Getting My Rhythm

17 March 2019

[Above photo: A good ad for Nutrivita! And Myanmar can-do! I always love to watch the “helpers” gawking.]

I awoke this morning with the expectation of calling my nephews and sister-in-law in Williamsburg, Virginia. We’ve tried to connect a couple of times but it can be difficult with busy schedules and my fumbling the time change. I slept 9+ hours and awoke 20’ after the time I said I would call. I tried with Skype but they were off-line. Hmm. Then I had the thought that perhaps, like Linda, they are on Daylight Savings time now, which adds an hour (or does it subtract an hour?) to our 12 ½ hour time difference. Anyway, it is unsettling as I want to talk with them. I’ve sent a text and an email. Somehow the 6 hours difference from Blantyre was more easily considered.

We saw a number of children this week. One on Monday, 4 on Tuesday. Some were very hyperactive, whizzing and flipping all over the large play area in the Development Center where we work. Two stumped me: a huge 17yo mentally retarded (Intellectually Disabled) autistic boy without language who has been hospitalized many times for violent behavior. He became very anxious having to wait while we saw and discussed the three children who came before him. His mother, a physician-become-Chinese-businesswoman has started her own private mental hospital and the boy lives there with two strong men 24 hours/day. He is on a boatload of medications, including three antipsychotics, a benzodiazepine, a mood stabilizer, an SSRI antidepressant, and an antihypertensive. We are slowly trimming those down, since we have no idea of what they may be doing to his brain (and other) chemistry, what with cytochrome P450 inhibition and enhancement affecting the drug levels, and on and on. Another child, 11yo, had communicating hydrocephalus, mental retardation, a seizure disorder, left hemiplegia from a stroke at 3yo, no language, and aggressive behaviors. His parents, weighing the risks, refuse to have surgery and the placement of a shunt.

I did seize on those two patients as a teaching moment on the following day. Starting with Primum non nocere (Do no harm), we looked at our collective and individually-determined responses to feeling helpless and not having much to offer.  A large proportion of health care expenditures in the US occur in the last 6 weeks of life with the futile efforts to prolong it.  This can serve as a useful example. It is so hard in the “helping professions”, especially as a physician, not to feel you can help the primary problem. We can always, however, attempt to make the patient safe and comfortable, look for antecedents of problem behavior, and support the caregivers. How is it in “Hamlet”? “Diseases desperate grown are by desperate appliance relieved, or not at all.” The above are two desperate cases.  Acting desperately, but futilely, will not improve things at all. It may allow us to feel we are “doing everything in our power” which is a perversion, since it potentially violates “Do no harm”. It certainly will do no good to throw more medications at their poor, damaged, struggling brains.

After that discussion, the class opened up and we talked a lot about Myanmar culture, how emotions are rarely discussed, how girls are usually left to understand their menarche on their own, how “family business” remains unspoken, how sex education is ignored in the schools, and so forth. It is very familiar and similar to Malawi—or Kansas! The rise in teen pregnancy in the US with Bush-era abstinence programs, including no [effective] sex education, is not too hard to understand. I suppose what angers me are those leaders who oppose sex ed in public, as well as family planning, contraception, abortion, and homosexuality, but practice it clandestinely themselves. The lives damaged, if not ruined, by their cynical ambition—it seems to be men, again, often politicians or televangelists. Those who need an approving flock to ensure their power and livelihood.

Then one of the women in the class said, “We have never been taught psychotherapy in our training. We have been taught diagnosis and how to use medications only. You are giving us something new.” Kvell—is that the appropriate Yiddish term? I mean, pleased that I can do this but mostly so proud of the students for grasping—-nay, embracing what I am about here.  It is so wonderful to be able to teach Child and Adolescent Psychiatry in accordance with my experience, my understanding, and my convictions.

I saw photocopies of some of the chapters of the electronic Child and Adolescent Psychiatry textbook I am using being passed among the students. Realizing what was happening I volunteered to copy the rest of the articles. So much for saving paper and costs with flash drives! It is much easier to read dense material on paper, rather than on a computer. When I went to pick up the print job, about 75 papers, 11 copies of each, there were three large boxes full of them. This will dent my Fulbright salary, I thought. Nope, $64.16. Live and learn. “We don’t take copywrite laws seriously here.” It does, again, suggest the brilliance of Harold’s idea in starting the online journal(s) PLOS, the Public Library of Science. Why should medical information, crucial to people’s well-being and often funded by tax dollars, be sold at exorbitant prices by journal publishers? No one in the developing world, specifically the physicians for the majority of the world population, can afford the multiple journal subscription fees, let alone the fees simply to read a single article in a journal. Business is important but health care research and information shouldn’t be for sale—and should be easily, publicly available.

At any rate, I had brought my large backpack to the printer and, after filling it, staggered home carrying two filled boxes in my arms. I could have taken a taxi for $1 but it was only a few blocks and pride wouldn’t allow. And I didn’t fall.

Yesterday at 12N my chief, Professor Tin Oo, called to ask if I had finished lunch. Nei le sa sa pyi byi lar? I hadn’t started.  He swung by and took me to lunch at a lovely lakeside restaurant. He told me some about his many years as a General Practitioner, being the only doctor in rural hospitals. He regularly did major surgery illuminated by a flashlight. They sterilized their own gloves. He was in 10 different hospitals, two in high conflict areas. When he was transferred away from one after 3 years, he had to walk for a day with armed guards because there was no transportation. He only lost one patient with surgery, a woman who presented with a ruptured uterus from prolonged obstructed labor. She died 3 days later of sepsis. This man is so sweet, quiet, and modest you would never imagine what a powerhouse of a mind he has.

I proposed that I take two of the students and we will present on our course, the Child and Adolescent Psychiatry Initiative in Myanmar, from opposite sides of the fence. The venue will be the Asian Society of Child and Adolescent Psychiatry and Allied Professions (ASCAPAP) conference, to be held in Chiang Mai, Thailand in October. That gives us time to pay attention to and collect information from the course. Strengths, weaknesses, omissions, highly valued parts, challenges, etc. It will be fun and informative to assemble the talks.

At the end of our lunch, Tin Oo gave me a bag in which were two pa so (traditional tube skirts worn by men), a white collarless eingyi (shirt), and a black taikpon (formal jacket). I must just find a pair of black, velvet pha ne (slippers) and I’ll be set for the black tie International School Yangon Gala at the end of the month. If I can finally master how to tie, and keep tied, my pa so.

A brief survey of signs on my street include: Eyebrow Tatoo, Eliza Skin Republic, Ruby Reflexology and Lounge, Fuxing (not sure but I don’t think it is risqué), and Aung’s College Phonetics.  Bubble Tea is across the street. Ju Fu Juan is the go-to Chinese place adjacent to my building. With street food tables and fruit/vegetable vendors at each end of the block, I want for nothing edible. Oh, there is a bulk drinking water dealer and a Chinese bakery with the best sweet yellow bean curd buns. I recall how irritating I found Melville’s lists in Moby Dick so I’ll stop here.

Life is good and I’ll see Linda in Kahului, Maui in 25 days at 5:30PM!  Life will get even better!!