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.