Yesterday: ROC --> LGA --> BDL

Tomorrow: Amtrak from Hartford to Penn Station

Up in the air

5am in MSN. 6am in ORD. 10am in LGA. Waiting for the 3rd leg to ROC.
Today is the start of my 2 month journey on the road. Let's call it
the grand Tour of America and Its Major Airports and Transportation
Infrastructure (TAIMATI).

Speaking of acronyms, yesterday we learned about SALT, a mnemonic for
disaster emergency response triaging in the field. S= sort. A= assess.
L= LSI. T= treat. The idea is that when there are limited resources,
triage is key to maximizing life saving measures for those who are
most likely to benefit from receiving care. Okay, "duh" you say. But a
catastrophic event is not the only time resources are limited. While
it doesn't feel as acute, the present state of health care is viewed
by many as a situation with limited resources. On the wards I see
physicians attempting to curb excessive test ordering in good faith,
but ordering only the hemaglobin instead of the H and H barely scrapes
the surface of grappling with limited resorces. I contend that, as
distasteful as it may be, it does not hurt to go through the mental
exercise of capping health care resources at different limits and at
least hypothetically prioritizing care, as we did in our disaster
preparedness course today. At the mere mention of rationing care,
people sling political career ending venom, like "death panels" and
"socialist medicine". But we accept that prioritizing and rationing
are reasonable in a disaster. Isn't this a disaster yet? I wonder what
the cost of Medicare would be if we decided to withold care that was
not expected to extend life beyond a few months. Twenty-five percent of Medicare recipients are spending 85% of Medicare costs, and much of this is during the last months of life.

We should be paying attention to what the profit driven entities are
doing. The pharm beomoth isn't jumping into cancer research just
because people buy pink or yellow wristbands, save yoghurt caps, and
walk 5k from time to time. They smell money. And we would be naive not
to pay attention. It doesn't have to be a battle ground, but it can
lead us to a better understanding of the perverse incentives
structures that are churning below.

Sent from my iPhone

Flight 1549

I have new adventures to add since I last listed my itinerary.

Nanjing --> Guangzhou --> Kuala Lumpur --> Krabi --> Railay --> Koh Phi Phi --> Phuket --> Chiang Mai --> Bangkok --> Nanjing --> Guilin --> Yangshuo --> Nanjing --> Shanghai --> Nanjing --> Guangzhou --> Hong Kong --> Jiangmen --> Huizhou --> Guangzhou --> Nanjing --> Haikou --> Sanya --> Haikou --> Nanjing --> HOME! --> Madison --> Home --> Madison --> SF --> Chicago --> Boston --> NYC --> LaCrosse --> Madison

Whew!

Coming back to the States always feels like the wrong time. There's always something left undone in China and when is anyone ready to merge into speeding traffic after not driving for a year? But that's what it feels like to reinsert oneself back into med school. No matter how much planning I put into my return, it always feels like an emergency landing. Now, three sub-internships later and applications all in, I can breathe a sigh of relief.

Onward!

Favorite quotes I borrowed from my sister

"People are often unreasonable, illogical, and self-centered; Forgive them anyway. If you are kind, people may accuse you of selfish, ulterior motives; Be kind anyway. If you are successful you will win some false friends and true enemies; Succeed anyway. If you are honest and frank, people may cheat you; Be honest and frank anyway. What you spend years building, someone could destroy overnight; Build anyway. If you find serenity and happiness, they may be jealous; Be happy anyway. The good you do today, people will often forget tomorrow; Do good anyway. Give the world the best you have, and it may never be enough; Give the world the best you've got anyway. You see, in the final analysis, it is between you and God; It was never between you and them anyway." -Mother Teresa

"Let me tell you something you already know. The world ain't all sunshine and rainbows. It is a very mean and nasty place and it will beat you to your knees and keep you there permanently if you let it. You, me, or nobody is gonna hit as hard as life. But it ain't how hard you hit; it's about how hard you can get hit, and keep moving forward. How much you can take, and keep moving forward. That's how winning is done. Now, if you know what you're worth, then go out and get what you're worth. But you gotta be willing to take the hit, and not pointing fingers saying you ain't where you are because of him, or her, or anybody. Cowards do that and that ain't you. You're better than that!" - Rocky Balboa

Digs in Guangzhou

My rent in GZ was probably the cheapest rent I'll ever have in my life. At $100/month it will be tough to beat. But then again I also lived with the landlord, had to install two door knobs, and buy an AC unit (see photos above). She is a sweet woman who lived simply and frugally as she tried to find ways to make a living after her husband passed away. When I moved in, she had recently acquired a kitten to get the rats that had crawled up through the squat toilet and chewed through her television set power cord. She called the cat "little cat" and me "little Chang." Several times, her voice became impatient when I forgot that "little Chang" was me and failed to respond.

My landlord preferred to lock the front door from inside, which seems like a death trap considering that she would make sacrificial bonfires in the living room. I wasn't to leave my window open if I left the apartment despite the bars across it since "thieves could cut the bars." I didn't bother to point out that they could also just break the window. Her paranoia of thieves bewildered me, but over time I realized that this paranoia is rampant amongst people in China.

She taught me about traditional Cantonese beliefs that I had little exposure to before when I was living in northern China. She never finished primary school so our literacy in Mandarin was approximately equivalent. Often, she would switch into a Cantonese dialect when speaking with me, leaving me in the dust as I stood there staring blankly. Other times she would ask me how to say things in Mandarin, these mini-ego boosts would be quickly squashed when I went to work and was reminded of how much Chinese I have yet to learn. Her perceptions of health and understanding of causes of illness initially frustrated me, but ultimately broadened my understanding of Chinese traditional conceptions of health. She firmly believed the cause of all her health problems was because she didn't appropriately zuo yuezi after she had her son 16 years ago. Zuo yuezi (坐月子) is a month long post-partum period when the mother is not to be exposed to the elements or consume any cold liquids. In Cantonese culture, they have a special black sweet and sour soup with eggs and pig feet that they have to drink every day to recover from being pregnant. There are a whole set of rules and diet that is more or less strictly followed, even by Chinese physicians trained in Western medicine--just in case.

Faking the little things

It's not unusual to see Gucci or Burberry handbags on just about every shoulder in Chinese cities. And despite the break neck GDP growth rates over the last three decades, incomes in China are not high enough to sustain standard issue luxury purses with price tags equaling annual per capita income. So, yeah, it's probably a knock-off. As anyone who reads Western media is aware, the Chinese figure out how to make excellent copies. Legend has it that when shown a knock-off Louis Vuitton handbag made in China, the head of LV was so impressed with the quality and workmanship that he wanted to find the factory to source his production there.

Copies indistinguishable from the orginals don't end with handbags however. Unfortunately, copies are made of just about anything, like network routers, cars, foods, and even medications. A second rate handbag wouldn't kill anyone. Nor would a knock-off router. But second rate medications, even without road paint coatings or toxic contaminants, can. Some counterfeiters, in good faith perhaps, include the active compound but at lowered doses. This is puts some patients at risk of sub-optimal treatments and treatment failure. Sub-optimal treatment with antibiotics (blood levels below the minimum inhibitory concentration) can threaten the general population by speeding the evolution of drug resistance in diseases like malaria, TB, or HIV. If it were easy to tell the fakes apart from the real drugs, it might be less of a problem with savvy consumer education. But the copycats have honed their skills down to the packaging. There was a report on the evolution of fake security holograms that found that holograms intended to indicate the authenticity of the medicine had been so carefully recreated that the difference could only be determine using a microscope.

I have my own theory on why industry regulation continues to be so lax. And there are certainly many factors that I won't attempt to debate here. I will venture to say that there's adequate incentive for the tvog to strictly regulate money here. And yet it's a rare person in China who hasn't been slipped a counterfeit bill. Fake bills are so common here that when someone is receiving change it's not usual for her to feel each bill individually. No vendor will take a 100 RMB bill without holding it up to the light. When I first arrived in China, I marveled at the idea of a fake 100 RMB bill. All that work for only about $12 (at the time). But after considering the relative cost of living and PPP, it wasn't unreasonable. When I tried to pay for dinner one night, my 10 RMB bill was refused because it was a fake. I found it comical that a counterfeiter bothered to make 10 RMB bills instead of 100 RMB bills. Chinese friends make jokes about 30 RMB and 7 RMB bills all the time. They claim that the Chinese were willing to copy anything, even 1 RMB bills. The 1 RMB (1 RMB = $0.15) counterfeit seemed the stuff of urban myth. That is, until I received a 1 RMB coin the other day. Compared to the real thing, it was noticeably smaller and lighter and the edges looked like they had been pressed and welded. It was a pretty pathetic excuse for a 1 RMB coin.

So I got to thinking, for a 1 RMB counterfeit ring to be worthwhile, it would have to be a pretty big operation. Even the metal to make the coin must cost something (Note: the value of the metal in a U.S. nickel was more than $0.05 in 2006 and that was not including processing, labor, and transportation. And, because of rising costs of copper, the metal in a U.S. penny was worth more than $0.01 until they switched to the zinc pennies in 1982. Another side note from wikipedia: they even considered an aluminum penny, but that was rejected because 1) vending machine owners complained that they would cause mechanical problems and 2) pediatricians and radiologists complained that the radiodensity of of aluminum was too similar to the soft tissues of the GI and respiratory tracts, complicating detection on x-rays. My reaction to this is: what vending machine accepts pennies?!). Back to 1 RMB coins. And how would they transport these things? A suitcase of 100 RMB bills I can understand. A suitcase of 1 RMB coins? No way, you'd need a truck and a distribution system. And this gets to my point, here is something the tvog has every reason to regulate and, since economic growth and stability are top priorities, we know they want to rein in counterfeiting, and, still, it's worth someone's time to make an unconvincing 1 RMB coin. Until verifying the authenticity of the bills (and coins) here is no longer a national hobby, we probably won't see much effective regulation of anything else.

Please excuse the long silence

But this means I was busy, which is good, right? My travel itinerary since I last posted:

Nanjing--> Guangdong--> Hong Kong--> Guangdong--> Beijing--> Guangdong--> Ganzhou, Jiangxi--> Guangdong--> Hong Kong--> Guangdong--> Hong Kong--> Guangdong--> Hong Kong--> Norcal--> Las Vegas--> Norcal--> Hong Kong--> Guangdong--> Nanjing--> Beijing--> Harbin--> Beijing--> Nanjing

This is not to mention all the cities I visited in Guangdong. Whew! Needless to say, I'm happy to finally settle down and get some work done.