From the outlandish architecture and garish electric displays to the streets littered with pamphlets that advertise, in lurid detail, the services offered by esteemed ladies of the night, Macau resembles Las Vegas–except with Cantonese signage, a lamentable dearth of Starbucks outlets, an equally disturbing absence of public health measures, and an overabundance of cockroaches.

My trip to Macau begins with another memorable ferry ride from Hong Kong.  Gazing blearily through the haze of dried salt on the exterior of the window beside my seat, I begin to hear voices that sound Spanish.  “Hmm, auditory hallucinations are never a promising sign.  Must be the exhaust fumes,” I mutter.  Alternatively, I figure the voices could belong to Portuguese travelers.  Macau was a colony of Portugal for 400 years and remains heavily influenced by its colonial past, and Portuguese and Spanish are closely related Latin tongues.

Abruptly, the voices rise in volume, and they are undoubtedly Spanish.  I glance at their source and see, in the row ahead of me, two older Hispanic women arguing about Meclizine, an antihistamine medication used to combat seasickness.  Relieved to find corporeal owners of the voices, I interject in Spanish to explain to the women the proper use and administration of the drug.  After recovering from their initial shock at encountering a Spanish-speaking gringo doctor in East Asia, they–with the characteristic warmth and immediate familiarity of Hispanic culture–engage me in conversation for the remainder of the boat ride.

The women are sisters originally from Colombia, now residing in California, who are on a family vacation.  Their parents sit a couple of rows away from us, and the older sister’s teenage son–headphoned and looking notably bored–sits directly in front of me.  The older sister notices the Johns Hopkins t-shirt I happen to be wearing, and she launches into a panegyric about her son’s academic performance and the invitation he received recently to attend the Hopkins summer academy for talented youth.  As she describes the myriad curricular and extracurricular activities in which she has placed her son–piano and drum lessons; Mandarin classes; varsity swim, ski, and surf teams; weekly volunteer tutoring sessions–I begin to pity the poor youth, who, I decide, appears obtunded not from boredom but from sheer exhaustion.  Just about the time I reach the limits of my Spanish lexicon, we arrive at the Macau Pier.  I bid farewell to the two women, wish the son buena suerte on the Hopkins academy, and scramble onto the docks.

Macau is famous for its gambling scene.  Although the older, administrative district of the city reflects the long history of Portuguese colonial rule and has a distinctly European appearance with cobbled streets and quiet pedestrian squares lined by boutiques, the massive casinos are clearly the vital, economic hubs.  Storied names such as the Grand Lisboa, The Venetian, Wynn, MGM, and the Grand Emperor flash brightly on giant electronic billboards outside of the billion-dollar structures.  Day and night, tens of thousands of Asian tourists and the occasional starkly noticeable Westerner swarm in and around the gaming halls.  The venues are stunningly posh: lushly carpeted halls, golden handrails, gemstone chandeliers, and Michelin-starred restaurants.  As I casually stroll through them while wearing shorts, sneakers, and a t-shirt, I draw uncertain stares from the more formally attired employees and patrons.  They seem torn between considering me a gauche provincial or an eccentric millionaire.  Joke is on them.  Coughing from the dense cigarette smoke in the air (Macau has only recently begun to introduce any form of indoor smoking limitations) and unwilling to squander my tiny salary on slot machines occupied by crusty old widows who appear as though they have already died and petrified in their chairs, I venture out onto the city streets.

Once on the streets, I encounter more of Macau’s paucity of public health regulations.  The vast majority of crosswalks, in the few places where they exist and people do not simply jaywalk, have no signs to indicate when it is safe to cross and no streetlights to stop the oncoming traffic.  I watch, horrified, as small children and the aforementioned mummy widows step blithely into the middle of major traffic thoroughfares.  Somehow, incredibly, the vehicles do in fact stop for the pedestrians, though I witness no shortage of close calls.

Another vehicular safety issue is the complete absence of safety belts in the taxis.  The belts are not simply tucked away, disused, and soiled by unnameable grime as in cabs in the U.S.; they are not present at all.  The Macau cabbies then add to the automotive crash risk factors by reaching Formula 1 speeds while weaving radically in and out of the rickshaw and fruit-cart traffic that shares the pavement of the narrow, winding urban lanes.

A final public health moment comes when I venture into a poorer area of the city in search of a small, solo physician practice.  Unable to locate the practice, I prepare to return to my hotel, but need to withdraw some cash to pay for the taxi.  As I stand in front of a street-side ATM machine, a group of city workers tug at a manhole cover roughly three feet away from me.  All of the sudden, I hear a great crash, followed by a series of shouts, as the men finally succeed in removing the giant metal cover.  I glance towards them, and immediately gag.  The metal cover lies upended on the sidewalk, and streaming away from it in every direction are tens of thousands of cockroaches–each glossy brown in color and two to three inches in length.  They cover the sidewalk in a living, undulating, brown mat.  At the same time, from the open manhole arises a dusty plume consisting of noxious gases, cockroach exoskeletons, aerosolized sewer rat feces, and undoubtedly a substantial number of active plague spores that I inhale as I gasp with fright and disgust.  I figure the hemorrhagic pleurisy will begin to set in over the next several days.

In all, Macau has an appealing, Wild West-style freedom to it, if you enjoy smoking, illicit sex, auto-pedestrian collisions, clouds of pestilence, and losing money alongside undead zombie grandmothers whose hands remain forever clutched in the shape of slot-machine levers.

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