Impressions from China - Shanghai

My first impression of Shanghai as we headed to our service apartment from the airport, was that it didn't feel as "foreign"as Beijing. Things looked familiar - the roads were better maintained, the buildings looked more modern, even the people looked different (northern Chinese faces seem to be broader, & their complexion seems to be darker), closer to the southern Chinese faces that I have been so used to seeing in Singapore. More signs were bilingual (Chinese + English) so that I didn't feel so lost.

Traffic was just as bad (if not worse) than in Beijing. People seemed more aggressive, especially when we were in crowded situations like at the Bund or Yuyuan, which during the holiday season, was thronged, and I mean THRONGED, with visitors. It was literally push-and-shove in order to make ones way through to ones destination.

The crowd at Yuyuan

ATTRACTIONS

The city definitely looked more developed than BJ. Walking along the Bund, we noticed that one side of the Huang Pu River had architecture reminiscent of its colonial days, while across the river, modern buildings were the norm.

The "old"side of the Huangpu River

The modern side of the Huangpu river

The Shanghai maglev train is another example of modernization. We did a round trip on this train for the sake of our kids...after all, how often does one get to ride in a train at 430 km/h?!

Shanghai Maglev train

FOOD!

One does not visit Shanghai & not rave about the food! From fine Italian cuisine (read: expensive) at Cucina on the 56th floor of the Grand Hyatt in Pudong, to different varieties of buns at a Mantou restaurant in Yuyuan, to delicious (& greasy!) shenjian mantou costing us only 70 yuan for 72 buns which the 9 of us devoured, one can find an amazing variety of food available in the city. The pig's elbows ("tipang") is a must. Don't be turned off by the layer of wobbly fat & skin that you see on the surface. Underneath all that, you find the tasty lean braised pork meat...mmm...yummy...

"Souper" buns at Yuyuan

Shenjian mantou - delicious & cheap!

Braised pig elbows "tipang"

Impressions from China - New Year

(Written 12 MN, Feb 17/18,2007)

I gaze out of the bedroom window of our service apartment overlooking downtown Shanghai. The cityscape is covered in a haze created by a combination of fog and smoke from burning fireworks & firecrackers.

Right, left and centre, we seem to be surrounded by rainbow-colored shooting stars exploding to an incessant continuous cacophony of snaps, crackles & booms - explosive retorts from exploding fireworks. It seems neverending, this noise & light show that is welcoming in the Lunar New Year.

I am fascinated by this city, a seemingly foreign & Western Hub in an ancient Oriental country. It reminds meof Hong Kong & Malacca & Penang & Singapore all rolled into one. I look forward to exploring more.

The fireworks are still going off as I write this...and it looks like the city is not going to sleep...not tonight anyway...

Gung Hei Fatt Choy

I dreamt of my dearly departed grandmothers last night. The images are vague, as dreams tend to be. I remember snatches of the dream, images of my maternal grandma, my mom & I shopping along Orchard Road, taking shelter from the drizzling rain along the five-foot way near Peranakan Place just outside the Taka jewelry store. What we were shopping for, I don’t know.

Then the dream shifted to my paternal grandmother, urging me to make the booking for a cruise or a hotel or some kind of holiday online before it became all sold out! This is totally radical as my Ah Mah never had an inkling of how to use a computer!

Since time immemorial, people have wondered about dreams & their meanings. I won’t even begin to go into that. What the dream did for me was to evoke memories of Chinese New Year shared with those who are no longer with us, New Year celebrations when extended families were actually in the same country. New Year’s Eve would see us having dinner together: grandparents, uncles, aunts, cousins. We would pre-arrange the sequence of ‘visitations’ (actually, my beloved but dictatorial maternal grandpa would be the logistician), & even co-ordinate what kind of food we would have at each house so that there would be no overlap!

The morning of New Year’s Day would dawn with my siblings & I waking up, wishing our parents “gung hei fatt choi” & eagerly receiving hong baos from them. We would then dress in our new clothes & head out to the first stop, usually my maternal grandparent’s home. That would mark the start of a whole day of stuffing ourselves silly, mahjong, & for the kids, totaling up the hong bao takings (not necessarily in that order).

I know many people complain about the monotony & tedium of having to visit all their relatives year after year after year. To those people I say: Appreciate what you have when you have it because one day, you’ll wake up missing & wishing for those days.

I know I do.

Gung Hei Fatt Choi/Gong Xi Fa Cai/Happy Chinese New Year everyone!

Impressions from China - This & That

Been here over a month. Can't say I totally feel at home yet, but things are slowly & surely falling into place.

Our immune systems have been challenged. In total, the 4 of us have suffered from 5 bouts of URTI, & 4 bouts of GI-related illnesses in the short time that we've been here. Not fun, but I guess our resistance against new bugs has to be built up.

Chinese New Year is coming up & we're off to Shanghai to visit with some friends. People here get a whole week off for the "chun jie"(Spring Festival), as they call it here. Many return to their home towns & villages, & apparently bus & train tickets are impossible to get this week.

The tid bits I see being sold in supermarkets are not much different from those sold in Singapore. One big difference is that fireworks are allowed to be sold here for the weeks around CNY. We have already started hearing the booms of firecrackers being lit at night; I think this will escalate & peak on New year's Eve & the first few days of the New Year.

Another difference I see is that there is no "yusheng" here. Shouldn't be surprised though, since I think that is a Singaporean "invention".

Gong Xi Fa Cai everyone!

Numbers

Disclaimer: The opinion expressed in this entry is solely that of aliendoc’s, based on experience in both public & private sector. It in no way reflects policies or opinions of the Powers That Be.

There has been much discussion the last few weeks about MOH making it “easier” for foreign doctors to practise in Singapore. This is supposed to address the shortage of doctors in the country.

There have been arguments & questions raised on why & whether there is actually a shortage at all, especially in the private sector. No, I don’t believe that there is a shortage; it’s a dog eat dog world out there especially in GP-land*. (*I exclude aesthetic practitioners in this group, as I believe they are a different species from what one would perceive as a typical GP…but then, that is whole different kettle of fish altogether ☺. I also exclude doctors who are employees of a larger medical group – this will be expounded upon later.)

Doctors are not businessmen. We were not taught a module on business strategies & economics in medical school. Hence, GP’s end up “killing” each other trying to get a “market share” of patients. They undercut, sign on with HMO’s & MHC’s (whatever you may call it, these 3rd party administrators exist for the sole purpose of making money) just to make ends meet. Business consultants would probably cringe if they saw the kind of decisions that have been made by some of these doctors.

As for the larger medical groups, it’s a different story altogether. Speak to any of their operations managers or HR manager & you would probably discover that recruiting & retaining doctors is a difficult task. Many have a high turnover rate; take a look at the SMA newsletter & you’ll see what I mean - ads repeated issue after issue, seeking doctors to join them.

On the flip side, you have the government polyclinics – obviously overcrowded & evidently understaffed. Junior doctors in hospitals are also lacking (although this may have improved the last few years with increasing medical school intake).

So why the shortage in the government sector? Simple: doctors leave after they complete their obligatory bond. And why do they leave? Perhaps they seek the almighty $. Or they want some autonomy in how they practise. Or they are just sick of the bureaucracy. Like it or not, there is still a strongly hierarchical structure (not to mention the politics!) in the government departments (call it NHG or Singhealth, call it what you like, but in the end, it works the same way ☺). It is hard to be heard unless you go through the proper channels (i.e. somewhat of an obstacle course where you have to clear a few obstacles before reaching the finish line, if at all).

And how would you explain the medical groups’ dilemma of finding & keeping doctors? My take is that doctors working for these groups have very little say (if at all) in how certain patients (read: those under very restrictive HMO/MHC contracts) are managed. After all, these groups have to answer to their shareholders & clients (note: I use the word "clients", not "patients") & the bottom line is VERY important after all (sarcasm intended). So, see as many patients as possible, get as many contracts as possible, & save money for the clients (the companies who contract with them to look after their employees). End result is that doctors will use this as a stepping-stone, a temporary job before they venture out on their own to compete with their colleagues for patients, and the vicious cycle continues.

So will letting in more foreigners in do the job of resolving the numbers problem? Probably partially & temporarily, especially in the government sector & in the medical groups. But it won’t help the GP’s out there who will still be struggling to stay afloat, competing with each other, & forced to charge miniscule amounts for consultation fees.

So if the big wigs want to look at the long term problem of shortage (I prefer to use the word, skewed distribution) of doctors, they will need to examine the causative problems first. Otherwise this will just be another fire-fighting scheme, which does not prevent another fire from starting.

Impressions from China - Aliens

As an alien in China, you begin to appreciate the difficulties that foreign workers meet with when they leave the comfort (not neccesarily just physical, but psychological & emotional as well) of home. A strange new language, different transportation systems, electricity voltages/sockets, customs & culture...when one is inundated by a shock wave of all things new & unfamiliar, it can be extremely daunting. The simple task of shopping for groceries or neccesities in a store takes twice as long when one is trying to interpret the labels on a can/bottle/package.

I have met with many foreigners in the last month that we've been here, hailing from the various continents. It is weirdly comforting to know that no matter where we're from or what our mother tongue, we all share the same stories of fumbling & learning our way around an alien country. I guess being in a foreign land makes our differences seem insignificant in the greater scheme of things.

We have the advantage of accessibilty to information & resources like the Internet & guide books to help us settle in. But most of the manual foreign workers who travel thousands of miles from home searching for a better life do not have that. They rely on sometimes unscrupulous agents & employers to "help" them in their expatriation. And yes, by definition, they are expats too.

So the next time you see a foreign worker ,who labours to help us build those skyscrapers & condos, or who helps you to look after your home, take care of your children/parents, spare them a kind thought & put yourself in their place. After all, once upon a time, most of our ancestors were expatriates too.

Battlestar Galactica

I’ve been glued to the sci-fi series “Battlestar Galactica”. Not the old series from the 70’s, but the revamped one that has been playing on the SciFi channel in the USA since 2003. I bought Season 1, 2 & 2.5 & brought all 3 sets here, in expectation of a relatively barren TV listing in China (which I am now happy to report is not that bad after all ☺).

I was a huge fan of the original series (probably, in great part, due to my crush on Dirk Benedict who played brash, cigar-chomping ace pilot, Starbuck). Star Wars: A New Hope started off my fascination with the scifi genre. When BG came along, it became a favorite of mine. Looking back, I suppose that during my adolescent years was also when my mind started to question if there was something out there in the Universe; after all, statistically speaking, in our humongous universe, there has to be other worlds with intelligent life-forms apart from our big blue marble.

The new series is definitely different from the old. A lot darker for one, & despite its setting, delves into current day issues - war, terrorism, abortion, racism, torture of prisoners (season 2, rated NC-16, addresses the latter & had me cringing at some of the scenes).

With brilliantly written scripts & great acting by veterans Edward James Olmos (Commander Adama) & Mary McDonnell (President Laura Roslin), & relative newcomers Jamie Bamber (Capt Lee “Apollo” Adama), Katee Sackhoff (Lt. Kara “Starbuck” Thrace), Grace Park (Cylon sleeper agent Lt. Sharon “Boomer” Valerii) & Tricia Helfer (as the babelicious Cylon No. 6/Gina), I have been watching episodes from the series avidly in the last week, going through season 1 & now seasons 2 & 2.5 (don’t ask me why they divided season 2 up). Grace Park especially deserves special mention in season 2 with all the heart-wrenching emotions she must have had to drag up from the depths of her soul in order to portray her character’s situation so adeptly.

Season 3 is being broadcast now in the USA. I can’t wait for the DVD set to be released (or at least for the series to start showing on Cinemax).

Passport, please

I have no gripes against Singapore accepting more foreign-trained doctors into the country to practice medicine. If standards are in place to ensure that these doctors are adequately trained, & able to practice good medicine (whether as a GP or as a specialist), I think we should welcome them.

What I feel strongly about is the double standards that SMC seems to have for Singaporean foreign-trained doctors & non-Singaporean foreign-trained doctors. What one’s nationality is should not play a part in deciding whether one is fit to practice or not.

Why just a pre-requisite 2 years of conditional registration (for a Singaporean) as opposed to 6 years for a foreigner (according to current guidelines on the SMC website)? It used to be just one year for Singaporeans. The 6 year conditional registration for foreigners will be changed to 4 years as announced by Minister Khaw last week.

Still, why the discrepancy? Is it assumed that Singaporeans trained overseas are better than foreigners trained overseas?

I can understand that SMC may want to “protect” its own citizens. But when it comes to the practice of medicine, who will protect the patients & ensure that they receive proper medical care no matter which country the doctor may come from?

Impressions from China - Market Day

I am so happy I have found a wet market in Beijing! Somehow, FFV's* in supermarkets don't cut it for me. So when a neighbour (a fellow newcomer with similarly unconventional life experiences as me - originally from HK, married to American, have lived in US, then Suzhou/Shanghai & now Beijing) brought me to not one, but two wet markets on Wednesday, I was so happy! I found my leafy greens & fruits which don't look dehydrated/manhandled like the ones you find in Carrefour or Walmart (yes, they have a Walmart here). And prices were cheap too. I bought chicken legs/breast, pork ribs/loin, siew bak choy ,water cress, dou miao, ginger, apples, Chinese pear, watermelon, mandarin oranges (the mini ones which are intensely sweet - yum), mango & paid the princely sum of about 100 yuan** in total.

The northern Chinese don't eat a lot of leafy greens, for some reason. They mostly like gourds & beans & peppers in their food. Hence, one finds it difficult to find things like choi sum & kai lan in the supermarkets (local or otherwise). Well, you do see them occasionally in the aforementioned supermarkets, but most are wilted & not something I would use to cook.

Yay! Now I won't miss my Holland V vegetable ladies & Farrer market fruit man too much!

*fresh fruits & vegetables
**approx. SGD20 or US$14

Impressions from China - Grey

Grey.

That seems to be the predominant color in Beijing. In the almost 4 weeks that we've been here, we've woken up to grey skies most days. The number of days that I've actually seen clear blue skies can be counted on the fingers of one hand.

Driving into the city on the highway, one sees a shroud of grey haze enveloping the cityscape. Even the trees are grey. The "evergreens" are a sickly dark greyish green in color.

I don't remember the winters in Pennsylvania being so grey. I recall blues & greens even in the dead of winter.

It's like everything is waiting for Mother Nature's magic wand to wave away the dreary greyness, & breathe life & color into everything again.

I await with bated breath.

For all the Mothers out there...

I received this from a friend. I usually delete chain mails, but I couldn't resist putting this up...

JUST A MOM?

A woman, renewing her driver's license at the County Clerk's office, was asked by the woman recorder to state her occupation.

She hesitated, uncertain how to classify herself.

"What I mean is," explained the recorder, "do you have a job or are you just a ...?"

"Of course I have a job," snapped the woman.

"I'm a Mom."

"We don't list 'Mom' as an occupation, 'housewife' covers it," said the recorder emphatically.

I forgot all about her story until one day I found myself in the same situation, this time at our own Town Hall.

The Clerk was obviously a career woman, poised, efficient, and possessed of a high sounding title like, "Official Interrogator" or "Town Registrar."

"What is your occupation?" she probed.

What made me say it? I do not know. The words simply popped out.

"I'm a Research Associate in the field of Child Development and Human Relations."

The clerk paused, ballpoint pen frozen in midair and looked up as though she had not heard right.

I repeated the title slowly emphasizing the most significant words. Then I stared with wonder as my pronouncement was written, in bold, black ink on the official questionnaire.

"Might I ask," said the clerk with new interest, "just what you do in your field?"

Coolly, without any trace of fluster in my voice, I heard myself reply, "I have a continuing program of research”, (what mother doesn't),

“In the laboratory and in the field”, (normally I would have said indoors and out).

“I'm working for my Masters”, (first the Lord and then the whole family)

“and already have four credits” (all daughters).

“Of course, the job is one of the most demanding in the humanities” (any mother care to disagree?),

“and I often work 14 hours a day”, (24 is more like it).

“But the job is more challenging than most run-of-the-mill careers and the rewards are more of a satisfaction rather than just money."

There was an increasing note of respect in the clerk's voice as she completed the form, stood up, and personally ushered me to the door.

As I drove into our driveway, buoyed up by my glamorous new career, I was greeted by my lab assistants -- ages 13, 7, and 3. Upstairs I could hear our new experimental model, (a 6 month old baby) in the child development program, testing out a new vocal pattern.

I felt I had scored a beat on bureaucracy! And I had gone on the official records as someone more distinguished and indispensable to mankind than "just another Mom."

Motherhood! What a glorious career! Especially when there's a title on the door.

Does this make grandmothers "Senior Research associates in the field of Child Development and Human Relations"?
And great grandmothers "Executive Senior Research Associates?"
I think so!!!
I also think it makes Aunts "Associate Research Assistants."

Impressions from China - Counting Sheep & Blessings

On the way to dinner a couple of nights ago, we saw three flocks of sheep grazing on the side of the road, watched over by shepherds...sheep, I tell you! As my sons "oooh"ed & "ah"ed over this sight, I turned to them & said, "How random is that???!"

But on second thought, I figured that in China, this wouldn't be a 'random' occurence, & it shouldn't have surprised me; the same way how seeing mules still being used for pulling cartloads of goods/cargo shouldn't have surprised me either (we saw this while visiting one of the schools we were considering for our boys).

This country is such a unique blend of the old & the new, the urban & the rural, the rich & the poor, the East & the West. There is such a disparate difference between how & where people live.

The Shunyi district where we are is filled with "compounds" comprising of "villas" mostly occupied by foreigners & the well-off Chinese. These compounds usually have their own clubhouse with amenities like indoor/outdoor pools, gyms, restaurants, even spas on their premises. The houses are equipped with washers & dryers & dishwashers, satellite TV links & internet access.

Interspersed within this district, I see single level homes clustered together like a large village. From what I can see from the road, these buildings have sparsely furnished rooms, darkly lit, a single bed inside, laundry hanging on a line outside. These are occupied by local labourers & "migrant" workers who leave their rural villages to become "ayi"*s or manual laborers or taxi drivers in the greater Beijing area.

Truly an eye-opener for us.

*ayi = domestic helper

Impressions from China - I'm homesick

Yes, I miss my family, my friends.

But I also miss the efficiency of Singapore. There are so many procedures (many seemingly pointless) in place for the most simple things. Asking for a receipt (fapiao) here is a big deal especially for large items like furniture. Receipts here actually have a scratch off portion that tells you whether you have won money or not; it's the governments attempt at encouraging the public to ask for official receipts which retailers have to submit. This is their way of trying to stamp out under-declaring by the retailers.

I miss being able to look at road signs & know immediately what it says & where I am heading to.

I miss being able to say something to someone without having a puzzled look of incomprehension being returned to me.

I miss my vegetable seller in Holland V who helps me choose my veges for a great price.

I miss being able to drink water off the tap without wondering whether I am ingesting carcinogenic toxins into my system.

I miss being billed for gas & electricity. They use top up cards here for gas & electricity, for crying our loud!!! So if we forget to check the meter, we may end up sitting in the dark one night.

I know these are growing pains in the fledgling days of our time here. It will get better. It will.

Winter Wonderland

Winter is, putting it simply, very very cold. We all have romantic visions of snow-covered landscapes & tree branches encrusted in ice resembling jewels sparkling in the sun amidst blue blue clear skies.

Well, yeah, you do see that once in a while, but more often than not, the snow becomes grey with road dust & mud, cars become splattered with dirty snow, & sometimes salt, walkways become a hazard when the melted snow freezes over into ice & the landscaped is covered by a cloud of grey fog. With the short days & long nights, it is no wonder that people get S.A.D. (Seasonal Affective Disorder).

Good thing is that children still see winter through the rainbow glasses of innocence. Snow is something to look forward to & to play & frolic in. Catch a snowflake on your tongue! Walk in the snow instead of the cleared paths! Would that I could recapture that magical feeling!

...and we have touchdown...

Well, we are finally here. We landed in minus 3 degree Celsius weather under hazy conditions on a Friday night. As we disembarked, the first thing that hit me (apart from the frigid cold) was the smell of smoky fumes. Don't know if this was from emissions from the plane engine or the parking garage of the airport or from the famed pollution I've heard so much about...but I think air filters will definitely be a must in our new home.

We are in a serviced apartment for now until our new home is ready for us to move into in a couple of weeks.

No homesickness yet, however, saying farewell is never easy, especially to family members. That familiar cliche: 'Home is where the Heart is' is so true. Although I have my husband & children with me, part of my heart will always be with my other family: parents, sister, brother, best friends.

I have been nursing a cold the last couple of days, something I picked up during our last few days in warmer climes (no, one doesn't catch cold from, cold weather, thank you very much!). The dryness & cold here don't help my symptoms a lot, making my nasal & throat passages feel terribly uncomfortable especially compounded by taking antihistamines to stop the continuous sneezing & nasal discharges. Been trying to load up on fluids too - no need for silica gel here (humidifiers will be another must-have in our new home).

Hence my present entry at the unearthly hours of 5 a.m. in the morning...having been woken up by a very dry mouth (having to breathe through my mouth since my nasal passages are clogged up) & mild attack of asthma. No worries, I am fine - nothing that 4 mg of Ventolin can't fix. My good ol' trusty medicine pouch has served me well; it's something I always travel with - my own form of personal insurance, one may call it.

Ok, I am going to go read a bit, & allow the Ventolin to kick in & hopefully go back to sleep for a few more hours .

Weather aside, my first impression of BJ has been a good one - the people seem to be warm & friendly, very willing to help, and with customer service that beats Singapore. It has made this alien feel very welcome.

More later.

Happy Holidays

Hijacking my husband's laptop to wish everyone a happy Christmas, & happy 2007!

Zai4 Jian4*

*

Chinese for farewell




Well, my trusty ol' computer will be lovingly packed away tonight by my husband in preparation for our move.

I will continue blogging when/if I can during the interim. Once we are settled, I hope to write about the trials & tribulations & hopefully, joys of life in China as an "alien".

Ouch

Oooooh....I feel a tidal wave of reactions coming in response to this letter in today's Straits Times:

"Dec 14, 2006
'Hua Yu cool'? No, boorish Mandarin-speaking youths spoil the image

I can attest that Mr Peter Donkin's observations of young Singaporeans are true. I have many negative opinions of young Singaporeans too, despite being a youth myself.

My observations of inconsiderate behaviour among young Singaporeans almost always involve the Mandarin-speakers. While not implying that all Mandarin-speaking youths are rotten (nor are all English-speaking youth angels), an overwhelmingly large group of offenders are observed to be from this group.

This seems to stem from the Chinese school of thought which advocates 'If I don't take, I lose out' and 'If others can do it, so can I, otherwise I lose out', among other factors.

Before anyone takes offence at my discrimination, go on a MRT ride across the island first, and my theory will come to life.

On a train ride from Jurong East to City Hall last month, I saw three groups of Mandarin-speaking youths huddled with their handphones playing Chinese songs at full blast.

The three groups were in the same cabin. It was terrible. One couple left the cabin for another because they couldn't take the racket.

Many people glared at the youths. A girl from one of the groups declared in Mandarin and English 'Wa, wo men hen attract attention leh!', which translates to 'Wow, we are attracting a lot of attention!'.

Was she thinking that people saw her group as 'cool' just because her handphone played MP3 music and they were the latest Mandopop hits? I was outraged at the inconsiderate behavior.

The Mandarin-speaking Singaporean youths also seem to ignore rules that make the world an orderly place. For example, they ignore repeated reminders to keep to the left on escalators. They also ignore the markings that serve to allow passengers on trains to alight first.

A Malaysian classmate who recently visited Thailand spoke of how gracious the people there were, and their good etiquette on the train.

Step into a shop and you will notice that the Mandarin-speakers are rude to service staff and they never say 'please' or 'thank you'.

Based on their interactions with my peers, they take offence easily,

yet they have no qualms about being sarcastic and rude to foreign teachers.

Many young litterbugs are also Mandarin-speaking youths. When I visited Melbourne some months back, I was greatly impressed at the clean streets. I saw everyone putting their litter into bins, and there were no cleaners around.
While many Mandarin-speaking youths are nice on a personal level, their mentality can manifest the antisocial behaviour that I have mentioned.

My friends and I belong to the minority English-speaking

group and we are ashamed to speak in Mandarin in public. No, we are not elites, just normal teenagers.

Unless the association of bad behaviour with Mandarin-speaking youths can be negated, 'Hua Yu Cool' isn't going to work on us anytime soon.

Ang Lixing"

A rather unfair generalisation on the part of Ms Ang, I feel. There are boors in all segments of society, no matter what language they speak.

However, I must say that this boorish behaviour she describes is becoming more prevalent locally. It's the Me generation - forget about proper & appropriate CIVILISED behaviour.

Pity.

Supermom

There is a loud resounding silence as far as response to this letter is concerned.

Dec 2, 2006
Mothers deserve more support from Govt

I READ the articles under the heading, 'Disparate housewives' (The Sunday Times, Nov 26), with much interest.

I am a housewife by choice, having previously worked as sales support manager for a US-China joint venture after completing my Master of Science degree. I also have an MBA.

When our first son was born nine years ago, my husband and I decided that I would give up my career to be a full-time mother/housewife. This decision drew sneers from well-meaning relatives and friends, while my parents thought I was wasting my education and talents.

We now have four lovely children. Motherhood is truly a sacrificial and demanding task but I have no regrets. No childcare service can replace the mother. Mother is often the best caregiver and teacher.

However, what bothered me is the inconsistency in government policy. When I applied recently for permanent residency for my parents, the Immigration and Checkpoints Authority (ICA) rejected my application with the statement, 'You may wish to submit another application for our consideration after you are gainfully employed for a period of time.'

Does the Government think that full-time mothers are not gainfully employed? As reported, stay-at-home mothers/housewives contributed approximately 8 per cent of Singapore's GDP, not counting the long-term impact on Singapore's future. This has been clearly documented in academic-research finding after finding worldwide, including Nanyang Technological University Associate Professor Euston Quah's findings, as was also reported.

Since around 1999, the Government has been actively encouraging Singaporeans to have more babies, offering baby bonuses and tax rebates in the face of a declining and fast-ageing indigenous population.

While one can understand the Government's wish at the same time to encourage mothers to return to the workforce, a policy conflict-of-interests and dilemma is inadvertently created.

The future of Singapore is in mothers' hands. It takes commitment, patience and, above all, sacrificial love to nurture children, for the future of the country.

The letter I received from ICA was a true dampener. Should not mothers deserve more support and understanding from the Government?

He Ruo Fan (Ms)"

I guess one of the spin doctors in ICA is trying to craft a response that

a) empathises with Ms He's sentiments that SAHM's are important in the process of child-rearing;
b) will support the Government's call to have more babies;
c) calls for more companies to be more pro-family so that more SAHM's can return to work at least part-time (like being a mother is not work???);
d) will also support the Government's call for women to return to the workforce.

Maybe the silence from the general public is because many Singaporeans feel that housewives/full time moms don't really have a job? Forget about the night calls (i.e. night feeds/diaper changes for infants), nursing (i.e.sick child/sick husband), chaffeur (i.e. driving kids to/from school & activities), housekeeper (i.e. housework), accountant (i.e. keeping track of household accounts & making sure bills are paid), cook (self-explanatory), teacher (i.e. reading to kids/revision/helping them with assessments), COO (of the household). Oh, and also you cannot take MC as no one will be able to take over your duties, and also no vacation days either, for the most part.

Friendship

As the date of our departure encroaches, I find myself reflecting on what Friendship is, & how hard it is to find True Friends. In our new home in a foreign country, making friends is something I think of with some trepidation. Will it be easy? When one is far away from one's extended family, friends are such important & valuable commodities to have.

"Friends are relatives you can choose." I heard this somewhere that I can't recall at the moment. How true it is though. True friends are hard to come by. In my lifetime (so far), I have met so many different kinds of people & made different kinds of friends.

True Friends
These are the ones I have known from childhood or college. There are a couple whom I met as an adult, & despite being separated by continents, still consider ourselves dear friends. These are people whom I can share comfortable silences with - no need for small talk.

Good Friends
These are friends whom I feel comfortable chatting with, & who have gone through similar experiences (eg. Medical school classmates). When we meet, there are no awkward silences; we eagerly catch up with each other's lives & occasionally organise get-togethers to maintain this friendship.

Social Friends
These are the ones whom I may meet at various social gatherings or school functions. We may smile & nod at each other, then, if we happen to be seated next to each other at the table, are able to strike up a fairly interesting conversation about common topics like current affairs or the school system or medical cases (if they happen to be fellow doctors). Apart from these events, we would probably never see each other ever again.

It's a mystery to me how a friendship forms. Why is it that Person A can become one's closest friend while Person B, who may exactly the same interests as you, can not?

When I first moved away from Singapore to the US, I was petrified that I would be alienated, being a foreigner & all. This proved to be unfounded fears as I found a group of people in my neighbourhood who eventually became my Good Friends.

Returning here, I thought that I would be able to make more new friends, this being my home country after all. My True Friends have, needless to say, remained close, & we literally picked up where we left off. I also resumed contact with some Good Friends & made a few new Good & Social Friends along the way.

However, making new friends hasn't been as easy as I thought. Neighbours here tend to keep to themselves (at least the ones that I have had). At work, my life experiences although enriching, have made me into a strange amalgamation of being a local with a foreign "twist". In my kids' school, where foreign parents are abundant, I realised that befriending some of them is not as easy as it looks, as people still tend to be cliquish when they are in a foreign community...which leaves me sandwiched somewhere between the "locals" & the "foreigners". Plenty of Social Friends to be had, but hard to find Good Friends; & True Friends?....virtually impossible.

So I hope that in our new adventure in China, there will be more Good Friends to be made. If I am lucky, I may even find a True Friend.

A chocolate a day keeps the doctor away

Good news for fellow chocolate lovers out there!

This article from Medscape shows promising results that eating chocolate may have the same effect as taking an aspirin a day!

"Chocolate Has Antithrombotic Effects Similar to Aspirin"
Martha Kerr

November 17, 2006 (Chicago) — Subjects enrolled in the Genetic Study of Aspirin Responsiveness (GeneSTAR) inadvertently helped Johns Hopkins University researchers measure chocolate's inhibition of platelet function and show that eating chocolate slows clotting time. The findings may explain how chocolate and cocoa-containing foods exert a cardioprotective effect.

A group of 139 healthy individuals did not eliminate chocolate from their diet.

Senior investigator Nauder Faraday, MD, associate professor of anesthesia and critical care medicine at Johns Hopkins University in Baltimore, Maryland, told Medscape that "chocolate was just one of those things this group couldn't give up."

The subjects were ejected from GeneSTAR proper and were not randomized in the aspirin assessment phase of the study. But Dr. Faraday and colleagues took advantage of the subjects' noncompliance to assess chocolate's previously demonstrated role in cardiovascular risk reduction, using the same platelet function analyzer test employed in the GeneSTAR study.

The investigators measured agonist-induced platelet activation in the presence of shear and calculated time to closure in the system by a platelet plug. Platelet activation was also assessed on urinary excretion.

Chocolate consumption caused a significant increase in time to closure, but remained within the normal range, the investigators announced here this week at the American Heart Association 2006 Scientific Sessions.

"Chocolate, even in small amounts, was an independent factor in inhibition of platelet activation," Dr. Naraday said. It extended closure time, regardless of age, sex, smoking status, body mass index, systolic blood pressure, total cholesterol level, fibrinogen levels, or von Willebrand factor.

"The magnitude of the effect was quite small," Dr. Naraday emphasized. Chocolate had the same type of effect as aspirin, but by a factor of 5 to 10 times less, according to the assay used in the GeneSTAR study, he said.

Elliott Antman, MD, professor of medicine at Harvard University in Cambridge, Masssachusetts, told Medscape that he found the results intriguing. "It might help explain the tremendous variability among patients to platelet inhibition, particularly as seen in response to aspirin."

Dr. Naraday pointed out that "any time you shift the balance away from thrombosis, you set up a situation with the potential for increased bleeding time and other risks, but I don't think this is a big problem with eating chocolate!"

Dr. Faraday's study is funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Dr. Antman reports no relevant financial relationships.

AHA Scientific Sessions 2006: Abstract 4101. Presented November 14, 2006.

On Mediation Again

I wrote an entry about Mediation May 25th this year titled On Mediation. I was very skeptical about the workability of such a process here at that point of time.

In today's Today Online, this process is outlined & will come into effect next year. I think it is a good first step to take in trying to tackle the increasing numbers of complaints lodged against medical practitioners & healthcare institutions.


Now doctors can say 'sorry'

A freer, less painful approach to medical negligence cases

Loh Chee Kong
cheekong@mediacorp.com.sg

EARLY last year, Mr Surender Singh's wife died after she donated one of her kidneys to him. He still doesn't know why. He hasn't heard an explanation or an apology from the doctors concerned. The hospital is being fronted only by its lawyers — and for good reason.

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When something goes wrong, doctors worry that anything they say might be used against them in court, said lawyer Amolat Singh, who represents Mr Surender Singh.

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Starting next year, an initiative by Chief Justice Chan Sek Keong could change the complexion of medical negligence cases. All parties can meet before a case begins; patients or their relatives can find out exactly what happened; and, if necessary, doctors can say sorry.

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More importantly, everyone can speak freely, because the information exchanged cannot be used in court.

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In fact, experts said that if the move takes off, there could be less need to go to court at all. The air of mistrust can be cleared, and if an honest mistake has been made, the matter can be settled without relying on expensive litigation.

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Under this new protocol, once someone has paid a fee of between $75 and $100 for his medical documents, he should get a response from the hospitals and doctors within six weeks.

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After that, a face-to-face meeting can be arranged within two months.

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An average of nine medical negligence suits have been filed here each year since 1998. Most get settled at the Subordinate Courts' Primary Dispute Resolution Centre without going to trial.

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The new "open disclosure" policy could ease the pain further. Eventually, said Subordinate Courts Registrar Toh Han Li, it might even be applied to cases in the High Court, which hears civil suits involving claims of more than $250,000.

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Both doctors and patients could gain. More understanding — and fewer cases going to court — could bring down premiums on insurance policies for doctors and lower medical costs.

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Patients also know how hard it is to prove outright medical negligence. One of the last notable cases where a patient sued successfully was in 2001, when a botched operation shrank an American national's testicles to the size of a child's.

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Some patients get unnerved by high legal fees, while others find it difficult to find a medical expert to testify against his peers, said lawyer Peter Low.

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Doctors, caught in a legal tangle, get equally frustrated.

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Said Dr Chong Yeh Woei, a general practitioner: "When you get involved in a legal process, the first thing you do is to consult your lawyers and do what they tell you to.

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"You might want to say sorry — and sometimes, it's all the other party wants. But by saying sorry, you are admitting liability and guilt."

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Or, as Dr Melanie Billings-Yun, a consultant in conflict resolution, put it in her February lecture to a roomful of Subordinate Courts officials: "The adversarial system is based on faults. But in 80 to 85 per cent of malpractice cases, there is no fault to be found.

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"If doctors are forced by their lawyers or insurance companies to treat every adverse outcome as a dirty secret, is a patient or his family being unreasonable to imagine that fault must indeed lie behind a stone wall of silence?

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"With an open disclosure policy, doctors and nurses will no longer be made to hide as if they were criminals ... more importantly, they will find that their words have the power to heal their own wounds."

Loh Chee Kong
cheekong@mediacorp.com.sg

However, I am still skeptical as to how long it will take for the mindset of doctors & patients to change from one of blame & shame to one of openess & mutual understanding. As doctors, we have been so afraid of being open to admitting to mistakes because of the fear of litigation that I wonder how long it will take for us to embrace this new process.

And in addition, within our own community, this punitive culture is still prevalent enough to prevent most of us from owning up to honest mistakes. How many of us have, as junior doctors, been made to feel absolutely fearful & ashamed by our seniors when they belittle us for our lack of knowledge or skill?

Yup, this is a good first step. But I still see a rather long flight of stairs ahead of us...

Bizarro

Been getting really strange dreams this past week or so, possibly due to my subconscious mind reacting to the stress of the impending move.

Last week, I dreamt that my sister was married to Hugh Jackman! Not withstanding the fact that Hugh "Hottie" Jackman is already married, I really really really REALLY cannot imagine my sister falling for him. I do admit that in my dream, I was a trifle jealous (married woman that I am, I confess to a little crush on this hunk of a dude). The fact that I watched "Happy Feet" (in which HJ did the voice of Memphis, & was the first time I had heard him singing - lovely voice - wish I could have caught him on Broadway doing "The Boy From Oz"...but now I digress) last week probably contributed to the generation of this dream.

Then last night, I dreamt that I (Mary Jane Parker) went on some kind of weird vacation with Peter Parker (aka you-know-who) at this dumpy little motel located in what felt like a really bad part of LA. Every corner we went, there were these Hispanic gangs eyeing us, looking like they were about to attack us any minute....and dear old Peter refused to use his Spidey powers to intimidate these people!!! And I was quite upset by that. Bizarre. I think I have Spiderman on my mind after watching the latest trailer for Spiderman 3, which looks to be superb.

Maybe I am subconsciously calling for help from my superhero idols - Wolvie & Spidey - to help me pack & move house!!! Especially since my husband will be away for 2 weeks preceding the pack out, on a business trip & only arriving back here THE DAY BEFORE THE MOVERS COME!!!

Maybe tonight I'll dream of the whole X-Men team...

Organs For Sale?

There were two articles recently about kidney transplants.

The first was a heartwarming one about a 5 way swop of kidneys so that 5 needy patients with 5 willing but otherwise non-compatible donors, would be able to receive suitable kidneys. With the shortage of donors, this unconventional method of transplanting kidneys was a great success. Although it must have been a logistical nightmare, all came together with a resulting happy ending.

The second is about the legalisation of sales of kidneys in Iran. This is undeniably controversial. The question of ethics comes up. But if you were the patient, & had the means to pay for such a procedure, would you do so? Having said that, would this mean that only those who can afford it will get the kidneys they need while the poorer patients will have to wait till an available donor comes up, or till they die?

As doctors, our first response to such commercialisation of organ transplantation would most likely be that of disapproval. The idea of selling organs for money is a distasteful one. Whenever money comes into play, there is always the chance that eventually, the bottom line will become more important than the patient's health (IMHO, this is already happening - look at how aesthetic medicine is booming & how MHC's have affected the way medicine is practised).

But as humans, how do we condemn someone who only wants to live to see his/her children grow up & grow old with the one they love?

This is a complicated issue indeed, & something that we need to step back & look at from different perspectives...no easy answer to it.

Separation Anxiety

I think emotionally, I haven’t yet come to terms with the fact that we will be leaving Singapore in just over a month. I’ve been so busy taking care of the practical side of things like arranging moving dates, selling stuff etc. that I really haven’t had time to ruminate over what this move will mean.

This will not be the first time that I am moving away. Fourteen years ago, we left this island with an infant in tow. I was too excited about living in a new place & meeting new people to really be overcome with any kind of sadness over leaving. Definitely I missed my family & friends. But I was too busy with having to take care of a young child, & settling down to wallow in any form of misery (not that I am the wallowing kind in the first place!)

This time around, both my kids are more independent & don’t need round the clock care like 14 years ago (!!!). I will have more time to myself, since domestic help is readily available in China. I certainly don’t plan to immerse myself in self-pity. I hear that expats there make friends more easily than here in Singapore, for some reason. Hopefully that will prove to be true, as I find that the older I get, the harder it is to establish firm friendships like the kind that endures since childhood or college. That kind of comfort level where you can meet each other & feel immediately at home even though you have been apart for a number of years…that is the kind of intimacy that close & old friends share that is hard to capture in new friendships.

I know for sure that I will miss being able to visit with my parents/siblings/best friends when I feel like it. And I will miss the fluid efficiency of the way things are run here (despite our frequent complaining!), not to mention local hawker fare.

But with technology, Mom/Dad/Sis/Bro are just a phone or Skype call away, we can even use the webcam to have face-to-face conversations without having to worry about long distance phone bills. And a six hour flight is not that far away for one to visit or be visited by family.

busy, busy, busy

please excuse my absence. it's been a busy week, including a rockappella concert, and a short trip up to kl to attend a wedding of the son of an old friend of my mom's. talk about lifestyles of the rich & famous...this wedding was the wedding of the year in malaysia (imho). even the agung (king of malaysia, for the uninformed) attended. blessing ceremony by the lakeside; goody bags with amazing pressies for all the guests; carnival-like entertainment with magician, jugglers, pretty girls with pythons draped around their necks & parrot/parakeet on their fingers; hired band from singapore; beautifully made videos of the couple's love story (this beats, hands down, the usual slideshows played to cheesy romantic love songs that one sees at the "normal" wedding dinners) including the proposal video involving a mini cooper...you had to see it to believe it.

of course, no trip to kl is complete without the ritual rounds of yummy hawker food (wantan mee, char kuay teow, mee yoke, chee cheong fun, hokkien mee all cooked in ways unique to kl)...i think my arteries are semi clogged from all the cholesterol i ingested over 3 days!!!

now that i am back, it's back to the overwhelming task of preparing for the move. add to the list of things to do(refer previous entry):

1. choose furniture for housing (not easily done with pictures sent via email)
2. get influenza shots for family (hep a & typhoid already done; don't think we are at risk for jap encephalitis nor rabies so will pass on that for now...will have to warn kids to stay away from stray animals & rabid looking humans!)
   
3. get vital medical checkups done before leaving (ladies above 40, don't forget your annual mammograms!)
4. sell furniture that we are not bringing with us (almost done - surprisingly, lots of takers for 2nd hand stuff)
   
5. finish christmas shopping

add to this the 2 final locum sessions that i had earlier committed too, & you have one pretty busy lady. i didn't want to call the hiring doctor to say that i can't do the sessions, knowing that it's the school hols now & locums are in demand (especially lady ones)...ah well....i'll survive.


note: no caps in this entry - quite liberating. maybe i should try no punctuations one day, but then it would probably be too hard to read. :)

Aliendoc's Things To Do Before We Move

1. Sell home - check
2. Sell car
3. Decide what belongings to ship to new home
4. Decide what belongings to sell
5. Decide what to put in storage
6. Buy winter clothing for kids (IMPORTANT!)
7. Forward mail to either mother or sister’s address
8. Change address of credit cards/banks etc
9. Terminate some credit card accounts
10. Inform SMC of move - check

As can be seen only 2 out of the top 10 things to do before we move have been checked off. Which means that I STILL HAVE A LOT TO TAKE CARE OFF!!!

AAAARRGGGHHH!!!!!

On Being Parents

A couple of days ago, a toddler’s big toe was ripped off when it got caught on the side of an escalator. She was wearing rubber clogs (you know, the one that is damn ugly but damn comfortable). It was highlighted that these clogs are very pliable & hence would get caught & pulled into the gap between the side of the escalator & the step.

Hopefully, the clogs won’t be made the scapegoat of this kind of accidents. If you think about it reasonably, it would be quite difficult to edge your foot to the side of the escalator so that it would get caught. But knowing children, they have a propensity to stick things where they don’t belong. I have had to, on many occasions during my A & E posting, extract a variety of foreign objects from various orifices in the head of a number of children.

My point is this: an adult (usually the parent) is supposed to supervise the behavior of children, especially those under the age of 5. They are supposed to teach them that certain actions are dangerous, and that certain kinds of behavior are unacceptable in civilized society. They are supposed to teach them how to do certain things like crossing the road, going up & down stairs, going up & down escalators. Obviously, we don’t expect the kids to pick up on the safe way of doing these things immediately. You would expect the adult to hold the child’s hand, for example, while crossing the street (I still try to do that to my 12 year old, to his chagrin ☺). You would expect the adult to watch the child & admonish him if necessary, if the kid starts misbehaving on an escalator (like trying to stick his/her foot into the crevice between the step & the side…I don’t know if this actually happened in the above mentioned case, but it could have).


Parenthood is a full-time job. You need vigilance, care, and attention on top of TLC. It’s easy to love a child (especially your own☺!) but it is hard to keep them safe 24/7.

When my kids were little, I had child-proof locks on all my kitchen cabinets/drawers; child-proof covers on the knobs of the stove; a plastic shield attached to the front of my stove to prevent inquisitive fingers from reaching up & pulling a pot of boiling liquid on top of his head; child-proof gates preventing the kids from getting into the kitchen while Mommy was cooking (no maid while living in the US – I survived ☺); child-proof gates on the bottom AND top of the staircase, bumpers on the corners of my coffee table to prevent accidental bumps & scalp lacerations.

Whenever we ate out, I automatically would move breakable crockery or glasses full of liquid or hot dishes out of reach of grasping hands…I still do this if I happen to be dining in the company of small children!

Locally, many children are being looked after by domestic helpers. I think many parents become very lackadaisical when the time comes that they have to take care of their own child (eg. on the maid’s day off). They need to wake up, step up to the plate & take responsibility, not only for keeping their children safe, but also in teaching them how not to behave like hooligans.

“I yam what I yam!” (from Popeye the sailorman)

I read a report in the newspaper today about a 16 year old boy, D., who was convicted of robbery & given a 5 year jail sentence with 24 strokes of the cane (which is the maximum allowable). He had previously been sent to a juvenile facility for “reformative training”. D. himself shouted at the judge during his trial, threatening him & saying that this training was useless & that he should be sent to jail instead.

At first glance, the picture of this boy shows a typical face of a teenager. But look closely at his eyes & you see the vacuous expression, almost bereft of emotion. Who was it that said, “The eyes are windows into the soul”? How true.

This boy (yes, I consider him a child) is only 2 years older than my elder son. He started off in life with less than desirable circumstances - parents divorced, with dad apparently abandoning the family when he was just an infant. He is supposedly of below average intelligence as well – he has been faced with so many disadvantages in life already, I guess we shouldn’t be surprised with the outcome.


We are the result of our life experiences. As individual beings, we start off as a mass of organic material, with certain genetically pre-determined qualities. However, how these “lumps of clay” are shaped & what the end result is, is due to a complex interplay of factors including parental influence, family relationships, environmental push & shove and to a small degree, sheer luck.

Many of our neuroses stem from these factors. Whether we have been nurtured or battered by these childhood experiences & familial relationships, will determine whether that lump of clay will turn out to be a work of art, or just a rock to be hidden out of sight. I believe that all of us have, to varying degrees, dysfunctional families. If severe, this would express itself as neuroses. I would be the first to admit that I have issues to work out, all stemming from the factors listed above. However, I don’t think I am neurotic (yet…although it is probably matter of opinion, depending on whom you ask!).

It is sad that D. ended up where he is now in his short life. The African proverb “It takes a village to raise a child”, made famous by Hilary Clinton, is so true.

I guess D.’s village failed him.

Snapshots from Beijing

We managed to find some time to take in some sights in Beijing while we were there, in between looking at houses & schools. Here are a few of the more interesting shots:


External View of the Forbidden City
Some of the buildings inside were closed off for repairs. A bit disappointing.




Square inside the Forbidden City
Notice the worn out stones on the floor. Looks familiar? I think I saw it (or a facsimile) in a Jackie Chan or Jet Li movie. Or in a trailer of a Chinese epic... Those stones have probably been there for hundreds of years. Uneven & bumpy, could be hazardous for walking if you are not careful.




Speaks for itself!
The place to go to broaden your mind & expand your horizons!




East meets West, Old meets New
Want a cuppa Java? How about a Heineken? All available in the Forbidden City!




Ad on Bus Stop
This was an honest to God, true blue ad seen on the back of a bus stop along a busy street in downtown Beijing! I did a double take when I saw it. I guess this is the place to go if you want to become sterile? Looking at the Chinese words, I think it's for abortions & contraception (Chinese experts out there, jump in here to correct me if I am wrong).




Snacking in Beijing
Seahorse? Starfish? Bugs? Worms? How about live spiders (not in picture)?
I think I'll stick to satay or french fries, thank you very much. :P

Scoop

After reading the mixed reviews received by this Woody Allen movie, I decided to go ahead & watch it anyway (OK, OK, I admit it...Hugh Jackson was a BIG draw for me ☺), & managed to convince my guys to come along with me.

We watched it at the new mega-movie theatre at the spanking new mall called Vivocity (we're still trying to decide whether to pronounce it as Vi-VOc-i-ty -which rhymes with velocity- or Vi-VOH-City - derived from the Latin word "vivo" meaning life, I think).

I'm glad we did watch it, although it didn't blow me away. It showed my kids that comedy needn't always be the slapstick & pie-in-my-face kind that is typical of Jim Carrey and the SNL alumni like Adam Sandler, Rob Schneider & Mike Myers.

The dialog was, well, typically Woody Allen-esque, with witty comebacks & self-deprecating humor although Mr Allen's frequent stuttering (whether intentional or not) got a bit stale & annoying after a while. Scarlett Johanssen showed her versatility with her portrayal of eager, naive journalism student, Sandra Pransky, hot on the heels of her first scoop. Hugh Jackman didn't really shine here, although he looked mighty fine in Speedos (*GRIN*).

Sidenote: we were very impressed with the movie theatre. We were in Cinema Europa which is supposed to have a bigger screen, & allow movie-goers to enjoy the movie in an elegant & intimate setting. It was indeed very comfortable, & more "high class" than the regular theatres (tickets DID cost $1 more); but I wished that the seats could have reclined a bit more.
Sigh...which reminds me that I AM going to miss movie-going when we are in China...

Oh, & by the way, my kids actually enjoyed the movie & found it funny! I guess they are smarter than I think...heeheehee...

EEEWWW!!!

I came across this article on Medscape to which I subscribe. My very vivid imagination conjured up images I would have rather not imagined as I read it...ugh...read on, if you dare...

Circumcision, Religious Freedom, and Herpes Infections in New York City
Posted 10/17/2006
Howard Markel, MD, PhD

If you ever find yourself in the coffee line at a medical conference, be prepared to eavesdrop on a gaggle of doctors exchanging the medical equivalent of "war stories," wild tales of clinical misadventures and treatment plans gone awry. It was precisely at such a venue that I heard what easily qualifies as one of the strangest — and scariest — medical tale of recent times.

It actually began in 2004 when the New York City Department of Health received reports of 3 newborn, male babies who contracted herpes simplex virus (HSV-1). All of them required weeks of hospital care and intravenous injections of powerful antiviral medication. Tragically, one of them died from the infection.

Unlike a mere cold sore or an embarrassing, painful crop of genital blisters, herpes for a newborn is truly a life-and-death matter. Aggressive and relentless, the herpes virus can destroy an infant's brain in a matter of days. Every pediatrician who notices any type of blister on a newborn's body shudders as he contemplates whether its cause is merely an abrasive blanket or, far worse, a harbinger of a systemic infection with herpes.

But the story only gets stranger. Using a mixture of detective work and medical acumen, the New York City Department of Health figured out that all of these babies contracted herpes shortly after undergoing a ritual circumcision by the same mohel, the religious figure in the Jewish faith charged with conducting the ancient and spiritually important ceremony called a bris.

Under Jewish law, the mohel is required to draw blood from the circumcision site, ostensibly to remove what the Old Testament refers to as "impurities" and what we might interpret today as germs. The thought, back then, was that a flow of blood away from the circumcision site would carry these potentially dangerous entities away from the baby. But the traditional way to do this, a practice called Metzizah bi peh, calls for the mohel to use his mouth and suck out the blood.

To be sure, this peculiar means of viral spread remains rare. Nevertheless, there have been 11 cases of male babies who contracted herpes following circumcisions that included Metzizah bi peh reported over the past 5 years in New York, Canada, and Israel. In 2005, there were 4 infected babies in New York City and all of them were circumcised by the same New York-based mohel (who only recently was persuaded to take a prolonged vacation from his line of work).

According to Dr. Thomas Frieden, New York City's Commissioner of Health, coincidence is not an explanatory option. "There is no reasonable doubt that the practice of Metzizah bi peh has infected several infants in New York City with the herpes virus, including one child who has died and another who has evidence of brain damage," said Dr. Frieden.

Given that more than 70% of all adults 40 years of age or older are infected with the herpes simplex virus; that the mouth is the most common site of HSV-1 infection; and that most adults with oral herpes do not know whether they are infected, typically do not have symptoms, but can still spread the infection to others, one can begin to understand the potential public health problems associated with such a tradition.

Indeed, this is precisely why the Chief Rabbinate in Israel and the New York-based Rabbinical Council of America, which serves more than 1000 rabbis in the United States and Canada, began urging all mohels to avoid the potential spread of infection by using a tiny, sterile glass tube to draw the blood instead of putting their mouths directly on the circumcision wound. The overwhelming majority of mohels working today follow this interpretation of the custom.

Yet the ultra-Orthodox Hasidic Jewish community persists in adhering to ancient law precisely as it was written. That is, after all, what "orthodox" means. And despite the hedging and explaining by their less orthodox counterparts, Hasidic rabbis insist that performing the bris exactly as it was described in the Bible is essential to what it means to be Jewish.

So when the New York City Department of Health proposed a voluntary ban on the practice, the Hasidic community tersely told the government agency not to interfere in their religious beliefs or practices. Indeed, the ultra-Orthodox Hasidic community, one that has a great deal of political clout in New York City politics, has pledged to fight any health edicts restricting the ancient practice with the proverbial tooth and nail.

Even if such a law could be written, how would you enforce it? After all, the bris is almost always performed in the parents' home, out of the view of the health department or a police officer.

Certainly this means of contracting a deadly infection is rare. Only 7 cases of mohel-related herpes have been reported in New York since 1998, and each year there are 2000 to 4000 circumcisions performed in that city alone. But rare does not mean nonexistent. No one can deny that this practice presents a real and serious health risk.

Just as frightening, there have been reports of other Jewish parents who, while less exacting in their religious practices, hired ultra-Orthodox mohels without knowledge that they practiced the potentially risky Metzizah bi peh procedure.

Dr. Frieden, the same public health crusader who managed to get cigarettes banned from all public spaces in New York City, admits that negotiating the rocky shoals of this controversy represents the "most delicate issue I have had to deal with."

"My ideal would be to inform the community so that they stop doing this and a large part of the Jewish community has accepted it," Dr. Frieden explained to me in an interview. "But this issue is far from over and it is still going on among those who are most Orthodox. If it were simple, we would have dealt with it simply."

That's an understatement. It has been years since I studied Talmud, but I know what my Rabbi would have uttered in response to this quandary of Biblical proportions: "Oyyyy."

Howard Markel, MD, PhD, George E. Wantz Professor of the History of Medicine, Professor of Pediatrics and Communicable Diseases, Director of the Center for the History of Medicine, University of Michigan, Ann Arbor; author of When Germs Travel: Six Major Epidemics and the Fears They Have Unleashed (Pantheon Books)

Disclosure: Howard Markel, MD, PhD, has disclosed no relevant financial relationships.

Medscape Pediatrics. 2006;8(2) ©2006 Medscape

Wanderlust (II)

I’ve always wanted to see & experience new places. When I was young, I used to imagine myself under the Big Sky of Montana, or enjoying the sea breeze on the Greek Isles, or skiing the slopes of the Alps. Perhaps it was a presage of what my life has become as an adult with my own family.

We’ve moved multiple times in the last decade and a half, two of those moves halfway across the globe. I consider myself a global citizen, my ideas, perceptions, & values having been shaped (& still being shaped) by diverse & varied life experiences. An old classmate from Medical School commented recently that I have had a somewhat unusual life, compared to the rest of my cohort.

I don’t think this kind of life is for everyone. I know a few of my closest friends are befuddled at how I can do what I do. But it’s not that strange or unusual a lifestyle after all. There is a small percentage of the people of the world who are quasi-nomadic in nature. Their jobs bring them to different parts of the world, often far & vastly different from their home country. Their families are relocated every few years. Previously, these were mainly military families who went where they were directed to go. Now, with the globalization of so many companies, businesses are expanding to places all over the world, sending their senior managers to these places to help run their organizations. And these employees bring along there spouses & kids to unfamiliar environs.

Their kids are known as third culture kids. One usually finds these children in international schools, getting to know kids in the same shoes, from other cultures & ethnicities. And because they don’t live in their home country, they develop a unique culture of their own, assimilating views & opinions from their international friends.

I don’t think I would consider my kids TCKs. Half their lives were spent in their passport country, while the other half in their mom’s passport country. And part of the latter was spent assimilated in a local school while the other part in an international school. Perhaps a more suitable term would be “Different Cultured Kids”. I am not sure how this will affect them as adults. With our impending move to China, doubts & fears of settling into & living in such a different country arise, especially for my children, as they have to make new friends & get used to a new school. Heck, I will have to make new friends as well!!! And make do with less English movies/books/TV programs (sigh).

Despite how daunting the move may be, what I am sure of is that ultimately, their experiences & my own, will be unique and enriching. At least, we will be able to learn proper Mandarin!

Driving you crazy

And I thought driving in Singapore was bad.

I literally feared for my life while traversing the streets of downtown Beijing as a passenger as well as a pedestrian. This is what I learnt about traffic in Beijing:

A) Pedestrians DO NOT have right of way, no matter what color the little man is on the traffic light. It’s survival of the fittest as far as crossing the road is concerned. It seems like you almost need to have a death wish or at least faith that The Force Is With You. Even the pavements are not safe – you may suddenly find yourself leaping out of the way of a cyclist who decides that the pavement is a quicker (& less risky) way to get to his destination.

B) Horns in China are activated when you depress the brakes (& I suspect the accelerator as well). You honk when you need to let your fellow motorists/errant pedestrians/cyclist know to “Watch out, I am coming”/”Get out of the way”/”Move, you idiot”.

C) Cyclists are an entity unto their own – they have their own traffic rules which basically states that anything goes as long as you don’t get knocked down or don’t knock down anybody else.


Thank God I don’t have to drive when we move there.

goodbye, old friend.

just when i thought i was all cried out,
the tears start to flow again
trying to fill the void in our lives.

goodbye, old friend.
go in peace.

In The News

Pg H3, HOME Section, The Straits Times, October 18, 2006
Dispute Mediation helps both patients and dentists – Patients avoid legal bills and dentists pay less for insurance

by Salma Khalik

Hmm.

I didn’t realize that the Singapore Dental Association’s Ethics Committee handles mediation in patient-dentist disputes.

I wonder why the Singapore Medical Association doesn’t have a committee to do the same? Or at least facilitate the formation of a committee to do the same. I, for one, know that it is sorely needed.


Pg 23, World News, The Straits Times, Oct 18, 2006
Fast Track to Citizenship: Join the US military

This is an article taken from Reuters.

I find it ironic that PRs/immigrants in the United States are literally dying to take up US citizenship while Singaporeans & PRs here try all ways & means to get out of doing NS, or at least, to get their PES rating downgraded.

So much for patriotism, eh? It’s no wonder that the ICS responded to a reader’s suggestion to allow dual citizenship with this letter:

Oct 14, 2006
Singapore not ready for dual citizenship

I REFER to the letter by Mr Bertrand Teo Ming Shan, 'Can ICA be flexible in dual citizenship case?' (ST, Sept 27).

Dual citizenship is a policy that has to be considered carefully and thoroughly.

We have yet to reach the stage of nationhood where a Singaporean with a second citizenship would still retain his identity and loyalty to Singapore as his homeland wherever he goes, with his second citizenship being only of secondary importance.

Lim Jing Jing (Ms)
Senior Public & Internal Communications Executive
Immigration & Checkpoints Authority


Pg 20, World News, The Straits Times, Oct 18, 2006
Disabled girl without a home.

This story is about a girl named Charlotte Wyatt who was born 3 months premature in October 2004. Her parents had fought in the courts to require that doctors provide artificial ventilation if her condition worsened. I guess they succeeded, because she is still alive, albeit with serious brain, lung & kidney damage. Her treatment apparently costs close to S$900 a day; she requires 3 litres of oxygen every minute; she is fed & medicated through a nasal tube. Her parents are now separated (apparently due to the strain of coping with this situation), & now, social workers are looking for foster parents to look after Charlotte as both mum & dad are unable to do so.

I had previously blogged about this issue of sustaining life at all costs as part of an earlier entry.

Is it worth it?


Live Cell Therapy???

And finally, I spotted an ad in the Mind Your Body section of the papers for an organization called Villa Medica Asia which is “one of the few approved clinics to administer the live cell therapy”. A google search revealed that indications for this therapy which involves injection of animal derived cellular material into the patient, includes a whole host of conditions, ranging from exhaustion to menopause to retarded development in children! Wow!

Hmm (again). I wonder how MOH/SMC/SMA will respond to this amazing & miraculous treatment.

Wanderlust (I)

We will pay a visit to our ancestral homeland this week, my husband, our sons & I. This is part of our preparation for our eventual move there…a reconnaissance, if you will. This will be the very first time that I will step foot into the Middle Kingdom. I have never felt any pull to this country before. Any interest I've ever had to visit comes from a sense of wanting to experience different cultures & lifestyles, rather than from a need to “find my roots”.

Years ago, our forefathers left this continent for foreign shores, either under threat of persecution, or to seek their fortunes. Some planned to return after they had made their fortune, while others planned to grow roots in their new home countries.

Those who did not return spawned generations who developed their own culture, some very different from that of their ancestors. There are those who say that this is a bad thing. I disagree, as I believe that culture is a dynamic organism, which evolves & changes with the times. It is part of progression. This is not to say that we should forget the achievements of all those who have gone before us. But we shouldn’t dwell on the past & hold on to old practices & beliefs just because they were what our ancestors did.

I know this will be an eye-opening experience for us. I think it will show how different, and yet how similar, we all are, as human beings. I said the same thing about what I learned while living in the USA. Some will think that I am being deliberately paradoxical, but I’m not. Honestly.

Medical Tourism

Looks like Singapore is not the only country outsourcing its medical services. Dr Parker blogs about this phenomenon happening in the USA, where healthcare costs are ridiculously high, thanks to high insurance premiums & (IMHO) high litigation rates.

Unsurprisingly, this is creating a lot of unhappiness in the medical community & the patient's union. Quality of care, medical liability & follow-up care, especially in the face of possible complications are issues which have been raised & understandably so.

This particular patient is supposed to go for rotator cuff surgery & cholecystectomy in India. He would also go sightseeing on a two day tour that includes a visit to the Taj Mahal. The cost of the operations would be only 1/5 of that in the USA - a huge savings for his employer. But question is: who is going to take care of him if he develops complications post-op? Will the American insurance company still cover him for any medical care received as a result of such complications?

I know of someone whose brother, suffering from renal failure & undergoing hemodialysis for the past 20 years, decided to travel to China for a kidney transplant. It cost him about $60,000. Apparently he was hospitalised for a week before being sent home. He did develop post-op infection & required ICU care. His original nephrologist here refused to manage this problem, & he had to seek treatment in a different hospital.

Now we all have heard of the dubiosity (is there such a word??) of organ transplants done in China, & how the origins of these organs are rather hazy. (From executed prisoners? Sold by someone in need of money?) But aside from that, is it ethical for a doctor to refuse to give treatment to a seriously ill patient, who developed complications from such a procedure? No, I say. We may disagree with the patient's decision to go through the procedure. But we should not punish the patient by making life harder for him after.

The medical communities in countries where healthcare costs are escalating have to examine all these questions ASAP. Outsourcing is NOT going to go away. Especially in a world where money talks the loudest in most cases.