papain, which breaks down muscle protein. Despite what some fellow students would say, I swear I did not tell the lecturer, whose initials were E.V.E., that he reminded me of my grandmother.

Were Granny alive today, she would demonstrate reperfusion injury in double measure by cautioning me, on the same Saturday evenings when I wanted to run off to too much of whatever, to tarry a while after turning on the pipe to get clean water from a public utility authority.