A GP unable to prescribe antibiotics is like...?

A (non-medic) friend recently tweeted this story from the BBC to me. The headline commands GPs 'must cut use of antibiotics'. His additional tongue-in-cheek note was "is this your career unravelling?" peddling the longstanding myth that antibiotics form the solitary weapon in a GP's armoury.

The latest diktat is from the European Centre of Disease Prevention and Control and warns against inappropriate antibiotic use and increasing bacterial resistance. This is nothing new. Fortunately the powers that be have realised that the situation is not down to an incestuous relationship between GPs and drug companies but public (un)awareness. The government apparently launched a major advertising campaign earlier this year telling people that antibiotics do not work on coughs or colds.

Anecdotally patients I've seen seem less resistant to the idea that rest, fluids and over the counter medicines should see them through a viral illness. My family have stopped asking me for advice, safe in the knowledge that they can pre-empt my suggestion of "take some paracetamol and let's review things in a couple of weeks".

This year the picture's been complicated somewhat by the perpetual fear of swine flu that appears to be regarded by most patients as just a notch down in severity from the bubonic plague. An interesting result of the heightened swine flu awareness though does appear to be an increasing appreciation that antibiotics do not treat viruses.

What are your experiences?

On being Mr Wolf on Saturday mornings

A couple of Saturdays ago I found myself being awoken at 08:00 by an alarm I couldn’t remember setting. I lay in bed for a few moments toying with the idea of returning to sleep knowing full well that I’ve inherited my father’s inability to lie in. By 09:00 I was showered and shaved and working my way through a long list of neglected emails and admin. This was going to be a productive Saturday.

At 09:30 the phone rang. I didn’t recognise the number. Ordinarily I would have let it ring out but something compelled me to answer.

Carry on reading here.

The Sultans' Throne

The Imperial Toilet, Topkapi Palace, Istanbul ©Tauseef Mehrali 2009

on the iPhone and Twitter

The vast majority of the weekend so far has been unashamedly devoted to mastering the new iPhone. My heavily entrenched scepticism prevented me from riding the euphoric first waves of iPhone possession. It soon became clear that the fact I was drooling whenever I saw an iPhone within touching distance meant the time was right to become one of Steve Jobs' iChildren. Stephen Fry's panegyric in yesterday's Guardian has helped expel any remaining tinges of guilt.

On Friday I was part of a tutorial introducing us to the potential/emerging role of new media in medical education. The focus of the session was Twitter. Again something I'd given wide berth to and dismissed as a means for people to broadcast nothing more than updates on their bowel habits. The so-called Green Revolution in Iran (and its apparent Twitter dependency) however happened to coincide with tutorial lending it a surreal geopolitical air of significance. The utility of Twitter as an educational tool is actually quite exciting: the instant recording of Patients' Unmet Needs (PUNs) and Doctors' Educational Needs (DENs), the posing of concise clinical conundrums to a group of peers, to name a few.

Test Tweet

Trying to synch my blog with Twitter. Here goes...

On Meat Free Mondays

The next BMJ blog entry is now live:

My grandfather used to counsel my mother’s worries about my insatiable carnivorous tendencies as a child by suggesting that the only solution would be to ensure I gain a butcher as a father-in-law. I would frequently be teased at dinner parties when it looked like I was struggling to make it to dessert with mock incentives such as the profiteroles actually being meatballs. My meat eating was so ingrained by my teens that an aunt felt compelled to proclaim that I should stop making my stomach a graveyard for dead animals.

Read the whole post here.

Light & Dark

Hagia Sofia, Istanbul ©Tauseef Mehrali 2009

Hagia Sofia

Hagia Sofia, Istanbul ©Tauseef Mehrali 2009

Dispatches from Istanbul (5)

A mid-morning ferry from Eminonu took us to Eyup this morning. Eyup, the alleged resting place of the Prophet's companion Abu Ayyub al-Ansari, lies at the head of the Golden Horn. As it technically lies outside the precincts of the city, Eyup was, and still is used as one of Istanbul's cemeteries. The added allure of being buried in the vicinity of a holy personality has pretty much transformed it into a necropolis.

It was a cooler day today which thankfully eased our treck up the hillside overlooking Eyup to the Pierre Loti cafe, offering some of the best views of the Istanbul cityscape. A frequent sight at Eyup is of mace-wielding young boys dressed in regal clothes sheepishly in tow to family and usually gorging on sweets. Surely no amount of sweet-based bribery can divert their attention from what lies ahead later that day: sunnet or circumcision.

I couldn't resist ordering a Superman Pide for dinner from a local eatery we've discovered. Who could? A pide is a boat shaped pizza not too dissimilar to a calzone. The superman variant boasts a topping of salami, Konyan cheese, fried meat and egg.

Dispatches from Istanbul (4)

This morning my previously lack lustre breakfasting experiences underwent a real renaissance by virtue of a delicious homemade fig jam. Mixed with natural yoghurt, it's difficult not to have seconds and even more difficult to resist thirds. I suppose an infinite supply of figs is a useful counterweight to the physiological consequences of a toilet in the hotel room that must have been presented to the people of Lilliput by Gulliver. Ergonomically it's a disaster. A step ladder, or for that matter even a jar of homemade jam, would be indispensible in simply reaching this mighty throne.

We ventured westwards today towards Beyezit and the university. A timely pit-stop at a local Baklava vendor meant we probably significantly overcompensated in replenishing our blood sugar levels with a selection of sweets and Turkish tea. Actually it was just enough sugar to provide the necessary fuel for an afternoon of...haggling for towels in the Grand Bazaar. Apparently we won.

The language remains totally impenetrable to us. Turkish seems designed to neuter any advantage the amateur Arabist may have in the Middle East. I feel dyslexic and dizzy when faced with the barrage of consonants, umlauts and cedillas.

We had dinner dockside in Eminonu as the sun disappeared behind the pencil like Ottoman minarets. Unsurprisingly, it consisted of freshly cooked fish placed in roughly cut bread along with a helping of salad and onions to which you can add as much rock salt and lemon juice as you desire.

I can't sign off without mentioning a snippet of conversation overheard earlier today as a middle-aged American tourist rather naively requested of her tour guide:

So, like, what's happened over here over the last century then?

Dispatches from Istanbul (3)

No visit to Istanbul is complete without the requisite 'compare and contrast' tour of the Blue Mosque and its predecessor, the Aya Sofia. Which of the two great edifices you prefer tends to boil down to whether you're atracted to decoration or design. Intricate and exquisite arabesques in Iznik blue dominate the interior of the Blue Mosque whereas the architectural genius of Emperor Justinian's Aya Sofia lies in the seemingly freestanding dome and the resulting sensation of spaciousness.

We grabbed a bus and headed to Ortakoy in the afternoon. The village sits along the European shore of the Bosphorus and is feted as being one of among 'Istanbul's coolest, chic-est, most artsy neighborhoods'. Sunday is apparently the day to visit due to a bustling street market and we weren't disappointed. An eclectic Baroque mosque, the Etz Ahayim Synagogue and an Orthodox church punctuate the cafes, boutiques and bistros. Strangely, our take home memory of the village will be of the ubiquitous jacket potato. It appears as though the whole potato (rather than its multiple derivatives) as a dining experience has only just hit the shores of the Bosphorus. And it's hit hard. Almost everyone was carrying a jacket potato laden with a mountain of fillings. Those that weren't carrying, were selling.

Dispatches from Istanbul (2)

Traders in the Grand Bazaar have one of the best repertoires of inane comments to be found anywhere in the world's commercial hubs. Take this for instance:

"Lady, excuse me! Are you perfect? Then you need this perfect bag!"

I can't overcome the belief in the inevitability of being ripped off in such venues. This delusion is not aided by the fact that the Istanbulites seem to have agreed amongst themselves that Mrs Africanus and I are wealthy Arab visitors who can't wait to be parted from our dirhams. Our mission to eventually pass off as fully fledged Istanbulites though has come one step closer as we are now proud possessors of an Akbil, the oyster card equivalent.

We've worked our way through the role call of kebabs in all their guises - an idea for a potential 'Guess Who?' spin off - and were pleasantly surprised to find a halal Wagamama's in Beyoglu. The quality of coffee out here is impressive. Although I can't manage the traditional kahve - coffee flavoured molten lava - the more modern coffee houses pour some fine espressos.

Dispatches from Istanbul

Arriving in Istanbul this afternoon was somewhat reassuringly just as complicated as I last remember. This time however, in addition to the easily overlooked purchase of a visa on arrival, there was the added bureaucracy of Swine flu screening. The far from rigorous process consisted of fighting my travel sickness to complete a meaningless form which looked as though it was a photocopy of a fax of a scanned document and perhaps better suited to testing my appreciation for abstract art and visual acuity rather than risk of transmitting H1N1. As we touched down on Turkish soil, the Istanbulite sitting alongside me and Mrs Africanus promptly pulled out a 5TL note, flashed it before our eyes and pointed to the ageless image of Ataturk, I presume to give his bizarre welcome gesture some stately gravitas.

The city itself is thankfully as welcoming and relaxed as I remember. We took a lazy stroll through Sultanahmet, lunched whilst gazing at the Aya Sofia and spent the evening indulging in some caffeine fuelled people watching on Istiklal Street in the lively Beyoglu district. Tomorrow can't come soon enough...

On Ladybirds and Tree-hugging

From last week's Editor's Choice over at the BMJ:

And still in London, general practitioner registrar Tauseef Mehrali watches a film depicting brutal social realism as part of a training session on child protection: "We were challenged to investigate our own triggers for initiating child safeguarding proceedings and to confront subconsciously held stereotypes: is the failing of a parent to conform to our own usually middle class social norms a justifiable trigger? Perhaps more importantly, is conforming sufficient reason to overlook? ... The UK is the worst developed nation in which to be a child, according to both UNICEF and the Good Childhood Inquiry. General practitioners are at the forefront and therefore perfectly placed to guide a redressing of the balance. Encouraging trainees to discuss these issues in novel ways can only help this process."

Read the blog entry here.

On War and Medicine

The BMJ blog marches on:

My practice recently revamped its provision of short-notice medical appointments by transforming the Emergency Surgery into the (so far so good) Rapid Access Surgery. In essence, patients can now no longer pitch up to the practice between 11 am and 12 noon and definitely see a doctor regardless of their complaint, or lack thereof. This apparent erosion of choice has in fact seen the replacement of the dichotomous old system, which offered only routine and emergency appointments, for a myriad of appointment options: 24-hour access, 48-hour access, minor ailments being addressed by the nursing team and routine appointments. There are now more ways to see the doctor than means by which senior bankers can avoid saying sorry.

Read more here.

On Casting the Safety Net

You can bring yourself up to date with the 4th instalment of my BMJ Blog here.

Zapiro on Shoe Throwing

Masjid al-Quba

Masjid al-Quba, Medina, Saudi Arabia ©Tauseef Mehrali 2008

A Brief Break in Beirut

On returning from Hajj I was pleased to see that my account of a short stay in Beirut earlier this year has been published in this month's Emel magazine.

A Brief Break in Beirut

We stood out like the proverbial sore thumb. In reality, it was a sore foot and some luminous yellow crutches that made us stand out. A few days previously, across the border in the Syrian capital, my wife had re-enacted her own Damascene moment at the Eastern Gate of the Old City. Rather than a blinding light catalysing a religious revolution, her episode involved a stack of paving slabs and a third metatarsal, necessitating a visit to the nearby French missionary hospital. So it was with a limb wrapped in plaster of Paris and copious pain-killers that we crossed the border, one April evening, into Lebanon in the back of a weathered Chevrolet with an equally weathered taxi-driver at the wheel.

We were advised to give a wide berth to Lebanon let alone the volatile southern suburbs of Beirut. Since the assassination of former Prime Minister Rafik Hariri on Valentine’s Day in 2005, Lebanon has experienced a string of assassinations, rising political and sectarian tensions and a 34-day war fought between Israel and Hezbollah. The collective wisdom of the Lonely Planet’s online Thorn Tree Forum helped us put aside our misgivings though. As we checked into the Mayflower Hotel we drew further comfort from the knowledge that this hotel, a former hangout for seasoned journalists, had safely housed these hacks during the brutal civil war.

The Mayflower lies very near to the uber-fashionable Hamra Street (or in keeping with Beirut’s French-leaning sensibilities, Rue Hamra), the retail heart of Beirut. Fashionistas and fashion-victims patrol the street and emerge from gleaming SUVs. During daylight hours the street is thronging with shoppers and by night it transforms into an open-air catwalk. There are some gems amidst the endless clothes shops including the Lebanese branch of the ground-breaking Al-Saqi books, just off the main road. Bibliophiles can also find a cluster of bookshops near the American University of Beirut, originally a missionary outpost know as the Syrian Protestant College, locally referred to simply as AUB. Librairie du Liban, the publishing house responsible for the ubiquitous Arabic dictionary by Hans Wehr and the increasingly common place Lane’s Lexicon, is amongst them.

Soon we were drawing not only comfort but courage from the souls that had passed through the Mayflower and it wasn’t long before we found ourselves braving a freak rain shower to attend a photography exhibition in southern Beirut. We’d picked up an emotive flyer in a theatre foyer the previous day advertising the exhibition entitled Algerie: Photographies d’une guerre sans images (Algeria: Photographs of a war without images). The showing was taking place at the unassuming but outrageously named Hangar, on Haret Hreik. As we entered the southern districts of Beirut the areas’ political affiliations became increasingly apparent; forests of Amal and Hezbollah flags and insignia vied for prime position in our field of vision. The central reservation of the road we were driving along soon sprouted a column of street lamps, each hosting a picture of a fighter killed in the recent conflict with Israel.

The exhibition, hosting a decade’s worth of photography by Michael von Graffenried from the Algerian civil war, was a moving collection. The images captured the incredible human suffering, injustice and brutality of that conflict. The parallels with Lebanon’s own situation did not go undetected.

We emerged from the Hangar into yet another downpour and quickly made our way to the nearby Ramadhan Juice at the Ghobayri Crossroad to take shelter. A muscular bearded man with a neck wider than his head sat at the till and politely enquired what we’d like to drink, pointing to the framed menu behind him. Alongside the menu was a huge mural of Sayyed Hassan Nasrallah looking benevolently down upon the juice drinkers. Perhaps unsurprisingly, the first drink on the menu was a Katyusha rocket cocktail. After much deliberation though we opted for the less incendiary and far simpler mixed fruit cocktail and watched some al-Manar as we sipped our concoctions.

The dilemma that faces amateur Arabists when travelling through the Middle East is one of language. Modern standard and even classical Arabic are far more commonly taught in the West whereas the language on the street, ‘aamiyyeh or colloquial Arabic, is a far cry from the rigid grammatical structure of its more formal counterparts. Needless to say we reduced many Lebanese to tears of laughter as we requested assistance, directions and prices in the equivalent of Shakespearean English.

The language of food (and not only love) is thankfully universal. We enjoyed some excellent meals in Beirut, none surpassing the wares offered at the longstanding Kabab-ji which has outlets throughout Lebanon. The delicious kebabs and mezze being served up were even more palatable with some sumptuous muhammara, a walnut and roasted red pepper accompaniment. Nearer to our hotel, a Swiss patisserie that appeared to be untouched since the French mandate, provided us with some tasty treats. (To the genial old lady running the store, I extend my apologies for dripping coffee all over your shop floor).

A crucial stopover in Beirut has to be the corniche, where the Mediterranean Sea laps at the Lebanese shoreline. The people-spotter buried in each of us cannot fail to be unearthed by the panoply of characters promenading alongside the coast. We wandered past Pigeons’ Rock, an outcrop of rock jutting up from the mainland not dissimilar to some of the physical geography off the Dorset coast, and our collective consciousness was suddenly invaded with the dredges of GCSE geography that we carried with us.

The much lauded Downtown area proved to be a bit of an underwhelming experience. The area was the cultural heart of the city before being destroyed in the civil war. It has been painstakingly restored but the perfect, unblemished facades of the buildings make it feel a little surreal. Several security cordons were filtering access to the area resulting in a disproportionate number of well-to-do Beirutis dining al fresco while their rotund children were chased around with spoonfuls of food by their Philippino nannies. The fact that I was frisked by one of these security cordons did nothing to endear Downtown to us. However, there is something undeniably alluring about strolling around amidst the vestiges (some original, but mostly touched-up) of a huge spectrum of architectural periods and forms from Crusader to Ayyubid and from Mamluk to Ottoman.

We hailed a taxi outside Charles Helou bus station to take us back to Damascus without much difficulty. Our apparent stroke of good fortune was soon blacked out by the cigarette fumes from the living chimney that was our taxi driver. Through the clouds of ash we struggled to see him and breathing became a little tricky until we convinced him that on this occasion, open windows was a better choice than air conditioning. He soon got talking and was elated by me underestimating his age by a decade. He disclosed that he was a father of four allegedly demanding children and as a result not a great fan of Eid.

Our driver got us safely back to the Old City in Damascus and once again we felt like we’d stepped out of a time machine.

Postscript

A month after our visit, the country erupted in yet another bout of the cyclical violence that has plagued the tiny state. A poignant extract from Khalil Gibran’s ‘The Prophet’ follows the title page of Robert Fisk’s Pity the Nation and it remains just as resonant.

Pity the nation that is full of beliefs and empty of religion.
Pity the nation that wears a cloth it does not weave, eats a bread it does not harvest, and drinks a wine that flows not from its own winepress.
Pity the nation that acclaims the bully as hero, and that deems the glittering conqueror bountiful.
Pity the nation that despises a passion in its dream, yet submits in its awakening.
Pity the nation that raises not its voice save when it walks in a funeral, boasts not except among its ruins, and will rebel not save when its neck is laid between the sword and the block.
Pity the nation whose statesman is a fox, whose philosopher is a juggler, and whose art is the art of patching and mimicking.
Pity the nation that welcomes its new ruler with trumpetings and farewells him with hootings, only to welcome another with trumpetings once again.
Pity the nation whose sages are dumb with years and whose strong men are yet in the cradle.
Pity the nation divided into fragments, each fragment deeming itself a nation.

Sweet Cider

It was worth making the effort to get to the penultimate showing of Sweet Cider, Emteaz Hussain’s stage debut for Tamasha productions. It helps that I am enamoured with the plethora of Turkish grill restaurants, or mangal ocakbasis, that encircle the Arcola theatre in Dalston. (My cousin recently changed my life by introducing me to Hasan Meze & Mangal whose grilled onion with pomegranate juice, olive oil and lemon juice is simply superb).

The play itself was both charming and challenging. The audience is invited to share an unspecified period of time with two Muslim girls from somewhere near Manchester as they rebuild their lives having been forced to relocate to a women's refuge. It was refreshing to see the idiosyncratic Northern Anglo-Pakistani dialect replicated so wonderfully well on stage.

My only criticism would have to be the writer's succumbing to dealing with seemingly every single issue affecting British Muslim youth at the expense of character development. A noteworthy debut nonetheless.