Nagoya City University Hospital

A few years ago, I needed some surgery that wasn't available on Saipan, so I was faced with finding a surgeon to undertake my care.  Part of the issue for me was that I wanted to get the care close-by, and being self-insured, I needed it to be cost effective.

My main four choices came down to Australia, Hawaii, Manila and Japan.  I visited one of the top surgeons in Sydney during a trip there, and I wasn't impressed.  I scratched Manila off the list pretty quickly.  I've had a fair bit of experience with patients going to Manila for care, and although one of the surgeons I've worked with there is good, I've found that in general, the delivery was not up to the standards I expect when sending a patient to a major medical referral center.  Sorry guys, but that's the truth.  I wouldn't go to Manila unless it was a last resort.  I'm sure many have had good experiences there, but seeing many of my patients return, I haven't been too happy with the quality of care they received.

Hawaii was an obvious choice because, well, it's US quality medical care.  The problems with US care is that it's expensive.  If I'd had the procedure in Hawaii, it would have cost me $10K.  If I had had insurance, my 20% co-payment would have been $2K, for an outpatient procedure.  So, I just held this option in reserve.

I started to look seriously at Japan.  In the world of medicine, Japan is one of the areas, along with the US and parts of Europe, that lead medical research and publish in medical journals.  I know the quality of care there is top-notch, and that the cost is reasonable.  I ended up finding one of the best surgeons in the world for my condition, and headed there for my surgery.  I was very happy with the quality of the care I received, and the cost was only $2K.  That included the surgery, and five days in the hospital, getting fed and watered.  The system of care in Japan is a little antiquated, and many expatriates in Japan complain about it for this reason, but as someone in the medical field and as someone who has experienced the care first-hand, I think that the care is on par with anyplace in the US, and even better than the US, it's cost effective.

After I returned, I tried to convince the powers that be to start looking at Japan as a place to send our medical referral patients from the CNMI.  It close, it's cheap, and the quality of care is outstanding.  It's taken a while, but finally the CNMI has a relationship with the Nagoya City University Hospital (NCUH), and we have liaison people on the ground to help patients navigate a foreign country.

Nagoya City University Hospital is an 800 bed medical center (CHC has 72 beds).   The first patient from the CNMI that went there was an infant, a few days old, who was on the way to Hawaii for cardiac surgery, decompensated while on the tarmac in Nagoya, and was taken to the NCUH where the pediatric cardiac surgeons did an outstanding job on a very complex surgical procedure.  Since that time, the relationship has deepened, and in the next few weeks, I hope to send the first ophthalmology patients there.  This should provide closer and less expensive care than is available in Hawaii, and  as high a quality of care.   I'm looking forward to using NCUH as a referral center.

Saipan's Flirts with Third World Status

In his book, and The End of Poverty: Economic Possibilities for Our Time, economist Jeffrey Sachs points out,

When the preconditions of basic infrastructure (roads, power, and ports) and human capital (health and education) are in place, markets are powerful engines of development. Without those preconditions, markets can cruelly bypass large parts of the world, leaving them impoverished and suffering without respite.

Let’s take a closer look at this dense statement, that gives a very simple formula for economic success of a people. Development requires the combination of human capital (which consists of two parts – health and education) and basic infrastructure (which consists of three parts – roads, ports and power). Here on Saipan we lack reliable power, and therefore, we simply lack one of the key elements required for development. The lack of power is not just an inconvenience. It changes our status as a developed jurisdiction

Yesterday, at our home we had over five hours of unannounced power outages spread throughout the day. One came during mealtime, another just as we were getting children to bed. We were unable to cook, and our children cried as they tried to fall asleep in the sweltering heat. This is not a scene that you expect in a developed place, especially when it happens daily, as it is now. Power is part of basic infrastructure, and without it, there is limited opportunity for our markets to develop. I hate to say it, but our protracted power problems now bring us into the company of most third world countries. Our power situation puts us in a particular category of underdeveloped nations, and market opportunities cruelly bypass us.

Marine Monument Dies

I'm going to predict that the proposed Marianas Trench Marine Monument in CNMI has effectively been killed. After reading the story in today's Saipan Tribune, I don't think President Bush will give much attention to the Marianas. A variety of local government officials here have voiced their opposition to the idea, while no one at the same level is voicing support. Meanwhile, other jurisdictions are clamoring to have a monument designated in their area. If I were the President (or one of his advisers), I'd recommend taking the path of least resistance. Why fight with the CNMI?

As far as I can tell, the resistance to the monument ultimately comes down to a certain psychological stance that is explained in Bornstein's How to Change the World (who is quoting from O'Toole's Leading Change).

Resistance occurs when a group perceives that a change in quesiton will challenge its "power, prestige, position, and satisfaction with who they are, what they believe, and what they cherish....The major factor in our resistance to change is the desire not to have the will of others forces on us."

Marine Monument Activities

Folks are in town to educate the community on the proposed Marine Monument. Here is the list of upcoming activities.

Tuesday, May 20^th, 11:45am – Hyatt Giovanni’s Restaurant

William Aila will speak to the Rotary Club of Saipan

Tuesday, May 20^th, 5pm-6:30pm – Hawaii Bar & Grill, Garapan

Meet & greet for Jay and William to meet project supporters

Tuesday, May 20^th, 7:15pm – American Memorial Park Auditorium

Presentation to Saipan Fisherman’s Association by Jay Nelson with special guest William Aila

Wednesday, May 21^st, 7:00pm – John Gonzales Show, KSPN Channel 2

General introductions and project information the first half-hour followed by a call-in Q&A in the second half hour

Thursday, May 22^nd, 7:00am – KZMI Radio Talk Show with Harry Blalock

General introductions and project information with Jay Nelson and special guest William Aila

Thursday, May 22^nd, 6:00pm - American Memorial Park Auditorium

Presentation to general public by Jay Nelson with special guest William Aila

Jay Nelson

Director - Global Ocean Legacy for Pew Environment Group. Ocean Legacy originated as an outgrowth of work done by Pew in 2005–2006 to support the creation of a fully protected marine reserve in the northwestern Hawaiian Islands. Partners supporting Ocean Legacy include Pew, the Sandler Family Supporting Foundation, the Oak Foundation, and the Robertson Foundation. Inspired by this success, the Pew-managed Ocean Legacy project is dedicated to establishing, globally, over the next decade, at least three to five large, world-class, no-take marine reserves. Ocean Legacy marine reserves will provide ocean-scale ecosystem benefits and help conserve our global marine heritage.

William Aila

William is a long time harbormaster on the Waianae coast of Oahu and commercial fisherman. He is well-known as an advocate for indigenous Hawaiian rights works closely with the group Na Imi Pono. In 2006 he ran for Governor of Hawai'i in the Democratic primary. William was intimately involved in advocating for the protection of the NW Hawaiian Islands for Native Hawaiian cultural and religious reasons from the late 1990's through today. He remains active in decisions about the management of the NW Hawaiian Islands today. William is very familiar with fisheries management in the Pacific through his more than ten year’s service on various Wespac advisory panels.

The end of an era, the beginning of a new one...

President Bush signed the "Federalization" law. The Commonwealth of the Northern Mariana Islands will no longer control it's own immigration, and we will come fully under the US immigration system.

The repercussions are not yet fully known, but lots will change, for sure.

Various statements from members of Congress regarding the signing of the law can be found here.

Stuck to the Toilet

(Here is my Saipan Tribune column for this week.)

***

A few weeks ago, the news story was published about a woman who walked into her bathroom one day, and just decided to stay. She took a seat, and for two years, she sat on the toilet, until eventually, her skin grew around the toilet seat, linking her to it. Her partner commented that he thought that when she went into the bathroom, she would be out soon, but the minutes stretched into hours, days, weeks, months, and that it just became a way of life for them. Everything was normal, except that she was stuck on the toilet. Things become so weird, and you don’t know how to cope with them, so you eventually start to think they’re normal. Then one day, someone walks into your bathroom and you realize the anomaly of your situation. “Hello Mr. Fireman. What brings you into my bathroom today?”

Gradually, over the past few months, the city water supply to our home has diminished. We already only get water for an hour a day, but for years it’s been enough to fill our tank. Now, every few weeks, the tank runs dry. I call the ever-ready trouble desk at the utility. I say something like, “Salutations. Thou art hearkening to the namesake of biblical kings. I summon thee from yonder naval knoll. Liquid hath gone thither. Wherefore art thy words to bring peace to puzzled souls?” As expected, the answerer at the trouble desk says, “huh?” So I repeat myself, word for word.. “Hello. This is David Khorram. I’m calling from Navy Hill. Our water has run out. Can you help us.” Well, if I’m going to say the same thing, then the answerer is going to say the same thing. He responds, “huh?” This will go on for several exchanges, each time with me using fewer words to simplify the description of the situation, until finally, I’m down to “Nothing water Navy Hill.” The response: “Call back tomorrow.” I call back tomorrow. We do it all over again. Day after day, this exchange takes place with high anticipation of a different outcome. But every day, it ends with the same Shakespearean quote rambling in my head -- “Tomorrow, and tomorrow, and tomorrow creeps in this petty pace from day to day to the last syllable of recorded time; and all our yesterdays have lighted fools the way to dusty death.” I find myself getting used to the absence of a solution. So, we’ve been paying an extra $100 or so a month to have water delivered to our home when we run out. “Hello Mr. Fireman. Why are you bringing a crowbar into my bathroom today?”

I’ve been doing some work with a freelance graphic artist who lives in a country where snow is currently falling on the ground. All of his work is for clients that live around the world, all done through the internet. I was going to suggest to him that he move to Saipan. After all, his location matters not, because he is “internet based”. Then I realized I had forgotten that a one man show like his, and like thousands around the world, who would love to relocate to a low-tax tropical island and set up clean environmentally friendly businesses that consume and generate only electrons, needs a reliable source of electrons. Power. Electricity. Sure, bigger businesses can buy a generator. But the little guy can’t. And, wow, the economy that could be built around selling Saipan to these freelance internet entrepreneurs! But, people from most developed countries don’t think about the prospect of not having power for hours at a stretch, certainly not for days out of a month, and absolutely not on a scheduled rotating basis. “Hello Mr. Fireman. Look, my skin has grown into the toilet seat! Please don’t pry me loose.”

Let’s just fix it. Power and water. Those are some pretty basic first steps toward calling yourself a developed “investor friendly” “tourist friendly” “resident friendly” place. C’mon guys. It’s time to pry ourselves off the toilet seat.

_____________________________________________________________

David Khorram, MD is a board certified ophthalmologist and director of Marianas Eye Institute, as well as the author of World Peace, a Blind Wife, and Gecko Tails. Comments and questions are welcome. Call 235-9090 or email him through www.MarianasEye.com, or leave comments at www.MarianasEye.blogspot.com. Copyright © 2008 David Khorram

How did you end up in Saipan?

We all have it: the story we tell when someone asks, “How did you end up in Saipan?” I have a short version that goes something like this. “I always wanted to work internationally. I sent letters all over the world, ended up in Samoa, then a year later moved to Saipan.” It’s the version I tell when I meet someone. But I thought there would be some value in writing down the long version. The Saipan story is part of everyone’s Saipan experience, and it’s also part of my kids story of how they ended up in Saipan (actually, ended up being born and growing up in Saipan.)

I’m fascinated to hear the other stories out there, short, long or medium versions. So, I’m turning this into a game of tag. I’m tagging Angelo, Jeff, Boni, Bev, Brad and Bree to write about their Saipan stories. If you grew up here, what took you away, and why did you come back? If you just left, or are leaving, add that to the story too. Tag three more people to write their story of “How did you end up in Saipan?”

***

I’ve always wanted to work internationally. I grew up in a Bahá’í family, and there were two messages positive that infused my childhood. One was that the highest station for a human being was a life of service to others. The second was that it was a praiseworthy act to leave one’s homeland to serve in a place where one is really needed. The possibility of living internationally was something I grew up with. It was actually something I aspired to.

In the winter of 1992, as I was finishing my ophthalmology training, I was also in the midst of a huge personal crisis, wondering what would be the next step in my life. I prayed and meditated a lot, but I didn’t get very far. At the time, my sister, who is an attorney, was working at the Bahá’í World Centre in Haifa, in the Holy Land. So, I went there to pray and meditate some more, and also to have a chance to consult with some people who might have some insight to share with me.

My sister set up appointments for me to spend time with various individuals with experience all over the world. Many told me, “Oh, you must go to this place. The need is very great!” and depending on to whom I was talking, the place may have been Eastern Europe, Russia, anywhere in Africa, India, or South America. Finally, I landed at the desk of Don Rogers, a Canadian Artist who had been in Haifa for many years. He shared with me his own experience of being a struggling artists, and being told by his peers to stay in Canada and focus on his art, but he decided to let go of that paradigm, and managed to become an internationally acclaimed artist while still living where he wanted to live, and serving in the way he wanted to serve. When I asked him, “Where should I go then?” He said, “Send enquiries all over the planet. Give the Force some options to work with. (He actually said “Holy Spirit.”) You will be guided.” That gentle conversation in Don Rogers office at 4 Haparsim Street in Haifa turned my life.

I returned to Chicago, and began to send letters to NGO’s and Government Health Departments around the world – Africa, Asia, the Pacific, South America. But even though I was sending these letters, I was still hesitant. I wasn’t yet sure that leaving America would be my path, and so at the same time I continued to interview for the Retina Fellowships I had applied for earlier. My own residency program at Northwestern was holding a fellowship position for me, and needed me to let them know so they could pursue another candidate for the position if I didn’t want to take the spot. Time was running out.

I was starting to hear back from the hospitals around the world. Everywhere wrote back saying, “We’d love to have you. We cannot pay you a penny.” Thanks to my parents, I was lucky enough to get out of medical school without any debt, so I didn’t need a high paying job, but I did need to make some money. There were two places that could pay “subsistence” wages – a hospital in the Caribbean, and the LBJ Tropical Medical Center in Pago Pago, American Samoa. I found an ophthalmologist who had been visiting the hospital in the Caribbean every year for 20 years, and he didn’t recommend working there full-time. So, I was left with the job in Pago Pago. It was a bit familiar to me because seven years earlier, after my first year of medical school, I had spent a summer working in a dispensary on the outer island of Tau, and had spent a morning at LBJ.

But I still wasn’t sure if I should get further education or go to Samoa. It was winter, and I stood in a little bookstore under the El station in Chicago, opened a book, and on one page were the words, “Be bold and courageous. When you look back on your life you will regret the things you did not do more than the things you did.” That was it for me. I thought about those words and knew that I had to go overseas. I also realized that if I did a Retina Fellowship, I could get too specialized for the jobs available in developing countries, and I could also get stuck in America – stuck with a high-paying ego stroking job, a nice house, the white picket fence – the golden handcuffs. That night, I booked my ticket for Samoa. The next day, I let the fellowship programs know that I was withdrawing my applications.

I finished my training on June 30, and three weeks later I boarded a plane for Pago Pago. Tears welled up in my eyes as the plane left the ground. I knew it was big move. I was scared of the unknown. I didn’t known if I’d be coming back. “What am I doing?” I thought to myself.

The year in Samoa was phenomenal. There hadn’t been an ophthalmologist there in ten years, so I was incredibly busy, doing all kind of complex cases, and getting the kind of experience that people only dream about in their first jobs. It was also a year of discovery – I made some of the closest friends of my life there; I found my wife, Mara, there; and I found parts of myself and a new way of life there.

By the end of my year in Pago Pago my friends were leaving, some of the equipment was breaking down and there wasn’t a prospect of getting it fixed quickly. In the meantime, I had fallen in love with the Pacific and started to explore other possibilities – teaching at the medical school in Fiji, working in various health departments, etc.

Straub Hospital in Honolulu has a Pacific Island liaison office, and the liaison officer, Dr. Henry Preston, would travel throughout the Pacific touching base with various health departments. So he knew a thing or two about healthcare in the Pacific. When he stopped in Samoa, I asked him for advice on which countries or jurisdictions might be ready for an ophthalmologist. Many of the islands were, and are still, dealing with basic health care issues like immunization, and the resources are not available for more specialized areas like ophthalmology. Henry recommended I check out Saipan.

I had sent Saipan a letter in the initial round of inquiries a year earlier, but Saipan wasn’t ready at the time. This time, they were eager. So, in August of 1993, I took a month to travel to Saipan from Samoa, visiting hospitals and Bahá’í communities along the way in Fiji, Tuvalu, Kiribati, the Marshall Islands, Kosrae, and Pohnpei. It was a trip out of National Geographic.

I was initially hired by the CNMI government on a one month contract as a consultant – to treat patients, but to also look at ophthalmology needs in the CNMI. At that time, the place was flush with money, and the hospital had been bringing a couple of ophthalmologists here from San Diego, and paying them insane amounts ($500,000 for five weeks work – I saw the check with my own eyes). I offered to work full-time for half that amount, but of course, there were ceilings on government employees so that wasn’t a possibility, even though it made complete sense.

Anyway, my consulting contract was renewed a couple of times while the government worked to create a full-time position for an ophthalmologist, and within a few months I was hired as an employee of the Commonwealth Health Center with a usual salary.

I enjoyed my work there, and during those five years I built The Center for Eye Disease at CHC. It was fun. I published a couple of scientific papers, attended conferences at the CDC, and worked on public health issues. But, there was a limit in terms of how much I could improve things. The hospital couldn’t budget for the more advanced technologies I needed to raise the level of care, and each year there were worries as to whether or not funding would be available for my position.

By this time, Mara and I had decided to make Saipan home. (We had both left Samoa at the same time in August 1993, she heading off to Honolulu to start her Masters of Public Health, and me to Saipan. She moved to Saipan a few months later, in December and completed her MPH by traveling back and forth to UH. We got married here about a year after she arrived. That’s another very complicated, but happy story.) In making Saipan home, we realized that because of the funding issues it would be difficult to have a sense of security while working for the government. So we both quit our jobs (she was working as the epidemiologist for the Division of Mental Health at the time), and opened Marianas Eye Institute. That was ten years ago. And that’s the story of how we ended up where we are in Saipan.

I have a couple of other “Saipan stories” that I am asked about every month or so – “How did you come to open a school?” and “Four kids?!” Those stories are for another time.

Two Polls

There are two polls on Congressman Joe Camacho's website.

1. Land Ownership in the CNMI
2. Federalization of Immigration

Head over to his site and make your opinion known. Click here.

CNMI Investor Visa

I've gotten a few requests in the past few months from non-US citizens on whether or not it is possible to live in the CNMI. It is. Here is the response I sent to the last enquirer.

***

For “non-US” types, you can enter in one of three ways: as a contract worker, on an investor visa, or on a retirement visa. The first requires an employer, the latter two require money. Actually, there is a fourth option-- marry a US citizen.

I think the retirement visa is available if you are over 55 years old. I’m not sure of the financial requirements.

The investor visa requires an investment of $150K, but the investment can include the purchase/lease of property, i.e. a home. I have good friend who is Canadian, and living here by virtue of an investor visa. Here is his input:

The investor visa is obtained through the Dept of Commerce. Any questions you have should be directed to Lillian, she is very helpful and easy to work with. You can also download the application and its requirements, I believe it’s on the cnmi.gov website.

There is a long list of requirements and its a lengthy process, but its easy to follow and goes smoothly. Briefly, the investor must set up an "investment" in the CNMI, which is usually a corporation to do business, and a minimum of $150,000 in assets (real estate is acceptable). The assets must be in the CNMI, and they must all owned by the corporation.

My application has been almost an inch thick both times, but most of the info is the business plan, tax statements, etc. The application costs $1000 and the permit is good for two years.

Center for Advanced Diabetic Eye Care Opens

(From Today's Saipan Tribune. The story is generally accurate.)

Marianas Eye Institute's Dr. David Khorram, MD, chief executive officer Russ Quinn, Saipan Mayor Juan B. Tudela, Public Health Secretary Joseph Kevin P. Villagomez and Deputy Secretary for Public Health Administration Lynn Tenorio lead the ribbon-cutting ceremony for the Center for Advanced Diabetic Eye Care on Beach Road, Garapan Friday. (Jacqueline Hernandez)

By Rianne Pangelinan-Brown
Reporter

The Marianas Eye Institute held a grand ceremony yesterday for the opening of its new $200,000 Center for Advanced Diabetic Eye Care, which features the latest technology in eye care.

According to Marianas Eye Care chief executive officer Ross Quinn, the center was built specifically to address the ocular needs of the islands' diabetic population. The CNMI has one of the highest rates for diabetes in the world, third only to Nauru and the Pima Indians.

The expansion project includes the Ocular Coherence Tomography, a breakthrough eye scan technology that provides detailed color CAT-scan like images of the structures of the eye.

OCT helps guide a doctor's evaluation and treatment of a patient's diabetic eye diseases, particularly glaucoma and retinal disease.

According to Marianas Eye Institute owner and ophthalmologist Dr. David Khorram, the OCT is used at least five times a week. “It really is a huge necessity. We wish we can use it less,” he said.

The center also features a digital retinal photography and flourscein angiography. Marianas Eye Institute is one of the first two centers in the United States to acquire the specially designed high-resolution digital camera.

“With this camera, we are able to document the level of diabetic eye disease and its response to treatment. Digital photography allows you to instantly see what is happening inside your eye and to better understand your diabetes and our recommendations,” Khorram said.

The advanced cataract removal system is another one of the advanced technologies the Marianas Eye Institute implemented. It is one of the world's most sophisticated pieces of surgical equipment for restoring vision. It uses digitally modulated ultrasound to remove cataracts and provides for a gentle procedure with enhanced safety and rapid recovery time.

Another equipment is the biological modulator. It is used to treat diabetic eye disease at a molecular level.

According to John Garland of the Advanced Medical Optics in California, “Dr. Khorram uses the latest extraction techniques that are being used at U.S. mainland facilities. Your patients in the CNMI are truly getting a world-class cataract operation.”

Public Health Secretary Kevin Joseph Villagomez said the new center will lessen the need to send people to off-island referrals.

“When we send people off island for eye care, it is really for severe cases. It usually requires us to send that person there in less than a day because of needed surgery that cannot be done here.”

But with the installment of the new center for advanced diabetic eye, “that will lessen the need for travel and the need to wait for visiting specialists who are here one week and gone the next,” said Khorram.

He added he understands the financial burden that diabetes can bring to individuals and families. “For this reason, we established the Eye Foundation Fund. We want to make sure that you get the care you need, even if you cannot afford to pay for it. It is our commitment to the community.”

“What is more important here, I think, is that we are improving the livelihood of the people of the Commonwealth-and we can never put a price to that,” said Villagomez.

The two ophthalmologist of the Marianas Eye Institute includes Dr. Mark Robertson, OD and Khorram. Both doctors have received national recognition in eye care. [Mark is an optometrist, not an ophthalmologist.]

For more information, visit Marianas Eye Institute.

I Remember...

Angelo tagged me to write about 20 things I remember about Saipan, either from recently or from long ago. Here's my list.

1. I remember when calling the states cost $1.70 per minute. Mara was living in Hawaii, and I was in love, so I paid more for my phone bill than rent. (Just so as I don't get into trouble, let me clarify that I am still in love with her.)

2. I remember when La Fiesta mall was a happening place.

3. I remember getting married at the beach at the Hyatt.

4. I remember when Beach Road continued straight through American Memorial Park.

5. I remember getting one of the first email accounts on the island. I would have to call the CDC in Atlanta to download my email through my account with them.

6. I remember when prostitution had the semblance of being illegal in the CNMI... oh wait, no I don't.

7. I remember when DFS was about a quarter its current size and sat next to a dusty parking lot.

8. I remember being a government employee.

9. I remember the first time I saw footage of Saipan... a fishing show that I watched when I was living in Samoa.

10. I remember three of my children being born at CHC. (One was born in China.)

11. I remember when all the bloggers were nice.

12. I remember when soccer was small.

13. I remember thinking about leaving Saipan every year for my first few years here.

14. I remember my Dad visiting for the first time, and saying, "Okay, now I get why you won't come back to the mainland."

15. I remember five governors ago.

16. I remember when Marianas Eye Institute had one employee, and I used to answer the phones while she went to lunch.

17. I remember moving five times during my first year here.

18. I remember going back to the mainland for the first time in seven years, and realizing, "I don't know this place any more, it's no longer my home."

19. I remember a time when the government and the medical referral system were so flush with money, you could get a bone marrow transplant, just because you wanted one. Hot dog!

20. I remember a time when I didn't have to think so hard just to remember twenty things.

I tag Bev, Sean, Ken and Crystal, and anyone else who hasn't been tagged yet.

Understanding the American Mind

(My column from the Saipan Tribune, Nov 30)

America is a nation of immigrants. Almost everyone who lives on American soil traces their roots back to some poor foreigner who arrived on American shores, often with little more than a desire to purse a dream and a new life. Some, like my father, came with skills; many came with only determination. Most did not speak English. They came in waves, from around the world, and they continue to come. America became the great melting pot, each culture contributed its share to the culture of a new nation, while giving up parts of themselves to be a part of the new creation called America – a creation that continues.

The American Dream – that idea of limitless possibilities – of being able to succeed based on your own individual merit and effort – is a sacred idea in the American mind. It’s the story of the underdog, who against all odds, makes it: the guy who shows up at the dock day after day, to find work, doing anything, loading cargo, and who one day becomes the owner of the shipping line; the domestic cleaner who saves and invests her meager earnings, and before her death gives a gift of millions to a university; the kid from the ghetto who studies hard and becomes a brilliant scientist; the peanut farmer who becomes President.

These two ideas – a nation open to immigrants, and a land of dreams built by little people through hard work -- are intertwined, and deeply ingrained upon the American conscience. Any idea or act that somehow goes against these concepts strike a deep visceral chord. We cannot even begin to understand the federal policy makers until we understand these two concepts and their place in the American mind. The ideas have a history hundreds of years old in the American consciousness.

On the other hand, these two ideas are not so deeply ingrained here. In fact, in our recent history, the very ideas themselves are foreign to us. We have not had any significant immigration. Sure, we have contract workers, but not immigration in the sense of allowing people to put down roots and build for generations and to be a part of our society and government and culture. Unlike for most Americans, immigration is not part of our personal heritage.

Although life in the private sector rewards effort with success, the single largest employer – the government – relies to a large extent on a system of “who you know” rather than “what you know.” There are ceilings on advancement. And a new person in power can result in a complete change in your situation that has nothing to do with your merit. It’s the relationships that matter more. The icon of the immigrant who beats all odds to succeed, is not a dominant part of our family histories.

Thus the bewilderment with the federal perspective. We do everything we believe is required to protect our culture, which itself is not a dominant value of the ever-morphing American culture. We allow workers to enter, but not to immigrate. We pass laws that favor the hiring of our own ethnic group over others. We “reform” our labor laws, requiring aliens to exit periodically, for the expressly stated purpose of preventing them from growing roots and becoming part of the political landscape, the power base. It all makes perfect sense, and resonates with our core value of cultural preservation. We don't want to become politically alienated. We strive to protect our ethnic control over the institutions of power. But the American value and the local value smack hard against one another.

Never mind that in many ways, America is conflicted about immigration and race. The inconsistency does not negate the deep pride that many feel in having come from humble immigrant roots. And never mind that the aliens that are here didn’t arrive with promises of immigration. They have contributed greatly, and the American values seeks to find a home for them.

This is all worth bearing in mind when we sit at a table discussing issues with the representatives of the federal government. They are the sons and daughters of those immigrants who were once disenfranchised workers coming from a foreign land, and who entered America, whether literally or figuratively, beneath the lamp of the Statue of Liberty, on whose pedestal are carved these words:

“Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tossed to me.
I lift my lamp beside the golden door.”

Pink Eye Epidemic Quieting Down

It seems like the epidemic that struck Saipan about a month ago is starting to quiet down. We're still seeing a steady trickle of cases, but nothing like the huge numbers we were seeing at first. Here is the worst case I saw. Yes, that stuff on the left side is the conjunctiva (the white tissue on the surface of the eye -- here really really red) actually coming out from between the eyelids. She couldn't close her eye because of the tissue hanging out.

The CNMI's New Labor (and Immigration) Law

This controversial bill was signed into law yesterday. The most contentious section of the new law provides for an exit requirement. All non-resident workers must leave the CNMI for six months every three-and-a-half years. The business community has been fighting hard against this. Many rely heavily upon non-resident workers, and the prospect of being without key workers for a six month period, and the cost of filling the gap, have been concerning.

Why the clause? Today's Saipan Tribune gives the answer, quoting the Governor.

Fitial said the exit requirement is designed "to prevent the aliens from making the CNMI their home and making them eligible for permanent resident status [under future federal immigration law]."

There you have it.

Book Cover Completed!

Here it is! The designers have completed work on the cover of my new book, "World Peace, a Blind Wife, and Gecko Tails." I'm very happy with it. I though the designers were very creative to depict a fairly complex title. The next step is the interior layout design, and then printing. I was hoping it would be out by Thanksgiving, but it looks like it will be a bit later.

Saipan is in the South Pacific

(My Saipan Tribune column from yesterday. Some links show up here because I copied the text straight from Wikipedia.)

I have previously shared my view that we need to boldly state that we are located in the South Pacific. I think it helps our marketing in that the term “South Pacific” evokes an accurate image of what we are all about – sandy beaches, swaying palm trees, lush vegetation, coconuts. I’ve also argued that “South” does not need to be strictly defined in relation to the equator. It’s just in relation to some other place that’s north of us. We are certainly in the “southern” Pacific. There is no arguing that. The word “North” is not a good word to depict a tropical island.

Nevertheless, any time I say I live in the “South Pacific,” some wisenheimer pipes up, “We’re in the NORTH Pacific.” Arrrrgh. Think outside the equatorial box! I finally did a bit of research on the matter and I am now vindicated in saying we’re in the South Pacific. This phrase needs to be integral to all our self descriptions.

Now, granted, the only place that I could find anything on a Google search for “Where is the South Pacific” was on Wikipedia, an online encyclopedia whose entries are written by anyone that wants to write them. But still, unless you’re deciding about life and death, it seems to be a pretty accurate place for information, and I rely on it regularly.

Wikipedia’s entry on South Pacific states the following: “The South Pacific is an area in the southern Pacific Ocean.” Okay, that is good enough for me, but if you need more, the article gives you three options. It states that the term, South Pacific, may refer to

1. Australasia, an area including Australia, New Zealand, New Guinea and other islands including the eastern part of Indonesia;
2. Oceania, a geographical (often geopolitical) region of many countries/territories (mostly islands) in the southern Pacific Ocean;
3. Strictly taken, that part of the Pacific Ocean area south of the equator bordered by Indonesia, New Guinea, Australia, New Zealand, the 60th south latitude, the west coast of South America and the equator. South of the 60° latitude, it is part of the Southern Ocean.

We fall into the “Oceania” category. If you click on Oceania, you’ll find the following definition: “The exact scope of Oceania is defined variously, with interpretations often including Australia, New Zealand, New Guinea, and various islands of the Malay Archipelago. Ethnologically, the islands of Oceania are divided into the sub-regions of Melanesia, Micronesia, and Polynesia. The term is also used by numerous authors and in many languages to define one of the continents.”

Clearly, Oceania is a term that’s used rather loosely, but it does include the islands of Micronesia, and right there on the list in the article, you’ll find that the Northern Mariana Islands are part of Micronesia. I don’t think anyone disputes that.

It’s not that I was doubtful by my own inclination to place us in the “South Pacific,” but now I have something to help nudge anyone who is sitting on the fence, confused by the equator. At least someone else out there agrees that it’s appropriate for Saipan, Rota and Tinian to be called part of the South Pacific. There will still be the sticklers who will reference our location to the equator, and continue to say we’re in the North Pacific. But for the rest of us, the South Pacific is where we are. And for many of us, it’s okay to be in both the North and the South Pacific, depending on who we’re talking to, and what the situation is. For tourism and travel, and anyone north of us, we’re in the South Pacific.

Epidemic Strikes Mariana Islands

You may have seen the article on the front page of the Tribune today. We are in the midst of an ugly epidemic of "pink-eye." This strain appears to be highly infectious, striking members of entire families within ours of one another. It's also one of the "hemorrhagic" strains which causes bleeding on the surface of the eye. I've been seeing about a dozen patients a day with this for the past few days.

Pink eye is caused by one of several viruses. It usually takes a week or two to go away. I tell my patients that it's just like a cold. We can't cure it. You have to wait it out. But we can treat the symptoms -- pain, itching, tearing, irritation --- with a variety of medications. This is the reason people come to see me: to get relief of their symptoms.

The big danger with viral conjunctivitis of this sort is that it can cause permanent corneal scarring and vision loss. Scarring can be prevented if we catch things early enough.

The big effect of epidemic viral conjunctivitis is that it results in huge losses in productivity from the general misery it brings. And, because it's highly infectious, anyone who gets it needs to stay away from work or school for about a week.

Isolation is one of the ways to prevent spread. The virus is spread through indirect contact with tears. Someone has pink-eye, they rub their eye and open a door. You're the next person to open that door, then you touch your eye innoculating it with the virus and you get pink eye. Prevention lies in washing your hands after you touch your eyes, if you have the virus; and in washing your hands before you touch your eyes if you don't have it yet. Don't share towels or pillow cases.

It's not an airborne disease. There is some superstition that if you look at someone with pink-eye, you'll catch it. This isn't true. You have to come into contact with the tears, directly or indirectly.

Be careful. Wash your hands. This is a miserable strain right now.

Casinos and Public Health

(My column from today's Saipan Tribune).

I’ve thought it rather witty that those who don’t support the casino have been calling it the “casiNO,” and I’ve been surprised that we haven’t yet seen the “caSINo” signs. I also fully expect to see that the supporters, who are touting “Economic Jackpot” will soon be putting up “CASHino” signs. What spin we see when elections near!

With the signs going up, and the ballots being prepared for the vote on the casino issue, I decided to do a little research of my own on the health effects of casinos on a community.

There is actually quite a bit of experience and hard data on the issue, particularly from Canada, where provincial governments have about ten years experience with the effects of casinos on their communities. It’s recognized that casinos (and gambling in general) bring problems. The motivating factor for communities to allow gambling is always money. No one says, “Wow, this is a socially beneficial activity, so let’s bring it into our community.” They say, “We need the money, so let’s allow gambling.” When government revenues decrease, as have ours, people start to look to gambling as a way to increase government income, and it works! To the extent that governments either tax the revenues, or are shareholders in the gambling operations (such as in state run lotteries, or government owned casinos) government revenue does increase. Gambling, can indeed be an “economic jackpot.”.

Now, in order for that to happen, the casino users, MUST lose money. It’s how the casinos make profit. In order for the gambling operation to be profitable, the gambler must lose money, and so all the games and the machines are designed to make you, collectively, lose. It’s simple math. In fact, it has been said, that lotteries and casinos and other gambling operations are a way to tax people who don’t understand math.

Communities that allow gambling almost immediately experience an increase in both the number of people in the community who gamble, and the amount of money spent on gambling. For example, in Niagara, the year before their casino opened, 11% of the population had gambled. A year later, 43% had gambled. The amount of money spent per individual on gambling increased five times during this same period. That’s great news for the casino and the government, but not good news for the people who are spending (and losing) their money.

Most people who gamble don’t develop any problems (other than losing money). However, a small, but significant segment of the population will experience adverse effects from gambling. According to a study looking at public health perspectives of gambling in Ontario, “problem gamblers” are defined as those individuals that “have a continuous or periodic loss of control over gambling, a preoccupation with gambling and with obtaining money to gamble, irrational thinking, and a continuation of these behaviors despite adverse consequences.”

How many people are affected by problem gambling, and what effect does a casino have on this number? In Niagara, the percentage of residents with gambling problems before the casino was 2.5%. After the opening of the casino, the number doubled. If we apply those numbers to the CNMI indigenous population, presuming about 20,000 indigenous residents, we would end up with about 1,000 people with gambling problems after the opening of a casino. That sounds like a big problem for a small tightly knit interrelated community.

The health and social problems of gambling have been well documented, and we have experience already with this problem here in the CNMI. HealthUnit.org describes the health effects of gambling as follows:

Problem gambling, while providing additional revenues, also results in significant costs to the individual, his or her family, and society as a whole. Uncontrolled spending, the resulting debts and the strategies used to gain more money to gamble has a significant impact on many determinants of health and can cause marital conflict, child neglect, poor work performance, multiple addictions, stress-related physical ailments, crime and even suicide. Children of pathological gamblers are two times more likely to attempt suicide, have lower grades than their peers and have higher rates of substance abuse.

The cost of problem and pathological gambling does not only affect individuals and their families. Society also bears the brunt of gambling, with the overall cost to taxpayers estimated at $56,000 for each problem gambler, including cost of treatment, health-related costs, absenteeism at work and time spent in courts.

Problem gamblers are more likely than the general population to be involved in other forms of addictive behavior such as alcohol or drug abuse. Stress-related ailments such as ulcers, colitis, high blood pressure, heart disease, migraines and skin problems are also much more common among problem gamblers. Even more serious is the rate of attempted suicide, which is higher among pathological gamblers than among all other addictive behaviors. A Québec study of college students found that 26.8% of pathological gamblers had attempted suicide compared to 7.2% of college students with no gambling problem.

Crime is also an issue between problem and pathological gamblers and becomes a viable option to support gambling habits when all other resources are exhausted. "Studies show that two out of three pathological gamblers commit crimes to pay off debt or to continue gambling. While the majority of crimes are nonviolent and involve embezzlement, cheque forgery, stealing credit cards, tax evasion, fencing stolen goods, insurance fraud, bookmaking, and/or employee theft, in some cases they involve violence and armed robbery." (National Council on Welfare, 1996, p.28)

So, there is no question that casinos bring increased revenue to their shareholders and to the government. There is also no question that casinos bring social and health problems into their communities. There is no need denying the financial benefits, nor the problems. Where you stand on the casino issue depends on how you weigh the benefits against the problems. Either way, there are trade-offs. You give something and you get something. Either you give up the money, and maintain social and mental health; or you give up social and mental health and get money. That’s a definite. It’s been studied and shown in communities that have the experience with casinos. Casinos bring more money. And they bring more problems. No matter how you vote, you will be giving something up. Just have your eyes open to this fact.

As for me, I see enough social ills and health problems on a daily basis in our community. I don’t want to see any more. If we follow the pattern of other communities that bring in casinos (and there is no reason to think we won’t), within a year of casinos we will have twice the number of people suffering from problem gambling and the economic and mental devastation it brings to their families. From my perspective, the money just isn’t worth it.

The Joy of Drugs

You never really appreciate the little things in life, like narcotics, until you really need them. I drove down to the football field on Monday to thank Jason for the opportunity to try out for the National Team, and to let him know that I was bowing out due to the injury, and the family needs. Mara bought ice cream in celebration of my "return."

By 9 PM I could not move my leg, and I stood with my head against a wall, tears streaming down my face from the pain. I'm reading a book right now by a Buddhist monk, and he says that even suffering has value if we use it to be more compassionate to others who are also suffering. It didn't take the edge off, but it was an interesting thought at the moment. I took some Tylenol with codeine and fell into a drug induced sleep.

I woke up yesterday morning, still with searing pain and drove to the ER to make sure nothing was broken. Nothing was broken. The doc told me to take anti-inflammatory pills every six hours no matter what, to try to quiet things down -- 800 mg of ibuprofen, for a total of 3200 mg a day. If this didn't work, the plan was to take oral steroids. I also got a prescription for some more Tylenol with codeine.

After 24 hours of the anti-inflammatory meds, I can walk with only a slight limp. It's really amazing, the power of modern pharmaceuticals. Someone who had sustained this injury 100 years ago would have been in pain for weeks. Heck, even now, someone who has no access to basic medicines suffer needlessly.

So it looks like this saga is coming to a close for me.

I ran into someone last night who said they heard about my injury and what a pity it was because the word was out that I had a good sense of the game and was a decent player. Now that was the most unexpected part of this whole thing for me, mostly because I disagree, but it was nice to receive the complement.

Football Continues...

We had our third practice on Friday evening, which went well enough. There were no sprints.

Today we had our first game, playing against the Saipan Thai Team. We lost 1-2, but no goals were scored while I was on the field. We played three 30 minute periods and I was on for about 20 minutes. Nothing spectacular and nothing disastrous. I just wish I were quicker.

We have practice tomorrow evening and again on Thursday and at that time Jason will make the cuts to form the team. As much as I'd like to make the team, the reality is that it's hugely taxing on my family. Mara keeps encouraging me, saying that if I make the team, it's only a six week season. But I see the strain on her and the four kids, so I have a decision to make this week.

I will say that I think Jason is a great coach. He's firm and lays down the law when needed (like today), but he does it in a way that is respectful. He also encourages good play and brings out the best in everyone.