Saturday, June 30, 2007
I saw the premier issue of MP last night, and it looks terrific. I followed Bev's gracious example when I noticed that my name, too, had been misspelled throughout the entire issue. The Forces of the Universe seem to have a sense of humor.
Friday, June 29, 2007
Regular features of the bimonthly magazine will include several feature stories. This first issues main feature is on Article 12 and is authored by Tina Sablan. The other two features are on Mixed Martial Arts – delving into the idea of the island warrior -- and a Wedding Guide, which will look at the best in
I’m looking forward to reading the story titled “Pugua Nation” by Boni Reyes Gomez, which describes betel nut use locally and worldwide. I also know that quite a few people are eagerly anticipating the story on “Island Blogging” which delves into the rising phenomenon of blogging in
Throughout the issue, high quality photographs complement the stories.
Ed Propst himself writes for the MP Magazine, along with seven contributing authors in this first issue: Peter Bae, Reina Camacho, Bob Coldeen, Boni Reyes Gomez, David Khorram, Tina Sablan and Ben Salas.
The magazine will be distributed on July 4 at the liberation day festivities, and will be available for purchase at Joeten Susupe, Dan Dan and Garpan locations. The public is also invited to attend the Premier Party at Ocean’s along Paseo de
MP Magazine is a welcome new endeavor and a demonstration of confidence in the future of the CNMI. I agree with Ed that our peoples have stories to share, that our islands have beauty to be highlighted. I’m looking forward to exploring this first issue of MP Magazine.
Monday, June 25, 2007
It may seem strange that I’m doing construction management, but I’ve done it before. I spent my summer doing the same thing six years ago, when we moved the school up to its Navy Hill campus. Mara and I started this school through a series of fortuitous events, never imagining that what started as a Toddler Enrichment Program for Nava when she was a year old, would become a world-class school with 100 students representing some 14 ethnicities, programs for kids from 18 months to 12 years old, a magnificent campus, six classroom buildings with 7500 square feet of space, a seven member Board of Trustees and something like 15 faculty and staff. We just learned along the way, and for many years now, we've been in the background, letting all the other talented people lead the institution.
My other primary activity of the summer will be driving. Too bad these guys can't drive yet.
Take tomorrow for example. I’m transporting my kids to or from events at the following times: 9 AM, 10 AM, 12 PM, 1 PM, 3 PM, 4 PM and 5 PM. They need to get to
With gas at $3.54 a gallon now, I’m glad I drive a Prius.
The big, huge, humongous, stupendous event of the summer is that Mara’s mother, Carol, is moving to Saipan from Tucson. Mara is in Hawaii right now, awaiting her mom’s arrival from LA. They get to Saipan via Narita and Nagoya on Wednesday night. Mara has spent the better part of the last six months coordinating this move, which involves five dogs, two cats and a lifetime of personal effects. It’s a big move for Carol, and one taking a lot of courage. Here’s to family!
I'm looking forward to the start of the soccer season as a member of the acclaimed "Buns and Hoses" co-ed team. I haven't played since medical school, so I imagine I'll spend a fair bit of time just trying to breath. If you haven't joined a team yet, I think our team is still looking for some members. This is a laid back way to play on a fun team.
Oh, yeah, and I’ll be doing some eye surgery and stuff this summer too.
Sunday, June 24, 2007
Discussion about whether or not we should “allow” the federalization of immigration has been lively, even heated. I want to clarify at least part of the discussion. History wasn't my favorite subject in school, but our Commonwealth is so young it is generally easy to access the original sources of our legal system.
Section by Section Analysis of the Covenant to Establish a Commonwealth of the Northern Mariana Islands
Marianas Political Status Commission - February 1975
“Section 503. Section 503 deals with certain important laws of the United States, not presently applicable to the Northern Marianas. It provides that these laws will not apply to the Northern Marianas prior to termination of the Trusteeship and will not ever apply after termination unless and until the Congress of the United States specifically acts to make them applicable. Section 503(a) deals with the immigration and naturalization laws of the Unites States. These laws will not apply until, after termination, Congress acts to make them applicable either as they are applicable in other areas under the American flag, or in some special way which takes into account the particular conditions in existence at that time in the Northern Marianas.”The U.S. Congress has a right to federalize our immigration law. Your parents and grandparents negotiated the Covenant fully and freely. They did a good job. We have gained far more than we could ever lose by becoming part of the American family. I've heard some say that maybe we should reconsider that status. Although I respect a person's right to hold and voice that view, I flatly disagree. There were other Pacific islands under U.S. control at the end of World War II. Some of them chose different paths. We continue to benefit greatly from our Covenant with the United States. Other island states have not fared so well, choosing to be independent to one degree or another. Look around.
In my view, it is time to invest our energetic interest in this matter in finding the ways that federalizing immigration will work, not conjecturing about how it will not.
We have been and continue to be invited to provide input that will be considered when shaping the proposed legislation and hopefully, the law, if enacted.
I had some concerns about the proposed legislation and am pleased to find some of these issues addressed in some form or another, in the bill:
- The continuation of existing guest worker contracts.
- New CNMI guest worker permits with exemptions from standard limitations.
- A mechanism to “grandfather” long-term workers who have been legally working in the Commonwealth for several years.
- Assurance of “customer” access to the CNMI by permitting “CNMI-only” visas or visa-waivers for potential customers (tourists or students).
Another issue that is of concern to all the inhabitants of our islands is border security. The world is a very different place since 9/11. I for one am gratified to see the vast resources of the United States brought to bear on securing our borders. It is not just our ports that concern me. I believe good border security in the Northern Islands is also important. As the military gears up to move from Okinawa to Guam, this will continue to gain importance for the Commonwealth.
The bill, however, continues to be deafeningly silent on the establishment of a non-voting Delegate for the Commonwealth in the U.S. House of Representatives. There was a period of time when the message Congress was receiving was that the Commonwealth didn't want or need one. During those same years Congress was willing to address the issue. Today, all the negative publicity about Abramoff, immigration, and the minimum wage has caused members of Congress to avoid the issue. Having a non-voting Delegate now would be very helpful. We have some work to do to make this happen.
I recently offered to supply copies of the proposed legislation to any interested parties. The response has been good, and I'm proud to see how many people are taking an active interest in the process. The proposed legislation is complex, especially in that it amends or refers to existing U.S. law. I still have questions, and will continue to research them, but overall, I think it moves us toward a paradigm that is overdue.
I've noticed a frequent choice of words in day-to-day conversations. We tend to refer to nonresidents as “workers”, and residents as “employees”. I think that the difference between these two words is subtle, but profound.
We all need to think carefully when choosing words to describe the social phenomena that we have created. Words are powerful. We invited nonresidents to our islands. Many have been here a long time; some have started families. Some of our nieces, nephews, and grandchildren were born of these unions. Many long-term nonresidents are a valued and integral part of our community. The worth of a person does not lie in what country they were born in, or who their parents are, or what type of employment they hold.
Some view the proposed federal immigration legislation as a threat to our culture. I do not feel this way. The proposed legislation presents us with issues about the changing face of our society that many have not considered before. One cannot “legislate” the survival of a culture. A culture will survive because it is honored and nurtures its people. Our culture is constantly changing, in some ways I'm glad, greatly preferring a car to an ox-cart.
Change also brings with it a degree of uncertainty, a state of being that few take any pleasure in. Often, the benefits of change are not realized or understood until long after the fact. No one can be certain about the outcome of the proposed legislation. It may be amended after being presented to the Congress and it may not even become law.
What I know is that to date, our immigration policies, although much improved over the years, have not been satisfactory for numerous reasons. Congress plans to take a very difficult and expensive problem off our table. I continue to support their efforts, as I feel the long term effects will be more positive than detrimental for all people in our Commonwealth.
Saturday, June 23, 2007
Every couple of months, the staff at Marianas Eye Institute plans an outing. This month, we closed the clinic on Friday afternoon and headed down to American Memorial Park for a picnic and a softball game with our families. I learned two things. First, if you're out of shape, softball actually is an aerobic activity. Second, man, those Chamorro girls can hit that ball! I'll post more pictures later, especially when Mark sends his. It's hard for me to believe that this institution supports so many people and their families. And this isn't even everyone!
Friday, June 22, 2007
Here's my column from today's Saipan Tribune.
A friend of mine recently asked me to think into the future and come up with a vivid image of the “ideal” CNMI. What will be the
As I began to think about the ideal CNMI, I realized that my initial thoughts are not related to our industries or our economy or our landscape. My primary thoughts focus on our most important resource, a largely untapped and latent resource: the human beings that populate this land. It’s far more important for me to live in a place where the people are vibrant than to live in a land where all the infrastructure is developed, and the economy is booming, but the people are not.
I realized that I had gone through a similar exercise about seven years ago. At that time, I was involved in creating what we hoped would become a world-class school. We sat down and defined the vision of the institution. We didn’t focus on the buildings and grounds and income. Our vision was focused on imagining the type of people we wanted to emerge from the school. And even then, we didn’t ask, “What do we want our kids to be when they grow up?” We asked “What do we want our kids to be like when they grow up?”
And so again, as I ponder the future of the Commonwealth, I think that we need to focus our vision on the people. What do we want to be like? As I sat at a table defining the vision of Brilliant Star School, we all tried to imagine our children as adults, in a room with other people, and we imagined what we hoped they would be like. We distilled all the thoughts and images into four key qualities.
As I thought about my friend’s challenge to imagine the ideal CNMI, I realized that in my mind these same four qualities will define the vibrant person of the Commonwealth. There really is nothing to prevent us from excelling as a community, to be a global showcase of vibrant people. We have developed many vibrant individuals who personify these four qualities, but the untapped potential is vast. The only limitation placed upon us is in our own minds, and our failure to visualize the possibilities. Now, as we are swept up in profound changes, we have the opportunity to define our vision for the one resource that will define the future of the Commonwealth more than any other – the people. A vibrant people will naturally develop an economically and ecologically vibrant community. But by focusing first and foremost on economic fixes, we are placing the cart before the ox. It’s time to think primarily of the people, and to define a vision of what we will be like as individuals and as a society.
Here is my vision of the four defining qualities of the people of the future Commonwealth. They are the same four qualities that define the vision of
- Global understanding. We recognize that the world of the 21st century is one of increasing interdependence among peoples and nations of the world. We recognize the fundamental truth of the oneness of humanity – that all people are one. Our policies derive from this reality. We are comfortable as “world citizens”, with a global perspective and understanding of issues. We are free from all forms of prejudices -- race, national origin, ethnicity, language, economic status and religion. We recognize the equality of the sexes, and we celebrate the diversity of the world’s peoples and cultures. We are promoters of unity.
- Exemplary Character. We recognize that ultimately, the strength of ones character is the essence of ones self. Character is that set of virtues that are developed in an individual. We have developed, foremost among our virtues, truthfulness, trustworthiness, kindness, courtesy, compassion, confidence, joyfulness and humility. We are emotionally and spiritually well-developed.
- Service to humanity. We recognize that meaning and happiness come from selfless service to others. We strive to find ways to serve others – our friends, families, neighbors and co-workers; our community; and humanity as a whole.
- Creative minds. The creative mind is one that can bring knowledge to bear on new situations and challenges. To this end, we are well versed in the branches of knowledge, with emphasis on mathematics, literature, science, history and arts. We have learned to independently investigate reality, to seek intelligently, and to discover things for ourselves. We practice applying this body of knowledge and this set of skills to the challenges around us. We use our minds to become agents of meaningful change in our communities.
It is not only possible to move in this direction. In my mind it is imperative. What is your vision of the people of the future Commonwealth?
Grumbling, we get back in the car and try to figure out how we're going to do this. Mara leaves Sunday to meet her mom in Hawaii who is moving to Saipan from Tucson. We want to get this passport thing done quickly, and not put it off another week. But on Friday, I have a full clinic in the morning, and with four kids and summer, there's a bit of coordination to be done to get everyone where they need to be.
Mara and I decide to get up early and get down to the Passport Office by 7:30 AM, so that we can get everything done and I can get to the office by 8:00. It will mean waking a sleeping 4 year old to get her down there too.
By morning, the plan is seeming a bit too painful, with everyone tired. We decide I'll go to the Passport Office at 7:30 AM, and Mara and Jaleh will go down later, and hope this will count as "everyone appeared."
I get there at 7:27 and sit and listen to the end of Harry's radio show (new driving school on the island 322-2220). At 7:31 I head to the office door. Locked. I knock. Nothing. I read the sign again just to make sure. Yep, we accept passports between 7:30 AM and 1:30 PM. I wait. 7:37, the door is still locked. Maybe it's an austerity Friday. I call the hospital and ask the operator, "Is this an austerity Friday?" "No, that's next Friday. Government offices are open today." Hmmmm. Maybe they're inside and just forgot to unlock the door. After all, the aircon is running. Oh, look, there's a sign on the side of the building with the phone number. I get my cell phone and prepare to call. The phone number on the sign says, 664-476. That's not a typo. The last digit is missing. Under the phone number, there is another sign that says "Ha ha!" I wait some more. I knock some more. By 7:47 I decide this isn't going to work today, I move into my happy zone, get in the car and drive to the office.
Thursday, June 21, 2007
The Child Citizenship Act of 2000 provided for overseas children adopted by US citizens. If both parents are present to pick up the child, the child enters the US on an IR4 visa and US citizenship is granted automatically.
Since I went without Mara, Jaleh entered the US under an IR3 visa. When she entered the US, she automatically became a permanent resident, and we received a green card a few weeks later. But in order for her to become a US citizen, the adoption has to be repeated in the US. And according to CNMI law, she had to reside in the CNMI for one year before the adoption could be completed. We completed this process a few months ago. She is now a US citizen, automatically with the completion of the adoption.
We are going down to the Passport Office tomorrow to apply for her passport. It's a pain to travel with a Chinese passport and we're trying to plan for a trip later this summer.
It has taken me a while to sort out all the details of this "journey to citizenship", so I'm posting below the most useful pieces of information I found.
From the US Embassy in Guangzhou, China:
How do I apply for my child抯 U.S. passport once we抳e returned to the United States?
According to the provisions of the Child Citizenship Act of 2000, if your child has received an IR-3 visa they become United States citizens the moment they are admitted to the U.S. border. You can therefore take your child抯 Chinese passport that contains the IR-3 visa and the admittance stamp to any Passport Agency and this will constitute the evidence of U.S. citizenship that is required for a passport. In order to receive the child抯 passport, you will need: (1) Evidence of the child's relationship to a U.S. citizen parent (a certified copy of the final adoption decree); (2) the child's foreign passport with BCIS's I-551 stamp or the child's resident alien card; and (3) the parent's valid identification.
If your child receives an IR-4 visa, you must first complete the adoption process and receive your child抯 Certificate of Naturalization. Once you receive it, you can proceed to any Passport Agency to obtain your child抯 U.S. Passport.
But I get the sense that this is not completely accurate. It seems a Certificate of Naturalization is not necessary to apply for a passport. It's a nice document to have, but the finalized adoption decree is the document the passport office can use as proof of citizenship.This more detailed explanation is from Adopting.org:
In January, 2004, U.S. citizenship procedures for internationally adopted children changed. This follows the Citizenship Act of 2000.
Change Affects only IR-3 Families
The IR-3 entry visa (the IR stands for "immediate relative") is issued to the child when the adoption has been completed abroad and when both parents (in the case of a married couple) have met the child. Children who enter the U.S. on an IR-3 visa are automatically granted U.S. citizenship, and under the new regulations, will be sent a Certificate of Citizenshipwithin 45 days of their entry. Parents do not need to complete a separate application on behalf of their children for this document.IR-4 Families must apply
The other type of entry visa issued to children in connection with international adoption is the IR-4, which means that the adoption has not been completed abroad, and/or that both adopting parents (in the case of a married couple) have not met the child.
In these cases, adoption or readoption must be completed in the U.S. to satisfy federal requirements for subsequent citizenship. Citizenship will be granted automatically upon finalization of the adoption/readoption procedure, but IR-4 families must apply separately if they want a Certificate of Citizenship for their children.
To obtain proof of citizenship for your child, you, as the child's parent (one or both of whom are U.S. citizens), must file USCIS Form N-600, Application for Certificate of Citizenship in Behalf of an Adopted Child, on behalf of your child, in order for your child to receive a Certificate of Citizenship.
Applying made easy
To make filing for proof of U.S. Citizenship for your child as easy as possible, Patti Urban of Legal-Eaze has put together a Citizenship Packet for you to use with her compliments. It is designed to be completed by hand and mailed directly by you to the USCIS.
The sample letter can be mailed to the USCIS (United States Citizenship & Immigration Service) address at 26 Federal Plaza in New York City for those families living in the following New York counties: Bronx, Kings (Brooklyn), New York City (Manhattan), Queens, Richmond, Nassau, Suffolk, Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester. If you live outside those areas, it is suggested that you send it to the local office that serves the area where you live. You can write the address on a label, and place it over the existing address on the sample letter, or use the sample letter as a guideline.
- Download the free form, Application for Certificate of Citizenship in Behalf of an Adopted Child (Will require an Adobe reader. Download it free here.)
- Print out the Sample Letter to the USCIS
In addition, you should be aware that the 1996 Immigration and Naturalization Act included, among other things, a provision requiring automatic deportation of non-citizen immigrants who are convicted of a felony charge. This means that an adopted child, arriving on an IR-4 visa, of U.S. citizens who fail to get the child U.S. citizenship by the time he or she is 18 years old, could be sent back to his or her country of origin following any felony conviction.
Therefore, it is urgent that any child arriving on an IR-4 visa go through the adoption or readoption process in his or her state as soon as possible. Your child then becomes a U.S. citizen upon the issuance of the Certificate of Adoption in your state. Once this is completed, you can then file for the Certificate of Citizenship as proof of citizenship.
All families are strongly urged to apply for and get a Certificate of Citizenship on behalf of their internationally adopted child as soon as possible. It takes only a short time to assemble the documents needed for your child's U.S. citizenship application... and a lifetime to enjoy its privileges!
NOTE: A flag that has flown over the U.S. Capitol building in Washington DC may be purchased to commemorate your child's citizenship. Be sure to plan in advance, as your request must be received at least four (4) weeks prior to any commemorative date. Click here for more information.
Is a Certificate of Citizenship necessary?
For IR-4 families, the most frequently asked question is whether or not this step - and the additional cost - are necessary in addition to passports. Here are some facts about passports, certificates, and citizenship to help you decide for yourself:
- Passports are issued by the State Department; Certificates of Adoption are issued by the USCIS (United States Citizenship & Immigration Service) which is a part of Homeland Security.
- Every child adopted abroad currently entering the U.S. must go through Immigration upon arrival. USCIS issues a Permanent Resident Card. Your child, however, still retains the permanent resident status on the records with USCIS until a Certificate of Citizenship is issued.
- The only way to get the USCIS to change the status to U.S. citizen for those entering on the IR-4 visa is to apply for a Certificate of Citizenship using Form N-600.
- Passports expire, Certificates of Citizenship do not.
- Immigration attorneys believe it is a necessary step. (See Adoptive Families magazine, May/June 2002 issue.)
- Passports are more likely to be stolen, given the enormous black market in passports.
- Passports have been questioned, especially in the instance of multiracial and multicultural families.
We're going to mail off Jaleh's passport application and hope it works out quickly. I hope this information compile here will be useful to someone trying to sort this out.
We painted our roof white. It's dropped the temperature inside the house by at least 10 degrees. Now the ceiling doesn't radiate heat all night long. If you haven't painted your roof white, now's the time. We did it at the beginning of last summer, and I was expecting it to last for a few years, but we needed to re-coat it again. Amazing thing, white paint.
On a related topic, here is the cover of the new issue of National Geographic. For those who heard the recent presentations by Bob Schwalbach on global warming, this will likely be an interesting read.
Finally, it's confirmed: Taste of India is coming back! Here is the sign at their new location, on Middle Road, just south of the Verizon building. They have an "Opening Soon" banner up, but no confirmed date. It's great to see they're returning.
One more thing. Today (or yesterday, I'm not sure officially) is the longest day of the year. I'm not sure why, but I'm always aware of the solstices and the equinoxes. Must have had some druids in my anscestry.
Tuesday, June 19, 2007
Shortly after I started blogging, I was asked by the newly launched MP Magazine to write a feature piece on “Saipan Blogging”. (By the way, the latest news is that the issue will be out in July). I headed to the Saipan Bloggers meet-up and among the questions I asked was, “Is it typical for bloggers to get together in person.” Absolutely not. It’s an anomaly. But here on
I was thinking this as I walked into Southern High School this afternoon. Bree, whom I met for the first time at that bloggers meet-up, had invited me to give a presentation to a group of 19 high-school students who are in the midst of a two week Health Career Camp. They, along with Bree and other instructors, are sequestered away at an undisclosed location (
I spent a couple of hours answering the student’s questions, giving the “doctor” perspective on healthcare. How long does it take to become a doctor? Do you have time for your family? What do you hate about your job? What do you love about your job? Is it okay to swim with your eyes open? Is there a cure for mono?
More than anything else, I tried to impress upon them the absolute fact that if they have enough brains to tie their shoes, they can probably make it through medical school. It just takes discipline.
I hadn’t put together any fancy Power Point presentation for the talk, but Bree had pulled some of the gory eye pictures off of my blog, and she projected them onto the screen while I told the students the details of the photos.
Everyone has a good time. They applaud. We take a picture. I pack up my stuff and head out the door. As I’m leaving, Bree is passing out two of my blog entries, Magic and Medicine, and Medical Care in the CNMI to the kids. Over the next hour, they are to read the pieces and write responses to questions that Bree is writing on the board. How cool is that!
Monday, June 18, 2007
Before 1946, the modern bikini -- the two piece swimsuit with a G-string back -- did not exist. It was introduced at a fashion show in Paris on July 5, 1946. A few days earlier, out here in Micronesia, atomic testing had taken place on Bikini Atoll. Was the swimsuit really named after the island? Yes, indeed. The bikini was expected to result in a burst of excitement like unto the explosion of a nuclear device. There's something to mention at the water cooler tomorrow!
I'm running a little experiment here. If you found this post interesting, go to this link, and just click on the button that says "vote" next to this post.
Sunday, June 17, 2007
Being medically under served is just part of the reality of living on a remote tropical paradise with a relatively small population. It's as much a function of geography and demographics as anything else. Sure, things could be better, but people will still die for reasons that would not exist in LA. There are trade-offs for everything. If you live in LA there are certain trade-offs. I'm raising four kids here, by choice, and I'm intimately familiar with the shortcomings of the health care system. Yes, something might happen out here that results in a worse outcome than if I were living in LA. But overall, I'm okay with it. For most of us here, where we live is a choice. For me, Saipan wins out over LA (and Aukland and Honolulu and Sydney and Tumon and every other spot on the face of the earth.) This is where my heart is.
I’ve always said that our health care system in the CNMI is among the best in the region, and that the overall quality of physicians here is as high as in other rural communities anywhere in the
. Yet our population is medically under served. The resources for care, though good, are limited. There are not enough doctors to serve our population. The public health care facilities are often short of supplies and specialists. On the operating room wall there hangs a quotation from Dr. Howard Tait, who served as the CNMI’s orthopedic surgeon for many years. Speaking to other surgeons, he said, “If you have to have everything you need to do the case, you probably shouldn’t be here.” Strangely, these are the very reasons that many of us choose to practice medicine here. We get personal satisfaction from making a difference to the people we serve, and we learn from the challenges of not having everything we need. United States
The US Department of Health and Human Services routinely evaluates the access to care in all
jurisdictions and gives each geographic area a Health Professional Shortage Area (HPSA) score. This HPSA score is an indication of how badly doctors are needed in an area. The scoring system used by the Department of Health and Human Services takes into account such factors as the number of doctors available for the population, and the travel times to the nearest available source of care. The higher the score, the worse off a region is, and the more badly doctors are needed. A HPSA score of 25 is bad, 1 is great. US
How do you think the CNMI ranks on this list? Well, it’s pretty bad – in fact, among the worse. For non-metropolitan areas in Region IX, the highest shortage award goes to the FSM, with a HPSA score of 25. There is no other area in the entire US with a greater need for doctors. This is followed by a few Indian Reservations in
, Arizona and California that have HPSA scores between 21 and 19. Next comes Nevada with a HPSA score of 20. And then, the CNMI with a HPSA score of 18. A HPSA score of 18 is bad. It is an indication that despite having one of the best hospitals in the region and having great doctors on the island, we are among the most under-served areas in the entire country. American Samoa Guamfares much better than we do, with a score of 8. Many Indian Reservations have better HPSA scores and less of a doctor shortage than we have.
Areas that have doctor shortages typically do everything possible to bring in more doctors. There are tremendous challenges in bringing in new doctors to the CNMI. After all, the area is underserved for a reason. If it were considered a great place to practice medicine, there wouldn’t be a shortage in the first place. This is one of the reasons that our public facility is constantly short of doctors and specialists. There has to be a compelling reason for people to move half-way across the world, to an unknown land, far from their families, and take a pay cut to work under challenging circumstances.
In my case, I had always wanted to work in an under-served area and to feel like I was making a real difference to the people I served. When I arrived in the CNMI 12 years ago (now 14 years ago) as a government employee, I thoroughly enjoyed establishing the first eye care services at CHC. It was a challenge, and I was able to make a big difference quickly. We saved the government hundreds of thousands of dollars in referral costs, and I had the privilege of making life better for my patients. After five years at CHC, my wife and I decided to make the CNMI home and realized that this would be difficult to do while working for the government. Each year there were questions of whether or not funding would be available for my position and whether or not my contract could be renewed. I had also reached the limit of what I could build under the government system. I came from one of the best training centers in the
, and I wanted to bring in the best eye care technologies to the CNMI. The emphasis of CHC was rightfully on providing primary care to as many people as possible with the limited resources available, so it just wasn’t possible to spend money on the more advanced technologies I was requesting. For these reasons, and with the enthusiastic support and encouragement of the administration I entered the private sector. And this is where I believe the future of improving health care in the CNMI lies. We will always need a government supported hospital. But one of the keys to addressing our poor HPSA score, and building a stable medical community is to encourage the development of private medical practices. US
Most of us in private practice came to the CNMI as government employees. Dr. Tony Stearn’s venture into private medicine resulted in the establishment of FHP (now PacifiCare), and more recently of
. Dr. Hocog and Dr. Aldan built Saipan Health Clinic. Dr. Ahmad Al-Alou established Marianas Medical Center . Tony Glad built Pacific Medical Center . And most recently, Dr. Norma Ada has opened Medical Associates of the Pacific. Together, these practices, along with my own, remove the burden of some 60,000-76,000 office visits from the shoulders of the government facility each year. Private practices provide stability and continuity of care. The average number of years that each of the physicians in private practice has served in the CNMI is somewhere between 10-15 years. We put down roots. Those of us in specialty care like myself, provide support to other physicians, like those in the emergency room, when complex cases arise. Private medical offices are more likely to invest in the most advanced technologies which raise the level of care for the whole population. It was Dr. Al-Alou at PMC who had the vision and the means to bring the Island Medical Center first CTscanner into the CNMI. Marianas Eye Institute brought in technologies that most eye care practices in the mainland don’t even have. Private medicine raises the level of care available to you. US
I share these benefits because I believe that stimulating the development of private medical practices can be more actively pursued in the CNMI. In
Guam, we see that the entire medical care system, like that in every other developed jurisdiction in the , is built upon a strong and healthy private practice model. We need to actively attract doctors into private practice. As a community and a government we may wish to consider the big picture of health care, and of our severe physician shortage, and consider which legislation, policies and regulations -- which decisions -- will move us closer to addressing our doctor shortage, and which will take us further away. Quality health care for the greatest number of people is a guiding principle that can serve as a touchstone when considering the impact of various decisions. United States
More on the blood situation later.
Friday, June 15, 2007
We were in
Nevertheless, our friends, like many first time parents, were frazzled. I introduced them to the idea of how to eat out, and they were so liberated by the simplest of concepts.
The reason it’s hard to eat out with young kids is that they don’t sit still and they don’t like to wait. The eating part isn’t so bad. It’s the waiting-for-the-food part that leads to mayhem and beaded sweat on your upper lip. So, Mara and I long ago came upon a simple solution: we place the order from home.
We have the menus of our favorite restaurants at home, and when we do want to go out to eat, one of us becomes the waiter and collects everyone’s order. We call the restaurant, and place the order. The restaurant inevitably asks “Will this be for take out or delivery?” and we say, “We’re eating there. We’re coming with kids, so we want to have the food ready when we get there.” They understand. They are soooo thankful. After all, they don’t want our kids sitting idle for 20 minutes waiting for the food to arrive, because, well, they won’t be sitting idle. They’ll be shooting spitballs, making toothpick forts, spilling water, torturing one another by looking at each other, dropping silverware, wasting napkins, and commenting way too loudly about the wads of chewing gum stuck under the tables. So the restaurant loves that we call ahead. We walk in, they whisk the food out as we pull out our chairs, we eat, and go home with minimal disruption to anyone’s sunny disposition.
That’s all. Nothing earth-shattering. Very easy. Call ahead and order so the food is ready when you get there. It’s a way to reclaim your dignity… sort of… or maybe not really. After all, you’re still carrying a diaper-bag and wearing a “dad badge” – that patch of dried drool on your shirt.
I do this a few times a week. Most of the time I'm injecting a "wonder-drug" called Avastin into the eyes of people with severe diabetic eye disease. One of the problems with diabetes is growth of new blood vessels or "neovascularization". The standard treatment is to blast them with a laser, but sometimes you but in all the laser you can, and the blood vessels still grow. Avastin is a biological drug that neutralizes the molecule that sends the signal for new blood vessels to grow. The molecule is called VEGF, which stands for vascular endothelial growth factor.
Avastin was developed by Genentech to be given intravenously for treatment of colon cancer. Most cancers rely upon growth of new blood vessels to nourish the cancer mass. Avastin kills colon cancer by interfering with the growth of the blood vessels that feed the cancer. An amazingly smart (and courageous) ophthalmologist, Philip Rosenfeld (MD, PhD) from Bascom Palmer Eye Institute figured that this VEGF inhibitor ought to work for growth of new blood vessels in the eye. About three years ago, he injected it into the eye of one of his patients, and the next day, the new blood vessels were gone. That injection has revolutionized the care of both diabetic eye disease and macular degeneration. I met Phil earlier this year in Hawaii, and he's one of the nicest, most generous smart guys I've ever met. We've been in touch by email since then, and he's helped me identify some top-notch retinal surgeons in Japan.
Avastin was approved by the FDA for use in colon cancer, but in the US, we're allowed to use a drug "off-label," meaning we can use it for treatment of conditions for which it was not specifically approved, as long as we let the patient know it's an off-label use. At Genentech, the same company, was developing a VEGF inhibitor to be specifically used in the eye -- sort of a cousin of Avastin. They were in the midst of the FDA study phase when Phil decided to try Avastin and it worked. They invested millions to get the new eye drug through the FDA approval process, only to have their own drug compete with it through "off-label" use. The cost of the new eye drug, $2,000 per dose (yeah, three zeros). The cost of Avastin per dose, less than $200.
You usually need to get the injection every six weeks or so. The cost difference is huge on a cumulative annual scale.
Anyway, I really enjoy this part of my work -- the procedures. During my internal medicine training at the University of Chicago, my co-residents found out that I was going on to do an ophthalmology residency. Many were envious. But one said, "Are you kidding. He's going to make a living sticking razor blades and needles in people's eyes." Yeah, and I love it.
Wednesday, June 13, 2007
I went in this morning. I have a corneal ulcer. It hurts, and it looks gross. But he's putting me on antibiotics, and drops that I have to put in every hour. He said I'll be seeing a lot of him until this gets resolved. The good news is I got new glasses, so I don't have to wear the ones I broke and glued back together in London.
So, thanks, Dr. Khorram!! Thanks for the exceptional service, and thanks for keeping me from going blind! I enjoyed meeting you in person, although I would have preferred to meet in a less serious setting. I am continually amazed by the friendships and professional relationships that are fostered by something as menial as me writing my random thoughts down for the world to see.
I caught the talk this morning, which Bob tailored for the CHC Medical Staff to highlight the health consequences of Global Warming. It was a comprehensive presentation and fascinating to hear about.
Anytime someone asks me what it's like to work in Saipan, I quote this sign. It hangs on the operating room wall at the Commonwealth Health Center. Although the statement was made by Dr. Howard Tait, CHC's former orthopedic surgeon, regarding surgical cases I think the principle applies to working anywhere in the government.
It succinctly alludes to the qualities necessary to survive, thrive, and to be happy at work here: flexibility, resourcefulness, love of challenges, contentment.
Howard is fixing bones in Canada now. But his words make a lot of sense for those considering taking a job here. You have to consider if you can do your job without everything you usually need to do your job.
Tuesday, June 12, 2007
We attended a birthday party at the Fiesta on Sunday, and the photographer captured Arman in a happy action shot. That's him on the right on the front page of today's Saipan Tribune.
The caption reads:
"KID's CLUB: Kids beat the summer heat frolicking on the brand new multi-faceted Kid's Pool of the Fiesta Resort & Spa Saipan Kid's CLub during its opening Sunday afternoon. The pool also features slides and fountains for every kid's enjoyment."I will add that this is a great pool for small kids. It's only about a foot deep, maybe a little more, so our 2 year old son was able to play all afternoon without fear of getting dunked. There aren't any 1000 gallon buckets that get dumped every few minutes, just gentle sprays of water. Hopefully, the Fiesta will put a shade structure over the pool, much like PIC's.
Monday, June 11, 2007
Sometimes a patient comes in and wants to test the competence of the doctor before trusting the doctor with her care. That happened to me today.
Mrs. Marcos, as I’ll call her, is in her 60’s. Like many people on
Mrs. Marcos told me that there was nothing wrong with her. She was just here for an eye exam. “Okay, let me see if there are any problems.” After a few seconds of looking at her eye under magnification, I say, “Mrs. Marcos, you have a cyst full of fluid on your eye. Have you noticed this?” She looks stunned. I’ve uncovered a secret. I’ve seen it. I must be trustworthy.
She becomes animated. “Doc, let me tell you the story of how this happened.” Now, I’ll admit, when a patient in my examining room offers to tell me stories, I get a little nervous. Stories take time, and there are lots of people outside my door waiting to see me. But I long ago learned to be attentive to the person in front of me at that moment. “I was asleep in my room one night,” she says. “It was two months ago. A man came in and I awoke. He seemed like an ordinary man, but he was this big.” She holds her hand at shin height, indicating that it was a miniature man. “He came into my room. I heard the sound. And I saw him. And then he came back with a woman who also seemed ordinary, but was like him. They keep coming back to bother me night after night, making noise. One night they climb into the ceiling and every night they throw pepper into my eyes and wake me up. And they are the ones that caused this bump on my eye.” She’s agitated. She’s crying, tortured by the burning in her eyes, and the evil little people that are causing it. I take her hand and listen. “It sounds very frightening,” I say. “Would you like me to take that bump off?” “Please, yes.”
She’s not crazy. In her world, there are explanations for illnesses that are not based upon the germ theory of disease or Starling’s law or biochemistry. Try to talk her out of her world view, and you’ll lose all credibility. You’ll cut your own legs out from under yourself. You’ll eliminate yourself as anyone that can help her. But you can’t just tolerate her world view. You have to approach her with humility, recognizing that your world view makes sense to you, but it’s not the only one, maybe not even the right one. Just one that works for you.
We set up the tiny little scissors and forceps and in about 30 seconds the mass is removed from her eye. She is completely relieved and she is comforted by my words that if it comes back, I’m here with my own little bit of magic.
(Published in World Peace, a Blind Wife, and Gecko Tails.)
He's still got some open times if you want to contact him to schedule a presentation before he leaves on June 19.
Sunday, June 10, 2007
Many thanks to Angelo, Brad, Bree and Michael for their ongoing contributions. Anyone else interested in helping out? You get to be a member of a very cool team.
Even if you're don't want to make posts to the blog, even if you don't have a blog and are just reading this, send us an email about any events. SaipanThisWeek@gmail.com.
Now, I know it’s very difficult to see. In fact, I had to use my infrared goggles and special stealth night film to capture this shot, but if you look very very carefully you can see that there are people in this photo. They are difficult to see because the auditorium is dark, and especially because they are wearing BLACK. Not just BLACK, but a special Ninja BLACK that makes them almost totally invisible as they come out between sets to change the props. You get only a sense of a presence on the stage as they work, silently and swiftly, and couched in BLACK. You are not sure that they are there, and it was only after examining my pictures that I realized what was really happening between sets. It was magical, and made possible because of the BLACK outfits.
Kudos to Bree and all her crew.
Saturday, June 9, 2007
I ran into Robert Schwalbach this morning and got the update on his presentations on Global Warming. Bob has worked with former Vice President Al Gore in making the movie "An Inconvenient Truth" which focuses on global warming. He is on Saipan until June 19 and he is here to give these slide presentations. He will give his presentations anywhere, anytime. "I'll give it for one person in their living room." Last weekend he gave a presentation for four people up at Coffee Care, so anything is possible and available.
There are a couple of presentations tentatively scheduled. Mariana Islands Nature Alliance (MINA) is hosting a presentation at the Aqua Resort this Friday evening, June 15. The time is not yet set, but I'll try to keep you updated.
There is another scheduled for Saturday evening, June 16 by the Tanapag Community Association. The time and place are not yet known.
I have Bob's contact information, so if you would like to set up a presentation, leave a comment or send me an email through my email by clicking on "My Profile" over there on the right.
(This great photo is not from Bob's presentation, but from Neat-o-Rama.)
In honor of my grandmother, I thought I'd post this column I wrote a year or two ago for the Saipan Tribune. I checked on flights, but part of the reality of living on an island is that you can't always get where you need to be when you need to be there. Nothing could get me to Edmonton until after the funeral.
Having spent the first few years of my life in the desert of the Middle East, I was two years old when I first saw snow. I woke early one morning and looked out of my grandmother’s house to see the land covered with something white. Having never even heard of snow, I excitedly ran through the house awakening my aunts and uncles, shouting “Come everyone, get your spoons! There’s yogurt everywhere!”
I grew up with yogurt, though in Middle East it’s eaten differently than in the West. Instead of mixing it with fruit or honey or vanilla, it is mixed with shredded cucumbers or garlic or salt and pepper.
With the price of yogurt on the island now topping seven dollars for a quart, I’ve heard people talking of buying yogurt-makers. My grandmother had a yogurt maker. It was called a pot. And all my life I’ve made yogurt with a simple pot and a spoon. So, if you want make yogurt, here is how it’s done.
It’s all based on the principle that yogurt is a live food. It consists of a certain type of bacteria that turns the milk to yogurt. (If that scares you, don’t think about it.) My grandmother’s way of making yogurt was to pour milk into a pot, boil it to kill everything in it, let it cool down to a lukewarm temperature, put in a couple of spoonfuls of yogurt (the live stuff that will start changing the milk into yogurt) and then let it sit covered in a warm place for about eight hours. Open the pot, and you’ve got yogurt. It really is that simple. No need for fancy machines and powdered yogurt mixes and all the rest.
You can make as much yogurt as your pot can hold starting with just a spoonful of live yogurt. In fact, typically we would save a spoonful from the last batch of yogurt to start the next one, and in many families, the successive “generations” of yogurt would carry down through the families from year to year and decade to decade. Generations were connected through their yogurt.
Now, if you don’t trust grandma’s way (or if you just don’t want to take any chances) here is the “scientific” way of doing it. You’ll need a candy thermometer, an oven thermometer, milk, and one of those small 79 cent containers of plain yogurt. This starter yogurt has to be plain, not flavored. Pour the milk into a pot, and heat it to 180 F. Then let it cool down to 110 F. This may take a long time, so a quick way of cooling it down is to put the pot into a cool water bath (but make sure you don’t get any water into it). Once it’s cooled down to 110 F, put in 2-3 tablespoons of the starter yogurt. Now cover the pot and put it in a place that’s about 110 F, and that will stay at that temperature for the next eight hours. This is the prime temperature for the yogurt to grow. In my house, if I just click the oven to “on”, it gets to about 110F. Another common trick is to just turn on the light in the oven and put the pot in the oven, leaving the light on for the next eight hours. Most oven lights generate enough heat to keep the oven at 110 F. I’ve also made yogurt by balancing the pot on top of my computer monitor, a nice warm place.
If you want to make the yogurt a bit thicker, while the milk is heating up, stir in about 1/3 cup of powdered mild per quart of milk. More will make it even thicker and creamier.
After eight hours, take a look and you’ll see that the milk has been transformed to yogurt. It will be warm, so place it in the refrigerator for a few hours. Many people like to start the yogurt in the morning, put it in the refrigerator in the evening, and then the next morning it’s cool and ready to eat. At this point, you can add whatever you want to it – fruit, cucumbers, jam, flavorings.
You can make a quart of yogurt this way for the cost of the milk and the cost of a couple of spoonfuls of yogurt. The small cup of yogurt that you bought as the “starter” will last through quite a few batches of yogurt. Or you can save a spoonful from one batch for the next, but despite the stories of generations connected through their yogurt, sometimes the batch loses its potency with time. All in all, it comes out to about $1.50 per quart.
Enjoy! But don’t try to ski on it.
Thursday, June 7, 2007
Her life was full, and like the life of everyone in a developing country, it had its share of tragedy, children lost to accidents and illnesses. In midlife, she immigrated with my grandfather to Canada, that great country that welcomed with open arms people from around the world. Canada was her home, and it was there that she passed away last night. Even when she was in her 70’s and her mother in her 90’s, they would go sweetly together, their big leather purses in hand, to adult English classes, eager to learn. She never became fluent, but she could get by. She kept the habits of the old country. She persistently bargained with any cashier at the Safeway to give her a better price on the fruit she was buying on a given day. And she cooked. When I think of her, she’s often standing before a massive pot of bubbling Persian food, the aroma filling the neighborhood, her fingers holding a knife, chopping onions on a well worn cutting board.
For the past few years, it seemed our conversations on the phone were a series of missed words. Her mind remained sharp, but her hearing a bit far away. I feel closer to her now that her spirit has joined the Concourse that surrounds us.
Her genes will run through the generations of our family, but more importantly we’ll remember her for her courage in the face of massive changes, and we’ll remember her with the food we eat. Tonight, I’m going to make some of her yogurt. And if you wish, remember my Grandmother Banoo with a prayer and celebrate her rich life with bowl of her yogurt.