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.

Remote Globe Puppy

crowned.tamed.raced

The New York times just ran a story about how Mongolia uses a system for their mail where each address consists of three words. A clever British start-up company What3Words divided a map of the world into 57 trillion pieces, each 9 square meters (about 10 x 10 feet), and assigned a 3 word combination to each one.

I checked the address of my office, and it’s crowned.tamed.raced. Given that each address takes up such a small area, I honed in on the map to where the actual rooms in my building are. Here are some of the address I came up with: remote.globe.puppy, patio.thin.ropes, living.quit.exit, castle.lofts.roses, famous.learns.cheek, and minds.agent.former.

I would say that as a geriatrician, living.quit.exit is a pretty good description of what I do, but from a marketing perspective, I’d have to go with remote.globe.puppy.

Healthy Kitchens, Healthy Lives

 

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Dr. David Eisenberg with his son and daughter demonstrating healthy cooking.

I recently attended the 11th Healthy Kitchens, Healthy Lives Conference put on by the Harvard School of Public Health and the Culinary Institute of America. It was a literally delicious combination of lectures from physicians, dieticians,  chefs, and others.

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Chef Adam Busby of the Culinary Institute of America

There were 411 people registered for the course, coming from 35 states, and internationally from 29 countries. Including spouses, faculty, chefs, and exhibitors, more than 550 people attended. For those registered, 59% were physicians, 11% nutritionists, 5% nurses & nurse practitioners, 5% masters of public health, and 20% others (chefs, psychologists, physical therapists, exercise trainers, physician assistants). The majority of physicians were internal medicine and family medicine, but also pediatrics, OB/GYN, sports medicine, psychiatry, anesthesiology, cardiology, endocrinology, and surgical specialties. A diverse group, indeed.

We had lectures from top notch physicians, dieticians, chefs, and others. Many were book authors. I already made a couple of recipes from Suvir Saran autographed book.

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Dr. Eward Phillips talking about exercise.

They fed us well, with something like 350 different healthy dishes to try.

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We also had a hands on kitchen session, then ate our own cooking.

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Chef Thomas Wong

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Now the challenge is how to use all the information and get my patients to eat healthier. As a start, I’ve posted some healthy recipes on Pinterest.

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.

PhRMA Two-Step Dance

As part of my practice I conduct research studies for pharmaceutical companies. In order to get medications approved by the Food and Drug Administration, companies need to do studies to prove the medications are safe and effective. Studies are often conducted by multiple physicians around the world in order to get a sufficient number of patients, and to help them get the drugs approved in many countries.

The kinds of studies I do are mostly big and fairly complex endeavors. They usually have an investigator meeting prior to starting in order to explain the study, how to enroll patients, ship blood samples, order supplies, and many other details. It’s also a chance to ask questions and meet others involved in the study.

Pharmaceutical companies pay a certain amount of money to each practice for helping them do a study. That money is used for a number of things, including paying for staffing, and usually a small stipend to patients to cover their transportation and time. The budget includes money for investigators, such as myself, to attend investigator’s meetings, but unless it’s a local meeting, I make less money than I would just seeing patients in my office. A trip to the East coast takes about 3 days including the travel time each way, but I only get paid for the one day. It’s a nice change of pace, though, and it’s fun if I get to go to a city I’ve never been to before, or enjoy visiting.

Recently I was invited for the first time to an international meeting, in Vienna, Austria, by Novo Nordisk. I’d never been there so I figured I’d go a few days early to see the city. I called to book my flight but was told I could only travel the day before the meeting and return the evening of the meeting, or at most the next day. I explained that I intended to pay for the extra hotel nights and food expense, and it wouldn’t cost them any additional money. They said that they could not because of PhRMA guidelines which I’ve discussed before. They said if I arrived early they would not pay for my flight there. The concern was that they would violate the guidelines because if I spent more time at the destination than necessary, they would essentially be paying for a vacation. I pointed out that arriving early would be to their benefit as I’d be less jet lagged while attending the meeting. I also said that if I was taking a vacation, I would bring along my wife, stay for a couple of weeks if going that far, and I wouldn’t visit Vienna in the middle of the winter.

Going to Vienna I want to waltz, but PhRMA wants me to do the two-step, straight there and back. Well I have better things to do with my life, so they will need to find another dance partner.

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.
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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.