January 2015

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

JANUARY 2015

A brief history of sex Top gadget roundup Depression quiz: fact or fallacy Too many med apps?

MEDICINE ON THE MOVE

VISITS TO ANCIENT CULTURES The Southwest’s Four Corners A Belize lodge deep in the jungle Doctor families do Morocco Gunshots in Rio Wilderness safety guide T H E N O VA R T I S C O P D P O R T F O L I O

SEEBRI, ONBREZ, ULTIBRO and BREEZHALER are registered trademarks.

Product Monographs available on request.

14SEE034E © Novartis Pharmaceuticals Canada Inc. 2014

GO WITH THE FLOW

The AstraZeneca logo is a registered trademark of AstraZeneca AB, used under license by AstraZeneca Canada Inc. Š 2014 AstraZeneca Canada Inc.

Southwest beauty and history

JOSEPHINE MATYAS

Charles C. Mann, author of the wonderful book 1491, which reveals the extent of the thriving cultures that existed in the Americas before the arrival of Columbus, suggests that the building of great cities on this continent did not extend beyond the Rio Grande in the southwest. It’s true that, with the exception of earth mounds just south of St. Louis, there are few signs of large human constructs in the north. That’s not to say there was no one living in the northern half of North America. The area was teaming with indigenous people getting on with their lives from sea to sea to sea.

The Cliff Palace in Mesa Verde Mann’s point is that they were not builders in the National Park, Colorado. way the people living in Central and South America and Mexico were — the Olmec, Toltec, Maya, Inca and Aztec to mention but a few of the better known. The peoples of this part of the world flourished and declined and flourished again over thousands of years until the arrival of the Spaniards in the early 16th century put an end to the great building largely by infecting the population with smallpox and so killing off up to 90 percent.

In the southwestern US, significant settlements in the High Plains experienced a sharp decline in population beginning hundreds of years earlier, around 1000 BCE. The apparent sudden disappearance left abandoned ruins of great beauty, albeit more modest in scale than those to the south, and has lead to much speculation in recent years as to what became of those who built them.

It’s a fascinating and inspiring part of the world to visit. This issue’s cover story by Josephine Matyas is certain to whet your appetite for more.

On a related note, the article refers to the ancestors of those living in the Four Corners area, including the Hopi and the Zuni, as “Ancestral Puebloans.” It’s an awkward term to be sure. Until recently they were commonly referred to as “Anasazi,” but that term has fallen out of favour for two reasons: it means “ancient enemy” in Navajo and it never struck a cord with those who live in the long-established pueblos along the Rio Grande.

In addition to the Southwest, you’ll find an article on Belize, page 34, which again touches on ancient cultures, this time in a thoroughly modern setting. Margo Pfeiff visits a true jungle eco-lodge in Indiana Jones country and gets to taste some genuine Mayan chocolate.

You also won’t want to miss Jocelyn Edelstein’s award-winning glimpse into life in one of the most dangerous slums in Rio de Janeiro. Spoiler alert: it’s not what you think.

May your 2015 be stimulating, rewarding and fun.

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JANUARY 2015 • Doctor’s

Review

1

NEW

The rst

SMI

Soft Mist Inhaler

1-4

Ask for a demo of Placebo Respimat today ®

STRIVERDI® RESPIMAT® (olodaterol hydrochloride solution for inhalation) is a long-acting beta2-adrenergic agonist (LABA) indicated for the long term, once daily maintenance bronchodilator treatment of airflow obstruction in patients with Chronic Obstructive Pulmonary Disease or COPD (including chronic bronchitis and emphysema).

Consult the Product Monograph at www.boehringer-ingelheim.ca/content/dam/internet/opu/ca_EN/documents/humanhealth/product_monograph/StriverdiPMEN.pdf for important information about contraindications, warnings, precautions, conditions of clinical use, adverse reactions, interactions and dosing.

The Product Monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633.

Pr

† Comparative clinical significance unknown

* Solution is dispensed through mechanical energy4

References: 1. STRIVERDI® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., May 7, 2014. 2. Decramer M, Vestbo J, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of COPD (updated 2014). Global Initiative for Chronic Obstructive Lung Disease, Inc. 2014. 3. COMBIVENT® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Jan 8, 2014. 4. Data on file. Boehringer Ingelheim (Canada) Ltd., 2014. 5. ATROVENT® HFA Product Monograph. Boehringer Ingelheim (Canada) Ltd., Oct 29, 2010. 6. VENTOLIN® HFA Product Monograph. GlaxoSmithKline Inc., Dec 18, 2013. 7. ADVAIR® and ADVAIR® DISKUS® Product Monograph. GlaxoSmithKline Inc., Sep 24, 2013. 8. SPIRIVA® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Aug 21, 2012.9. SEREVENT® DISKHALER® and SEREVENT® DISKUS® Product Monograph. GlaxosmithKline Inc., Oct 16, 2013. 10. FORADIL® Product Monograph. Novartis Pharmaceuticals Canada Inc., May 9, 2013. 11. ONBREZ® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., Oct 24, 2012. 12. SEEBRI® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., Oct 12, 2012. 13. SYMBICORT® TURBUHALER® Product Monograph. AstraZeneca Canada Inc., Jun 21, 2012. 14. TUDORZA™ GENUAIR™ Product Monograph. Almirall Ltd., Jul 26, 2013.

Striverdi® and Respimat® are registered trademarks used under license by Boehringer Ingelheim (Canada) Ltd.

contents

GALYNA ANDRUSHKO / SHUTTERSTOCK.COM

JANUARY 2015

40

features 28

34 46

Head for the hills

An experienced outdoorsman shows how to enjoy nature and be safe

by Mike Nash

A Halifax MD drives beyond Marrakech on a 14-day road trip through Morocco

by Dr David Wood

34

How to hike grizzly country

Make Belize

A true agritourism lodge in Toledo where you can disconnect in its nature preserve

by Margo Pfeiff

40

Where ancient cultures thrive Native American cliff dwellings in the Four Corners region of the US’ Southwest that’ll make your spirit soar

by Josephine Matyas

28

Coming in

February • Music of the Deep South Without Dixie, there would be no rock ‘n’ roll • Oz’s Eyre Peninsula A glory where the sea meets the outback • A visit to Antarctica A traveller cruises to the last continent on her bucket list • The history of sleep We spend a third of our lives asleep yet know so little about it • Who treats depression?

Collaborative care means better care for most patients

JANUARY 2015 • Doctor’s

Review

3

NOW AVAILABLE

TrintellixTM is indicated for the treatment of major depressive disorder (MDD) in adults.

Pr

Consult the product monograph at www.trintellixmonograph.ca for important information about contraindications, warnings and precautions, adverse reactions, interactions, dosing instructions, and conditions of clinical use.

The product monograph is also available by calling 1-800-586-2325.

TRINTELLIXTM is a trademark of Lundbeck Canada Inc.

contents JANUARY 2015

15 48

What we do after gunre A very hot — and very dangerous — Sunday afternoon in one of Rio’s favelas

by Jocelyn Edelstein

52

Alone on the range Casseroles for supper — side dishes not required

by Betty Rosbottom

9

regulars

27

A quick quiz to test your knowledge

7 LETTERS

56

Great minds...

9

DEPRESSION POINTS

PHOTO FINISH Road to recovery

by Dr Charles Whelton

PRACTICAL TRAVELLER Bike from Paris to Moscow, an easy way to plan your African safari, Cirque du Soleil’s partnership with Club Med and more!

by Camille Chin

15

GADGETS Tech — backwards and forwards

by Roger White

17

BEST MD APPS The absolute essentials as the market matures

by Theo Sands

19

TOP 25 The biggest medical meetings happening this May and June

22

HISTORY OF MEDICINE

52 Treating chronic pain, our shared responsibility.

Human sexuality, part 2: celibacy, circumcision and the revolution in the ’60s

by Rose Foster JANUARY 2015 • Doctor’s

CLIENT: Purdue

DOCKET NUMBER: PQ9818

PROJECT: Magazine Ads

FILE NAME: PQ9818_BL_DR

Review

COLOURS

5

PRODUCER

DAT

NEW

for the Treatment of IBS-C and CIC in Adults CONSTELLA ® (linaclotide) is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults Pr

CONSTELLA showed significant improvement in abdominal discomfort vs. placebo (secondary endpoints, mean change from baseline at Week 12)1

IBS-C

CIC

IBS-C: -2.0 vs. -1.2 (Trial 1); -1.9 vs. -1.1 (Trial 2) (p<0.0001)* CIC: -0.5 vs. -0.3 (p<0.001)†

Study parameters are available at www.frx.ca/_products/constella.htm

Clinical use: Safety and efficacy in geriatric patients (≥65 years of age) have not been established.

CONSTELLA is contraindicated in children under 6 years of age and is not recommended for use in children between 6 and 18 years of age as the safety and efficacy of CONSTELLA in pediatric patients have not been established.

Contraindications: • Pediatric patients under 6 years of age • Patients with known or suspected mechanical gastrointestinal obstruction Most serious warnings and precautions: Children: Not recommended in children between 6 and 18 years of age

Other relevant warnings and precautions: • Diarrhea most common adverse reaction; may cause serious diarrhea • Use in pregnant women only if the potential benefit justifies the potential risk to the fetus • Caution should be exercised when CONSTELLA is administered to nursing women For more information: Please consult the Product Monograph at www. actavis.ca/NR/rdonlyres/94008767-D103-460E-B854766C324A3CE8/0/CONSTELLA_ProductMonograph.pdf for important information relating to adverse reactions, food interactions and dosing information not discussed in this piece. The Product Monograph is also available by calling Actavis Specialty Pharmaceuticals at 1-855-892-8766.

linaclotide capsules * 11-point ordinal scale; Trial 1, Trial 2.1 † 5-point ordinal scale; Trials 3 and 4.1 CONSTELLA® is a registered trademark of Ironwood Pharmaceuticals, Inc. and is used under license by Actavis Specialty Pharmaceuticals Co. or its affiliates. ©2014 Actavis Specialty Pharmaceuticals Co., Mississauga ON. All rights reserved.

REFERENCE 1. CONSTELLA® (linaclotide) Product Monograph, Forest Laboratories Canada Inc., May 12, 2014.

LETTERS

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David Elkins

Great minds...

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Subscription rates: One year (12 issues) – $17.95 Two years (24 issues) – $27.95* One year U.S. residents – $48.00 *Quebec residents add PST. All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

A FREE SPIRIT I read about the Joggobot in the History of Medicine section [How the West got fit, November 2014, page 23] and it reminded me of an article I read a few months ago. It was about a new running app called “Mind.” It was about how “Mind” is all you need when you’re exercising: it can play any song that you can think of and help you work out problems that you had that day. It’s portable, waterproof and gets stronger every time you use it. It was a very funny article that made fun of all the technology that people turn to when they’re working out. I don’t even run with music. Here’s the link if anyone wants to read it: runnersworld.com/ fun/the-only-running-app-you-need.

Dr C. Wong Via email

BIRD IS NOT THE WORD Jeremy Ferguson’s restaurant article [Victoria’s real secret, December 2014, page 42] made me want Indian food!

And Tibetan food! And Vietnamese food! It all sounded so good I didn’t even want any darn bird for Christmas.

I’ve never been to Victoria, but now I want to go.

COLD COMFORT The cover of your November issue made me laugh. I’d love to sit outside on my deck, with candles and drink tea, but the winters in Winnipeg are too cold! I wouldn’t even be able to smile like the folks on the cover because my face would be frozen!

Dr Jamie Dahan Via email

The Sanctuary of Truth temple in Pattaya, Thailand.

Dr Pierre Thayer Quebec City, Quebec

ARTIST APPRECIATION The large photograph of the Buddhist monk with a camera in Made in Thailand [November 2014, page 39] was great. I actually stared at the beautiful teak arches for a few moments because of all the detail. It’s amazing that all of those lovely gods were carved by hand.

I would love to visit Thailand and that temple one day. Please keep all the dreamy pics coming.

Suzanne Riesco Via email

JANUARY 2015 • Doctor’s

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Telemedicine is an efficient and effective way for Ontarioâ&#x20AC;&#x2122;s specialists to connect with patients anywhere in the province â&#x20AC;&#x201C; not because you need more patients, but because more patients need you. Join the thousands of specialists, family physicians, nurses and allied health professionals who are already going the distance for better patient care. Let OTN help you add all the benefits of Telemedicine to your practice.

Get started at otnhub.ca/gothedistance.

P R AC T I C AL T R A V E L L E R C a mi lle C hi n

PICHUGIN DMITRY / SHUTTERSTOCK.COM

by

Your African Safari is only three months old, but it already seems like the website should be one of your first stops if you want to see elephants and rhinos. Founded by avid safari traveller Jennifer Goetz, the site features 1230 tour operators and 1500 safari itineraries in 14 African countries. It’s designed for travellers who don’t know which tour operator to use or even which countries they want to visit. If you think you’re keen on Kenya, a click on the country will display an intro with basic info like airports, currency, recommended vaccinations, and even voltage and plug type. From there, you can search by “activities you can do,” “activity level,” “parks,” “length of safari tour” and “price.” Users can ask for quotes from multiple operators at once and browse operator reviews written by travellers. There are also articles by

BIKERIDERLONDON / SHUTTERSTOCK.COM

A site to see

journalists; Fran’s profile reveals that she’s from South Africa, has been on 11 safaris and has written 65 articles on everything from Ebola and South Africa’s new travel regulations for kids to the Google-funded drones watching over Namibia’s wildlife. yourafricansafari.com.

JANUARY 2015 • Doctor’s

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P R AC T I C AL T R A V E L L E R

A hot new act

Showing its age San Diego’s Balboa Park celebrates its 100th anniversary in 2015. Built for temporary use during the 1915 PanamaCalifornia Exposition, its now 485 hectares consist of eight gardens, 15 museums and the San Diego Zoo. The 45-metre California Tower at the Museum of Man is open to the public for the first time in 80 years for 360-degree views of the park and its surroundings.

The Museum of Photographic Arts is doing something special, too. It’s presenting 7 billion Others, February 21 until September 13. Launched in 2003

by French photographer Yann ArthusBertrand, the multimedia project asked 6000 people — from an Afghan farmer to a Brazilian fisherman, a Chinese shopkeeper to a German performer — the same 45 questions. What have you learnt from your parents? What do you want to impart to your kids? What does love mean to you? The portraits reveal our differences and similarities. Listen to “first memories” or “love stories” or “testing times” at 7billionothers.org.

10

Doctor’s Review • JANUARY 2015

Cirque du Soleil is indeed all about the sun recently. The Quebec-based company premiered its first permanent production Joyà in Mexico’s Riviera Maya this past November and it recently announced a partnership with Club Med. Its Creactive program will debut at the Club Med Punta Cana in the Dominican Republic this June and will be complimentary as part of your all-inclusive package.

There’ll be a custom-designed big-topstyle circus tent where guests can learn how to be acrobats on trampolines, tightropes, trapezes and aerial silks under the supervision of Cirquetrained staff. There’ll be face painting, juggling and unicycling for younger kids, and anyone who doesn’t want to get in the swing of things.

Tour de force Ride & Seek’s second Epic Adventure is scheduled for July 18 and it’s not your average bike tour. Following in the footsteps of Napoleon and his Grande Armée, it begins in Paris and ends in Moscow. The 45-day trip covers 3852 kilometres; you can do all or just one of its six, weeklong stages. The second stage is through Germany’s hills. Quaint Polish villages are featured in stage three, followed by the Great Masurian Lakes segment, the Baltic States and St. Petersburg (not conquered by Napoleon) and finally Moscow. The entire trip is €12,995; from €2295 per stage.

Accommodations, breakfasts and dinners are included as are guides, road support, luggage transfers and shuttle transport. Airfare is not. Bikes can be rented for €30 a day. rideandseek.com.

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P R AC T I C AL T R A V E L L E R

Centres of attention

You can now get inside one of Vincent van Gogh’s paintings. Designer Daan Roosegaarde has created a bike path with 50,000 glow-in-the dark “stones” that evokes The Starry Night.

Located in Nuenen, in the Netherlands, where the post-impressionist artist lived and worked from 1883 to 1885, the path commemorates the 125th anniversary of Van Gogh’s death in 1890. The installation is solar-powered, but also has LED lights for cloudy days when there’s little sun for powering up. The path is one kilometre long and part of the 335-kilometre Van Gogh Cycle Route that connects five Van Gogh heritage sites. For more anniversary events in Belgium, France and the Netherlands: vangogheurope.eu.

12

Doctor’s Review • JANUARY 2015

STUDIO ROOSEGAARDE & HEIJMANS

A glowing tribute

1 2 3 4 5 6 7 8 9 10

Da Nang Vietnam Sihanoukville Cambodia Limassol Cyprus Ao Nang Thailand Bodrum Turkey Naha Japan Hurghada Egypt Kazan Russia Manaus Brazil Eilat Israel

PHONG.TRAN / SHUTTERSTOCK.COM

According to TripAdvisor, a lot of people want to visit Da Nang in Vietnam (pictured). The travel site with more than 190 million reviews determined this tidbit using an “algorithm” that measured “the year-over-year increase in positive TripAdvisor traveller review ratings on accommodations, restaurants and attractions across destinations worldwide.” A bit of hocus-pocus? Maybe.

But Da Nang’s beaches and new resorts are attracting some buzz. Here are more places on TripAdvisor’s radar.

IES R E S T R A P THREE

Rise & Shine!

Start the day right with a delightful breakfast recipe It is well known that breakfast is the most important meal of the day. It can provide an excellent chance for you to take in foods rich in bone-strengthening calcium, such as cereals, milk and yogurt. Add a glass of orange juice, fortified with vitamin D, to support the absorption of calcium, and improve muscle function, especially important if youâ&#x20AC;&#x2122;ve been diagnosed with osteoporosis. This three-part recipe series puts breakfast in the spotlight bringing you tasty, bone-healthy recipes.

New recipes every month!

doctorsreview.com

FOR THE TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS ACTONEL DR SHOULD BE TAKEN IN THE MORNING WITH BREAKFAST

ON THE GO

OR

TAKING IT SLOW

EITHER WAY, IT’S BREAKFAST AS USUAL.* Actonel DR® is the only oral bisphosphonate designed to be taken with breakfast.1†

D

VERE O C BY MOST

PRIVATE DRUG PLANS‡, ODB and EDS in SK

Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp by searching for ACTONEL DR for additional important information including adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available on request through our medical department at 1-855-892-8766. * Breakfast may include high fat foods, coffee, tea, milk, orange juice, etc. A higher incidence of upper abdominal pain was seen when ACTONEL DR was taken in a fasted state before breakfast. ACTONEL DR tablet should be swallowed whole (not chewed, cut or crushed) while in an upright position and with sufficient plain water (≥120 mL). Patients should not lie down for at least 30 minutes after taking ACTONEL DR. † Comparative clinical significance not established. ‡ Based on a coverage survey conducted by Equilibrium Health, July 2012.

ODB: Ontario Drug Benefit; EDS: Exception Drug Status; SK: Saskatchewan Consult formulary for full coverage information.

Reference: 1. Warner Chilcott Canada Co. ACTONEL and ACTONEL DR Product Monograph, Toronto, July 3, 2013.

ACTONEL DR® is a registered trademark of Warner Chilcott Company, LLC. © 2015 Actavis Specialty Pharmaceuticals Co., Mississauga, ON. All rights reserved.

TAKE WITH BREAKFAST *

GA D GE T S by

R og e r W hi t e

Tech — backwards and forwards The past often gives a glimpse of what’s in the future and this is especially true in the gadget world. Choosing the best offerings of the previous 12 months is always fun and hindsight can be valuable.

Tech gadgets dominated again in 2014, of course, and, glad to say, some of the most popular of the expert’s choices appeared in these pages earlier in the year. Door locks that can be operated by a smartphone came into their own in 2014, as did some early versions of the connected home. Nest launched a learning thermostat and a phone-connected smoke alarm.

At the end of the year came the SmartThings Smart Home starter kit (US$199; smartthings.com), which allows your cell phone to monitor almost anything in your home including your kids and cars, and it was on most gadget hot lists.

The Whistle Activity Monitor (US$99; whistle.com) went animal with a health tracker for your dog. Before you scoff, consider this: the device attaches to the pet’s collar and tracks what Fido is doing all day.

Whether he’s active, sleeping or eating, it sends the info to your phone, something especially useful when you’re not at home.

In the cell-phone world, Apple snatched back a lot of the action with the launch of the iPhone 6 and 6 Plus (from $749; apple.com). Both cells made it to most top10 lists. Some favoured the 6, but the 6 Plus was generally ranked higher thanks to its superior camera, longer battery life and screen resolution. The size of the slab remains controversial — too big for a phone, too small for a tablet? Apple also scored with the new, super-thin iPad mini 2 (from $329) considered good enough to do anything you don’t do on your phone.

Staying with the category, the Mophie space pack (from US$149.95; mophie.com), which can add up to 64 gigs of storage and eight hours of battery life to the iPhone 5 and 5s, became a must-have accessory for heavy iPhone users as the year ended.

This year is also likely to start strong for Apple with the launch of the Apple Watch. The sheer number of apps available for the device will put it out in front of the existing wearables, but it won’t have the market all to itself. The Pebble Watch and Pebble Steel (getpebble.com), launched in 2014, work with both iOS and Android phones, and what they lack in apps they make up for in price at US$100 for the Pebble Watch versus US$350 for the Apple Watch. One thing is certain; a lot more people are going to be looking at their wrists in 2015.

JANUARY 2015 • Doctor’s

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15

BEST MD APPS by

T he o S a n d s

The maturing of the market It was bound to happen. There is such a proliferation of medical apps out there with more launching online almost daily it’s hard to keep them straight — and that could be dangerous. Now a group of German physicians is calling for regulation in a paper titled Future trend medical apps: from the apps store directly into medical practice (ncbi.nlm. nih.gov/pubmed/25388438).

Highlights of suggested areas in need of regulations include: errors in content that could lead to incorrect diagnosis and treatment, and risk patient outcomes; data privacy including unauthorized access to stored info and the need for assessment by physicians in connection with other new and existing apps.

Look for more such initiatives in 2015 likely beginning in the European Union, but also on the FDA’s radar in the near future. Health Canada is not expected to take up the matter before it’s clarified internationally. That said, a hierarchy of the most popular go-to apps has emerged that includes essentials for most electronic medical bags. No single list can be the be all and end all — but this one comes close.

All the applications listed here come in both iOS and Android versions, unless otherwise noted. Will new medical apps emerge in 2015? Absolutely, thousands of them, but the market is rapidly maturing and most are expected to be a refined version of existing apps or geared to specific specialties.

Medscape Over 4000 clinical references including obscure diseases, up-to-date, easy to use. Downloadable for offline use.

Free.

Figure 1 After a somewhat rocky start over privacy concerns, the Canadian developed “Instagram for doctors,” which allows the sharing of clinical photos, has come into its own. 800,000+ views a day and growing. Free.

Micromedex Drug Reference Essentials The top-rated Micromedex pharma/drug reference contains all Canadian and US brand-name products, but ran into trouble crashing on iOS 8.

A December 14 update is said to have fixed it. $2.99 for iOS (formerly free); $3.28 for Android.

Eponyms Most extensive database of the bunch. Free.

Journal Club The best way to wade through the sea of evidence-based medicine. $4.99 for iOS; $5.65 for Android.

Honourable mentions: MediBabble Translator (free; iOS only); Epocrates (free); Diagnosaurus DDx (free on iOS, $1.99 on Android).

UpToDate Long a desktop favourite, if not the favourite — as long as your institution has a subscription, pricey otherwise. Lots of recent improvements including a mobile application make it the most popular go-to. Free.

JANUARY 2015 • Doctor’s

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17

Treating chronic pain, our shared responsibility.

As one of the leading pharmaceutical companies in Canada, Purdue Pharma is dedicated to ongoing research and development in the field of drug delivery and the use of pain medications. However, we also recognize that prescription drug abuse is a public health issue. A recent survey conducted by CAMH showed that 81% of students who use medicines non-medically obtain them from family or friends.1 Purdue Pharma, together with health authorities and the medical community, is actively working to reverse this trend so that the right medications get to the right patients.

Through our educational programs and strong community partnerships, we are confident that we can continue to make great strides in addressing the use, abuse and diversion of pain medications.

For more information on our products and our role within the community, please contact your Purdue Health Solutions Manager or visit www.purdue.ca.

1. Boak, A., Hamilton, H. A., Adlaf, E. M., & Mann, R. E. (2013). Drug use among Ontario students, 1977-2013: Detailed OSDUHS findings (CAMH Research Document Series No. 36).

Toronto, ON: Centre for Addiction and Mental Health.

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

Canada Charlottetown, PEI May 20-23 36th Annual Scientific Meeting of the Canadian Pain Society canadianpainsociety.ca/en/conference_2015/ index.html

Montreal, QC June 6-11

Ottawa, ON June 27-30 70th Annual Meeting of the Canadian Urological Association cua.org

Toronto, ON June 3-6 17th Annual Conference of the International Society for Bipolar Disorders isbd2015.com

June 9-12 50th Congress of the Canadian Neurological Sciences Federation congress.cnsfederation.org

June 20-25 XXV Congress of the International Society on Thrombosis and Haemostasis isth2015.com

UBC’s Museum of Anthropology.

© CTC

12th World Congress of the International Neuromodulation Society neuromodulation.com/inscongress

June 24-27 92nd Annual Conference of the Canadian Paediatric Society annualconference.cps.ca

Vancouver, BC June 8-13 23rd World Congress of Dermatology derm2015.org

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June 27-30 XXVIIth International Symposium on Cerebral Blood Flow, Metabolism and Function and the XIIth International Conference on Quantification of Brain Function with PET brain.kenes.com

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the top 25 medical meetings Around the world Baltimore, MD May 31-June 2 Fifth Annual Meeting of the American Delirium Society americandeliriumsociety.org

Denver, CO May 15-20 2015 Annual Meeting of the American Thoracic Society conference.thoracic.org/2015

Dublin, Ireland May 16-20

Glasgow, Scotland May 28-31 5th World Congress of ADHD: from Child to Adult Disorder adhd-federation.org/congress2015

Madrid, Spain May 20-22 10th European Congress on Menopause and Andropause emas-online.org/home2015 Glasgow’s Clyde Arc Bridge.

The Rose Main Reading Room at the New York Public Library.

New Orleans, LA May 15-19

Seattle, WA May 31-June 4

2015 Annual Meeting of the American Urological Association aua2015.org

10th International Symposium on Pediatric Pain ispp2015.com

New York, NY May 15-19 2015 Annual Scientific Meeting and Exposition of the American Society of Hypertension ash-us.org/Scientific-Meetings.aspx

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Vienna, Austria May 27-30

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Washington, DC May 16-19

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H I S T O R Y O F M E DI CI N E by

R os e F os t e r

Celibacy to Masters and Jo Part 2: We’ve come a long way and still have far to go History of Sexuality: Part 1 (December 2014) covered the period from the dawn of time through the Greeks and Romans. Part 2 carries on from there.

Joan of Arc embraced celibacy and said she found strength in her virginity.

Stepping off the sexual straight and narrow led to damnation 22

Doctor’s Review • JANUARY 2015

CENTRE HISTORIQUE DES ARCHIVES NATIONALES, PARIS

A

new theme emerged in Western thought with the rise of Christianity, perhaps

as a whisper on the wind from the Hindu and Buddhist ascetics: celibacy. For a religion that began with a virgin birth, it is perhaps not surprising that celibacy became a major theme. And while other cultures like Judaism had formal guidelines for sexually appropriate behaviour, the central role of celibacy in Christianity, and the inherent rejection of sexuality that went with it, pushed prohibitions and condemnations to another level of significance.

Celibacy wasn’t a disaster for those who found rewarding careers in holy orders and, for a very few women like Joan of Arc, it led to a kind of freedom, a noble reason to avoid the drudgery of housewifery and live a different life, albeit, in Joan’s case, with unfortunate consequences. For the hoi polloi though, men and women alike, sexual desire became contorted in a confusing pit of shame, guilt and rigid social constructs where stepping off the straight and narrow led to damnation.

It wasn’t that you couldn’t experience real love outside a consecrated relationship. Take, for example, courtly love, where a man is permitted to fall in love/lust with a pure woman he admires from afar, and then sacrifice himself at war in her honour. One medieval writer describes the process as a thing “at once illicit and morally elevating, passionate and disciplined, humiliating and exalting, human and transcendent.” Sex can clearly be twisted to meet most contingencies.

Those who succumbed to the filth and wretchedness of illicit carnal relations didn’t have to wait for damnation in the next world. They were mutilated, hung in cages to starve to death, or lost their heads, bowels, or worse in this one. The joy of sex still existed, of course, but public expressions of that delight went underground for the next several centuries and only emerged not so very long ago.

Johnson A HEINOUS SIN Masturbation, the most common sexual behaviour, has hardly fared any better. As recently as 1994, Bill Clinton had to fire his Surgeon General, Joycelyn Elders, over the public outcry she caused by saying masturbation was safe and healthy, and should be mentioned in school health curricula.

Which brings us to chastity belts. There is very little evidence that they were a veritable staple in medieval sex life or even in use back then. Fact is, the first time the belts became widely available was in the 1800s for a different reason entirely: preventing self-love. Until the 1930s, when it was proven to be harmless (if not beneficial), masturbation was seized on as the root of a great number of mental and physical health problems. In the 13th century, St. Thomas Aquinas believed it was worse than rape, incest and adultery on the ground that at least the others had a chance of leading to procreation.

The craze against playing with oneself received fresh fuel with the 1716 publication by the Dutch theologian Dr Balthasar Bekker of a tract titled, “Onania, or the Heinous Sin of Self-Pollution, And Its Frightful Consequences, In Both Sexes, Considered: With Spiritual and Physical Advice To Those Who Have Already Injured Themselves By This Abominable Practice.”

A 17th century law in the Puritan colony of New Haven, Connecticut made masturbators eligible for the death penalty. Such harsh treatment was supported by arguments from luminaries like Kant and Voltaire who established the perception of the practice as a debilitating illness for the next two centuries.

torises to prevent self-harm. Genital cages, hand tying and electric shock were also effective, he thought.

“Neither the plague, nor war, nor small-pox… have produced results so disastrous to humanity as the pernicious habit of onanism,” he pronounced. He concocted a bland food made of flakes of corn which he believed would help curb the sexual appetites of the youth, which generations then promptly scarfed down from the box with the cheerful big green and red cock on it. A little later, Reverend Sylvester Graham invented Graham crackers with a similar intent.

A LONG ARM As if it wasn’t enough for the population to be forbidden from “knowing” themselves by hand, so to speak, Sigmund Freud introduced the idea that the origins of our sexual impulses exist deep in the unconscious, far from reach. Here began a journey to discover the “truth” of sex, says contemporary French philosopher Michel Foucault, a journey that continues to this day.

Obsessive discussions and great questioning about sex abounded in Victorian times, and were not quite as “Victorian” as we like to think. There’s a reason why sex comes to mind when we think of Dr John Kellogg concocted a bland food he claimed would curb the sexual appetites of the youth.

TOP: The Jugum penis, anti-masturbation device, circa 1880.

FLAKES FOR PURITY The rising popularity of circumcision can be attributed in part to the belief that it functioned as a preventative for masturbation. In the US, the renowned Dr John Kellogg advocated circumcising boys sans anesthesia and applying phenol (an acid) to girls’ cliJANUARY 2015 • Doctor’s

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23

If masturbation was safe and healthy why the public outcry? that era, and it isn’t because no one was having any.

Family planning was coming into view, and new ideas about morality and biology influenced perceptions of sexual roles. Darwin placed sex at the centre of his story of evolution and, increasingly, people’s identities became tied to their sexuality.

POST-WAR SEX Women were considered to be far less sexual creatures than men, though a young American sexologist was soon to dispel that fatuity. The bisexual Alfred Kinsey founded the Institute for Sex Research at Indiana University in 1947 and a year later published Sexual Behavior in the Human Male followed, five years after that, with a book of similar title on the human female. Kinsey is credited with having liberated female sexuality and dispelling notions of female disinterest in sex. He is also remembered for his eponymous scale used to determine sexual orientation.

The dynamic duo of William Masters and Virginia Johnson took Kinsey’s work a crucial step farther.

While Kinsey based his research on information gleaned from interviews and somewhat biased personal observation (as well as participation), Masters and Johnson acquired the data for their Human Sexual Response (1966) and Human Sexual Inadequacy (1970) in the laboratory where they observed and measured masturbation and sexual intercourse at a more scientific distance. Initially able only to use prostitutes for their experiments, eventually the team recruited over 600 women and men volunteers from the community who were then arbitrarily matched as partners.

More significant than any single one of their findings was the tone of their writings which showcased sex as a healthy and natural activity to be enVirginia E. Johnson and William H. Masters pioneered research into the nature of human sexual response.

24

Doctor’s Review • JANUARY 2015

joyed as a source of intimacy and pleasure, though they considered homosexuality to be a correctable dysfunction. This misperception aside, their works very much set the tone for the Sexual Revolution of the 1960s.

Books like Sex and the Single Girl, The Way to Become the Sensuous Woman and Everything You Always Wanted to Know About Sex (But Were Too Afraid to Ask) became handbooks for a youth culture that broke taboos about premarital sex, homosexuality, public nudity and abortion. The widespread availability of the contraceptive pill from 1972 onward levelled the playing field at last for women.

ARE YOU GGG? The subject of sex and the “truth” of our sexuality is as much of an obsession today as it ever was, in spite of the fact almost nothing is taboo. In the past decade, gay sex columnist Dan Savage has introduced a population of readers young and old to the many sexual lifestyles open to those who are “GGG” — his abbreviation for “good, giving and game.” His kindhearted, savvy, almost grandmotherly approach has normalized kinks and emphasized the importance of pursuing one’s personal sexual impulses. But in spite of all the good words and sex-positivity, we have yet to learn how to have intimate relationships that don’t end in trauma. Given our 50 percent divorce rate and a declining interest in marriage especially among under 40s, a social crisis is brewing with the nature of our sexuality at its core.

The partners/authors of Sex at Dawn, Christopher Ryan and Dr Cacilda Jethá, suggest that while we can’t go back to a prehistory where love was freely given between all members of society, it may be time to reconsider our conception of monogamy and the sexual relationship-destroying restrictions it imposes. It’s a think-through that has stumped humankind these thousands of years. There’s a chance that we can make a better job of it this time around by remembering that while, as the research shows, sexual expression is a healthy, beautiful thing, sex for sex’s sake can never be allowed to rival the blessing that is love.

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In major depressive disorder

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Nicole*, 37

For patients like Nicole...

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symptom relief No statistical difference in mean weight change vs. placebo was seen at 6 months (p=ns)†

* Fictitious case. May not represent all patients. † Results of the final on-therapy assessment in the 6-month, double-blind, placebo-controlled phase of a long-term trial in patients who had responded to PRISTIQ during an initial 12-week, open-label phase.

Indication and clinical use • PRISTIQ is indicated for the symptomatic relief of major depressive disorder • PRISTIQ is not indicated for use in children under the age of 18 • The short-term efficacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The efficacy of PRISTIQ in maintaining an antidepressant response for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Contraindications • Concomitant use with monoamine oxidase inhibitors (MAOIs) or within the preceding 14 days • Hypersensitivity to venlafaxine hydrochloride Most serious warnings and precautions • Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with: - Behavioural and emotional changes including an increased risk of suicidal ideation and behaviour - Severe agitation-type adverse events coupled with self-harm or harm to others - Suicidal ideation and behaviour; rigorous monitoring advised • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is recommended Other relevant warnings and precautions • Concomitant use with venlafaxine not recommended • Allergic reactions such as rash, hives or a related allergic phenomenon • Bone fracture risk with SSRI/SNRI • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment)

• Increases cholesterol and triglycerides (consider measurement during treatment) • Hyponatremia or Syndrome of Inappropriate Antidiuretic Hormone (SIADH) with SSRI/SNRI • Potential for GI obstruction • Abnormal bleeding with SSRI/SNRI • Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions For more information Please consult the product monograph at http://www.pfizer.ca/en/our_products/ products/monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece.

The product monograph is also available by calling 1-800-463-6001.

Reference: PRISTIQ Product Monograph, Pfizer Canada Inc., July 3, 2013.

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D E P R E S S I O N K E Y P OI N T S

A quick quiz about depression

Some of the clinical statements below are true and some are not. Can you distinguish the facts from the fibs in diagnosing and treating depression?

TRUE FALSE

a)

b)

c)

d)

increase the amount of serotonin for use by neurotransmitters decrease the amount of serotonin for use by neurotransmitters have no effect on the amount of serotonin for use by neurotransmitters have an entirely different effect

faster acting blocks the reabsorption of both serotonin and norepinephrine improved remission rates fewer suicidal thoughts fewer side effects

6. In depression, the risk of a recurrence: TRUE FALSE

a) b) c)

d)

increases with each episode declines with each episode is 50% higher after the first episode is 90% higher after a second episode

7. SSRIs/SNRIs take effect: TRUE FALSE

a) b) c) d) e)

within a few hours within two to four days within a week between two and four weeks between two and six weeks

1. All are true except d) The 18-question test is designed to give a sense of the degree of depression a patient may be experiencing. The late Dr Ivan Goldberg was a noted New York psychiatrist.

3. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are the current antidepressants of choice. They:

TRUE FALSE

a) b)

c) d) e)

ANSWERS

2. d) In mild cases, treatment often begins with either talk or cognitive therapy.

If the depression fails to show signs of lifting after 4 to 6 weeks, antidepressants should be considered. In severe depression, antidepressants are always indicated.

c)

d)

antidepressants alone antidepressants combined with talk therapy antidepressants combined with cognitive behavioural therapy talk therapy or cognitive behavioural therapy alone

5. The chief advantages of SNRIs over SSRIs are:

insomnia weight gain loss of appetite asthenia sexual dysfunction reduced patient compliance

3. a) is true, but much remains to be known about serotonin and the role it plays in mood.

TRUE FALSE

a) b)

an increase in the amount of oxygen going to the brain an increase in heart rate an increase in glucose release an increase in urine retention an increase in breathing rate shuts down metabolic processes

4. d) is false, the rest are true.

2. The most effective treatment for mild to moderate depression begins with:

a)

b) c) d) e) f)

5. a) is false, the rest are true. Remission rates, an important factor in the treatment of depression, are estimated to be 5–10% lower with SNRIs.

doing things slowly difficulty concentrating when reading difficulty making decisions difficulty keeping friends disturbed sleep feeling like a failure

TRUE FALSE

a) b) c) d) e) f)

6. All are true except b)

a) b)

c) d) e) f)

TRUE FALSE

8. Some of the side effects of antidepressants include:

7. e) is true. These antidepressants take at least two weeks to begin to work and can take as long as six weeks.

TRUE FALSE

4. Norepinephrine is a neurotransmitter secreted in response to stress and causes:

8. All are true.

1. This symptom is among those evaluated in the Goldberg Depression Test:

References: 2. A Meta-Analysis of the Effects of Cognitive Therapy in Depressed Patients. Valérie Gloaguen, Jean Cottraux, Michel Cucherat, Ivy-Marie Blackburn. J Affect Disord 1998;49(1):59-72.

3. Patient Information: Depression Treatment Options for Adults (Beyond the Basics). Wayne Katon, Paul Ciechanowski. Uptodate. 4. Adrenaline and Noradrenaline. David S Goldstein, National Institutes of Health, Bethesda, Maryland, USA. Published online Sept 2010. 5. Meta-Analytical Studies on New Antidepressants. Ian M Anderson. Br Med Bull 2001;57(1):161-178. 6. The Human Cost of not Achieving Full Remission in Depression. Roger S McIntyre, Claire O’Donovan. Can J Psychiatry 2004;49[Suppl 1]:10S-16S. 8. SNRIs: Their Pharmacology, Clinical Efficacy and Tolerability in Comparison with Other Classes of Antidepressants. Stephen M Stahl, Meghan M Grady, Chantal Moret, Mike Briley. CNS Spectr 2005;10(9):732-747 JANUARY 2015 • Doctor’s

Review

27

I P R E S C R I B E A TRIP TO...

MOROCCO

Head for the hills A couple of MDs drive beyond Marrakech on a countrywide tour text and photos by Dr David Wood Tafraoute is in the heart of the Anti-Atlas Mountains and it’s refreshingly quiet compared to Morocco’s big cities.

M

orocco has an immense variety of experiences to offer the visitor.

There are snowy peaks and sun-soaked deserts, dazzling coasts, cities of domes and minarets. In between, the fortunate traveller

will discover palm oases, almond trees, gorges and rock formations of the Anti-Atlas. Each of its ancient cities of Berbers and Arabs has a medina, or old town, with hundreds of narrow winding streets, while its newer districts tend to have a distinctly French influence.

Morocco was a French protectorate from 1912-1956.

28

Doctor’s Review • JANUARY 2015

Last February, I travelled with my wife, Nina, our daughter, Lindsay, and a classmate of mine, Dr Michael Evans, and his wife, Mirella, on a two-week adventure through Morocco. We rented an SUV and did our own driving, both on the good highways and on the not-so-good back roads.

Dr Wood and his wife, Nina, in Ait Benhaddou, which is known for its collection of kasbahs or fortified mud-brick castles.

David Wood was born in Charlottetown, but grew up in Halifax and attended medical school at Dalhousie. He and his wife Nina share a passion for travel.

After doing locums for six months in New Zealand, they travelled around Australia, Singapore, Malaysia and Thailand, returning to Halifax in 1988 where Dr Wood continues to work as a GP. Dr Wood has also lived in Europe and plans to visit Slovenia and Croatia this summer. This was his first trip to Africa.

Large cities like Fez have labyrinths of individual souks that sell everything from spices to green olives.

Marrakech, Morocco’s most visited city, was a good starting point. It’s bustling, chaotic and full of life. Inside the thousand-year-old walls there are palaces, mosques, tombs and, of course, souks, or markets, with their endless alleys and streets lined with every kind of shop imaginable — except those that sell alcohol. This is a Muslim country, after all. Its principal landmark is the Koutoubia Mosque. It was built in 1147 and its splendid tower stands over 70 metres tall. No building in the city is permitted to exceed its height.

From Marrakech, we headed to Essaouira on the coast, and were immediately struck by the light and beauty of the seaside port. Huge rolling waves crashed into the ramparts that protect the town and medina. It has a big beach and a fishing harbour, so seafood is a must here.

As we drove along through argan tree orchards, we noticed something extraordinary. Climbing to the highest branches, almost as agile as monkeys, were goats! We’d read about it — and doubted it — and yet there they were, defying gravity and feasting on succulent argan leaves and fruit. Some of the trees were positively weighed down by goats, and we saw a kid perched at the top of one tree, the branch bent beneath his weight. The fruit of the argan tree produces an oil that’s a treasured commodity in Morocco and very expensive. It’s used for cosmetics, cooking and medicine.

Nearly 600,000 people live in Fez’s medina with 13,000 little streets and alleys, most unmarked For more glorious beach scenery, head further down the coast to Morocco’s premiere beach resort, Agadir. The town was levelled by an earthquake in 1960 and has been rebuilt to host sun worshippers from all over Europe. The nine-kilometre beach makes for a spectacular walk and surfers are aplenty. While it may not be “the real Morocco,” it’s certainly a nice place to take a break in the sun and surf.

Southeast of Agadir, in the heart of the Anti-Atlas, is Tafraoute — or “tough-route” as we called it because of the drive on narrow winding roads. We drove JANUARY 2015 • Doctor’s

Review

29

From our perch atop the camels, we saw dunes that changed in colour from caramel to pink to ochre as the sun went down

Dr Wood’s daughter, Lindsay, at the Riab Maktoub, which is a short walk to the kasbahs of Ait Benhaddou.

Prior to the French occupation in 1912, Marrakech’s carpet souk was the site of slave auctions.

through spectacular arid mountains filled with almond trees in bloom. Clouds of rose coloured blossoms were everywhere! At sunset, the rock formations and mountains turned pink.

HIGH AND DRY A six-hour drive east through more mountains and almond groves brought us to one of the most famous Kasbah towns, Ait Benhaddou. Now a UNESCO World Heritage Site, this collection of Kasbahs, or fortified mud-brick castles, has crenellated towers and arches, and its wild beauty has attracted movie makers. It’s a must-see on anyone’s list. Our guide boasted about having been an extra in a number of films, including James Bond, The Living Daylights, The Jewel of the Nile and Gladiator. During our trip, Ait Benhaddou was the only “dry town” we encountered. Otherwise, most B&B and small-hotel owners seem to know where a bottle of wine or beer could be purchased.

Driving east leads through a series of palm oases and a couple of amazing gorges: the Dades and the Todra. A bit further brought us to one of the highlights of our Moroccan adventure, the Erg Chebbi dunes.

30

Doctor’s Review • JANUARY 2015

We stayed in Merzouga, at the Hotel Kasbah Azalay (kasbahazalay.com), a stunning place near the dunes, on the western edge of the Sahara Desert. Our host, Mohamed, greeted us with mint tea on his rooftop terrace and then quickly ordered a delicious “Berber omelette,” full of onions and vegetables, and fruit salad for lunch. After a brief siesta, we were off on a camel trek in the desert. From our perch atop the animals, we saw dunes in every direction. It was spectacular. They changed in colour from caramel to pink to ochre as the sun went down, bringing on a brilliant starry night.

A lot of these small towns are “dry,” but we wanted some wine with our evening meal so Mohamed sent me off with his brother, Omar, to the only licensed place in town, the local campground, where I was able to purchase wine and beer to celebrate our great day. Supper was typical Moroccan fare: a delicious tagine, a meat stew full of vegetables, spices and sometimes prunes, cooked over low heat in a special clay pot and served hot. Subsequently our hosts put on a magnificent Berber music night, complete with drums, singing and chanting.

The next day was an eight-hour drive through the Ziz gorge and over the eastern side of the Atlas mountains, which brought us to Fez, Morocco’s oldest imperial city and a UNESCO World Heritage Site.

Nearly 600,000 people live in its medina with 13,000 little streets and alleys, most unmarked! It’s like Marrakech on steroids with its multitude of souks and famous tanneries and carpet shops.

The Erg Chebbi dunes stretch for almost 30 kilometres from north to south and rise to 150 metres in places.

We stayed at the beautiful Riad Rcif (riadrcif. com), a former Pasha Palace that dates back to 1372 and has been painstakingly restored. Absolutely fabulous! The intricately carved patterns adorned all the walls and doors that weren’t covered in mosaic tiles. Again the food was excellent, and the ladies even tried the hammam, a Moroccan hot bath with massage.

COASTING TO RABAT Just east of Fez are the ancient Roman ruins of Volubilis, filled with magnificent mosaics and triumphal arches from the second century CE. This city is thought to have been founded by Juba II and his wife, Cleopatra Selene, the daughter of Marc Antony and Cleopatra.

Further west on the coast is Rabat. At one time, it was a haven for Barbary pirates and known as the Republic of Bou Regreg. In 1912, the French protectorate made Rabat the political and administrative capital of Morocco, and it now boasts a population of 1.5 million, and is also home to the country’s main university.

Rabat’s minarets, Kasbahs and medina contrast its wide avenues and green spaces and fountains cre-

The trees were weighed down by goats and we saw a kid at the top of one, the branch bent beneath his weight ated by the French. The Oudaia Kasbah has ramparts that overlook the Atlantic, and its pretty little blue and white streets and doors are some the nicest in Morocco.

One of the most striking sites is the Mausoleum of Mohammed V, the father of Moroccan independence (1956). Made of white Italian marble, the mausoleum has an amazing 12-sided dome over the sarcophagus of Mohammed V. Next to it is the halffinished minaret of the Hassan Mosque. Built in 1196, the 44-metre-tall tower stands over rows and JANUARY 2015 • Doctor’s

Review

31

Dr Wood and his wife at the Hassan Mosque, which, if completed, would’ve been the largest building in the Muslim west.

rows of white stone columns. The mosque, which was to have been the largest building in the Muslim west, was never completed and the great hall was destroyed by an earthquake in 1755.

Morocco’s current king, Mohammed VI, has been on the throne since 1999. He brought modernity and justice to the country. Improvements in infrastructure and law enforcement have provided much needed stability, making Morocco a safe place for western travellers.

Finally, on the northern tip of the country, facing Spain across the Strait of Gibraltar, is Tangier. Once the Roman capital of Mauritania and Tingitana, it was an “International City” during the French protectorate. People travelled there from all over the world. Tangier’s pretty hilltop medina overlooks its rapidly expanding port and massive beach, which is lined with hotels, clubs and restaurants. The Musée Archéologique, housed in a former sultan’s palace, has the amazing Roman mosaic The Voyage of Venus from Volubilis on display. This city is often the landing point for day-trippers from Spain, who barely get a taste of what Morocco really has to offer!

An interesting side trip is the Grotte d’Hercule, which has an interesting view over the Atlantic through an opening that is the shape of Africa in reverse.

Morocco has many fascinating cities and beautiful landscapes. It’s now truly opening up to western tourists, who can feel quite safe among these friendly people. While Arabic is the official language, everyone from the cab drivers to the hotel receptionists speaks beautiful and fluent French, and many also speak English. Throughout our travels we felt welcomed by the Moroccan people, who were proud to show us their beautiful country and its myriad riches.

Indication and clinical use: Symbicort® is indicated for the treatment of asthma in patients 12 years and older with reversible obstructive airways disease. In patients with asthma, there are two treatment approaches: Symbicort ® Maintenance Therapy, where Symbicort® is taken as regular maintenance treatment with a separate rapid-acting bronchodilator as rescue, and Symbicort Maintenance and Reliever Therapy (SMART®), where Symbicort® is taken as regular maintenance treatment and as needed in response to symptoms. Symbicort® should not be used in patients whose asthma can be managed by occasional use of a rapid onset, short duration, inhaled beta 2 -agonist or in patients whose asthma can be managed by inhaled corticosteroids along with occasional use of a rapid onset, short duration, inhaled beta 2 -agonist.

Contraindications: • Hypersensitivity to inhaled lactose Most serious warnings and precautions: Risk of asthma-related death: Long-acting beta 2 -agonists (LABA), such as formoterol, one of the active ingredients in Symbicort ®, may increase the risk of asthma-related death. This was found with salmeterol and is considered a LABA class effect. LABA may increase the risk of asthma-related hospitalization in pediatric and adolescent patients. It has not been established whether concurrent use of inhaled corticosteroids or other long-term asthma control drugs mitigates the increased risk of asthmarelated death from LABA. Therefore, when treating patients with asthma, Symbicort ® should only be used for patients not adequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid, or whose disease severity clearly warrants the initiation of treatment with both an inhaled corticosteroid and LABA. Once asthma control is achieved and maintained, assess the patient at regular intervals, and do not use Symbicort ® for patients whose asthma is adequately controlled on low- to medium-dose inhaled corticosteroids.

Rescue medication: Inform patients to have rescue medication available at all times.

Recommended dosage: Do not exceed.

Use in adolescents: Periodic reassessment should be considered as severity of asthma may vary with age.

Other relevant warnings and precautions: • Treatment should not be stopped abruptly • Cardiovascular effects • Candidiasis • Hyperglycemia, hypokalemia • Enhanced effect of corticosteroids on patients with hypothyroidism and cirrhosis • Adrenal insufficiency in patients transferred from systemic steroid • Susceptibility or decreased resistance to infection • Paradoxical bronchospasm • Potential risk during pregnancy, labour, delivery or nursing • Control of asthma should be monitored For more information: Consult the Product Monograph at azinfo.ca/symbicort/pm796 for important information regarding adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling AstraZeneca Canada at 1-800-668-6000.

SY1180E

SYMBICORT , SYMBICORT SMART , TURBUHALER and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. © AstraZeneca Canada Inc. 2014 ®

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Explore the possibilities.

Make Belize Escape the real world at a hidden jungle lodge in Toledo

BROWN CANNON III

by Margo Pfeiff

Set in the hills above the Caribbean coast of southern Belize, the Belcampo jungle lodge sits in a 5000-hectare nature reserve.

olting upright with goose bumps and a racing heart is my least favourite way to wake up in the pitch black of a jungle night. Sweaty air and the otherworldly roar and rasp of what sounded like a T. rex synced with my marauding dinosaur nightmare.

Then I remembered last night’s JANUARY 2015 • Doctor’s

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ALL PHOTOS MARGO PFEIFF UNLESS OTHERWISE NOTED

The resort has an organic farm and an agritourism program, and is the region’s largest private employer.

dinner talk about very big sounds made by very small critters. Oh, yeah. Howler monkeys.

It was a fittingly dramatic ending to my first full day in Belize, a cultural cacophony of chocolate-making with Mayans, banana-beaked toucans whizzing through 50 shades of jungle green, swimming in the dark through a giant cave, blonde Mennonites trotting their watermelon-filled horse-drawn carts along potholed roads. Then there was that caretaker at Lubaantun Mayan ruins who showed off yellowing newspaper clippings about a spooky crystal skull allegedly found amid the rubble by the daughter of an adventurous Brit named F. A. Mitchell-Hedges, one of the inspirations for the Indiana Jones character.

And this place has never been on my bucket list?

When my longtime friend, chef and food activist, Mara Jernigan, left Vancouver Island in 2011 to manage a jungle lodge for three years in Belize, I had to ask Google where that was. Before recently leaving the lodge, Mara finally convinced me to visit, but since she was ensconced in the remote, rural southernmost district of Toledo, I hedged my bets with a potential exit strategy of scuba diving the world’s second biggest barrier reef off Northern Belize.

I never left Toledo.

Belize is a rare English-speaking country in these

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Spanish-speaking parts. In the 17th century it was the pirate-haunted Spanish Main, then the British Honduras until independence in 1981. About the size of Massachusetts, it’s wedged between Mexico and Guatemala. My small plane hopscotched south from Belize City to Toledo’s Caribbean-flavouredand-paced main town of Punta Gorda or “PG” (pop: 6000) with its funky mix of dreadlocks, expats and rickety seaside watering holes.

When I arrived it was market day, and fishermen and farmers displayed their goods in street-side stalls.

There were many Mayans, but also an ethnic kaleidoscope that included descendants of American Confederates, Caribbean slaves, British buccaneers, Garifuna, East Indian indentured labourers and dairy-dealing Mennonites.

Toledo is off-the-beaten-track. There are only a few B&Bs in Punta Gorda and its surrounds, as well as several farm inns at jungle locations. Come here to go exotic bird watching, saltwater fly-fishing, hiking, snorkeling, kayaking, caving, and visiting Mayan ruins and villages. I bumped along a 20-minute shuttle from PG to a hilltop perch where Mara was the general manager of Toledo’s only luxury lodge, Belcampo Belize, an agri-tourism eco-resort set amid a 5000-hectare nature reserve.

Mayan staff teach guests how to grind dried cocoa beans into a paste the traditional way.

When I asked her how far my breakfast travelled to reach my plate she did a quick count: “about 500 metres” I have a pet peeve about resorts branding themselves “eco” when they simply ask guests to hang up their towels for a second use. At Belcampo, all the laundry is line-dried and the furniture crafted on-site from sustainably harvested wood. Kitchen and table waste are composted or fed to chickens and pigs residing on the resort’s farm which Mara helped set up when she first arrived. It’s the source of the dining room’s organic free-range eggs nestled alongside cinnamon-bark-house-smoked bacon, freshly squeezed orange juice and papaya marmalade. When I asked her how far my breakfast travelled to reach my plate she did a quick count: “about 500 metres.”

Roughly 70 percent of the food they put on the table is local (imported wines and spirits make up much of the rest), she told me, and what they don’t produce themselves they source from nearby farmers whose practices they know well. The resort is the region’s biggest private employer and it’s owned by Oakland-based Belcampo Inc. whose mandate it is to manage land and animals in an organic, sustainable and humane manner — and make a profit. And they’re doing it on a bigger scale than has ever been attempted before. Belcampo Belize is part of a threecountry project that includes olive oil-growing in Uruguay and ranchlands near Mount Shasta in

California, the source of the grass-fed, free-range meats sold in their first Belcampo butcher shop/café in Larkspur, north of San Francisco, with five more slated to open statewide by year’s end.

Next on Belcampo’s menu? Indigenous Belize products.

I signed up for the lodge’s Bean-to-Bar chocolatemaking workshop. It started with plucking almondsized beans from freshly harvested cocoa pods.

Then we headed into one of three new pavilions to taste the beans throughout the entire roasting, grinding and tempering processes until we finally poured satiny liquid into our very own chocolate bar forms.

Cocoa is “Mayan gold” and is still used as currency in Belize; by 2015 Belcampo will be the country’s biggest producer.

The other two pavilions will soon be used for similar hands-on workshops with estate grown coffee and sugarcane for artisanal rum — two stills are currently under construction — some flavoured with homegrown spices like cinnamon and nutmeg.

Working with San Francisco-based Blue Bottle Coffee and Chicago’s Vosges Chocolate, the plan is to take organic, ethically-produced high-grade rum, coffee and chocolate from the farm to the US marketplace while supporting much-needed jobs in Toledo and JANUARY 2015 • Doctor’s

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BROWN CANNON III

Punta Gorda is Toledo’s economic centre and where people from surrounding villages go to work and trade.

A lot of the lodge’s furniture was crafted on-site from sustainably harvested wood.

RESORT TO THIS

You can have a traditional lunch with a family in Blue Creek, an electricity-free Mayan village of about 270 people.

Mayans believed that the rain god lived in places like the Hokeb Ha Cave, which is also home to a waterfall.

Belcampo Belize (Wilson Road, Punta Gorda; tel: 888299-9940; belcampobz.com; doubles from US$288 per night) is a luxury, agritourism eco-resort with 16 suites.

It offers plenty of hands-on gastronomic and outdoor activities — at extra cost. Their Intro to Bird Watching workshop, for example, costs US$25. The Lubaantun, Blue Creek Village and Cave Swim costs US$125 per person, the Bean-to-Bar Chocolate Making Class is US$160 and Snorkeling with the Chef is US$190. The use of mountain bikes, canoes and kayaks, airport shuttle and a full breakfast are included in nightly rates.

Consider Asha’s Kitchen (74 Front Street, Punta Gorda; facebook.com/ashasculturekitchen) for casual Belizean fare on a waterfront terrace or Coleman’s (Main Road, Big Falls; facebook.com/colemanscafe) for a traditional Belizean buffet lunch.

For more info on the region, visit Travel Belize (travelbelize.org); Southern Belize Tourism (southernbelize.com) is also useful.

I lazily bird watched from the hammock on my meshed-in deck with rainforest surrounding me like wallpaper building a global market for Mayan products that were made in a country with no McDonalds, Walmart or Costco. “I want Belcampo to be a benchmark for success in sustainable agriculture,” said the company’s intense and passionate California-born CEO, Anya Fernald, over dinner.

A

forgotten corner of Central America, Toledo is lucky to have retained about 75 percent of its rainforest. Drenched with an average of four metres of annual rain, it’s home to iguanas, jaguars, ocelots and more than 500 species of birds. I joined a small group of keen birders and trotted out at first light along a network of jungle trails with guide Emmanuel Chan, binoculars combing the gumbo-limbos to put faces on the avian chatter that awakened me every dawn after the monkeys had settled down. There were toucans that croaked like frogs and hummingbirds the size of chickadees aptly named melodious blackbirds. Every bit as obsessive were the early morning saltwater fly-fishermen we crossed paths with, hell bent on pursuing the elusive saltwater trio of tarpon, bonefish and permit.

Much of Toledo is protected as parks or reserves, including marine regions with lush offshore cays.

Over the following days, I kayaked along the snaking Rio Grande River meandering past the base of the resort, hiked along jungle trails and lazily bird watched from the hammock on my meshed-in deck with rainforest surrounding me like wallpaper.

When Mayan guide Vince Ical took us to the ancient Lubaantun ruins we passed the welcoming Earthship Belize, a castle-like eco-house built of discarded bottles and trashed tires by a colourful expat British couple. Toledo’s end-of-the-road jungle scene attracts plenty of quirky fringe-dwellers.

“There’s Pentecostals, Jehovah’s Witnesses and hippies looking for a place to live sustainably,” Dr Mandy Tsang had told me at dinner the previous night. Her partner is also a physician and they live off-the-grid themselves, supplementing their income by hand making organic soap from coconuts on their land as well as bush-distilling an innovative range of tropical alcoholic elixirs that put a kick into

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Belcampo’s cocktails. “There’s a lot of crazies like us down here,” she confessed.

After prowling Lubaantun’s crumbling temples and ball courts, and hearing horrid tales of human sacrifice, it was time for lunch in Vince’s own Mayan village of Blue Creek, one of 36 such villages in the region. His wife laid out a delicious traditional Belizean feast at their home. Our meal included curried heart of palm that Vince harvested himself, marinated grilled chicken thanks to the free-range backyard critters, corn from their field ground into fresh hot tortillas and homemade haberno salsa. We dined overlooking a bright turquoise stream that we then followed upstream to the gaping Hokeb Ha Cave. Slipping on life vests, we swam with headlamps into the vast cool blackness towards a small waterfall, headlamps spotlighting sparkling stalactites dangling from the high ceiling.

On another day, in the Mayan village of San Pedro Columbia, I met cocoa farmer Eladio Pop who sells much of his product to Britain’s Green & Black’s for their premium “Mayan Gold” bars. His wife and several of their 15 kids took part in roasting beans over a fire, grinding them on a stone metate that’s been handed down through generations, then passing out calabash shells filled with real-deal, genuine Mayan hot chocolate sweetened with killer bee honey. Their simple, foil-wrapped bars sprinkled with home-grown sesame seeds didn’t have the smooth mouth-melt of machine-processed chocolate, but the flavour gives the world’s best a run for its money, especially when it’s tasted so close to its source.

On my last day, I went Snorkeling With the Chef cruising down the mangrove-lined Rio Grande into the Caribbean ocean where we snorkeled and helped Captain Jackie — whose Confederate grandmother emigrated to Belize after the Civil War to grow sugarcane — free-dive for conch. Chef Brandon Genus speared two snappers and headed aboard to slice and dice while we explored the warm waters off tiny Moho Cay in the company of barracuda and sergeant majors. On the sail back, Brandon delivered conch and snapper ceviche. We scooped it up while swishing freshly picked allspice leaf around in our Mayan Sunset cocktail.

Mexico by way of Maya. doctorsreview.com/features/ mexico-chiapas-san-cristobal-maya JANUARY 2015 • Doctor’s

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Where ancient The astonishing Four Corners region shelters the real Southwest

SUMIKOPHOTO / SHUTTERSTOCK.COM

by Josephine Matyas

Most of the cliff dwellings in Coloradoâ&#x20AC;&#x2122;s Mesa Verde National Park have one to five rooms; the Cliff Palace has 151.

cultures thrive

he locals call it a shortcut, but it’s not really a shortcut. On the map it looks like miles saved, but a jarring two-hour crawl along a washboard dirt road doesn’t add up to much of a time saving.

When Joe Day leaned over his map and traced a route from his shop in Shungopavi on Hopi Second Mesa to the cliff dwellings at Mesa Verde, he clearly meant business.

To the uninitiated, Shungopavi may look like the middle of nowhere. The cluster of small buildings

sits atop one of the three Hopi mesas in the heart of the Four Corners region — where Arizona, New Mexico, Utah and Colorado intersect. It is dry. It is barren. If I’d been looking for the antithesis of Toronto or New York, this might be it.

But middle of nowhere? Joe Day would disagree.

Canyon de Chelly in Arizona features two paved rim drives, 10 overlooks and one public trail that you can hike on your own.

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“For a Puebloan person everything you do, see and breathe is spiritual” “This is a real place where real people live. The Hopi reservation is the oldest continuously inhabited town in North America and the people who lived here were contemporaries with the ancient puebloans whose ruins are all over the Southwest — Mesa Verde, Chaco Canyon, Canyon de Chelly.”

These remote mesas are not somewhere you just happen upon. Hopi is a destination. “Visitors are not coming here just because they broke down and had to spend the night because they’re halfway to the Grand Canyon. They’re interested in culture, they’re interested in history, they’re interested in archeology,” explained Day. “Being 65 miles from the interstate screens out some of the riff-raff; no rubber tomahawk customers at all.”

R

oads crisscross the Four Corners region, some of them blacktop, some dirt washboard. Many lead to and from the ruins and communities from whom today’s Southwest people are descended. Each ruin, every village or pueblo, as the Spanish called them, have stories to tell — of the ways these great

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cultures came together, diverged and then crossed paths again. Over the arc of time, migrations occurred, powerful communities disbanded, and new ones grew and flourished, continuing traditions laid down by their ancestors. Roaming these roads, from ruins to vibrant communities, is a way to follow that arc.

The Four Corners is a place for exploration. Several hours along that rough road and then paved highway — past the soaring red and orange cliffs of the high desert — brought me to Mesa Verde in southwest Colorado, the only US National Park based on archeology rather than natural features alone.

“For a Puebloan person everything you do, see and breathe is spiritual,” explained guide Mike Petrose who has spent most of almost six decades living on top of the mesa. “It’s not that we’re all the same, but the energy that built us is the same.”

Case in point: on a four-hour, architecturethemed tour that just barely touches the 4500-plus archeological sites at the park, Petrose pointed out the construction of a kiva, a subterranean religious ceremonial space. “Most classic kivas share a southern orientation with a vent, fireplace and spirit entrance

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These three Hopi women on adobe steps were photographed by Edward S. Curtis in 1906.

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The Canyon de Chelly dwellings were inhabited between 350 and 1300 CE; today a community of Navajo people live on the canyon floor.

forming an axis that points south. Roofed, the kiva would appear to be a part of the earth, the traditional pueblo spirit world.”

We travelled along the Mesa Top Loop, through changes in architecture that traced a timeline of the people who lived here from 600 to 1300. At first there were pithouses, large spaces dug into the ground where people of the Basketmaker period would have lived and stored their winter supply of corn. Several hundred years later, the buildings moved above ground to single wall “waddle and dab” masonry.

As time and techniques progressed, walls became thicker, constructed of stone and mortar.

The architecture builds to a crescendo at Cliff Palace, the jewel of the massive archeological collection at Mesa Verde. At 151 rooms it is the largest cliff dwelling in the southwest. The people who lived and worked and raised families under these rock overhangs were there for 750 years, almost three times as long as the United States has been a country.

With a guide, we followed a narrow trail into the ruins and spoke in hushed tones. The dwellings demand reverence. There were no shouts to bounce echoes from one cavernous wall to the next. But there were questions. Lots and lots of questions.

There are about 600 cliff dwellings here and about.

Best guess is that the people who built them knew and understood math, although we are at a loss about where that knowledge came from. It would have taken many years to build all of this without the benefit of the wheel or the horse. Education must have been an important concept, with ideas and information being passed from one generation to the next. They lived in this final stage of building styles — the cliff dwellings — for less than a century. By the year 1300, Mesa Verde was deserted. The reasons why? Unknown.

As with many of the ruins in this part of the country, there are more questions than answers.

There’s a lot made of the migration of the people from these great communities. Some say that they

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There are many petroglyph styles, but those by Native Americans in the northern hemisphere depict animals drawn from the side.

just disappeared, a wording that makes Petrose bristle.

“They never vanished. We know where they are — they moved. We find them in the Zuni, Laguna and the pueblos along the Rio Grande and on the Hopi lands right square in the middle of Arizona’s Four Corners.” The point is that many of the native cultures that thrive today can trace their ancestry to these ancient builders at Mesa Verde.

G .

one does not mean disappeared. This idea is also at the crux of Chaco Canyon, the ruins in northern New Mexico’s high desert that experts speculate were once the ceremonial, trade and cultural centre of a great civilization that stretched across much of this area.

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There are plenty of ways to explore Canyon de Chelly including hiking trails and guided horseback-riding tours.

GETTING THERE Fly to Phoenix, AZ or Albuquerque, NM. Air Canada, WestJet and American Airlines have service.

NAVIGATING AAA publishes an excellent detailed road map called Indian Country. It is available at AAA offices in the southwest and for sale at local shops.

WHEN TO GO The Colorado Plateau area is high desert — and this can mean cooler temperatures in the winter months.

Spring and fall are the best times to visit and many of the desert cacti are in bloom during March and April.

Now is a good time to plan a spring visit.

Kin Kletso in New Mexico’s Chaco Culture National Historic Park is a medium-sized great house that was once occupied by one or two households.

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WHERE TO VISIT Mesa Verde National Park: nps.gov/meve Chaco Culture National Historical Park: nps.gov/chcu Acoma Pueblo: acomaskycity.org Gila Cliff Dwellings National Monument: nps.gov/gicl Heard Museum: heard.org Museum of Northern Arizona: musnaz.org

These remote mesas are not somewhere you just happen upon. Hopi is a destination There is nothing quite like Chaco anywhere else.

Archeologists and archaeoastronomers pinpoint this as the high-water mark in the thriving puebloan cultures of millennia past. Because of its remote location the UNESCO World Heritage Site has few visitors. Spread out across the canyon’s wild beauty of rock, scruff piñon pine, creosote and manzanita brush, the excavated ruins are dominated by monumental architecture built with an estimated 50 million slabs of sandstone.

Multi-storey buildings with hundreds of rooms called Great Houses — including Pueblo Bonito, Chetro Ketl, Pueblo Alto — were oriented to solar, lunar and cardinal directions. How the Chacoan people managed such sophisticated calculations is one of the great mysteries. In some cases it would have taken decades, or even centuries, to construct these buildings. More of these public structures are concentrated here than in any other spot across the Southwest. The question is, why? Experts believe Chaco was the hyper-organized ceremonial centre

of the ancestral puebloans, creating an even deeper significance for today’s indigenous people.

Astronomy clearly played a major role in Chacoan culture. Like all pre-historic cultures, the residents organized their lives around the harvest of corn, squash and beans. The Chacoans attuned themselves to seasonal patterns by following the progress of the sun, tracking the path of its shadow as it cut across stones erected as astronomical markers. So precise was this ancient calendar that they aligned the massive walls of Pueblo Bonito along the axis of the summer-winter equinox, and then oriented distant buildings and roads to the same coordinates — an impressive feat of engineering.

These concepts of the seasons, of balance and symmetry, and of the landscape’s spiritual nature forge close bonds between the ancient people and their descendants. Traditions and ceremonial knowledge are still very much alive with the spirit of ancestors who left their imprint on these sacred lands.

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How to hike grizzly country A common sense guide to enjoying nature’s wild places

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by Mike Nash

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I

read Hiking grizzly country – or not (September 2014, page 50) with great interest. It was sent to me by a physician friend asking me what I

thought of the article. Why? I am the author of several books related to the topic and I have had my share of bear encounters.

My first reaction was not to comment at all since the article is about an aborted hike and an imagined bear encounter that never actually happened. Also, I preferred not to second-guess someone else’s decision not to hike alone. However, the next day as I was solo-hiking in the mountains, I reflected on the article and I felt that there were aspects worth addressing.

The topic was especially relevant as I was walking in a place where, just over a year earlier, I had chanced upon a grizzly while leading a group of hikers on an exploratory off-trail route. And there was a powerful second reason. Directly across the Rocky Mountain Trench from where we were climbing, a friend had died in 1998 after encountering a grizzly bear that was

is in a more precarious position than with a group. A detailed itinerary left with a trusted contact and/or carrying one of the many satellite communications devices now available can mitigate this risk. In short, a decision to hike alone is not cut and dried, which was the point of the story as the author agonized over his options after his guide cancelled.

CARRY SPRAY

In the article he also downplayed the value of carrying bear spray, whereas it has been demonstrated to have good efficacy in deterring grizzly bears. For its slight weight and cost, it is a “must have” in grizzly country, although I will concede from personal experience that it can seem quite insignificant when faced with a surprised grizzly that is pirouetting and pounding the ground in a powerful display of upset. That particular situation seemed to hang on a hair trigger and could have gone either way, but fortunately the right neurons fired and the bear took off in another direction. And that is the way it usually plays out in direct grizzly encounters, as well as in the more numerous occasions when we unwittingly walk past a bear that stays quietly out of sight.

Bear attack statistics suggest that two may be the least safe number defending a moose carcass — generally the most dangerous of all bear encounters and something I’d written about in my book, The Mountain Knows No Expert.

ALONE NO…

I’ll start by saying that hiking alone in the backcountry is not recommended. A minimum of three hikers allows one to remain with a disabled person while another goes for help. The Rocky Mountain National Parks recommend groups of four or more staying in close proximity of each other in certain high-use grizzly areas. In the article, the author says he was prepared to hike in a group of two before his guide cancelled out. Bear attack statistics suggest that two may be the least safe number. There are plenty of cases where two people have been attacked resulting in injury or death. Two people seem to offer little more deterrent than someone alone and might be perceived as more of a threat to a surprised grizzly bear.

If a person is knowledgeable about, and comfortable with, hiking alone, he or she will likely have a safe and satisfying outdoor experience without significant added risk. But if something does happen — even a simple mishap like an ankle sprain — the solo hiker

…ALONE YES

As the author explains, it’s not always possible to find willing companions when you want to go on a hike. But in deciding whether to go alone, consider the benefits of walking and reconnecting with the natural world versus the risks that we run in everyday life on the highways and with sedentary lifestyles. The choice, for me, is easy: unless there is a known problem that should be avoided, I would choose to go, but equip myself with knowledge about outdoor safety and the habits of wildlife I am likely to encounter there.

Mike Nash is the author of Outdoor Safety & Survival and Exploring Prince George: A Guide to North Central BC Outdoors both published

by Rocky Mountain Books; and The Mountain Knows No Expert, published by Dundurn. www3.telus.net/pgoutdoors.

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Some of Rio’s favelas have become “urbanized slums”’ with banks and restaurants, but they’re also crime-ridden and dominated by gangs.

What we do after gunfire February in Rio de Janeiro can be very hot and very dangerous

by Jocelyn Edelstein

from her limbs and lap. I rest my elbows on the iron bar of the window and spread my fingers in the space between outside and in.

The first blast sounds like an avalanche untangling itself from the mountain. The sudden and boundless rumble shakes in my belly, echoing above my head and below my feet. From the window I see Jaque stumble down the stairs with her baby clutched to her chest and her daughter and son grasping at the hem of her skirt. She glances my way for a second, and the look on her face makes my stomach tighten. I see the warning in her eyes, and I hit the floor. My cheek presses into the dirty blue rug, and I stare at the red flashing numbers on the digital clock beside the television. It’s 3:30pm on a Sunday afternoon.

When I first met Jaque, she was silent and smiling, and her third child was still in her belly, waiting to enter the battleground of Falet — one of Rio de Janeiro’s five hundred plus favelas, or slums. We pressed ice cubes against our foreheads to protest the sun that ferocious summer, and the neighbourhood kids shouted “Teacher!” when they saw me on the street. Jaque’s mother called me her white daughter, but for the first two months I lived in her home, Jaque and I barely spoke to each other. She watched me, curious yet unmoved by the strange American

dance teacher who had befriended her mother and become an unexpected guest in their tiny, tin-roofed house. She refused to let me help with dinner.

There are close to 1000 favelas in Rio and one million people call them home.

JANUARY 2015 • Doctor’s

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J

aque sits on the porch steps that lead from her tiny house down to the basement home of her uncle. Her three children, sunburned from Rio de Janeiro’s blazing February summer, hang like ornaments

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But one night as I danced with her mother in the living room, overcome with the beat of my favourite Brazilian song, Jaque leapt from her seat with a wail and started shaking her hips in circles around my body, yelling, “Eu nunca soube sobre seu coração maluco do brasileiro!” “I never knew about your crazy Brazilian heart!”

They called Jaque favelada, meaning someone with the real style of the favela. The favelas of Brazil were notorious for their tangle of colourful shacks, drug trafficking rings, violent encounters with the police, and Brazilian funk music. And oh, how the favela could be stylish. Stylish like AK-47s slipped between the hipbones and Bermuda shorts of 22-year-old drug lords. Stylish like high-heeled women stomping their feet to the rat-a-tat percussion of funk songs blasting from hand-painted boom boxes at all hours of the day and night. Stylish like the coded victory cry of three bullets released into the air while dancers chanted, “The police don’t come to our parties!”

Jaque knew all the shortcuts in Falet’s maze of staircases and gutters, and she knew the people who did their business there. Because she could move quickly, without bus fare, she ran all the errands for her family. She understood the favela like a gardener understands the geometry of her garden and is willing to touch things that have not yet become beautiful.

Jaque never looked worried when the guns fired.

Her two-year-old cried loudly and her mother clucked her tongue and muttered about the end of Brazil’s slums are usually located on the outskirts of large cities like Rio and São Paulo.

I see the warning in her eyes, and I hit the floor My body is still flat on the floor, legs wedged under the bed, face against the scratchy carpet. Yes, I think. This is craziness. The hail of bullets has stopped and been replaced by an uncertain stillness.

Twenty minutes have passed since Jaque fled down the stairs with her children, and I console myself with the thought that she’s in her uncle’s house taking cover in his bedroom, but the air is empty of the two-year-old’s tears or the baby’s giggle.

I crawl to the doorway, where I weigh the risk of standing upright to move toward the staircase that will take me outside, and to her. I wonder in this moment if we mimic our surroundings. If we yell back at bullets and bite our tongue in the ceasefire.

When the kids in this neighbourhood hear hip hop on the radio, they imitate the sound of machine gunfire to accompany the beat. I don’t know what sound we make when we imitate death, but I’m sure I have heard it here. I’m sure that in the space between Jaque and me, there is a path from the hand that resists violence to the hand that accepts it. I silently plead with Jaque’s children to make noise, but only the high-pitched wind whistles in my ear.

Jaque’s favourite time of day, it seemed, was at night when all her kids were asleep and no one had come home yet. I often found her in bed covered in a blanket with her youngest baby on her chest, her four-year-old at the other end of the mattress, and her two-year-old on the bed by her side. The air echoed calmly around the breath of the children.

And though her eyes were closed, she was always awake and whispered my name.

We had our most intimate conversations on these nights. Jaque didn’t tell secrets to her mother because they were too much alike, and she didn’t tell secrets to her sister because she was younger and more religious. But she confided in me when we were alone and her kids were asleep in the bedroom in Falet.

She told me how much she missed the father of her four-year-old daughter. He was the one she still

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the world, but Jaque just kept sweeping the kitchen floor in her cutoff denim skirt or tickling her baby’s face. Then she’d look at me with large amber eyes and laugh: “É malucera neh?” “This is craziness, huh?”

Doctor’s Review • JANUARY 2015

ELENA MIRAGE / SHUTTERSTOCK.COM

Many of the slums in Rio have running water and electricity, but disease is rampant in poorer favelas, and infant mortality rates are high.

loved, but he chose to be a trafficker. “And that,” she insisted, “is not a life. Just a short existence before death.”

One afternoon, months after this, I sat crying in her living room over a broken heart. She walked in and spilled a bag of rice as she waved her arms around and shouted through a beaming smile, “We deserve good men! We deserve good men!” It was the first time I’d heard her say she deserved anything good, and I nodded my head slowly with wide eyes.

Because we did.

The digital clock above my head now blinks 4:15pm.

Forty-five minutes since Jaque and her kids ran down below. The gunfire has returned, but this time it’s a distant reverberation. I stand up.

When Jaque cleans the house she moves briskly, never putting anything back in place carefully, yet somehow managing not to make a sound. This is how I move downstairs now. Like a gust of wind.

In front of her uncle’s door, I pause and press my ear to the splintered wood. I want Jaque to teach me how she walks through her world like a queen. I want her to show me the swiftness of her hands and the abandon of her hips. If I had a sound to mimic Jaque, it would be Rio at four in the afternoon, when the sun crackles on concrete and feet tap, preparing to dance.

The door’s creaky hinge is the first sound to break the silence. Next is the whisper of my name on Jaque’s lips. She is lying on her uncle’s bed, eyes closed, her baby on her chest, the other two children at her feet. She grins as I curl my body into the tiny spot beside her.

“They were tired,” she says, brushing a long braid off her face. “It’s so peaceful when they sleep.”

Reprinted with permission from The Best Women’s Travel Writing: Volume 8 (Solas House, Inc.) JANUARY 2015 • Doctor’s

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Alone on the ran All-in-one casseroles that can be served solo for supper recipes by

Betty Rosbottom

photos by

“

Susie Cushner

A good marriage is like a casserole; only those responsible for it really know what goes into it.

”

— Anonymous

W

hen food writer Betty Rosbottom discovered that many cookbook indexes go straight from “carrots” to “caviar,” she went to work creating

Sunday Casseroles, published by Chronicle Books. She defines casseroles as gratins, baked stews, pot pies, pilafs and stratas that are all-in-one dishes — including

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Doctor’s Review • JANUARY 2015

your favourite lasagna. They’re easy to assemble, endlessly versatile and can often be made ahead. Plus, many can be served as a main all on its own — a

CHICKEN POT PIES WITH GOLDEN CHEDDAR CRUSTS

nge

When asked to choose a favorite comfort food, chicken pot pies are often at the top of the list. The pies featured here, though, are different from storebought ones. The filling, chicken, sau­ téed butternut squash, Brussels sprouts and mushrooms, all enrobed in a smooth white sauce, is spooned into ramekins, then covered with cheeseflecked pastry rounds. When baked, the golden crusts are tender and flaky, a perfect contrast to the creamy chicken and vegetables beneath.

For the crust 3 c. (750 ml) sifted all-purpose flour 1 c. (250 ml) grated sharp white cheddar cheese ¾ c. (180 g) cold unsalted butter, diced 4½ tbsp. (67.5 ml) vegetable shortening, chilled and broken into small pieces ¾ tsp. (3.75 ml) salt ¼ c. (60 ml) plus 2 tbsp. (30 ml) ice water

Chicken pot pies with golden cheddar crusts.

saviour on hectic weeknights. Rosbottom updated old favourites (like the chicken pot pie that follows) and invented new recipes that take advantage of the diversity of fresh ingredients at supermarkets — not the case when casseroles first became popular in the mid-20th century.

The recipes that made us want to reach for our cookware are included here.

For the filling 2 tbsp. (30 g) unsalted butter 2 tbsp. (30 ml) canola oil 1½ c. (375 ml) diced butternut squash (½-in./12-mm dice) 4 oz. (115 g) small Brussels sprouts, bases trimmed and quartered lengthwise 4 oz. (115 g) small brown (cremini) mushrooms cut into ¼-in- (6-mm-) thick slices ½ c. (125 ml) thinly sliced leeks (white and light green parts only) 1½ tsp. (7.5 ml) crushed dried rosemary ½ tsp. (2.5 ml) salt freshly ground black pepper 2 c. (500 ml) diced cooked chicken or turkey (½-in./12-mm dice) For the white sauce 5 tbsp. (75 g) unsalted butter ¼ c. (60 ml) all-purpose flour 2½ c. (625 ml) whole milk salt freshly ground black pepper 1 large egg, lightly beaten

For the crust: combine the flour, cheddar, butter, shortening and salt in a food processor, and pulse for 15 seconds. Add the ice water and process until a loose ball of dough forms, about 30 seconds. (If you have a small-capacity processor, divide the ingredients in half and make the dough in two batches.) Remove the dough and shape it into two equal balls. Flatten each one, wrap in plastic wrap and refrigerate for 45 minutes.

For the filling: in a medium, heavy frying pan over medium heat, melt the butter with the canola oil until hot.

Add the squash and Brussels sprouts, and sauté, stirring, for 3 minutes. Add the mushrooms and cook, stirring, for 3 minutes more. Add the leeks, rosemary, salt and several grinds of pepper, and cook, stirring, until the vegetables are lightly browned and just tender, 2 minutes. Transfer vegetables to a large bowl and add the cooked chicken.

Arrange a rack in the middle of the oven and preheat to 375°F (190°C).

Have ready six 1-cup (250-ml) ramekins and a rimmed baking sheet.

For the sauce: melt the butter in a medium sauce­pan over medium heat.

When hot, add the flour and cook, stirring constantly, for 1½ to 2 minutes.

Add the milk, ¾ teaspoon (3.75 ml) salt and 1 teaspoon (5 ml) pepper, and bring to a gentle boil, whisking constantly until the mixture thickens enough to coat the back of a spoon, about 5 minutes. Pour the sauce into the bowl with the chicken and vegetables, and toss gently to combine. Season with salt and pepper, if needed.

Divide the mixture evenly among the ramekins.

On a floured surface, roll out one ball of dough to a circle about 11 inches (28 cm) in diameter and ¼ inch (6 mm) thick. Cut out three rounds that are 2 inches (5 cm) larger in diameter than the tops of the ramekins. (For example, if your ramekins are 4 inches/10 cm in diameter, cut out 6-inch/15-cm rounds.) You may need to gather the dough scraps and roll them out again to get three rounds. Repeat with the remaining ball of dough.

Brush a ½-inch (12-mm) border around the edge of each round with some of the beaten egg (this will help JANUARY 2015 • Doctor’s

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Saffron rice pilaf with lamb meatballs and dates.

the pastry topping to adhere to the ramekin). Cover each ramekin with a circle of dough (egg-brushed-side down) and press the overhang­ ing dough against the sides. Make a 1-inch (2.5-cm) slit in the centre of each crust.

(The pot pies can be prepared up to this point 1 day ahead. Cover each with plastic wrap and refrigerate. Bring to room temperature 30 minutes to 1 hour before baking. Cover and refrigerate the remaining beaten egg and whisk lightly before using.)

Place the pot pies on the rimmed baking sheet, and brush the pastry tops and sides with the remaining beaten egg. Bake until the tops are golden, 30 to 35 minutes (slightly longer if the pies have been refrigerated). Remove from the oven and cool for 5 minutes before serving. Serves 6.

Notes: You can use leftover chicken or turkey or buy a rotisserie bird. If you choose the latter, count on using more than half the chicken.

To make the dough by hand, mix the flour, cheddar and salt together in a

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bowl. Cut in the butter and shortening with a pastry blender or two table knives until the mixture resembles oatmeal flakes. Gradually add the water, mixing just until the dough holds together.

SAFFRON RICE PILAF WITH LAMB MEATBALLS AND DATES For this easy casserole, petite meatballs prepared with ground lamb and seasoned with Moroccan spices are nestled into a baked rice pilaf during the last few minutes of cooking. The rice, scented with saffron, cooks to a rich, golden yellow and is accented with bits of red bell pepper and Medjool dates.

For the meatballs 1 tbsp. (15 ml) ground cumin 2 tsp. (10 ml) paprika 1 tsp. (5 ml) salt ¼ tsp. (1.25 ml) cayenne pepper

1 lb. (455 g) ground lamb ¼ c. (60 ml) very finely chopped onion 2 tsp. (10 ml) minced garlic 2 tbsp. (30 ml) olive oil 1¼ c. (310 ml) long-grain rice, preferably basmati ¾ c. (180 ml) red bell pepper cut into strips, ¼ in. (6 mm) wide and 1½ in.

(4 cm) long 8 Medjool dates, pitted and cut lengthwise into quarters 3½ c. (875 ml) reduced-sodium chicken broth ¼ tsp. (1.25 ml) saffron threads, crushed salt 3 tbsp. (45 ml) julienned fresh flat-leaf parsley 3 tbsp. (45 ml) julienned fresh mint 2 tsp. (10 ml) julienned lemon zest

Arrange a rack in the middle of the oven and preheat to 375°F (190°C). Oil a shallow 2½-quart (2.5-L) baking dish.

For the meatballs: in a medium bowl, mix together the cumin, paprika, salt and cayenne. Add the lamb, onion and

garlic, and mix with two forks to combine well. Scoop 1 tablespoon (15 ml) of the lamb mixture into your hands and roll into a small ball. Repeat until all the mixture has been used. You should get about 24 meatballs. (The meatballs can be prepared to this point 1 day ahead; cover and refriger­ate. Bring to room temperature at least 30 minutes or up to 1 hour before continuing with the recipe.)

Heat the olive oil in a heavy, large frying pan over medium-high heat. When hot, add the meatballs and brown on all sides, 2 to 3 minutes. Set aside.

Spread the rice evenly in the prepared baking dish and then scatter the bell pepper and dates over the rice.

Heat the chicken broth in a medium saucepan, covered, over medium heat until it simmers. Add the saffron, taste the broth and season with salt, if needed.

Pour the hot broth over the rice. Cover the dish tightly with foil and bake until almost all the liquid has been absorbed and the rice is tender, 20 minutes. Remove the casserole from the oven and carefully remove the foil. Stir in the meatballs, cover again and bake 5 minutes more. Remove from the oven.

Combine the parsley, mint and lemon zest in a small bowl, and sprinkle over the casserole before serving.

Serves 4 to 6.

2 tbsp. (30 ml) all-purpose flour 1 tbsp. (15 ml) chopped garlic 1 tsp. (5 ml) dried basil 1 tsp. (5 ml) dried oregano dash of red pepper flakes 1 28-oz. (800-g) can diced tomatoes, with their juices ¼ c. (60 ml) white wine ½ c. (125 ml) pitted Kalamata olives, quartered lengthwise salt 1 lb. (455 g) extra-large (16 to 20 count) shrimp, shelled and deveined ½ c. (125 ml) crumbled feta cheese 2 tbsp. (30 ml) chopped fresh basil

Arrange a rack in the middle of the oven and preheat to 50°F (180°C). Oil a 9-x-13-in. (23-x-33-cm) or another shallow 3-quart (3-L) baking dish.

Cut the baguette into ¾-inch (2-cm) slices and cut the slices into ¾-inch (2cm) cubes to get 2 cups (500 ml). (Save the extra bread for another use.) Mix the 2 tablespoons (30 ml) olive oil and the saffron in a medium bowl, add the bread cubes and toss to coat well.

Spread the bread on a rimmed baking

sheet and bake until golden and crisp, turning once, 7 to 8 minutes. Remove from the oven and set aside.

Heat the ¼ cup (60 ml) olive oil in a large, heavy frying pan over medium heat until hot. Add the onion and artichoke hearts and sauté, stirring often, until the onion is slightly translucent, 3 to 5 minutes. Add the flour, garlic, basil, oregano and red pepper flakes and cook, stirring, for 1½ minutes. Add the tomatoes and their juices, the wine and olives, and stir to combine. Season with ½ teaspoon (2.5 ml) salt, add­ing more if needed.

Remove the pan from the heat and stir in the shrimp. Spoon the mixture into the prepared baking dish. Sprinkle with the feta and top with the croutons.

Bake, uncovered, until the shrimp are pink and curled, about 12 minutes.

(The cooking time may vary, depending on the size of the shrimp.) Sprinkle the casserole with the chopped basil before serving. Serves 6.

Recipes and photos from Sunday Casseroles: Complete Comfort in One Dish (Chronicle Books, 2014).

SHRIMP AND ARTICHOKES UNDER SAFFRON CROUTONS This casserole is so simple. You add shrimp to a quickly prepared tomato and artichoke sauce, and spoon the mixture into a baking dish. A sprinkle of crumbled feta and a topping of homemade croutons complete the assembly before the dish goes in the oven.

1 day-old baguette 2 tbsp. (30 ml) olive oil, plus ¼ c.

(60 ml) ¼ tsp. (1.25 ml) saffron threads, crushed ½ c. (125 ml) chopped onion 1 9-oz. (255-g) package frozen artichoke hearts, defrosted and patted dry

Shrimp and artichokes under saffron croutons.

JANUARY 2015 • Doctor’s

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P H OT O FI NI S H by

Dr Cha r les Whe lt on

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After the first few days, the blisters and the aches settle, and all that matters is the walking. You wake in the morning and you walk. You walk until you find your rhythm, simple and profound. Until the extra baggage is stripped away, and all that’s left is the important stuff: the walking and the companionship.

It doesn’t hurt that you get to see the sun rise over the Pyrenees. That you get to share this experience with some of the wisest, funniest, most down-to-earth people from around the world: Russians, Irishmen, Germans, Spaniards, Australians, even a few other Canadians. That you get to walk through some of the most beautiful countryside, and taste foods and wines you will thereafter yearn for. That once you get there, it costs very little. And that among it all, in ways you never expect, you find joy… and serenity, which you get to bring home.

The Camino de Santiago is an ancient pilgrimage route that traverses the north of Spain to arrive in Santiago de Compostela. It has been travelled for a thousand years, by ordinary people, like you and I. This picture was taken with a Sony Cyber-shot digital camera.

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Doctor’s Review • JANUARY 2015

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