Stories from the Front Line: Islands in the Sun
A monthly reflection from inside rural medicine, written by Dr Trevor Lloyd.
Kos—the Greek island that launched a thousand myths. Near the main town on the island is a shrine, to Aphrodite, the goddess of love, built to protect sailors and fishermen. Also worshipped on the island, with his own temple, is Apollo, son of Zeus, which in some versions of the stories makes him Aphrodite's half-brother. One of the sons of Apollo was Asclepius, who inherited from his father the arts of healing, including the ability to raise people from the dead. Asclepius in turn became immortal, and passed some of his knowledge on to his five daughters, each of whom became a goddess associated with an aspect of treatment or healing.
The island has its own home-grown medical hero, Hippocrates, who was born on Kos in the fifth century BCE and was educated at the medical school there, one of a group of establishments called an Asklepion. He is commonly called the "father of medicine". This claim to fame is at best an overstatement. Hippocrates to be fair was one of a cohort of doctors at that time who attempted to make diagnoses and derive treatments based on scientific principles, rather than attribute illness to supernatural causes. But his knowledge of medicine was limited if compared with the ancient Chinese and Egyptians. Probably his biggest contribution to his patients' care was his determination not to interfere with the body's ability to heal itself, which is a medical principle I strongly agree with, even in these more modern times of more aggressive and more effective treatments. Increasing his fame in the wider Mediterranean, Hippocrates travelled widely popularising his ideas. Historians found the ancient library in Alexandria contained a group of about seventy medical books known as the Hippocratic Corpus, categorised as such by an unknown librarian at the time. They are now believed to have been written by nineteen different people, possibly none of whom was Hippocrates.
Hippocrates is best known for the Hippocratic Oath. Which was written by somebody else sometime after his death. The original oath includes prohibitions on the administration of poisons for the purpose of euthanasia, termination of pregnancy, and "using a knife". Modern surgeons, especially urologists, who are specifically forbidden from using their knives on "sufferers from stone", would find it quite limiting. The oath is widely believed by the general public to be taken by doctors graduating from medical school before going into practice. It is not, at least not in its original form, although many medical associations and individual medical schools have come up with their own versions. The World Medical Association uses The Declaration of Geneva, which incidentally was amended in 2017, on the insistence of New Zealand doctor Sam Hazeldine, to include the new clause: "I will attend to my own health, well-being, and abilities in order to provide care of the highest standard."
Outside of medical circles, the island of Kos is probably best known as the origin of cos lettuce. Which probably didn't come from there. Cos lettuce is in fact named from the Arabic word khus, meaning ... lettuce. In America, where it is called romaine lettuce, it is the main ingredient of Caesar salad. Which is frequently made with some other cheaper kind of lettuce. To my mind, if the salad is not made with cos or romaine lettuce, and extra virgin olive oil, and lemon juice, and anchovies, and Worcester sauce, and mustard, and eggs, and Parmesan cheese, and croutons, and black pepper, then it is not a Caesar salad. But others are less fussy about food. The famous salad is popularly believed to have been a favourite dish of the Roman emperor Julius Caesar, which is also wrong. Another myth. The salad was invented by, and is named for, an Italian chef, Caesar Cardini, who came up with the recipe in 1924 while working in Tijuana, Mexico.
Kos is one of the Dodecanese islands, in the Aegean, 338 km from Athens, 98 km from Rhodes, and 172 km from Santorini. It is popular with tourists. It contains mountains, beaches, ancient temples, Roman ruins, crusader forts and castles, even a mosque. There are hot springs at Therma Beach, and numerous other beaches. In summer, all the main towns and the port of Agios Stefanos are crowded with people from all over Europe, swimming, eating, dancing, drinking, and soaking up the Mediterranean sun. Kos is close to other islands. The trip from Kos to Santorini by the popular Blue Star ferries is just over six hours. This ferry trip between the islands is a comfortable and scenic journey, and I would like to describe it for you in some detail.
Except for the fact that I didn't go there. I didn’t go on the ferry from Kos to Santorini. I didn't really go to the island of Kos at all. Sorry—I have just created yet another Greek myth. Hippocrates and the others were too important to the story to leave out. So, I made it up. I didn't go to Kos. I have never been to Kos. But I did go to Santorini, and to Mykonos, and to Paros, and to Crete.
Our journey to get to the islands—unless you include twenty-three hours sitting in cramped seats on planes catching up on old movies, and six hours walking round the shops at Dubai airport—started in the Greek capital city of Athens. The occasion was the 27th annual European Stroke Conference, put on in Athens by one of a number of competing organisations that support and report on the investigation of stroke and its care, and host these events. I don't understand the differences between the different organisations, and I don't care. For me, the conference provided a useful overview of stroke and its modern treatments, and how these have come about.
Athens has had something of a makeover since I last visited in the 1970s. No doubt a lot of borrowed money was poured into infrastructure at the time of the 2004 Olympics. There is a modern light rail and subway system, extending into the city from the airport. It works. The port at Piraeus is the starting point for an efficient and comfortable ferry system. But more about that later. It all worked well apparently at the time of the Olympics. Now, unfortunately for the Greeks, the rest of Europe wants its money back. In 2010 the European Union agreed to extend most of the sizeable loans from northern European banks on the condition that Greece introduce a range of austerity measures. Unsurprisingly, these have been unpopular. They have resulted in at least one change of government. At the time we visited, the local people were still protesting on the streets.
We stayed at the Dryades Hotel, a cheap place on the western slopes of Strefi Hill, with good views down into the city, including a distant glimpse from our bedroom window of the Acropolis lit up at night. Breakfast, a welcome feature, we came to realise, of travelling comfortably in Greece, was served on a terrace on the roof top. We ate fresh fruit, cereal, the best Greek yoghurt I had tasted up to that point, topped with stewed sour cherries, bread, cheese, olives, cake if we wanted, and excellent coffee. The staff were friendly. The kitchen was run by a woman who had lived in Canada, spoke good English and was interested in our travels. We sat on the dining terrace outside surrounded by grape vines. Central Athens, including the Parthenon, was laid out before us like a map. The eastern aspect was dominated by nearby Mount Lycabettus, the highest point in Athens.
Down the steps from the hotel is a street called Emmanouil Benakis, which is named after a Greek merchant who was a former Minister of Agriculture and was elected Mayor of Athens in 1914. It contains a number of excellent Greek restaurants, including one unpronounceable place near the top of the street that has been in the same family for generations and serves traditional favourites in a style that appears not to have changed since the 1970s. The first night we visited, the owner told us that he had no moussaka, which we had seen on the blackboard menu and was what we were after. By that time, late in the evening, all the moussaka been eaten. The man said we should try what else he had on offer, and despite the availability of other restaurants in the area, he was confident we would want to return the next night. We sat down to a dish of stewed okra and beans in a spicy tomato sauce. We came back the next night and had the moussaka, which was excellent. To be fair to ourselves, we tried the other restaurants in the area, but could find nothing to match.
The district is called Exarcheia. It is a poor neighbourhood. Once a centre for intellectuals and artists, it is now home to many of the city's migrants and refugees. There have been clashes with the authorities. In 2008 it was the site of a fatal shooting by the police of a fifteen-year-old student called Alexandros Grigoropolous. There were resulting riots, and there have been continuing riots more recently following the introduction of the austerity measures. In the evening, groups of youths, who seemed to be unhappy about everything, other than themselves, were congregating on the steps at the top of the street, necessitating in our mind taking the long way round to get into our hotel. At least one taxi driver refused to take us to the hotel, saying the area was unsafe. Others laughed it off, assuring us that we would be safe from the young people there, “as long as we did not look and act like the police.”
We found it a bit of a trudge into town, but decided we could make more sense of the layout of the city if we walked using a map than navigating from station to station on the metro. We headed to the Acropolis area. First stop was to a local travel agent, a father-and-son business in the Plaka area, so that we could use their services to book our planned travel round the islands after the conference. This turned out to be a good investment of our time, as we were to find out later. We followed the crowds across the centre of the city to the Acropolis. Sometimes we could see it—the same view as from our hotel window. At other times we could tell we were getting nearer by the increasingly tacky souvenirs, the burning red skins and skimpy clothing of the people in the streets, the proliferation of fast food chain restaurants, and the number of potato chips on people's plates as they sat in the outdoor cafes. I skipped the tour of the Parthenon and museum. My wife came back to visit later, on the metro, while I was at the conference.
I wanted to find out how to get to the conference venue, which was on the other side of the hill from our hotel. The first day, we made the climb all the way up Mount Lycabettus. At 300m, the view from the top of the surrounding countryside is worth the climb. They have a funicular railway, we discovered, that can get you there more easily. On the mountainside is an amphitheatre where classic plays are sometimes held. At the top there is a small church dedicated to Saint George, and the inevitable cafe and restaurant selling over-priced food and drinks. I soon worked out a way around the side of the mountain to get to the conference venue, an opulent modern building called the Megaron, set in an extensive landscaped garden, which doubles as a concert venue. Like much that is new in Athens, it has a strong smell of borrowed money. It was a spacious and comfortable venue for the conference.
A memorable early session was on the history of stroke. Stroke, appropriately for our conference, held in Greece, was recognised and described well over 2000 years ago by our old friend Hippocrates. In those days it was called "apoplexy", meaning something like "struck down by violence", and this term persisted into later European times. It was not until the 1600s that it was discovered that some strokes were associated with bleeding into the brain.
The heroes and pioneers of stroke care and research are doctors who used to work all day providing clinical care to patients, then worked all night dissecting the brains of those who had died of stroke, accumulating a treasure trove of detailed information about which part of the brain does what. A few of these older doctors presented at later sessions, giving insights into their work. These days, their methods have been superseded by modern imaging such as functional MRI, which can show the parts of the brain working, or not working, as well as the network of connections between them, while the patient is still alive.
The first known description of transient ischaemic attacks, a temporary version of a stroke, we learned, was not by a doctor, but in 1841 by the famous French novelist Stendhal, the author of many works including Le Rouge et le Noir. "All of a sudden,” he wrote in a memoir of his affliction, "I forget all French words ... I watch myself with curiosity: apart from the ability to use words, I keep all the natural properties of the animal. Ideas are fine, but without words. It lasts eight to ten minutes. Then, slowly, the memory of words comes back, and I am tired." The following year, he died of a massive stroke.
I attended a later session at the conference on bilingual speech therapy, by a Spanish speech language therapist working in Montreal, in Canada, where many people speak both English and French. Like Stendhal, some people suffering a stroke or transient ischaemic attack lose the ability to speak and sometimes to understand their naturally acquired language. This means that bilingual people who learn both languages as young children typically lose both. Learning a second language as an adult seems to use different parts of the brain, so that the patient's first language may be lost but their acquired language may be retained. In Montreal, they need to have bilingual speech therapists so that both languages can be used in their efforts to aid recovery.
People presented insights into future therapies. One in development is the use of monoclonal antibodies that inhibit an enzyme called proprotein convertase subtilisin kexin type 9, known as PSK9 to its friends, that releases the more dangerous form of cholesterol-carrying protein from liver cells into the blood. Injecting this currently expensive antibody every week or two has the potential to make cholesterol disappear from blood. It is complicated to manufacture and will never be cheap. Even more difficult to understand, but equally promising, are the many new therapies that can be used at a molecular level to prevent or delay brain cell damage after stroke.
A popular recent intervention for some strokes is endovascular clot retrieval, where a catheter is threaded into an artery in the groin and used to remove the clot that is blocking an artery to the brain and causing the stroke. On average, about half the people who receive the treatment derive some benefit. Some of them who would otherwise suffer a major disabling stroke are completely cured. Clot retrieval has been called the "Lazarus treatment", after the man raised by Jesus from the dead. Though in Greece, as we know from what we are told about Kos, Asclepius was performing the same miracle much earlier and more often.
Ideally, clot retrieval is done quickly, though there was much excitement about two recent trials that have shown later treatment can also be effective, if a perfusion CT scan, for patients where contrast injected into a vein to show the circulation within the brain, shows a large potentially salvageable area. We were lucky to hear from the researchers who designed and conducted the relevant trials. Unusually for clinical trials, one large trial called DIFFUSE 2 was stopped early because another trial called DAWN had shown such a positive result.
Much international effort has been put into recognising strokes at an early stage, identifying those with large vessel occlusions who are most likely to benefit from clot retrieval, reducing the time of getting them to the right hospital, and reducing the times once they are within the hospital to getting CT scans and the appropriate treatment. All these times of course are measurable. One of my lasting memories of the conference is of groups of German men in suits, all trying to prove that, by some feat of superior organisation, the times at their hospitals were shorter than the others. Many of us, I'm sure, couldn't help thinking of them as ten year olds, lined up at a urinal, competing with each other as to which one could pee the furthest up the wall.
Not all the delegates and presenters were European. And not all were from large cities. One American presenter, in a session that was of special of interest to me, was speculating on how the emerging new treatments for stroke might be delivered to people in rural areas. One example he gave of a remote rural location was of Camp David, in Maryland, the holiday residence of the American President. Ten of America's 44 presidents have suffered strokes, most recently Franklin D Roosevelt who died of a massive stroke in 1945. Donald Trump, the president at the time of the conference, the presenter pointed out, is old, obese, inactive, and has a poor diet—all risk factors for stroke. The presenter was wondering how, if Trump had a stroke at Camp David, he would get to a major centre for treatment. Many of the audience were laughing at the idea. One man, not far along from me, was laughing louder than the others. I looked at his name badge to see if he was American. He was from Iraq.
From deciding between the available treatments for stroke, we moved on to deciding which Greek Islands to visit. There are more than 6000 of them. Most are uninhabited. Some, like Kos, we decided are a bit too far away, and perhaps are better imagined. Some have more attractions for tourists to visit—definitely a mixed blessing. The more popular islands are more accessible, have better infrastructure, and have more to look at. But obviously they can be overrun with tourists. Worse, in a touristic version of the Hawthorne effect, the available attractions are changed from their traditional origins and practices into some inauthentic version that the locals have learnt tourists want to experience and are willing to pay for. As with most decisions to do with lifestyle, we opted for moderation: to spend a small amount of time at the most popular places and a longer time in the places we thought might be more authentic and more relaxing. It was not yet summer, so we decided to travel by ferry to the Cyclades, which contain many of the iconic features we would have wanted to experience, and are close together, then go on to Crete. This plan, as it turned out, was to some extent thwarted by the unreliability of the Greek ferry system.
First stop was Mykonos, the island that everybody has heard of, and seemingly everybody goes to, at least in summer. There are the windmills, the iconic old town right on the water, with its confusing network of narrow streets, the white houses are set off by brightly painted wooden framing, over-priced souvenir shops, and a profusion of bougainvillea and other colourful flowers. There are said to be discos and gay bars pumping out music throughout the night, but maybe not at that time of year. We don't know. We were asleep in our comfortable hotel on the hillside above the old town.
Next was Paros. This was a bigger less populated island, a place where ordinary people could live. The travel agent in Athens had booked us into the Apollon Hotel, in Parakia, which was a few blocks away from where the ferry stopped, and turned out to be one of the most peaceful and tastefully decorated places we have ever stayed at. It was a short walk into town, which was just as pretty as Mykonos but cleaner and less crowded. In place of the tourists, there were groups of school children on the street. We ate on the first evening at one of the many tavernas along the waterfront—grilled octopus, washed down with ouzo, baked fresh fish, with retsina wine, and a complimentary desert of freshly cooked filo pastry filled with thin slices of apple.
We took the local bus into the middle of the island and got dropped off at the top of the hill at a marble quarry. This was the origin of the marble for a statue of Aphrodite found by Northern Europeans on the nearby island of Milos, not the statue of Aphrodite that some people get to see on Kos, but the one appropriated by the French and displayed in the Louvre, called by them the "Venus de Milos". There were other big blocks of marble lying around waiting to be sculpted, and a lovely old man, who spoke no English, but I think was called Michael, showing us some small carvings, he was making of goats.
We were having some difficulties with the language. The names of food were familiar, but we probably pronounced them wrongly. We had a phrase book and had learned some greetings—kalimera for good morning, parakalo for excuse me or please, efcharisto for thank you. The alphabet was tricky. It is possible, using the knowledge learned from algebra or trigonometry, to transliterate the words. Pi, or π, is "p". Theta, written as θ, is pronounced "th". On the toilets, Άνδρος, pronounced Andros, is for men; ϒυναικος, pronounced Gynocos, is for women. It all sounds vaguely familiar from the terms we use in medicine. Or you can more simply look at the pictures on the outside wall of what men and woman are internationally supposed to look like and use that more reliable method to go into the right one. We practised our language skills on the cleaner at the hotel, who understood very little English. "Kalamari," my wife greeted her in the morning. "Why did you call the cleaner a squid?" I asked her. After that off-target effort, we pretty much gave up, and didn't try out our phrase-book Greek on Michael. As far as we could tell, he had no finished statues of goats to sell.
From the quarry, we needed to make a hot walk, longer than we expected, sharing the path with chickens and pigs and donkeys, over an ancient stone bridge, and up the hill to a village called Leftkes. We looked at the church there and had a cool home-made lemonade. From there we walked on the Byzantine path to Prodromos. Paved in marble and surrounded by olive groves, this trail has been the road between the two villages for more than a thousand years. In summer, it is full of tourists. Prodromos has the white buildings covered in flowers found throughout the Cyclades, and is every bit as beautiful as the more accessible and more touristed places. From there, we enjoyed a short walk down to the port at Piso Livadi, where we had a swim in the Mediterranean and caught the bus back to town.
Back in Parakia, we had time to look around the Panagia Ekatontapiliani Church, also from the Byzantine era. This era was the long period of European history between the 400s and 1400s when Rome had degenerated and the power of the Empire was shifting East to Byzantium, formerly Constantinople, now Istanbul. Importantly to the church, this difference between West and East was reflected in religious disagreement, particularly over the authority of the Pope, culminating in 1054 in an official schism between the Roman Catholic and Eastern Orthodox churches. The church provided literature in multiple languages explaining to visitors that the Eastern Orthodox Church is the one true church and practises the original Christian faith. The original building is old, dating back to the Emperor Constantine. It is sparsely decorated, letting the complex architecture speak for itself, and the vaulted interior has a uniquely spiritual feel.
From Paros, we found our way back on the ferry and on to Santorini. Not so conveniently close to Athens, but more spectacular than the other islands, it is one of the most visited, especially by cruise ships. Santorini is basically a big hole in the Mediterranean where a massive volcano erupted in 1646 BC, turning a ring of small islands into a huge crater. Well-heeled visitors have outbid each other over the last few years to build houses, hotels, bars, and restaurants, along the rim of the caldera, hundreds of metres above the sea. My wife, who grew up on an active volcano and has learned to avoid such things, thought they were mad. We did enjoy the available view, walking along the path from Thera as far as Imerovigli, stopping on the way for a drink and a little bit of expensive food in a bar beside a pool perched on a cliff top.
Thinking we had only one full day on Santorini, we booked a tour to see what all the fuss was about. The highlight was the archaeological site at Akrotiri, a city that was buried in the big eruption. There is evidence of humans living there seven thousand years ago. Unlike Pompeii in Italy, with which it is often compared, the site contains no dead bodies: people had some warning and had time to get out. We also visited the beach at Kamari, the inland village of Megalochori, a winery, and ended the day enjoying a spectacular sunset at Oia.
Returning to our hotel, we discovered that the ferries were on strike for two days. We might not be able to go on to Crete as we had planned. There was no guarantee of a place on the ferry. We might miss our flight from Crete back to Athens. The hotel on Santorini was full so we had to find another place to stay. The hotel in Heraklion on Crete, where we were booked for two nights but were now unable to reach, was refusing to refund our payment. Feeling sorry for ourselves, stuck for an extra two nights in one of the world's top tourist traps, we phoned the travel agent in Athens to explain our predicament. Obviously used to this situation, he rebooked everything for us, including a refund.
We were determined to enjoy our extra day on Santorini. First, we caught a local bus back to Oia. As every Instagram user knows, the light is better to take a photo of yourself there in the mornings, with the background of the sea and the iconic white churches with blue roofs. Each important family—and Oia has more than its share of rich landowners—has its own church, some bigger than others, and even those with homes and businesses in faraway places such as Athens return to them for significant family occasions. After Oia, we took a boat to the island of Nea Kameni in the middle of the caldera, formed by a later eruption in 1570. It has its own volcanic crater, complete with a steam vent, waiting for its chance to erupt again in future. Back on the mainland, we took the 588 steps up the Karavolades staircase from the old port to the town, sharing the atmosphere with a large number of smelly donkeys, whose owners were trying to take money off us to ride them up the path.
Next morning, the ferry to Crete turned up on time, as if nothing had happened. We arrived in Heraklion late in the afternoon, found the bus station, and took the bus along the coast to Chania. It was late at night before we found the hotel the travel agent had booked for us. The place was locked up. The receptionist was at another nearby hotel watching American basketball on TV. He was a big fan of Steven Adams and the Oklahoma City Thunder, and was pleased to welcome a couple of New Zealanders.
We had hoped to get a bus into the hills the next day and walk the Samaria Gorge trail down to the South Coast, but a woman at the bus station told us it was closed. It was not yet summer. It was still early in the morning, so we had a walk around the town and the harbour. There was not much else to see, and we still wanted to do a walk out of town, so we went back to the helpful woman at the bus station. She suggested we take a bus to Paleochora on the South Coast. We travelled past the tourist resorts on the North Coast, pleased we were not staying there, and through the interior to the South.
Paleochora, as promised was much more relaxing than the city. We enjoyed a walk along the shore with a view of the beach, complete with deck chairs and sun umbrellas, waiting for the summer influx of drunken tourists and naked bodies, which had not yet arrived. Mine was the most naked body on the beach, also the coldest, as I took a quick dip in the Mediterranean in my swimming shorts. Further along the bay, we found another fish restaurant. Unable to explain to us what was on offer, the owner took us into the kitchen to show us the fresh fish in the chiller. We selected some sardines, which he grilled whole for us with a side dish of green vegetables. There was the usual complimentary dessert, and a complimentary glass of Raki, the local fire water, which is basically grape-flavoured alcohol.
I wasn't learning much about stroke at this stage, though relaxing on the beach eating a lot of vegetables and a little bit of fish, cooked in olive oil, is probably a good form of primary prevention. People on Crete have low rates of cardiovascular and cerebrovascular disease, and have long lives as compared with other people in Europe. The food is obviously healthy. I'm not so sure about the alcohol.
From here, we enjoyed another bus trip back to Chania, remembering to thank our friend at the bus station, another night in our hotel, back along the coast, in daylight this time, to the airport at Heraklion, and a flight back to Athens. It seemed only a short distance in the plane. We didn't recognise the different islands from the air. But they are firmly etched in our minds, and we took our memories of them, as well as the lessons from the conference, back home on our flight to New Zealand.
This year marks a remarkable milestone for Trevor Lloyd, one of Dunstan Hospital’s senior clinicians. Trevor has just renewed his medical registration for the 50th time, with 26 of those years spent caring for patients at Dunstan Hospital.
He is a rural doctor, leader, writer, and long‑time advocate for our community. Trevor’s journey from his humble beginnings in Mataura and Cromwell, through his years around New Zealand, and the experiences gathered during time spent in places like England and Vanuatu - all before making Central Otago home - reflects a life lived in service of others. His creative writing has become a beautiful extension of that care, sharing stories that celebrate the people, places, and quiet acts of kindness that define our region. Whether in the ward or with a pen in hand, Trevor continues to give back in ways that deeply enrich the Dunstan whānau.