Homemade tofu demystified

Adapting to local food realities is a process. I’ve posted about it many times. Today I have a DIY success story about tofu. An old myth I’ve carried around has been exploded, thanks to some help from fellow Brazil Blogger Laura at Back-to-the-Land in Brazil.

Fresh, homemade tofu – welcome to my kitchen.

Given the silly-high price of tofu in the natural foods stores I have not eaten it (aside from in restaurants) in years. I just can’t bring myself to spend R$10.50 on a 250 gram (8.8 oz.) block. Tofu has been one of those items I used to eat a lot of that I have given up since I moved to Brazil.

Somehow I got it into my head that making tofu was difficult. I spent time a few months back (maybe more than a year ago now) searching online for a home kitchen tofu maker that I could add to my extensive collection of electric kitchen conveniences. All I could locate were soy milk makers. I thought that was a dead end, so I gave up on the idea of making my own tofu.

Man was I confused (ignorant).

Thanks to a calming walk-me-through email from Laura and a companion DIY video she made, I set out to make my own tofu. I also watched a few more videos on You Tube, including this one from America’s Test Kitchen.

Take it from me (and Laura). Making your own tofu is easy and the results are delightfully wonderful.

Here is what I did:

Ingredients: 500 grams of dried soy beans, 2 teaspoons of Sal Amargo (a coagulant) and water. == that’s it!

The dried beans sold in bulk at my favorite natural foods store are half the price of those sold in packages at the supermarket. I got them for R$5 per kilogram (store bought pkgs go for R$5 per 500 grams). Finding the coagulant was more of an adventure. Sal Amargo is magnesium sulfate (sulfato magnésio), commonly called Epsom salt in the USA, and can be found at some pharmacies. Laura had suggested that I might also find it at my local grocery store in the spice section, but I had no luck there. I actually went to about 10 different pharmacies before I found it, including a couple homeopathic shops who offered to order me some for a crazy price. When I finally located a pharmacy that sold it, it was just R$3.80 for a 30 gram pouch (enough for 4 or 5 batches of tofu).

Keep in mind that Laura lives in an area in Brazil with a larger Japanese immigrant population than here in Niterói. It makes sense, then, that Sal Amargo would be more commonly available there. So if you live in such an area, perhaps you will find it more easily than I.

Anyway, here is the simple procedure. I went with the America’s Test Kitchen procedure because it seemed slightly easier than Laura’s but they are VERY similar.

-         Wash your soybeans, removing any bad beans or small stones that may have found their way into your supply. Cover substantially with water and let them soak overnight. You want at least 8 hours of soaking.

-         Drain and rinse your soaked beans.

-         Place about 1 cup of beans and 3 cups of water into a blender and liquefy the beans. Pour into a large pot for boiling. Repeat until all of your beans have been liquefied. Use a sturdy stainless steel or aluminum pot. Avoid a non-stick pot as the boiled mixture will create a film ring (and maybe some scorching on the bottom) that will require a bit of scrubbing to clean and you do not want to scrub away at your non-stick coating.

-         Stirring to avoid scorching, bring the slightly grainy mixture to a boil, reduce heat and simmer for 10 minutes. It will foam up so keep an eye on it and stir.

-         Strain the heated mixture through a sterilized straining cloth (I used a new saco de farinha = recycled flour sack or tea cloth) into another pan for further heating. You want about 3+ liters (or 13+ cups) of milk, more or less. You can add more heated water to your leftover soy solids to extract more milk, if desired.

-         Dissolve two teaspoons of Sal Amargo into a cup of water.

-         Heat your strained soy milk to boiling. Remove from heat. Using a figure 8 stirring pattern to ensure good mixing, carefully pour in half of your coagulant liquid. Stir for about 30 seconds then let it sit for about 2 minutes. You will see the curds forming. They form from the bottom up, so liquid will gather at the surface.

-         Gently sprinkle the remaining coagulant over the top and stir the surface carefully so as to not break up the curds already forming lower in the pot.

-         Put a lid on your pot and let it sit for 20 minutes or so.

-         Carefully strain out your curds with a slotted spoon or other utensil and transfer to your prepared mold. Here Laura first uses a small strainer pressed into the curds to isolate the whey which can then be skimmed off with a ladle. I did this too. It concentrates the curds and seemed to help keep them firm and together when transferring to the mold.

-         For a mold I used a cheese mold I bought some time ago at the Mercado Central in Belo Horzontes. It was perfect for the task at hand. You can easily make a mold by lining a perforated plastic container, like those grapes are sold in, with your cleaned straining cloth.

-         Cover your curds with the rest of your cloth and then weigh down the top with a box of milk or juice.

-         Apply pressure, draining your curds, for about 30 minutes.

-         Place your compressed curds into an ice bath. It helped to transfer the wrapped curds into the water first, give them a few minutes to chill, then remove them from the wrap and chill completely.

-         Thats it! Fresh tofu!

-         Store in an airtight container covered in water in your fridge. It will stay fresh for about 5 days, changing water daily.

This stuff is delicious. And the texture turned out nice and firm, the way I like it. Plus, I just spent about R$3.25 making a quantity of tofu that would cost R$21 or more in the store.

Goodbye tofu-making misconceptions.

It seems my fears were unfounded. My impulse to buy a machine to help in the process was half right. The real work in the effort to make tofu is first making the soy milk. You need fresh soy milk because the stuff sold in stores has been treated in such a way that it no longer works to make tofu. So if I were to get me a soy milk maker it would take care of more than half of the work. But then, I would have to clean the machine. Personal preference here, I guess. Overall the process was pretty simple and if I am doing the laundry or other chores that have me in and around the kitchen anyway, the down time needed to boil, set and press the tofu could be doubled up into other activities.

The best part is the great lunch of fresh tofu. Or maybe a green Thai curry with tofu and vegetables… the possibilities have opened up. Tofu is back in my life!

Be sure to check out Laura’s blog for lots of heartwarming posts about living in Brazil (especially if you love to make bread).

A glimpse into a corner of the Brazilian healthcare system

Brazil has so-called universal healthcare available free to all citizens. I say so-called because depending on where in the country you live, the hospital may or may not have running water now and again throughout the year. Doctors dealing with certain specialties may not be available for several days after you have been admitted.

One of the public hospitals in our city, for example, has an MRI machine that has been out of service for more than a year…

On the bright side, if you can hang in there long enough you will likely get the help you need. And in some parts of the country this medical attention is excellent in quality.

To skate over the wild card realities that befall the public system, most people who can afford to buy into a private insurance system do so. Fancy hospitals, short or nonexistent lines, specialists ready to see you in short order, etc.

Luiz and I both have private healthcare coverage. It’s not top of the line, but certainly WAY better than the strict public system.

Recently I was admitted to the hospital to drill down into a health situation we are still trying to totally understand. Let me highlight some things I’ve encountered along the way.

Regarding our insurance coverage: First, I cannot be denied a policy due to a pre-existing condition, and they charge premiums by the age of the consumer (ill or healthy). There are no co-payments, deductables or lifetime limits. If a treatment is determined by your doctor to be essential in your overall treatment plan, the insurance company cannot deny coverage (although they might make you jump through a few hoops).

I shouldn’t say there are NO co-payments. Some office visits include a co-payment (R$4). But follow up visits are not charged for. For example, if your cardiologist sends you out for a series of tests, your next visit to the cardiologist to review the results and discuss moving forward is a FREE office visit.

I was admitted into the hospital. Once in the hospital everything is free of charge (including all meds, which can be expensive when bought in a pharmacy). I had two ultra sounds, x-rays, a CT scan an MRI and an endoscopy. Every three days they did a full blood workup. I was on an anti-biotic drip four times a day, plus several other meds. All no charge.

The facility was very modern (old building, but totally refurbished on the inside).  It had all the fancy diagnostic machinery, in working order. Doctors of all stripes were on site.

I got excellent (and friendly) care.

Here in Brazil it is not possible legally for medical providers (or bill collectors) to make you liquidate your family assets (lose your home) as a result of medical expenses. Oh, and all your insurance premiums, misc. costs and pharmaceutical expenses are tax deductable.

If I had one complaint it would be the lack of wireless internet service in my room, but then… STFU Jim.

My premium is R$300 per month and will not jump up to nearly R$500 until I reach age 60, so I have a while.

Of course – keep in mind this is simply what I experience in my situation. Results may vary depending on the insurance company you have and where in the country you live.

Breast implants and public policy

Note I refrained from posting some of the outrageous images that come up when you Google breast implants.

I simply adore the social conscience exhibited by the Brazilian government. OK, so they are not perfect, but some decisions are so right-on.

In this case, silicone breast implants by a now-defunct French company have been seen to be crappy - specifically, they burst. Ouch. Danger.

So the government has ordered insurance companies and the public health system to cover the cost of replacements.

NEVER in the USA.

A bit more here.

Luiz health update

I’m always nervous when we go to Luiz’ appointments at the National Cancer Institute. How will the blood tests come out? Will we get good results? Is he maintaining his slow-and-steady situation --- or will he move into the more aggressive stage of his disease?

In this case I can attest to his “slow and steady” progression.

At his last appointment we can report that he is at about (statistically) the same place he was one year ago. That is GOOD news. Luiz has to worry about progression when it starts to be very aggressive. That is NOT the case. His blood count numbers are very stable.

I could not be happier, nor him.

Shout out to Brazilian health care

I’m going to say it again: I admire the Brazilian health care system. OK - what I’m really referring to is the system when you have supplemental private insurance.

Regular readers know that I had gastric bypass surgery back in July.

Since then I have had to do a great number of follow up tests to be sure all is going well.

Significantly, Luiz and I live in the epicenter of doctor’s offices and diagnostic labs. We can literally get any test done within a four block radius. All our doctors: cardiologist, endocrinologist, dental surgeon, dermatologist, physical therapist, allergist, and of course the fat-to-skinny surgeon have offices within a ten minute walk.

Everything is covered by the insurance we have. No co-pays, no limits - the doctor takes the hit (low reimbursements) not us.

Recently I had to have a CT scan, multiple blood tests, and a 24 hour blood pressure mapping. Done. Done. Done. Everything was done within two days. No waiting. No delay. And I paid nothing (aside from my affordable monthly insurance payment).

The worst of it is waiting in the waiting room for a long-delayed appointment (my fat-to-skinny surgeon guy is ALWAYS one or two hours late for appointments -- thank the goddess for iPods!). Waiting in Brazil is most certainly NOT the exception to the rule.

But the best of it is the kind and personal conversations you have with doctors who seem to care about you and who want to know more about your life than just your situational illness.

I could not be happier. Easy, quick (to set appointments - not to see the physician), efficient, great quality, and by USA standards - ridiculously cheap.

It must be said that the free public system has its problems. - especially in rural areas. But we have a dear friend, with no extra insurance,  that was recently diagnosed with prostate cancer and he was in for surgery within a week. It seems if your case is dire, you get immediate attention. There are of course horror stories of those with non-emergency situations that had to wait...

For me, the lesson is that if a community - a country - commits itself to providing universal health care -- it is possible. Even if they have scarce resources. There are ways to make it work. Take note US America.

[Did I mention that 100% of Luiz’s cancer treatment/medication (totally separate from our insurance) is free?] ‘nuf said.

Qualidade de Vida

I’m sorry – can I say these words?  I am so glad I am not living in the United States of America.

Seriously - let’s look at the facts.

I earn a living by working about 15 hours a week.

I drink fresh fruit juice almost every day (name your fruit – I drink it – for cheap).

The Brazilian government is not chomping at the bit to invade another country.

Family is everything here. More than vacation or ice cream.

Health care for all citizens is mandated in the constitution.

Gay couples have the right to partner and get the subsequent benefits.

The beaches are perfect, and the people at the beaches blow you away.

OK – so taxes are high, but don’t sweat the small things.

Our housing bubble has not burst yet.

You can eat chicken hearts at almost every restaurant.

Men in Speedos look better than men in surfer shorts.

There are two huge specialty chocolate company chains competing for your loyalty.

Mango ice cream.

I have not worn laced up shoes (except sneakers) in three years.

Which Sunday is today?

Qualidade de vida, baby!

Some thoughts on the healthcare system in Brazil

I have been repeatedly impressed with the “universal healthcare” system here in Brazil. That being said, coming from the US and our/their “get insurance or get screwed” system, it may not take much to impress me. Things here are not a bed of roses, for sure, but there are some important plusses and minuses.

On the plus side is the language in the Brazilian constitution that says (essentially):

Article 6. Education, health, work, leisure, security, social security, protection of motherhood and childhood, and assistance to the destitute, are social rights, as set forth by this Constitution.

Article 196. Health is a right of all and a duty of the State and shall be guaranteed by means of social and economic policies aimed at reducing the risk of illness and other hazards and at the universal and equal access to actions and services for its promotion, protection and recovery.

In short - healthcare is a citizen's right and it is the duty of the government to provide it.

The healthcare matrix here in Brazil is a complicated mix of public and private providers. Only about 25% of Brazilians have private health insurance, the rest access public clinics and hospitals (which vary wildly in terms of quality and efficiency depending mostly on whether they are in urban or rural areas). More than half of registered nurses and nearly half of doctors are public employees.

The stated principles of the Unified Health System (Sistema Único de Saúde or SUS) are universality, integral care, health promotion, and community participation, with public funds to provide free health care to all Brazilian citizens.

That’s the good news. And for many, many Brazilians it has been very good news. According to this summary article, over the past three decades infant mortality decreased by about 6.3% a year, and life expectancy increased by 10.6 years. Mortality due to infectious disease decreased from 23% of total deaths in 1970 to less than 4% in 2007.

But then there is the bad news. Well, let’s remember that nothing is perfect.

There is a wide gulf in service and efficiency between those with private health insurance, accessing private hospitals, and those going to public facilities. This is certainly not always the case, but in many poorer areas (urban or rural), the conditions at the “hospital” can be alarming.

But I think what I’ve found more disturbing in my reading on this subject is that there is an insidious dynamic at play within the university education system that is broadening the gap between public and private healthcare. No surprise, really, but it’s a bummer to see it studied and articulated.

Capitalism. There it is again, f*cking things up. Early on I saw the irony of the public university system here. It’s free, but only the privileged can access it (with notable exceptions, of course). Competition to get in is fierce and students take expensive preparatory classes to score their best on the entrance exam. No money, no prep course – no high score, no free university. The poor and working class pay to attend private universities.

But that’s not the real problem. The problem seems to be the ethos among the privileged class that financial reward and status are the end goal and working in the public sector is viewed essentially as a lower-paid job with little status. So many educated professionals are self-selecting out of the national healthcare system in favor of the more profitable private system. Many people will tell you that there is a shortage of healthcare providers in the public system.

So we have the ever-corrosive dynamic of private enterprise and personal desire for wealth working against the common good. Nothing too strange about that – but it would be a shame if it erased the benefits gained to date seen with the public healthcare system here in Brazil. I would prefer to see the momentum moving in the other direction.

So tell me – if you can afford it, would you choose to buy private health insurance here in Brazil? Why or why not? While it is cheap by USA standards, it still costs a lot. Is it worth it when you have universal coverage provided by the government? Is it necessary, or just a convenience?

[To view Brazil’s constitution in English, go here. It’s a good read.]

Helping Luiz outlive the rest of us

More times than I can count, Luiz, after revealing that he is living with Chronic Lymphocytic Leukemia, is hit with the blithe question: “Why don’t you just get a bone marrow transplant? That would be a cure, right?” Trust me, if that were the case we would have been there, done that by now.

Don’t get me wrong. We love that people are concerned and click into problem-solving mode when they learn of Luiz’s situation. But as most of you know, it’s better to hold your tongue until you know a little bit more about what you are talking about.

Let me take this opportunity to share some information that generally helps people understand why the “watch and wait” approach employed by cancer specialists in this field is the standard course of action for someone like Luiz. And then I’ll challenge readers to step up and be a part of the solution to Luiz’s long term worries. (I’m not asking for money.)

Chronic Lymphocytic Leukemia (CLL) is “chronic” because it progresses slowly in most cases, and people generally live with the disease for many years. (There are unfortunate exceptions, but Luiz definitely fits into the chronic category.) It’s true that it has been detected that Luiz’s bone marrow is producing white blood cells that are non-functioning and failing to die already and make way for more functioning cells. Over time this will lead to too many dud white blood cells taking up all the space and too few functioning white blood cells to adequately protect him from opportunistic infections. Thus is the simplified understanding of CLL.

Since it is our bone marrow that produces healthy white blood cells, we can see that Luiz’s bone marrow is asleep on the job.  Replacing his degenerate marrow with more enthusiastic marrow with a good work ethic would certainly be an improvement – if it were only that easy.

A bone marrow transplant is a life threatening procedure. In order to introduce a whole new colony of bone marrow ready to get to work, you would first have to destroy Luiz’s immune system so it doesn’t go after the new marrow as enemy tissue.  That means ridiculously high (life-threatening) doses of chemotherapy and radiation to strip him of his natural ability to fend off infection. Then you have to hope that the new marrow doesn’t go crazy thinking that it is now in an alien and enemy organism that it must destroy – going after Luiz’s cells (graft versus host disease).

So things can go wrong going in and things can go wrong coming out of the procedure. That’s a lot of risk for a patient that continues to live a-symptomatically for the time being. Better to watch and wait.

If and when Luiz’s disease (or the symptoms thereof) become more life threatening than the risk of the “solution,” then, and only then, will we move for transplantation. It is generally considered a final stage Hail Mary pass. But hey – when it works, it works great for the patient!

Oh – I forgot to mention the difficulty finding a suitable bone marrow donor. None of the possible good health outcomes are even in the picture if we cannot find a suitable donor.  The best-chance possible donors are brothers or sisters. Luiz is an only child.

According to the National Cancer Institute in Rio, the leading bone marrow transplantation facility in Brazil, the odds of finding a non-first-relative bone marrow donor match are about 1 in 100,000. That’s the bad news.

The good news is that Brazil maintains the third largest registry of volunteer bone marrow donors in the world, the US and Germany being first and second respectively. Better yet, most countries with a donor registry participate in a global registry that lists more than 18 million donors from 47 countries. That helps close the odds a bit.

So here’s where you can be a part of the solution for Luiz and others, when the time comes. Register as a bone marrow donor volunteer. In the USA you can do this from the comfort of your home (the "Be the Match" National Marrow Donor Program will send you a kit and all you need to do is take a cheek swab for testing). In Brazil blood centers in every state will draw just 5ml of blood for testing. (No appointment necessary at INCA in Rio.) In the US, donors must be between the ages of 18 - 60; in Brazil it is between 18 - 55.

Once you are registered, the chances of your being called upon to be a donor are less than 1 in 500. However, if you have the opportunity to donate, the procedure is nearly painless and totally risk free. Localized discomfort from the procedure will likely not last even a weeks’ time. Less than 2% of your bone marrow will be extracted and this will be naturally regenerated by your body in about a month.

So what do you say? Can you spare a little time to join the global bone marrow donor volunteer registry – and maybe save a life? The life you save may be one we all love and hold very dear.

Follow these links for additional information about being a donor volunteer in the USA, Brazil and beyond.

Be the Match: Myths and facts about bone marrow donation

Be the Match: Sign Up As a Volunteer Donor

Brazil's Registry: INCA / REDOME

A list of international registries

And I want to acknowledge this column by Chris McGowen on the Huffington Post that stirred me to post something similar (using some of his words) on my blog.

Thank you in advance for whatever you may be able to do in this effort. Feel free to re-post on your blog or to your Facebook page. We are working to surmount the odds.

Even my surgeon has an angle

Once I decided to get gastric bypass surgery it was necessary to choose a surgeon. Luiz and I asked everyone we know in Niterói for a recommendation. Surprisingly, lots of people knew someone who has had this procedure. We got several suggestions, but one surgeon kept coming up again and again.
Dr. W was recommended by two of our doctors, a couple friends and even one of my students who is a doctor. Sealing the deal was the fact that he is among the doctors participating in my health insurance network.

Our first meeting with Dr. W went well. While waiting for our appointment (they were running 40 minutes late) Luiz took the opportunity to tell my whole story to the women waiting alongside us. But as you know, there are few secrets among patients in a doctor’s waiting room in Brazil. The secretary brought us each a glass of water.

Talking with Dr. W felt a bit like talking with a salesman. He asked a few questions of me, but mostly he spent the time touting his Cracker Jack team and the sure success associated with the procedure. He did reference the need for me to make behavioral changes so as not to balloon out again in two years, but mostly he kept moving things forward.

Turns out Dr. W’s team is mostly off the grid. In addition to my appointments with Dr. W I was to make three appointments (each) with a psychologist, a nutritionist and a physical therapist (all on his team) but they do not accept UNIMED insurance and their fee is R$100/visit. It seems pretty clear to me that, since UNIMED requires a referral from each of these professions stating the appropriateness of the procedure, Dr. W hires these specialists to do just that. He has eliminated the unpredictable.

I began to feel like the place was a “Tummy Mill.” Whatever – I still felt confident with the Dr.’s skill (he has done the procedure more than 130 times). And I, too, didn’t want anything less than a positive referral from the other professionals for the procedure.

If you have had to have a bunch of tests done here in Brazil you know that it is YOU that wanders the neighborhood from lab to lab to get the tests, and it is YOU that collects and files the results in a safe place. In my experience results are not sent directly to the doctor. I had my work cut out for me to complete my numerous tests and to keep a file with the growing pile of documents and films listing the results.

When I finally had all the results in hand, we returned to Dr. W’s office for a consult. During the “consultation” Dr. W went through all the documents and entered the results into my data file in his computer. That was it. I had to say, “Excuse me, but are you going to discuss with me the results of these tests? What does each test tell us about my suitability for the surgery?” In one case I said, “Why are so many of the results printed in red ink?” To which he replied, “That means you have high blood pressure.” I said, “So don’t you think you should tell me that? Don’t you think you might want to refer me to a cardiologist for follow up?” Sigh.

I’ve found that doctors here are often focused on getting you in and out quickly, don’t explain things well unless they are asked and are annoyed with patients that have a brain and ask questions (this goes for our experience at the Cancer Institute as well). It seems very old school – just do what they say and say “thank you doctor.”

So my opinion over time of Dr. W has been less than stellar.

Each time I went for a consultation with any of the professionals in his stable I got a stray piece of paper that filled in one more piece of the overall puzzle. What I wonder is – if every patient is basically going to go through a similar process, why not put together three or four pages, double sided, that lays it all out and give that guide booklet to the patient? No. It was all disjointed and a bit confused.

Trust me, the secretary was never busy. She could easily have printed and collated said booklets.

To the team’s credit they host a 3 hour meeting once a month for patients to go and listen to presentations by the members of the team and to ask questions. But I found the meetings more like a Mary Kay sales pep talk than a careful presentation of the details and procedures associated with the surgery.

In the end I didn’t actually go to all three consults with each of the team members, but I didn’t miss anything. I was not going to part with my money that easily.

Then two days before the surgery the secretary just happened to ask, “Have you called to arrange the anesthesiologist?” What!? Who knew? It was our job to call the anesthesiologist and tell him when we needed him (because, of course, the secretary had no time between chatting with her girlfriends on her cell and standing in the hallway talking with the other secretaries in neighboring offices).

So we called the guy and made arrangements to meet so he could get a sense of what he needed to bring to the surgery. While he was examining me (now the day before the surgery) he said, “You’re pretty big. I think we will want to use an extra instrument to ensure there are no difficulties. There will be an extra charge.” “How much?” we asked. “We can talk about that tomorrow,” he said. WTF?

The Brazilian penal code has a section addressing fraud. The first three numbers of that section are 171. There is a popular expression when something is illegal that it “looks like it’s 171.” That was our take on this last minute extra charge.

The day after the surgery the anesthesiologist came to my room and checked in. Mostly he came to show off the shiny stainless steel instrument he used “just to be safe.” “I bought it in America!” he said with enthusiasm. (I was not impressed.) With his voice lowered so my roommate could not hear, he let us know that his additional fee was R$1,000. We firmly asked for a bill (which he did not have prepared) and said we were first going to submit it to our insurance company for reimbursement. He got all freaked out and told us that the insurance company would not cover it. Winking at each other, Luiz and I just smiled and said we were going to give it a try anyway. We offered our phone number so he could call us when his bill was ready. He said “No, no, you just give me a call.” Yeah, right. We’ll get right on that! Ha! What was up with that?

There were a few other bits of shenanigans we came across in the final days, but I’ll spare you.

In the end my experience was (unfortunately) similar to what I have with so many business people here; so often people have an angle, or a gimmick, or a scam to squeeze a few extra bucks out of you. Money is tough to come by in Brazil, no doubt, but thinking I’m getting scammed by my surgeon and anesthesiologist… that’s a bit much.

[I continue to heal well and lose weight at an incredible pace.]

Surgery report back

At the risk of talking about myself too much I’m going to mix a “How did the surgery go?” post, that many have requested, with a fresh fruit juice post.

Last Friday Luiz and I arrived at the hospital at 6:30 a.m. to get the necessary paperwork out of the way and get me to the pre-op room in time to be ready for my scheduled 8:00 a.m. gastric bypass surgery.

Santa Cruz hospital in Niterói is a mind bending hybrid of a WWII hospital fortress with wooden window shutters and occasional ancient, stork-like steel- legged rolling tray tables sharing the space with computer screens and recently widened swinging doors.  The walls appeared freshly painted in a pastel blue.  Santa Cruz is a private facility utilized by several insurance networks. It is not within the public system.

I knew I was not at a boutique fat surgery facility when I was handed a “one-size-fits-all” modesty wrap that ties in the back (you know the one) and it did not fit across my shoulders, barely wrapped around half my torso, and given my belly, there was no modesty action at all going on below my waist in front.  The nurse covered me with a sheet once I laid down on the gurney. [She understood, having gotten a similar surgery herself 7 years earlier – she showed us her scar.]

Once in the operating theater the lead nurse encouraged whoever was able, to speak with me in English.  Several folks could bridge that gap. There was on nurse who seemed like a fish out of water, confused, but she mostly stood next to me and stroked my arm or left her hand on my leg offering moral support. Before long I was out.

About five hours later I heard a male nurse telling me it was all over and I could feel myself being rolled into my room. I shared a room with another guy who had been in there for five days after a prostate surgery of some kind (not cancer-related).

Honestly, there was no pain. Luiz adjusted my bed to a 45 degree sitting position and slowly the fog of the anesthesia lifted. Before long a nurse brought me my lunch: coconut water, which I was to sip in tiny quantities throughout the rest of the day.

By about 7 p.m. I was getting restless so I got out of bed and went for a little walk down the hall and back. It was pretty uncomfortable, but I was a bit surprised to be on my feet so quickly.

The next morning, by about 9:00 a.m. I got a visit from the surgeon who debriefed me on the procedure, which he said went without a glitch, and wrote up my discharge papers. 

Within the hour Luiz and I had taken a cab back to the apartment and I was signing on to Facebook to check in.

For the first week I am on a “clear juice” diet: 30 ml every 15 minutes.  It doesn’t sound like much, but when your stomach is the size of a walnut, just a couple tablespoons of liquid are pretty filling.

We found a delicious white grape juice at a local natural food store (no sugar added) and I made up some apple juice. Luiz added coconut water to the mix and made some chamomile tea. Not exactly a rodizio, but enough to get me started.

I also made some carrot juice, which I then strained through a cloth and colander, but that was still too heavy and did not sit well. Maybe next week.

All in all it has gone very well so far. I appreciate all the support I’ve gotten from readers and friends. I’ll keep you posted as interesting developments occur.

My first big encounter with a Brazilian health insurance company

Most people who have the means opt into a private health insurance network. There is free, universal health service for all Brazilians, but the quality of care can, at times, be sub-standard, and there are usually long waits for any interaction.
Luiz and I pay for private insurance as members of a large purchasing pool and get pretty good rates.  As a 51 year old consumer, my monthly premium, for example, is just over R$300 a month.

The system works pretty much like it does for HMOs in the States.  There is a network of providers, labs, hospitals and an ambulance service.  You must stay within the network.  Contrary to the USA comparison, there are no co-pays, deductibles or gate-keeper physicians.  If I want to see a cardiologist I just call and make an appointment, no need for a referral from a GP.

In November of 2010 I decided to get a gastric bypass operation to help me manage my weight and improve things like my high blood pressure and aching knees and feet. So we went to the surgeon’s office and started the process.

Over the coming weeks I went for numerous tests (endoscopy, 24-hour blood pressure monitoring, overnight sleep apnea testing, multiple blood tests, x-rays, etc.).  I never paid a dime for any of it.

We also went to our insurance provider, UNIMED, to get the details as to what we needed to get approval for the procedure.  It seems being fat is considered a pre-existing condition. So I would not qualify for the procedure until I had logged two years with the insurer.  While I had been a client of UNIMED for over 3 years, it turns out that when I switched from UNIMED-Rio to UNIMED-Fluminense that moved me from one independent entity to another.  So I had to have two years with UNIMED-Fluminense.  Sigh.  So that pushed things back about 5 months.

Other than that delay, the insurance company pretty much played it straight down the middle.  If I could provide all of the necessary tests and recommendations, they would sign off. So eventually they got what they needed and approved the procedure.

From my point of view I got very good coverage.  But if you ask any provider along the food chain they will scream about how low the reimbursement is for their services.

Now – the story of the surgeon’s office and that adventure – ha! That’s another story! Stay tuned.

Gastric bypass surgery scheduled for Friday

Say goodbye to my hearty recipes. Brazilian BBQs, all-you-can-eat pizza or sushi restaurants, big pousada breakfasts – soon to be just a memory.
On Friday I am scheduled for elective gastric bypass surgery.  By sometime after noon on Friday my stomach will be cut and stitched down to the size of a shot glass.

Just last night I ate three pieces of a fabulous cauliflower, leek, sun dried tomato pie.  The sun is setting on that reality.  In a month or so I will again be able to eat whatever I like, but the portion size will be a fraction of that three-slice indulgence.

It’s time.  I have been on one diet or another for the past 35 years.  I like to say that I was skinny for about 15 minutes in 1999 and met Luiz. Lucky me.  Since then I have been heavier every year (unfortunately).

The decision is made. I’ve spent the past 6 months taking multiple tests, consulting a psychologist, nutritionist and physical therapist. The insurance company has finally signed off (although they have five more days to screw things up). I am preparing for surgery with specific exercises.

Wish me well!

Here is a video that briefly explains the procedure.

Surviving a hangover

Ever have one of those parties that picks you up all night, but then slams you down the next morning?  All night raucous parties are pretty routine here.  It seems every weekend its someone’s birthday or anniversary or reunion with out of town family, or it’s just a night to party with friends.

Among our circle of friends the parties run past 2:00 am pretty regularly, and well on to 4:00 am on occasion.  When the beer runs out someone passes the hat and either calls for a delivery of another few cases, or hops in a car and makes a beer run to the neighborhood barzinho.

Eventually we call it quits, often sleeping at the house where the party was.

The next morning a few people light up the stove and start cooking off eggs while someone else makes a bakery run for some fresh bread. And of course, someone walks around offering ENGOV and a glass of water to those with a hangover.

Have you tried this stuff?  People swear by it.  It’s an anti-hangover pill sold in every pharmacy.  You are supposed to take one pill before you start to party, then another one when you wake up the next morning (although many of my friends will pop a pill before going to bed – for good measure, I suppose).

According to one of those “Ask me anything” websites, ENGOVE contains mostly asprin for your headache, with some antacid to calm your stomach, some antihistamine to reduce nausea and vomiting, and caffeine to combat lethargy.

So ENGOV is designed to fight the symptoms of a hangover, but it does not actually prevent a hangover.  But it clearly seems to work.

Public / private healthcare observation

Today we went to a private hospital followed by a public health clinic.

Zozó wrecked up her big toe on her right foot two nights ago. She was returning from some travel and while dragging her heavy rolling suitcase up the stoop to her apartment, she yanked it over her foot and (since she always wears open-toe shoes) ripped open her toe (and nearly tore off her nail) – OUCH! But it was 2:00 in the morning, so she took one for the team, wrapped her foot and went to bed.

The next morning she called me to come help her clean and dress her wound. It was NASTY! I got her comfortable, and then I went to the pharmacy to get what I needed to attend to her toe and the pain it was giving her.

Then today we thought it best to take her to the ambulatory urgent care center at a nearby private hospital to make sure we were not in over our heads. I waited in the air conditioned waiting room and enjoyed a coffee from the machine in the corner while Luiz and his mother were seen within about 10 minutes. We did not have an appointment.

The doctor took off Zozó’s toenail, cleaned up the torn flesh and wrapped her up. But for some reason they referred us to a public health clinic for Zozó to get a tetanus shot. I have no idea why they did not just give her one there on site.

A quick bus ride later we were dropped off in front of the public clinic. The line in front of us had about 20 people in it. No air conditioning, in fact, the waiting area was outside with cement benches. No coffee machine (or drinking fountain for that matter).

Zozó never lets a line stop her from walking right up to the front to inquire about the best course of action. Being a senior female with a bandaged toe and a story long enough to stall the line for 20 minutes, they decided to escort her to the nurses giving shots (Hep B, rabies, flu shots, baby vaccinations, and tetanus). In spite of the line we were in and out in less than 15 minutes.

Work it girl!

There is definitely a gulf between the realities of private and public healthcare here in Brazil, but if you’ve got a no-nonsense 79 year old Brazileira (whose middle name is jeitinho) on your team, you can often bridge some of the gap.

What the United States can learn from Brazil

Don’t get me wrong.  There is WAY MORE that the United States can learn from humble Brazil than what I’m about to note.  But let’s just name a couple things.

According to the Brazilian Health Ministry, an estimated 33 million people, or 17 percent of Brazil's population suffer from hypertension and some 7.5 million suffer from diabetes.

If you were a concerned politician and you knew that about 34% of the deaths in your country each year were caused by hypertension- and diabetes-related complications, would you pick your nose up out of the trough long enough to consider a remedy?

Lucky for us we have a socialist-minded president who gets it that helping people AVOID these conditions will save lives and save a gazillion in health care expenses.

As such, Brazil’s new president Dilma announced recently that the government will now provide free hypertension and diabetes medication though the “Popular Pharmacy” program.

The diabetes medication was already available at nearly free prices, but this extends the wellness program even further.

As a further note (and one I extend to my policy maker friends in the US) I will mention that in the case of poor people with cancer, the government also offers a helping hand.

My mother in law is a breast cancer survivor.  When she completed her treatment she was placed on a drug called Tamoxifen, which is designed to prevent the recurrence of breast cancer.  It is state of the art treatment, and it is expensive.  She must take this drug for five years.

Well, my mother in law could not afford the R$500+ needed per month to buy this drug, so she went to the city government and said: “Look, I’m a poor old woman.  I’m retired.  How am I going to afford this drug?  Give me a break.”  And guess what?  The government said “OK, we understand.  We will provide the drug to you for free.”

And so my mother in law receives the drug at no cost to her and continues to live a robust life – and it is worth noting that she did not have to sell her house and all her family’s assets in the process.

Take a note United States.  If a poor country like Brazil can do this for its people, so can you.

No wonder Americans (USA) are so fat

It's so-called Super Bowl Sunday weekend back in the States.  Time for a giant pan of aunt Tracy's famous 7 layer taco dip (with extra sour cream).  Or your brother-in-law Paul's famous double bacon and cheese sliders (with extra mayonnaise mixed right in the meat!)  Or better yet: food blogger Amanda's double stuff Oreos baked inside chocolate chip cookies (no kidding).

I was doing some TasteSpotting this morning (nibbling on real Triscuits, compliments a care package from Rachel -- shout out!)  And what to my wondering eyes should appear but a chocolate, sugar, fat bomb disguised as a cookie.

In all honesty, I could see myself eating one of these - but just one, with a scoop of vanilla ice cream.  Count me among the fat Americans, unfortunately.

It's important to remember that there are very few Big and Tall clothing stores here in Brazil.  Style and selection are narrow.  Better that I stick to the banana mango sorbet.

[Photos and the recipe are from here. No offense intended Amanda.]