Mubarak’s Gallbladder Removal Doesn’t Remove Questions

Here is what came in the news. By Samer al-Atrush (AFP) – March 6, 2010

CAIRO — Egypt's President Hosni Mubarak had successful surgery to remove his gall bladder on Saturday, a German hospital said, after the veteran leader handed over power to his prime minister while he recovers.

Heidelberg University Hospital said in a statement that a growth was also taken out of Mubarak's small intestine, and that the president was fully conscious after the operation.

Mubarak, 81, had suffered from chronic calculus cholecystitis, an inflammation of the gall bladder accompanied by gall stones, and a duodenal polyp, said the statement.

"Accordingly, a successful open surgery was carried out this morning to remove both the gallbladder and the duodenal polyp safely," Dr. Marcus Buchler was quoted as saying.

"The frozen sections taken during the operation were all negative," he added without giving any details on the tissue that was examined and what ailment the tests were meant to detect.

"I am fully satisfied with the performance and outcome of the surgical intervention conducted this morning," said the German doctor.

This opens many questions in my mind:

First of all: Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies and fried foods. It is usually accompanied by a low grade fever, vomiting and nausea. More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders: Peptic ulcer, Hiatus hernia, Colitis, functional bowel syndrome. That means the president case is more complex to diagnose. Nevertheless, the president must have suffered many episodes of pain before. One has to ask the first question: what did the president do during those episodes?

2nd Question: The president had an episode of collapsing while giving a speech before. It was explained before as suffering from flu and antibiotics during fasting Ramadan. That could very well be true. It may have been also a severe episode of gallstones moving through the cystic duct, which leads to shock and jaundice.

3rd Question: Even though the chronic symptoms can be confused with many other common disorders, one has to think that the president doctors ventured into at least doing an ultra-sound to rule out the gallbladder possibility. The chronic cholecystitis develops over years. It is hard to believe that a president in his 70s has not had ultrasound in several years to reveal this disorder given that he must have had episodes of abdominal pain. Either his doctors in Egypt are extremely incapable or they have done it and they were able to diagnose the cholecystitis. It is really hard to miss the gallstones on the ultrasound.

Let us assume that Mr. Mubarak did not do a single ultrasound in years even though he got episodes of abdominal pain. Here is the 4th question. Cholecystitis - Caused by blockage of the cystic duct with surrounding inflammation, usually due to infection. Typically, the pain is initially 'colicky' (intermittent), and becomes constant and severe, mostly in the right upper quadrant. Infectious agents that cause cholecystitis include E coli, klebsiella, pseudomonas, B. fragilis and enterococcus. Murphy's sign is positive, particularly because of increased irritation of the gallbladder lining, and similarly this pain radiates (spreads) to the shoulder, flank or in a band like pattern around the lower abdomen. Laboratory tests frequently show raised hepatocellular liver enzymes (AST, ALT) with a high white cell count (WBC). With such a chronic case that Mubarak’s German doctors described, his liver enzymes most likely have been elevated particularly because of the blockage of the cystic duct. It is hard to believe that during the past few years, Mr. Mubarak (who is 81 and is after all the president) did not do a single liver function lab work particularly after suffering episodes of pain.

Why am I asking this 3rd question about ultrasound and lab work? Cholecystitis is cured by removing the gallbladder. This can be done in one of two ways: Laparoscopic procedures or open surgery. Laparoscopy can have less morbidity and a shorter recovery stay. Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. Doctors almost always prefer to perform laparoscopy particularly in a patient who is 81. If the doctors have diagnosed Mr. Mubarak’s disorder before, why didn’t he undergo a laparoscopic procedure few years ago? If they havent diagnosed it before, then one has to wonder about the kind of healthcare that Mr. Mubarak is receiving and the capability of his doctors in Egypt unless they were able to diagnose it and were not able to operate because of other complications that nobody knows about yet? It could also very well be that they had to do an open surgery because of the detection of the Duodenal Polyps.

Screening for duodenal polyps is usually done with a duodenoscope, a pencil-thin, flexible tube inserted into the mouth and guided down the esophagus, through the stomach, and into the duodenum. If polyps are found, they may be removed or cauterized during this procedure.

If duodenal polyps become large or numerous, the duodenum may need to be surgically removed. It could be that the detection of both the polyps and the Cholecystitis has led doctors in Germany to make the decision to operate with an open surgery. But this tells that the case was not a simple one but has been let’s say above average in terms in number of polyps and the extent of the Cholecystitis. Which again, opens all the previous questions. These cases develop over years and they cause pain and even if they do not, one has to wonder why the president of Egypt who is 81 years old did not undergo a single ultra-sound, a single duodenoscope, or a single liver function lab work in the span of years? Or if he has undergone any of those, why weren’t the results diagnosed properly. And if they were diagnosed properly, why didn’t doctors operate early on using duodenoscope or the laparoscopic surgery?

11 September 1961 !!

I applaud the work by the Nasser foundation and the Alexandria Bibliotheca to create a virtual library housing Gamal Abdel-Nasser’s documents. It is a treasure and a wealth of information available there and I encourage every Egyptian to go there and read the documents to have a glimpse of an important period in Egyptian history. http://www.nasser.org/.

This one in particular attracted my attention:

http://www.nasser.org/MinistryMeetings/MinistryMeetings.aspx?ID=5&x=5

It is the minutes of the council of ministers meetings chaired by President Abdel-Nasser on 11 Sept 1961 (just a coincidence to be 11 Sept).

Here are excerpts from the minutes and my comments.

The discussion starts with the president giving an update about his trip to Yugoslavia and the international situation. That part was very short, clear, and lucid. Then, the president switches to internal affairs and he starts by saying: “we have no agenda today.” I wonder how a 5-hour meeting of the council of ministers can effectively go without an agenda. Clearly, Bogdadi whispered in the president ears that all other ministers are not cooperative with him and that the numbers coming are confused. That instigation from Bogdadi makes the meeting to be tense and ineffective. We will see more of that later.

It is clear the president doubts what is going on underneath him. He feels genuinely confused by what is being told to him. However, he lacks the operational tools to set up the right mechanisms even though he is asking the right questions.

Mr. Sayed Marii is asserting that the baseline year cannot be doubted and is attacking those who doubt the baseline year.

Bogdadi who instigated the whole discussion, is the vice president and is a fellow free officer, doubts the baseline year but he says that in a cryptic way. He says a weird thing like: “we doubt the baseline year but the numbers of the baseline year are not controversial!” Completely meaningless utterance.

The president is back to asking questions and apparently reading from notes in front of him. He asks a question that how come wages in the ministry of health are decreasing. Bogdadi (who again instigated the whole thing to begin with by whispering in the president ears), is now trying to appear a team player and gives justification for how that could happen. Aside from the political aspect of the discussion of a minister backtracking to appear better, the president still cannot get an answer to his question even though the minister of health is sitting right there. It is obvious that nobody knows anything.

The president goes on now on a diatribe that clearly shows his irritation.

The diatribe continues and you can tell the president is really upset with the results and goes on to scold his ministers. However, he lacks the ability to provide solutions. His only solutions provided are: “this needs a solution. It needs martial courts, it needs a new revolution.” So, unfortunately the only tools that the president can provide are the extreme ones of martial courts. It is not clear to me how martial courts could resolve in a complex situation that involves managing a large Egyptian bureaucracy. The president, who provided a clear picture of what happens at the international arena, lacks management ability of the bureaucracy. He really needed an operational manager next to him who can handle it. Someone like a vice president. However, Mr. Bogdadi burnt his bridges with his fellow ministers as we saw earlier and nobody is volunteering to step in except based on political calculations. The hint of martial courts obviously makes the atmosphere even tenser and more political.

The president still goes on and sharpen his attack now on the minister of Education Mr. Hussein, who is also a fellow free officer. Now, Hussein responds back and stages a direct attack on Bogdadi saying that the planning concepts were not clear to any of the ministries. He ends his sentence by saying: “I am not accusing anybody,” which obviously contradicts with what he just said. Hussein who knows the president is liable to people whispering in his ears, understood what has happened between Bogdadi and the president and decides to respond. The exchange will become more heated later.

Hussein and Bogdadi have just clashed. The sad part is they brought a key issue. What is the goal of education in Egypt? Is it number of schools, number of teachers, or number of students. This is a strategic discussion that is well worthy of a council of minster meeting. However, it is lost in the political tension. Unfortunately, this led to disastrous consequences for Egypt. Till today, number of students and schools is the metric for education in Egypt. The president missed to latch on the strategic aspect of the discussion and drive it where it needs to be.

The president now steps in but in the wrong direction. He is gives a motherhood and apple pie direction that all ministers should work together, which as we know leads to nothing. Hussein is sticking to his guns that the numbers from Bogdadi are wrong. The fellow free officers are clearly fighting now in full view of the other ministers. The sad part is that the people who actually have knowledge did not open their mouth almost at all. So, someone like Mr. Al-Kaissony (finance) said only one sentence during the whole exchange about metrics even though he probably knows about metrics more than the free officers would ever know. The sad story of sidelining knowledgeable people to create positions for the free officers is manifesting itself again with sad consequences for the whole country.

Few ministers now dare to charge in after the successful counter-attack by Hussein. Unfortunately, they say nonsense. They try to be more royal than Hussein and support him further assuming now that Bogdadi is sufficiently weakened in the discussion.

Unfortunately, what those ministers just said like: “investment is the metric of progress,” is nonsense. It is sad to see someone reaching a ministerial level and saying something like that. Now the president starts to lose patience and goes on to explain that results measure progress not investment.

The above part of the discussion is now turning into philosophy. They are now defining what is investment and what is expense. This of course is something that finance graduates know very well and there is a unified code for those definitions. Bogdadi should have said that these are standard definitions. Instead, he says that everything spent is considered investment! Complete ignorance unfortunately. A finance freshman would have known better.

Mr. Marii (who is clearly a very politically savvy guy) goes on explaining complicated details. So he is clearly confusing the crowd sitting there who by now we know how shallow they are. He also is showing off his knowledge to the president. Unfortunately, what he brought up is a side issue. The real issue is how to measure and develop proper metrics for the Egyptian bureaucracy.

Now, we discover now that the whole Egyptian bureaucracy is dependent on one (yes only one) employee who came back from the United States (yes believe it or not despite the long disputes between Nasser and the US which will amplify soon thereafter) and has enough knowledge to set up metrics for complex organizations. So, the answer to that should have been to send more people (including those sitting in the council of ministers) to the US to learn and understand.

The president goes on another diatribe. He says that even a person who owns a ranch, knows the results. Of course he doesn’t know that none of the people sitting there behaves like he owns. He is failing to realize the difference between a capitalistic society and one that is not. This of course as we know led later to the collapse of the Soviet Union. I really think the note by Said Marii regarding the employee returning from the US should have sparked a discussion on the differences between the 2 systems and how to create an efficient system in Egypt. None of that happened. More interesting, the president says that every ministry should “establish a department for follow-up and measurements.” The president completely ignores Marii’s comment that Egypt lacked the skills. The president thought that creating façade organization is enough. This unfortunately led years later to what we see in Egypt right now.

That was one of very few sentences that Mr. Kaissony said and one of two that Abdel-Hakim Amer said! I tried to understand what Mr. Amer is trying to say. I could not. Translating what he said: “Adjusting the baseline year will show us the net increase in GDP but investments will show us if we are achieving our planned targets or not.” The 1st part of the sentence is obvious while the 2nd part is meaningless. This is his whole contribution to the council of ministers meeting!

Mr. Kaissony (who probably is the most knowledgeable in this whole crowd) only said that the increase in GDP is resulting from prior years investments. This is probably a very true statement as capital investments rarely yield results in the same year. Nobody paid attention to what he was trying to say and the only comment it attracted from Bogdadi was: “this all was calculate.” Another military approach to a very serious discussion that Kiassony tried to start which is: are we willing to only accept short term returns or do we want to look at long-term returns. Kaissony also is implying the older plans were more successful as GDP growth is now decelerating.

Now, here comes the solution. We need to create a monthly form for every establishment to measure the goals. The solution is the form! Not to agree on the proper metrics, not to define what those metrics are. The president clearly lacks the managerial skills and his vice president knows only how to manage using forms. Another ailment of the Egyptian bureaucracy that lingers till today.

The president now talks about importing without currency exchange to summarize the 5-hour discussion. Hardly that subject was discussed! The meeting ended at 11:10 pm. Few points to conclude:
1- President Nasser  is charismatic but lacks the managerial experience to operate the large Egyptian bureaucracy. A 5-hour council of ministers meeting that ends at 11:10 pm lacks a specific agenda for example.
2- He is prone to advisors whispering in his ears causing tension in meetings and creating unnecessary palace intrigues.
3- Discussions do not go to the depth of the strategic issues facing the country resulting in the consequences we live through till today.
4- The council of ministers is hijacked by the political and personal disputes of the free officers even as late as 1961, which is 9 years after the 1952 revolution.
5- Everybody is afraid of President Nasser and he is not afraid to use threats leading to accentuated tension in the meeting.
6- Knowledge and capability of those attending is shallow. And those who know do not speak.
7- There is a general under-estimation of the importance of knowledge.

This was no attempt to attack President Nasser or blame him for Egyptian problems today. He is dead for 40 years. It was an attempt to understand the inner working of how Egypt was governed through a rare window of opportunity.




 

Egypt Suffers from Cabin Fever!

Cabin fever is a term used to describe the claustrophobic reaction that takes place when a person or group is isolated and/or shut in, in a small space, with nothing to do, for an extended period (as in a simple country vacation cottage during a long rain or snow). Symptoms include restlessness, irritability, forgetfulness, laughter, and excessive sleeping, distrust of anyone they are with, and an urge to go outside even in the (possibly dangerous) rain, snow or dark. Cabin fever can also be known as a term for a lack of sexual intercourse. Egyptians suffers from all the above symptoms.

 

Egyptians are currently completely locked within the boundaries of their country like it has never occurred before. Egypt is completely now sealed and isolated from its surroundings. Let’s explore that hypothesis:

 

Syrians and Lebanese had significant presence and influence in Egypt. For example, Beshara Takla founded Al-Ahram. Cinema and theater started with Syrian immigrants and those immigrants continued to have significant influence on Egyptian arts. Salahu-Al-Din Al-Ayoubi was an Iraqi Kurd who ruled Syria first then ruled Egypt to grow from that point onward and form the coalition that expelled the crusades. Religions came to Egypt through the Sinai whether Yussef PBUH or Islam or Christianity.

 

One does not have to go that far back in history. Till the 1960s, Greeks and other Europeans were strong part of the Egyptian economy. Mohammad Ali Pasha brought many Europeans to build Egypt, not least among them was Soleiman Pasha Al-Fransaoi, or the French, who was a prominent doctor and introduced modern medicine into Egypt.

 

Even when many of those Europeans left Egypt in the 1960s, Gamal Abdel-Nasser replaced them with many Poles and Russians who also participated in arming Egypt and building the Aswan dam. Moreover, Abdel-Nasser himself formed unity with Syria and many Syrians came to Egypt to settle and live during that time. Even under Sadat and after the severing of diplomatic ties between Egypt and most of the Arab world, many Egyptians left to the rich Gulf States (with dire consequences but that is a different subject). Throughout history, Egypt had a network of connections within its surroundings with free movement of people and ideas.

 

This network is extremely important Human societies need to interact with different cultures and school of thoughts to hone their own ideas and borrow new ideas and technologies. It has never happened that any human society was able to prosper and develop its civilization without the benefits of trade. Trade in the broader sense optimizes ideas, propagates them, and provide an ultimate test of the ideas’ usefulness. Agriculture as a technology did not start in Egypt. It started in the Levant but through trade and migration, agriculture moved to Egypt and created there one of the most prosperous agriculture-based civilization in history. Journalism did not start in Egypt. It started in Europe, then came to Egypt through the Levant creating in Egypt some of the most successful press in the Arab world. Cinema did not start in Egypt. It again to Egypt through the migration of few pioneers who settled in Egypt and created a movie industry that Talat Harb later capitalized to create one of the most successful movie industries in the world. Press started in Germany and through trade migrated to the rest of Europe. This phenomenon is called spatial diffusion of technology and is one of the key mechanisms by which human societies grow.

 

The current status of Egypt is that all of its historical routes of spatial diffusion have been severed. First, Egypt for the first time in history has lost its connection to most of the Arab world and to Europe. Up to the 1970s, many Egyptians had the ability to travel to Europe relatively easily. Not any more. Getting a visa to Europe is a significant hurdle that most Egyptians cannot afford. Traveling to Libya is shut down. Many Egyptians do not even think of going to Sudan or Syria or even Lebanon, countries that are natural extension to Egypt. Travel to the rich Gulf States has been significant curbed. The outcome is that Egyptians are virtually locked inside Egypt.

The status of Egypt now is that we have two men, a Muslim and a Christian locked together in a cabin with nothing to do except fighting with each other. They are both frustrated at their current situation. They are both frustrated at whoever locked them in this room but unable to reach him (the government in this case) but they have to vent, and then vent on each other.

 

If we analyze the symptoms of the cabin fever, we find them exactly applicable to today’s Egypt. Symptoms include restlessness (accusing everybody), irritability (think of Algeria and the unjustified Egyptian reaction to losing a soccer match), forgetfulness (for example think of forgetting basic tenants of Egyptian history and their significance and being confused about the role of Nasser or Sadat in Egypt), laughter (sometimes Egyptian laugh at the current sad situation for no obvious reason), and excessive sleeping (often it feels that the whole country is sleeping), distrust of anyone they are with (Muslims distrust Christians, Christians distrust Muslims, they both distrust Israel and America and blame both for anything that happens even though it is often not true), and an urge to go outside even in the (possibly dangerous) rain, snow or dark (think about the hundreds and maybe thousands of Egyptian youth willing to risk their lives to cross the sea to Europe).

 

Cabin fever can also be known as a term for a lack of sexual intercourse. Unfortunately, most Egyptian youth out of lack of means and out of cultural and religious barrier suffer from sexual deprivation that causes things like the current phenomenon of sexual assaults in streets, which is now unfortunately commonplace.

All the symptoms of cabin fever are there…very sad situation indeed.

The Treatment

First, the causes of the cabin fever need to be eliminated. Egypt needs to restore its relationship with the Levant reaching all the way to Turkey. Politics should not interfere with the historical relations between the people. It is interesting to note that France’s Sarkozy is leading Europe to restore relations with Syria even though Syria is still bound with its strong ties to Iran. That is while Egypt is unable to turn around its relations with Syria on the grounds of Syrian role in Lebanon and in support of Hezbollah. A role that even the United States is willing to omit and despite which re-establish its diplomatic ties back with Syria. Many more Egyptians and Syrians need to visit each others, opening businesses and prospering. Ties to Syria should be the pinnacles of a strong Egyptian-Turkish relation. Turkey and Syria recently abolished visas between the two countries. Same should happen between Egypt and Turkey. Turkey and Syria both have a strong business community that can benefit Egypt significantly particularly in the area of improved banking and improved financial system. Turkish investment will also be key to the re-industrialization of Egypt particularly in both capital and know-how.

Similarly important, Egypt needs to reconnect with Sudan. The Chinese infiltration of Sudan is alarming as I discussed in a previous article. Sudan must be included in any regional settlement to avoid its constant drifting into despair and splintering.

A free trade zone between Turkey, Syria, Lebanon, Jordan, Egypt, Sudan, and potentially later including rich Gulf States, and Iran will encompass 300 million people (same as the EU) with significant capital within, know-how, agriculture land, territorial contiguity, and a massive market. This community does not have to include rich Arab states initially but they will have no option but join later on. The beauty of it is that most of these states initially have similar income per capita and can easily open boarders among themselves. Rich Arab states can provide capital without joining but will have little option except joining in later when the core team is more prosperous.

 

This is a policy that is designed to unlock Egypt from its current box and restore its historical ties with its surroundings.

Finally, there are tactical steps that have to be taken with respect to the Palestinian issue, Israel, and Gaza. First, Egypt has to open the boarders with Gaza within the framework of the regional coalition above. Gaza can be granted a special status in Egypt similar to Hong Kong within China. A regional peacekeeping force consisting of Egyptian-Jordanian-Turkish troops can maintain the peace in Gaza and can even be joined by US troops to assuage Israeli fears. An influx of Arab investment must be guaranteed within a regional framework to reinvigorate Gaza and Sinai economy. A tunnel should connect Sinai into Jordan and direct flight links need to be established from Al-Arish to Syria and Lebanon. Sinai need to be restored again as the link between Egypt and the Levant. That historical link needs to be re-activated.

With a regional collation such as the one proposed, Israel will have little option but to settle the West Bank issue. Territories conceded by Israel will be put under the regional coalition auspices with security guarantees provided by US, EU, Egypt, Jordan, and Turkey. On the long run and with better economic status, the regional collation can negotiate a better settlement of Jerusalem particularly if Iran turns out to join the coalition as a more democratic country (after getting rid or moderating its current corrupt regime) with nuclear potential.

These steps will restore Egypt again to its historical role in the region.

Egyptian Natural Gas Prices

Israel's Natural Gas Grid. Completely Supplied by Egypt. Cheaper than LNG, less polluting than oil, and sold in Israel for at least $12 per Million BTU, compared to a buying price from Egypt of $3, Egyptian gas affords a margin of 60% to Israeli grid company ... a sweetheart deal of unbelievable proportion.

Yael Gruntman: Feb 10 11:43

Israel Electric Corporation (IEC) (TASE: ELEC.B22) has notified Egypt's East Mediterranean Gas Co. (EMG) that it has received all of the required approvals for the coming into force of the amendment to their gas sale agreement, EMG shareholder Ampal-American Israel Corporation (Nasdaq: AMPL; TASE:AMPL) announced today. The companies signed the amendment on September 17, 2009,.

EMG has contracted to supply to IEC 42 billion cubic meters of natural gas for a total value of about $6 billion.

El-Arish Gas Compression Station

This means that Egypt sells the gas to Israel at a. price of $140 per 1000 cubic meters. I can only compare Egypt gas price sales to Russian gas prices to Europe. According to New York Times (http://www.nytimes.com/2009/05/16/world/europe/16gazprom.html), Gazprom sells gas to Eastern Europe at a price of $340 per 1000 cubic meters throughout 2009. The price reflects a complex formula that is based on oil prices. Ukraine (a country that Russia is keen on courting before its elections) gets Russian gas at $230 per 1000 cubic meters. While the average country-to-country gas prices in Europe were $280 per 1000 cubic meters. These prices reflect 20-year contracts so they are based on long-term contracts in the same way that Egypt-Israel gas prices are based on.

This means that after a 40% escalation in Egyptian gas prices, it is still 40-50% below Russian gas price that is being sold to Ukraine, a country that Russia wants to court. This still opens a lot of questions in my mind about the sale of Egyptian long-term assets at discounted prices and what the political favors are that Egypt is courting Israel for, 

Why?