Category: Travel

Speaking Truth to Power

On 4/18/22, a federal judge in Florida struck down the CDC requirement of wearing masks on trains, planes on domestic flights, and other public transportation. This came less than a week after the Centers for Disease Control extended the mask mandate through 5/3/22. Immediately a number of airlines, including Delta and Alaska, announced that they were removing the requirement.

She made this ruling before a hearing was held, and nationalized the ruling rather than limiting it to the plaintiffs who had filed the case. In addition the mandate was probably going to go away in 2 weeks in any case.

Who was this federal judge? It was Kathryn Kimball Mizelle, appointed for a lifetime position at the age of 33 by President Trump, despite that she had never tried a case, and the American Bar Association rated her as, “Not Qualified.”

Just because she had the power to make this ruling, doesn’t mean she’s right. Of course when it comes to the law, I’m even less qualified than this judge, but from a medical point of view, we’re still in a pandemic. I, for one, will continue to wear a mask in an airplane, at least for a while, even if it’s just to avoid the common cold.

What to Do After You’re Vaccinated for COVID-19

I recently received my second of two COVID-19 vaccinations, which happened to be from Pfizer/BioNTech. Although it’s a big relief, and I’m much better protected now, it doesn’t mean it will change much that I do for a while. Let me explain why.

Vaccines don’t act right away. The way they work is to prepare your immune system to recognize something that is bad for you, so if it arrives your body is ready to attack it. But it takes time to do this. Imagine you’re running a race and someone is trying to chase you down before you can cross the finish line to safety. The faster they are, the more head start you need. What makes a bacteria or virus faster, besides the basic nature of it, is how much of a head start it has, which is basically how much of it you’re exposed to. It’s an over simplification, but supposed the virus doubles every 6 hours and you initially breath in 10,000 virus particles. After 5 days you’d have about 10 billion of them. After one more day you’d have close to 168 billion, a massive increase. So you have to have enough of a head start that the virus can’t grow to the point of overwhelming you. Every day after your initial vaccination is that much more of a head start.

Another way to look at it is to imagine you body is a village and a company of hostile enemy soldiers shows up. They would quickly overrun and capture the place. But suppose these soldiers were not not yet nearby but you knew they might attack. You’d have time to enlist people to provide more security, train them what the enemy looks like, and set up additional lines of defense. Then if they were to attack it’s likely you’d successfully fend off the attack, though you might be a little worse for wear as a result. But if they attacked with a larger force, such as a battalion, they could still overwhelm you.

So you can think of getting a vaccine as giving you a greater head start, or having more bodyguards. That should protect you from most situations, but you still wouldn’t want to run the risk of getting a massive exposure, or perhaps being someone who didn’t develop a good response to the vaccine. So wearing a mask, maintaining distance, etc. all minimize the risk. We don’t know yet how much exposure it would take to actually get someone sick if they have been vaccinated with sufficient time to be fully effective, so my concern now is just theoretical, but there are other reasons to remain cautious, particularly until the number of cases in one’s community falls significantly.

For one thing, the vaccine was 95% effective in the studies. That’s impressive, but it still means 1 out of 20 were infected sufficiently to have symptoms. For another, we don’t know if vaccinated people can subsequently get infected and not have symptoms, but be capable of spreading it to others. Finally, people who have not yet been vaccinated may feel anxious, or resentful, seeing people who are not wearing masks.

Some of my patients have told me they are concerned about the vaccine, and some of have even decided they just won’t get it. Let me address some of the concerns. One worry is the vaccine was rushed and they don’t know if they can trust it. Although it was rushed, it was mainly from everyone working longer hours than usual, companies prioritizing the research and production, and governments willing to promise to buy vaccine before before approved, with the risk that they could have spent billions on something that would never be used. The FDA did approve it before having longer term studies than usual, but given the risk of not being vaccinated, it was the right thing to do.

Although sore arms and flu like symptoms are relatively common, particularly after the second dose, serious reactions are very rare. You shouldn’t look at the risk without considering the context. Without a vaccine you have a high chance of getting infected. Those infected have a relatively high risk of serious complications, including death, particularly if older, or have various medical conditions. Those at the lowest risk of getting COVID-19 or getting significantly sick, will be the last to get it the vaccine, which means they will have the benefit of there being more experience with it. Even if you are not worried for your yourself, getting vaccinated is good for the community. We need to get a high proportion of the country vaccinated to reach herd immunity so the virus can no longer take off. Unfortunately there have been a lot of misinformation spread about the coronavirus pandemic, and politicization about it, but that doesn’t mean that these are not excellent vaccines.

I’ll have to see what happens, but between having been vaccinated, and the pandemic probably being much better controlled, I hope that I’ll finally be able to take a real vacation by this fall.

First Thoughts on Coronavirus From a Primary Care Physician

Young girl wetting hands in fountain in Stockholm, Sweden.

The coronavirus infection COVID-19 has spread from Wuhan, China to my backyard in the Seattle area. I experienced firsthand the impact of this infection while on vacation in Hawaii over two weeks ago. The day after arriving in Honolulu, and just before traveling to Hawaii, a report came out that a Japanese tourist had been in Maui, then felt ill after arriving in Honolulu, then was diagnosed after returning to Japan. I started to see people wear masks, and friends who live there wanted to meet in a park for a picnic rather than go to a restaurant as a result.

To date 6 people in Washington State have died from COVID-19, which makes people, including healthcare workers, more nervous. We’ve already had several meetings to discuss how we will manage things. Things are still being worked out, and there are still a lot of unknowns.

As healthcare workers we are concerned about patients infecting us (and if we get sick, who will care for the patients?), or other patients. It’s a balance between asking patients not to come in if sick, and not wanting to miss other causes. It’s still flu season, and someone with a cough and fever is still more likely to have influenza then COVID-19. There are also other viruses, as well as bacterial infections that can cause pneumonia and need to be treated.

As the CDC says, the most important thing is hand washing. It’s important to not touch your face, which we tend to do often, myself included. I’ve started applying moisturizer lotion each morning as dry skin tends to itch more, which leads to touching the face more often.

I just saw a patient for hypertension and needed to start him on a medication. There are lots of choices, but for various reasons I usually start with an ACE inhibitor, such as lisinopril. That’s what I ended up prescribing, but I had second thoughts as the most common side effect is cough and I worried that people might think he had coronavirus if he developed a cough. I consider an angiotensin renin blocker, such as losartan or valsartan, but there have been frequent shortages of that class lately due to chemical contamination issues leading to recalls.

There will be lots of other things to consider as things progress. In the meantime, don’t panic, but wash your hands often. Don’t wear a mask if you’re not sick or around someone who is (it probably doesn’t help, and we need to make sure we don’t run out for those who really need it), and don’t touch your face!

Drawing Lessons From a Disaster

Three days ago an engine explosion on Southwestern Airlines Flight 1380 caused a sudden cabin depressurization. Oxygen masks dropped as designed, but as reported by the New York Times, photos showed that many people had the mask over just their mouth, and not the nose and mouth as instructed. The conclusion? Passengers didn’t pay enough attention to safety instructions.

Although that is probably true, I don’t think reminding people to pay attention is really the answer.  As a physician, I have to re-certify in CPR every year. It’s not just the knowledge, it’s practicing it and getting muscle memory. Even with that, my skills surely deteriorate as I rarely have to do CPR now, and practice makes perfect. The key point is that passengers don’t get to practice. If you’ve ever taken a cruise, you know that shortly after you board, they have you actually go your assembly point and actually don a life vest. They don’t have you watch someone put on a vest, and they don’t point to where you should go.

As a medical student in the Air Force, I had the opportunity to take altitude chamber training. This is where you are in a chamber where the oxygen and pressure simulates being at high altitude, such as 25,000 feet. You then take off your oxygen mask to learn how you are affected by hypoxia (low oxygen). You are supposed to observe a few of the effects, then put your mask back on. I remember noticing some of the changes with curiosity, then someone tapping on my shoulder and telling me I had passed out. When I told him I hadn’t, he asked me who put my mask back on. At that point I realized that I had passed out, and it drove home the point of why they tell you to put the mask on yourself first, before helping your kids or anyone else. Otherwise you may pass out, then you are not in a position to help anyone else.

The article quoted a retired flight attendant as saying it didn’t matter that people didn’t have the mask over their nose as they could breath through the mouth. Although that’s true, that doesn’t mean they necessarily did. Many people breath through their nose most of the time, and in a high stress situation they may not necessarily realize that the mask is not covering their nose, or if they do, that they should breath through the mouth.  A better option might be to make the masks shaped more like a mask designed to cover the mouth and nose. You know, kind of oval shaped, not a circle.

It certainly not possible to put everyone who flies on commercial planes through altitude chamber training, but actually practicing putting on a mask would make people more proficient if they needed to do so in an emergency. On an airplane it may not be practical to do so because of the need to clean the masks, but in the terminal they could put booths where people could practice putting on masks, that could be cleaned and reused, and life jackets  to practice putting on, all while waiting for their flight. They could encourage participation by giving people who do so coupons for a snack or to be eligible to win a prize each flight.

Politicians Playing Doctor

Recently the British baby Charlie Gard has been in the news. Unfortunately he was born with a rare disorder called Infantile Onset Encephalomyopathic Mitochondrial DNA Depletion Syndrome. The parents of the 11-month-old boy have been in a court battle with the London Hospital caring for him since October. The hospital obtained a court order to remove the boy from life support as the doctors treating him said his condition was terminal and that treatment would just cause the boy additional distress.

The parents have held up hope for an experimental treatment with nucleosides a U.S. doctor has offered, even though he had not examined the patient. In fact no person or animal with Charlie’s condition had ever received the treatment. Reportedly 9 patients with a related disease had some improvement with the treatment.

President Trump weighed in:

Recently Republican House Congressmen Brad Wenstrup (Ohio) and Trent Franks (Arizona) said they would introduce a bill to give Charlie permanent residency in the United States so he can travel for the experimental therapy.

I sympathize with the parents. It’s awful to see your children with serious illness. However sometimes stopping care really is the best thing to do. The US doctor reportedly said a 10% improvement in strength was possible. But that’s the same as saying you can go from lifting 10 lbs to being able to lift 11 lbs. It’s just not going to make a significant difference.

I also believe in research studies. In fact close to 20 years ago I had a patient with a different neurological disorder who could not be removed from a ventilator. I received FDA approval to administer an experimental treatment. It may have helped – they did get off the ventilator, but they died not that much later. That drug had preliminary treatments in animals, then in humans.

If our politicians were really that concerned about the health of an infant in another country, maybe they would accept refugees from countries such as Syria, where innocent people have been in terrible conditions. Their chances of improvement would practically be guaranteed. Unfortunately for Charlie, that’s just not realistic.

Exploring Cuba – Part 2

In my prior post, I discussed a trip I made to Cuba in December. In this second part I will focus on some medical aspects.

When my patients ask about foreign travel where there may be health concerns, I usually direct them to the CDC site. It’s also where I go to check for my own travel, though I look at the more detailed Clinician view.  To start off it recommends typhoid vaccination.  You have a choice of the oral or injected. The oral is a live virus that is taken every other day for 4 doses, starting 12 days before potential exposure. It gives better immunity, but should not be taken by people with a suppressed immune system, such as those on steroids. The injected form is a non-live vaccine, a single injection taken at least 2 weeks before potential exposure. The injected form is harder to find, and even pharmacies that carry it may need to order it in advance. The injection is more expensive, and neither vaccine is usually covered by one’s health insurance. There are other vaccines recommended, but typhoid was the only one I needed.

Cuba has mosquitoes that may carry Dengue Fever, and more recently Zika. I chose to travel in December because it was outside hurricane season, it was the cooler time of the year, and there are less mosquitoes around that time. Cuba does a better job than many other countries controlling mosquitoes, but I was still cautious. Due to the cost, they don’t use insecticides to fumigate buildings, but rather burn oil, as can be seen in the photo above. We checked in to one place not long after they had done their weekly spray, and had to wait 30 minutes for smoke to stop poring out the window! I sprayed much of our clothes with permethrin spray, and applied DEET to exposed skin, especially in the evening when the mosquitoes are more apt to bite.  I texted PLAN to 855-255-5606 to get periodic updates from the CDC about Zika before the trip.

Food is generally safe to eat, but we avoided street food. The tap water is not safe, however. We mostly depended on bottled water and avoided ice except at a few restaurants and bars that filtered their own water. Bottled water is kind of pricey at times. The best deals are on large (3-4 liter bottles) that you can find sometimes in stores. They often cost the same price or less than a one liter bottle that is more readily found. I also brought along a SteriPEN which sterilizes water with ultraviolet light. I didn’t have enough experience to trust it completely to replace buying bottled water, but used it to sterilize water to rinse our toothbrushes, and would have used it if we didn’t have bottled water. I also recommend bringing Imodium, and an antibiotic from your physician for traveler’s diarrhea. I’d also bring some toilet paper. Many public toilets often didn’t have any, or  you’d get a small amount from an attendant after giving a tip.

Bring sunscreen. It’s not easy to find places that sell it in Cuba, and it’s expensive.

Months before my trip I tried to arrange to visit a hospital. It so happened that the fiancée of a Cuban in the travel industry who helped with some of the arrangements was an anesthesiology resident. He told me that he would love to show me his hospital, but that unfortunately the government required a 30-50 dollar payment, despite the fact that I said I would be bringing some medical supplies. He also said I would not be allowed to tour the medical school due to, “national security!” After I arrived we talked a number of times, and ultimately he could not get government approval for me to see his hospital, even though he said everyone at the hospital wanted me to come. He said the only exceptions they made were for those with an educational visa, coming to teach basically, and even then they needed at least 3 months notice.

Although I could not tour the hospital, I had some long conversations with that doctor and learned a lot about their system. All things considered, the Cuban doctors are apparently pretty good, but they are particularly hampered by old equipment and lack of medications and supplies. The anesthesiology resident showed me photos of anesthesia equipment they currently use that are from the 1980’s. He said they don’t have air scrubbers in the operating rooms, so sometimes everyone gets sleepy!  He told me about a colleague of his who was working with a nurse anesthetist. She let her go home early because she wasn’t feeling well. Later she had to intubate a pregnant patient. Unfortunately it didn’t go well and the patient suffered brain damage. During a subsequent investigation the government argued that had she not let the nurse anesthetist go home early, maybe the patient wouldn’t have died because she would have had additional help. She was sentenced to 12-15 years in prison, and even if she gets out after 5-7 years for good behavior, she won’t be allowed to be a doctor anymore! Because physicians are held responsible for a bad outcome, Jehovah’s Witness patients are told they can’t refuse blood if needed, though they do take measures to minimize the need. Doctors are paid poorly (the resident said after he finished he would make 80 CUC (about $80) a month), often less than taxi drivers. It’s very difficult for specialists to be allowed to leave the country, even on vacation, for fear they won’t come back. If they go on medical missions they are paid better than usual, but they only pay them the bare minimum while they are abroad to encourage them to return home after the mission. I was surprised to learn that they are fairly tolerant in terms of LBGT, in part due to Raúl Castro’s daughter, and they even have doctors who do sex reassignment surgery to change gender.

Many Cubans rely on natural formulations, such as herbs, they call ‘green medicine,’ due to cost or personal preference. The anesthesiologist told me that for a man to get a prescription for Viagra (sildenafil) he has to see his primary care doctor, a urologist, and a psychiatrist. Once they get a prescription, though, they are basically assured of getting it indefinitely. He said many patients research their condition and tell their doctors what prescription they want, and they often comply.

One of the most dangerous things in Cuba are the cars. They are famed for their old cars, many of which look fabulous, but they lack safety features, such as seat belts and airbags. In fact we were in a car accident. We hired a car and driver for 6 days through a contact in the travel industry in Havana. He was probably around 60-years-old, and reportedly one of their best drivers. He was very nice, funny, and knowledgeable, and arrived to pick us up in a pretty new Chinese car, a BYD (Build Your Dream). On the first day as we were driving, while my wife and daughter were sleeping in the back, the car started drifting to the left. I grabbed the steering wheel, noting the driver had fallen asleep. He quickly awakened, pulled the car to the side of the road, and got out to stretch. He came back in and apologized, saying he had gotten up early to pick the car up. The next day he said that actually he hadn’t slept well because he had witnessed a teenager, who was not paying attention listening to music, hit by a car the day before.

In the middle of the car trip I met with the doctor I mentioned above and told him about the incident. I wondered if he might have sleep apnea, though the driver had said he had never had such a problem.  He said that they don’t test for sleep apnea because they don’t have CPAP machines to treat it.

The rest of the road trip went fine until the final day. Once again my wife and daughter were sleeping in the backseat when the driver fell asleep again. This time he swerved too quickly for me to reach the wheel. We hit a guard rail, damaging the front end and side mirror and puncturing two tires. The driver said he did not know why he fell asleep and that he had been well rested. One theory I came up with is the possibility of carbon monoxide poisoning from a leak in the exhaust system. Our driver obtained another car and driver for us, who brought us back to Havana.

No one was serious injured, but my wife was seated behind the driver and her left elbow hurt immediately afterward. Back in Havana we went to a clinic that caters to foreign visitors. X-rays showed no fracture.  She was given a skinny piece of gauze to use for an arm sling (she had been using my belt up until that point). When it came time to leave they said we owed 100 CUC (about $100).

Boarding Pass

 

Cuba requires one to have medical insurance to visit the country, and they add $25 to the price of each airline ticket to cover it. Delta Airlines said to show the boarding pass if needed as proof of insurance. I showed the boarding pass, but they said it wasn’t good because it said AeroMexico on the top. I pointed out that below that is said that it was operated by Delta Airlines. They said they would have to investigate it. They gave no indication how long it would take, and given that it was the evening I didn’t think they would get an answer that night. I eventually gave up, paying the money so we could get her passport back and leave. I wrote Delta Airlines and explained the situation, sending them copies of the boarding pass and the medical bill. We were on something like their 4th commercial flight to Cuba, so I figured they would be eager to work out any glitches. I was wrong. Besides some email exchanges, they called twice at 7 am. When I pointed out the early hour I was told it was 10 am on the East coast. You would think an international airlines understood the concept of time zones! In any case, ultimately I was told we, “..must request a refund of the insurance premium directly with the Cuban insurance provider.” Really? They expect their customers to request a refund from the Cuban government?! All I was asking for was the approximately $100 I paid for the clinic. Not the taxi ride there and back, the medical costs after we got home, to say nothing of pain and suffering. Imagine someone of lesser means ended up needing much more care and being told the insurance they thought covered them didn’t. That might keep people from choosing to visit Cuba, at least on Delta Airlines.

Exploring Cuba – Part 1

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If you travel because you like to see different cultures and experience things you usually don’t, Cuba is a good place to go. For Americans Cuba has been kind of like forbidden fruit. I thought it was a good time to go as it recently became easier, and I wanted to see the country before it gets changed too much by hordes of tourists.

Although they do have beautiful beaches, as an American you can’t currently legally go there just to stay at a beach resort. You have to declare which category you are traveling under, and tourism is not one of them. Most people choose the people-to-people category. When I went last month with my wife and daughter, I chose the journalism category, as I have a blog and photography site, but in practice, I think it’s rare that anyone actually checks. That could change with the incoming administration, though. In this article I’ll get into some of the details of the trip, for those interested in going.

We flew from Seatac to Miami airport and stayed at the Miami International Airport Hotel, conveniently in the terminal, saving time to catch the early morning flight to Havana on Delta Airlines. We obtained our visa when we checked in, paying $25 for each one. That’s part of the reason they tell you to check in 3 hours early.

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Although you will see plenty of places that accept credit cards, including MasterCard and Visa, they do not accept American credit or debit cards. Thus you have to carry cash. There are two currencies, the Cuban Convertible Peso (CUC), which is about equal to a US dollar, and the Cuban Peso (CUP), mainly used by locals, and about 24 CUP equals 1 CUC. The official rate is used everywhere, except for the black market. You will pay about 3% to change you money to CUC and 3% to change it back, but if it’s US dollars they tack on an extra 10% as punishment for our embargo. I converted my dollars to Canadian dollars first, saving about 7% (saving 10% not converting from US currency, but paying 3% for converting it to Canadian). When I left Cuba I converted the relatively little CUC I had left to Euro, as I plan to go there later in the year.  You can convert money at the airport and at banks, but the later often had lines out the door. Major hotels often will convert money, but some require that you stay there. Most places did not give a receipt.

Except for one night, we only stayed at places we booked through Airbnb. One place was basically a guest suite connected to a beautiful large house with friendly hosts, and a very nice breakfast for an additional 5 CUC per person. Another place was really a hotel that they were using Airbnb for bookings. One was from an older couple that owned a few apartments and rented out a couple of them. Having to deal with just cash was a little nerve wracking. I carried a fairly large sum in a money belt most of the trip. I never worried about being robbed, but it was uncomfortable in the heat. Even more concerning was worrying about the possibility that I might run out of money. The first couple of days was more expensive than I anticipated and I contacted a cousin that by coincidence was arriving in Havana a week later than us. She brought me some money as a loan. I never ended up needing it, but it did provide peace of mind.  A big advantage of Airbnb is that you pay that in advance, so you do not need to bring money for your lodging. At a couple of the places they incidentally did offer to exchange dollars to CUC at better than the official rate, though probably not quite as good as if you exchanged using Euro or Canadian dollars. I didn’t use them, and you have to be careful, but I would have over standing in line at a bank. I advise you to convert a little more than what you think you will need for your entire trip, and carry emergency money in your native currency that you would only change if needed.

For the three of us, I rightfully worried about getting around with lots of luggage. We limited ourselves to one carry on luggage without any full check in size luggage. Particularly as I was bringing some medical supplies (more on that later), and anything you might need but can’t count on being able to buy there, space was at a premium. One thing I did was to buy two pairs of quick drying ExOfficio underwear, and Sea to Summit Lite Line clothesline to hang it up on.

It just so happened that we arrived in Havana the day Fidel Castro was buried in Santiago de Cuba. Raúl Castro declared a 9 day mourning period after Fidel died, banning public music and sales of alcohol. It was not followed completely, but it was certainly more subdued when we first arrived. They have 9 or so TV channels, and during the mourning period they played revolutionary type programming, such as black and white videos (or dramas?) of soldiers fighting in the jungle. As one Cuban told me, it was interesting, but not for 9 days.

We went on our own, not part of a tour, though I worked with a Cuban tourist guide someone introduced me to before the trip. She made suggestions to the itinerary I made, and helped me hire a car and driver for 6 days. One of the travel changes I made at her suggestion was to cancel a fight to Baracoa on the other end of the island. I hadn’t realized that it had been badly damaged by Hurricane Matthew. In addition, the only airline that flies there, Cubana de Aviación, is notorious for bad service. When I made the flight reservations I had to enter all our contact and passport information. To my chagrin the email confirmation included all of the details! I emailed them about my concerns about identity theft, but they never responded.

One of the other things our guide did was to make many restaurant reservations for us, which was surprisingly often necessary.  When it comes to restaurants, there are two kinds: state owned, and private. The latter were only allowed less than 3 years ago. They are generally more expensive, but better quality. We ate at a few of the state owned places. Although the buildings were often beautiful, the food quality was often lacking, serving such things as canned green beans.  In Havana, restaurants we particularly liked included La Guarida, San Cristóbal Paladar, Doña Eutimia, El Cocinero, Atelier, and Paladar Vistamar. In Cienfuegos Las Mamparas was quite cheap and pretty good food. In the Viñales Valley Finca Agroecologica El Paraiso was amazing.

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When people think of Cuba, they think about old cars. There are many American cars from the 1950’s, quite a few Russian Lada cars, plenty of Chinese and other cars. Cars are very expensive (it can be the same as a house there), and most everyone with a car is also a mechanic. You have to be to keep the cars running. Our driver said that a particular 7 person Hyundai van was popular for giving group tours, and a used one, if you could get it, cost 140,000 CUC!

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It was common to see people on horseback or in horse drawn carriages, particularly outside of Havana. I even saw two using the inside passing lane on the highway!

After a couple of days in Havana, we drove to Cienfuegos, stopping at the Giron Museum (Museo Giron) by the Bay of Pigs, and the Cueva de los Peces (Cave of Fishes). We passed by areas where the farmers spread their rice on the the edge of the road to dry, then would sweep it up at the end of the day, then repeat it for about 6 days to totally dry the rice.

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Cienfuegos is a nice port city that has a French influence. Outside the usual tourist things there, we toured a cemetery, where a couple of boys rode up on a donkey. We visited a botanical garden. We also took a day trip to El Nicho waterfalls, and another to Trinidad.

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Trinidad, also a UNESCO World Heritage site, is a charming cobblestone paved town. It’s reportedly often the hottest part of Cuba, and even in December it was pretty warm.

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We left Cienfuegos to drive to Santa Clara where we saw the town and the Che Guevera Monument. From there we drove to quiet but lovely town of Remedios to spend the night.

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Next it was on to the Santa Maria Cayo (key). The road there reminded me of driving to the Florida Keys. We spent 1/2 a day at the Lasterrazas resort. As I said earlier, technically you can’t go to Cuba just to take a beach vacation as a US citizen. It was just a small fraction of our trip not only for that reason, but because that wasn’t what I wanted out of a trip to Cuba, though I know many others could spend their whole time there.

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We then drove back to Havana, where we stayed the rest of the trip, except for a day trip the following day to the town of Pinar Del Río, where we toured a cigar factory,  then on to the Viñales Valley where we gorged ourselves over lunch at the amazing Finca Agroecologica El Paraiso.  We saw a couple of sites, including the tacky Mural de la Prehistoria.

Our driver said the Pinar Del Rio province, where they grow a lot of tobacco, is called the Valley of the Fools. He told the story of Pedro Perez. Before a race he was invited to answer a question for a prize. The announcer said, “OK Pedro, how much is 2 plus 2?”  “6,” he replied. The crowd roared, “Give him another chance. Give him another chance.”  The announcer said, “Ok Pedro, I’ll give you another chance. How much is 2 plus 2?”  Pedro scratched his head and thought about it and said, “5.” Again the crowd yelled, “Give him another chance. Give him another chance.” The announcer said, “This is your last chance, so think carefully, Pedro. I asked you how much is 2 plus 2. First you said 6, then you said 5, so what is your answer?” “4,” said Pedro. The crowd shouted, “Give him another chance. Give him another chance.”

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Back in Havana we took a trip to the outskirts to see Hemingway’s estate. Our taxi driver gave us a tour, though you will get a lot more information if you take an official tour (I listened in on some of them).

As a communist economy, mixed with a little capitalism, there are some strange things when it comes to prices. Taxi drivers often make more than doctors. Natural gas in Havana is cheap. Our driver said the prior month it cost him 25 cents. Because that’s the same price as a box of matches, some people leave their stoves on all the time.

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Dogs run wild in many places. They were never threatening and most seemed well fed. Although some people have them as pets, many are on their own.

The Cuban people are often critical of their government, when asked in private, though proud of some of their achievements, such as medical care and literacy. To thumb their nose at communism, many cars have Apple stickers on them. Kids may sing America from West Side Story in front of the neighborhood commander.

Cuba has a vibrant music scene. We enjoyed some of it, but missed a lot because we couldn’t stay up late enough.

There is no longer a limit on importing cigars or rum for personal use. At the airport I decided to buy two more bottles of rum, one dark, and one white, plus some honey, at the duty free shop. When we arrived at Atlanta we had to pick up our luggage then turn it back in to go to Seatac before going back through security. One of the workers there said clear bottles were not a problem going through the x-rays in security, but he recommended taking out dark bottles and putting it in our luggage. I showed the duty free bag and he said to put the dark rum and honey in my bag but the clear bottle could go in my carry on. I didn’t have room to check all of it in, and I questioned whether it was really ok to open the duty free bag. He said it was no problem at that point and to trust him. I shouldn’t have. When I made it to security they saw the clear bottle and said it couldn’t go through since the duty free bag had been opened. I was told I could go back to check it in (but my suitcase was long since gone) or throw it away. I didn’t ask if I could just drink it on the spot!

You can see more of my photos here. In my next post I’ll discuss some health and medical issues regarding Cuba.

 

Health in China

The Chinese are less concerned about safety than American. We worry about health risks, perhaps obsessively at times, but from my perspective it’s less of a concern to them. As I wrote, I thoroughly enjoyed a recent trip to China, but now want to discuss some observations on medical issues in China.

Smokers at tables flanking a no smoking sign in a Beijing restaurant.
Smokers at tables flanking a no smoking sign in a Beijing restaurant.

They smoke much more, and allow smoking in many more places. No smoking signs are often ignored.

In some of their cities, they breath in much more pollution. The Chinese government publicly posts measurements of the air quality, but it’s often significantly less than the United States Embassy measurements. Here are readings I recorded during our trip.

China Air Quality Shanghai - Official Reading
China Air Quality Shanghai – Official Reading

China Air Quality Shanghai - US Consulate
China Air Quality Shanghai – US Consulate

This score of particulate matter was created by the Environmental Protection Agency and goes up to 500, which was supposed to be the scale maximum. Recently readings in Beijing have been as high as 755. According to China’s Ministry of Environmental Protection, less than 6% of vehicles in the country meet the highest environmental standards, and there is particularly a problem with the tiny particles known as PM2.5, thought to be particularly toxic. Most of this is generated by older cars and trucks.

Bicycle and motor scooter riders don’t wear helmets. In 3 days of driving around Beijing our guide never wore seat belts, even on the highway. The driver only wore it one time briefly.  Eighty percent of car sales are to first time buyers, and many of them have little experience. Pedestrians do not have the right of way. One evening we drove past a man crumpled up on the street, with a man standing next to him talking on the phone, and no ambulance in sight. I can’t be certain, but I believe he was hit by a car trying to cross the street. Shortly after leaving our hotel in Shanghai on the way to the airport, our bus was temporarily stopped in traffic after a motorcyclist was hit and was laying on the ground. If we saw two people hit in 8 days, imagine how often it must occur.

They seem to be less germaphobic than most Americans. Their tap water is not potable unless you’ve lived there long enough to have developed resistance.  They eat family style sharing multiple dishes, but do not give serving utensils, so everyone dips their own chopsticks into the common food.

According to an article in the 11/14/12 China Daily newspaper, obesity is becoming more common in Shanghai.  It said that roughly 40 percent of adults in Shanghai are obese or overweight. A survey released at the end of 2011 showed the average weight of male residents had increased by 2.9 kg (6.4 lbs), and weight circumference had increase 2.3 cm (0.9″) since 2000. Certainly they have much less obesity than we do in the United States, but it’s likely to get worse. They are less physically active, with motor bikes more common than bicycles, and their diet is getting more westernized. I saw many McDonalds, Haggen-Daz, and Starbucks in Beijing and Shanghai.

Another article in the same issue said the number of people in mainland China with diabetes has doubled in the past decade to about 9.7% in those 20-years-old and older, and that only 40% of them have been diagnosed. Because of the increase in chronic illnesses there, pharmaceutical company Eli Lilly & Company plans to expand in China to increase sales of their drugs for diabetes, the heart and cancer.

We went to the China Academy of Chinese Medical Sciences at the Science and Technology Center (www.china-tcm.com). While our feet soaked in a tub of tea, someone came and talked about the center.  It was started in 1955 under the direction of Mao Tse Tung. It mostly serves the government leaders. He said none of them have heart problems, cancer or high blood pressure.  He said only Chou Enlai had liver cancer in 1976 when they were 20121109_SF-China_0420less developed. Next students massaged our feet while a doctor examined me, then my wife, while a woman translated. He felt the pulse with 3 fingers check on each side. He said I had problems with blood pressure and fatty liver and said I should lose 5-6 kg. I’ve not had problems with the first two, but wouldn’t argue with the last. He also asked if I had an eye problem. I actually have had some problems with eye inflammation, but perhaps he looked in my eyes and noticed the affect of a combination of air pollution and jet lag. He recommended 2 medicine, each ¥650 (about $100) for a month supply and said I needed to take it for only 1-2 months. He said I would be amazed at the difference. When I hesitated he asked if my patients take their medicine when I prescribe it. I ended up buying a one month supply for myself as I felt a little guilty they had spent all the time on us, and it was place that didn’t seem to get many foreigners. I figured if for nothing else, it would make a good blog post. In my n-of-1, non-blinded, non-placebo controlled study, I found no difference after taking the medications for one month. Well actually I did lose about 3 lbs, but I suspect that was from following my New Year’s resolution with more exercise and an even better diet. Considering that I felt the same, despite being a month older, maybe it did do something.

Although I joke about it, I suspect some herbal medicines are effective. After all, some pharmaceutical medications in use today are derived from plants. Before taking such medications long term, one should be concerned about not only effectiveness, but safety, including the risk of contamination with lead and other chemicals.

I was going to try acupuncture, but our guide couldn’t find a place she felt comfortable recommending (sterile needles, etc.).

Prior to the trip I obtained a hepatitis A vaccination. That’s the one viral hepatitis that can be transmitted by contaminated food, which although it doesn’t caused a chronic infection, can definitely put a damper on your vacation.

China seems to be moving in the right direction in some areas related to health and the environment, which I hope they sustain. They don’t need to adopt all the practices of Western society, nor would I wish them to do so, but the Chinese people shouldn’t needlessly suffer from from such things as traffic fatalities, pollution, and smoking, and those things should minimized as much as possible.

A Vacation to China

The Great Wall
The Great Wall

Last November I went on vacation to China. In a subsequent post, I’ll write about health issues in China, but for now I’ll just talk about the trip for those interested.

Why China, you might ask? Well I’ve always been curious, and had only been to Hong Kong about 20 years ago, and when a great deal came up, I couldn’t pass it up.

Through Travelzoo I learned of a tour from SmarTours. For an incredible $1099 per person, we had airfare on Air China from San Francisco to Beijing, 5 nights in a nice and well located hotel, a flight to Shanghai, 3 nights in a nice Holiday Inn, also well located, western and Chinese breakfast buffets in the hotels, the flight back to San Francisco, via Beijing, and all airport transfers with an English speaking guide. Additional tours were all optional, but I later learned that the trip was so cheap because it was subsidized by the Chinese government. The tours most people took stopped at government owned stores (silk factory, jade store, pearl store, etc.). As the guide told us, the Chinese government has lent a lot of money to the US, and they hoped us tourists would spend some of it in China!

In Beijing we opted to go with another tour company, recommended by a flight attendant we know, www.chinatour.net. I actually emailed them what I wanted just before getting on the plane. When we arrived at the hotel and I could get on the internet, I confirmed the email they had sent while we were in the air. Our guide called at 10:30 pm and we agreed to meet in the lobby at 8:30 the following morning. We took a private tour for the first 3 days. For a cost of ¥3000 ($484) for two people, we had a driver and tour guide, lunch and most admission fees. The first 2 days events lasted over 12 hours, with the driver waiting to drive us back after acrobatic and Kung Fu shows. For lunch the second day we paid a small surcharge to have a higher quality meal as we had them modify one of their itineraries.

The first day our guide and driver met us at 8:30 am. We went to Tiananmen Square and the Forbidden City. Because the 18th National Congress of the Communist Party of China was about to start to select the new president, security was tighter than usual, and some

Silk and larva after separating cocoons.
Silk and larva after separating cocoons.

buildings were closed to the public.  Our guide helped us get through lines faster. Next we went to a demonstration silk factory and store, then the Temple of Heaven.

Pee boy
Pee boy

We hadn’t asked, but our guide then brought us to an enjoyable tea ceremony where we were served five different kinds of tea. There was a “pee boy” to test the water temperature.  If you pour cool water on top of the head, nothing happens. But if suitably hot, the ceramic boy pees.Then we went to a Chinese acrobat show. Our guide purchased the tickets then took us to the entrance. The ticket taker tried to direct us to the 2nd floor, but when our guide said, ‘what?!’ he pointed us to much better first floor seats near the front.

Rather than go to the chain Quanjude for a Peking duck dinner, as part of the company’s tour, I opted for DaDong, which was well worth the extra cost. In addition to roast duck with condiments, we ordered peas, soy soup, and pomegranate salad.

One of the best places for Peking Duck, DaDong restaurant in Beijing.

One of the best places for Peking Duck, DaDong restaurant in Beijing.

Pomegranate salad at DaDong Restaurant in Beijing.
Pomegranate salad at DaDong Restaurant in Beijing.

20121107_SF-China_0240
Our guide.

Without us ordering they also brought persimmon and candied crab apples.  This was epicurean Chinese food fit for a foodie. At ¥288 ($46) for two, it was a bargain. Our guide sat across the table waiting for us as the driver had already left to park the car. It seemed a little strange, but she helped with ordering and explaining things.

On our second full day, our guide and driver took us to the Cháng Ling tomb of the Ming Tombs.We then stopped at a jade store, followed by lunch. Then it was off to the

Jade horse carving.
Jade horse carving.

Great Wall at Badaling. Despite being off season, it was pretty crowded, but definitely worth seeing. We were lucky with the weather. It had snowed a couple of days earlier, which prevented some tour groups from going, but it was nice and sunny for us. Afterwards I went to use the toilet before leaving. I pressed what I thought was a peddle on the floor to flush the toilet. When I heard a loud sound I looked again at the peddle and realized it said “SOS”. I then found the real flush handle and made a hasty retreat!

On the way back our guide had us stop at the Derun Pearl Gallery. They have the distinction of being located at the National Olympic Sport Center, apparently because the owner or developer owned some of the land before it was turned into the center.

szechuanNext it was time for spicy Szechuan food before attending the Legend of Kung Fu show. The story was a little campy, but it was enjoyable.

We asked our guide about housing. She said most people pay off their house or apartment in 2 or 3 year, longer if it’s a real expensive place. They don’t take loans for cars and pay cash.

The following morning it was off to the picturesque Summer Palace. In the afternoon we strolled down the Fuxiang Hutong. That evening we walked around a mall near our hotel.rink I was surprised by temperature extremes. On the bottom floor was an ice skating rink, yet in the stores it was much warmer than typical American malls. I felt hot with my jacket off, yet most Chinese kept their coats on and appeared comfortable.

We went to dinner at a restaurant near our hotel. As we found at most of the restaurants we went to, the waitress stood waiting to take our order as soon as they brought us to the table, before we had even removed potatoour coats, much less looked at the menu. The menu had many pages, and it was not always easy to figure out what a dish consisted of with their English translations (Heavenly dragon meat, anyone?).  One dish I was surprised to see was sweet potatoes with blueberry sauce. It was kind of bland, but it sure looked good.

The next day we spent most of the day at the Hongqiao (Pearl) Market. That was more time shopping then I bargained for, but it was interesting and we obtained some good deals. You do have to bargain aggressively. One saleswoman grabbed my wife’s arm to prevent her from leaving, and I literally had to pry her fingers off!

The following day a bus took us to the airport, and it was off to Shanghai. After checking in at our hotel, we went to the People’s Park then the Shanghai Museum.

The next morning we took the metro (subway) to see the Yùyuán Gardens and nearby stores. From there we took a taxi to the Bund. The distance was not far, but the man at the hotel desk suggested not walking as he said that area has a lot of pick pockets. The Bund is an elevated walkway by the water, which gives a great view of the Pûdong New Area financial district across the water, and an amazing skyline. To get across we took the Bund Sightseeing Tunnel. It was not nearly as fantastic as they made it out to be (unless perhaps you’re an 8-year-old boy), but it got us there. We stopped at the Apple Store there before going to the Shanghai World Financial Center, where we went to the 100th floor observatory for a stupendous view.

Another metro took us to the French Concession part of town. We walked a fairly long distance to go to the Bâoluó Jiûlóu restaurant. My Lonely Planet guide said it was a large soupand lively place. When we got to the address all we saw was what looked like a small, dumpy restaurant. We almost left, but then walked in and asked for a table. We were taken around the corner only to discover a very large room full of people. I enjoyed a thick pea or soy (?) and coconut soup.

The next day it was off to the town of Suzhou. The train station was close to our hotel, but we wasted a half hour in the wrong building before finally finding the place we had to go to buy the tickets. Fortunately they had a line for English speakers. Unfortunately we found out that we needed to show our passports just to purchase a ticket, though it wasn’t needed to board the train. So we had to go back to the hotel to get our passports. It was a fast train that took us to Suzhou, and the landscape blurred past. When we arrived at the station, we weren’t sure where we were in relation to the town, and our guidebooks made no suggestions. At the “Information” booth the attendants barely spoke English. They suggested a 30 minute bus ride. We and two others in our group decided to take a taxi. It turned out to be a 5-10 minute ride that only cost less than $2!

We went to the zen-like Suzhou Museum, designed by architect I.M. Pei. It contained modern art (some paintings were labeled with dates such as, “2011 AD” just in case you thought it might be 2011 BC), ceramics, jade, textile, and other pieces.

20121113_SF-China_0758Afterward we went to the Humble Administrator’s Garden. This is a very large, and not so humble, garden, with lots of water features and Asian buildings. We had lunch at a noodle shop then wandered down the colorful Píngjiang Lù road. One had to watch out for the numerous bicycles and motorbikes.

In the evening we took the metro to East Najing Road and walked down the heavily  neon-lit road. We were surprised to see a large group of mostly women doing a form of a line dance, as well as some smaller groups ballroom dancing.

We had dinner at the Lost Heaven restaurant, a large and delightful place serving Bai, Dai and Miao folk (Yunnanese) cuisine.   We ate tofu with eggplant, a shrimp dish, Burmese chicken curry, and a pumpkin truffle soup. This was the most expensive restaurant of the trip at about $100 per person. But the rest of the meals were cheap, and if you’re a foodie, it’s worth it to try a delicious, and hard to find cuisine.

We ended our sightseeing with another trip to the Bund to see it at night. We took our photos just in time, before discovering that they turn off many of building lights at 10 pm.

The SmarTour itinerary showed us flying from Shanghai to San Francisco. On the bus to the airport we learned that although that was true, it was not the whole story. We actually had a flight to Beijing with a 3-4 hour layover first, which made for a long day of travel. It took a long long time to get through security in Beijing. They did not ask people to take off belts, so almost everyone set off the metal detector. They subjected most people to a pat down and having a metal detector wand passed over them. Water bottles were confiscated, even if bought past security in Shanghai, and again just before boarding in Beijing, even if purchased after passing through Beijing security.

If you’ve made it this far, I think you will enjoy seeing more of my photos at http://www.danielginsberg.com/Travel/China-2012/27271654_z6ZLck#!i=2291644664&k=FqnMv9X. To reward my faithful readers, I’m offering 70% off those photos for this month only on all prints and merchandise, using the coupon code WBSChina. Feel free to just look, however.

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