9 June 2019
[Above photo: Dr. Kywe Kywe in front of Kyaik Hmaw Wun Ye Lai Pagoda on a class outing. iPhone 5S, compressed to 23%.]
Two weeks ago after I spent a few minutes settling my class so they could focus on my lecture, I announced that the process felt like herding cats. When they got it, they all began meowing and cracking up. Yes, they recognized, most of them are not followers and go their own way, to the inevitable detriment of their advancement up the academic ladder. I once asked one of the founding fathers of the San Francisco Psychoanalytic Institute over lunch what it took to become a Training Analyst; he said, “You have to kiss a lot of ass.” Norm’s candor amazed me. Our signal that lecture, exercise, film, etc. is about to start is a loud “Meow”. They are hilarious, fill me in on the psychiatric politics of the country, and are convincingly good at role play. They have had practice with the latter, especially in their substance abuse training, and it makes the dry details of a lecture explicating a diagnosis in DSM 5, with epidemiology and management thrown in, so much more fun. We have a “howling” good time learning! I keep searching for the optimally heightened affect zone where we learn best—not somnolent, not terrified.
This week was a good one. On Monday we saw a 14yo boy whose father worked abroad, home 2 months and away 10, until two years ago. Since his return he is consigned to the spare room as his 14yo son sleeps with his 55yo mother in her bed and both refuse to let the father sleep with his wife. To observe the mother and son together is like turning an electron microscope on the Oedipus Complex. The poor boy has had a developmental arrest at about 5 ½ years, unconsciously gratified and terrified, lost in an erotic and entitled fantasy of maternal possession. The mother has abrogated any generational prerogative and boundaries. We have yet to meet the father. It is sort of shocking which was exemplified when, after talking briefly with the mother, I shook her hand. Her son grabbed her arm, objecting to my touching her. I think it is time for some couple’s work, performed delicately or they will flee. We have had many good discussions in class since then on everything from Freud’s paradigm to the need for a developmentally-based diagnostic system. The American Psychoanalytic Association has one, of course, but it doesn’t serve the interests of organized psychiatry or the psychopharmaceutical industry.
Yesterday, the bright Neurology Registrar came by to announce that both of the girls we’d seen with possible anti-NMDA Receptor Encephalitis had positive tests for it. Both are having a trial of immunotherapy and while the one girl who became ill 3 weeks ago is dramatically better, the one I described in my blog 2 weeks ago is not improving. However, she has had this for 7 months at least. I am glad they were positive so they can be treated. The first girl we saw couldn’t afford the test and the neurologists wouldn’t have given her a trial of immune-suppressives without a positive result, so I, believing it wasn’t schizophrenia, coughed up the $60. I hope she improves with a bit longer trial of treatment. The next little girl was sent to us the following day, not for psychiatric assessment but to see how deep my pockets were (deep enough). As to the next 5 who come along, my money printer is running out of ink. I am incapable of not paying for the test if I meet the child and mother. How could anyone not pay? Of course, I can afford it. On the other hand, it is certainly not in the scope of my job description. I worry this will continue to occur. Working in developing countries presents such a range of ethical and moral dilemmas, repeatedly. In Malawi, I struggled to refuse a request to see a patient as there was literally no one else in the country qualified to do the needed psychotherapy with a complex adolescent or child patient. Training others in psychotherapy isn’t a quick process and if the child in question was quite ill, the son/daughter of a faculty member, or a College of Medicine trainee, it was difficult not to make time for them, an arbitrary decision I realize. Here, fortunately, I am not licensed as Fulbright won’t allow it. They want me to teach only.
I had my first monsoon baptism on Wednesday, walking several blocks with two students from lunch to the library in a torrential downpour. The great thing was, although I got soaked, despite my new and large umbrella, we then watched a film and by the end I was totally dry. I showed “The Lord of the Flies”, complimenting our discussion yesterday of subcultural and contextually-determined antisocial behavior. I had forgotten how grim and fierce the film was. It demonstrates so well how a charismatic sociopath can bind his followers to him with fear and how maintaining that fear is central to his control of them. Sound familiar?
On Friday we took a field trip to the Yangon Boys Training Center, a residential facility for street children and for under 16yo’s awaiting adjudication after being arrested. It is understaffed (17 total staff, with three out on disability), underfunded, (the government food allotment is 66 cents per child per day), overpopulated (204 in a facility built for 150 maximum), and grim. Kids try to run away regularly. However, there is no corporal punishment and the street kids, generally much younger, are in a separate facility and school from the arrested boys. We couldn’t go into their living quarters but could look in through the locked bars, seeing a large hot, dark, apparently windowless room where children were milling about and shouting. Training them for….what? It’s probably better than jail for the older and probably safer than the streets for the younger. It made me reflect on how wonderful Seneca Center was for the same subset of children. Ken Berrick demanded adequate funding in every county contract so that our facilities would be attractive and homey, which they were. Several Seneca (young) “old-timers” were known for their ability to select furniture, drapes, rugs, and paint colors that were appealing together. Honestly, the care that went into those programs was legion, reflecting Ken’s leadership and that of those he chose to work for him. Talk about focus. Working tirelessly, running the same agency to improve care for children since 1985, nearly 45 years. Was I lucky to stumble onto that bunch!!
The students had planned an outing for us to follow the rather grim training school visit. We drove in two cars to see a pagoda in the middle of the swirling, brown waters of the Hmaw Wun Creek, which looked like a wide, deep, and swollen river to me. The Kyaik Hmaw Wun Ye Lai Pagoda was built in the 3rd century BC and is only accessible by boat. It was beautiful and peaceful and several of the students prayed and lit candles before we took the obligatory pictures, returned to shore in the long-tailed boat, and drove 15 minutes to Dream Garden. The latter is a restaurant set in a lovely tropical garden, well off the road. We feasted, sharing all dishes—these guys are really into sharing everything except the bill. They insisted I was their guest and refused my offers to pay even for myself. “Next time”. OK, I’ll hold them to it. We laughed and ate. Dr. Thura asked if I’d like a beer. I demurred as I would be the only one drinking. Also, I’d probably doze off on the return car trip, missing out on some fun. At home and in Malawi I’d have a glass of wine or a beer 4-5x/week. Here, I don’t drink. Oh, I split a large beer when out for supper every 2 or 3 weeks but that is it. I enjoy the taste and the ritual but I really don’t miss the alcohol. Coming off the bridge from Dabon directly onto Maha Bandula Lan and continuing straight, we realized we were going the wrong direction on a one-way street. Kywe Kywe turned around but a policeman was there instantly, giving her a ticket for $6.50. He immediately caught another person doing the same thing. Since there is no sign saying, “One Way. Do Not Enter!” I must assume this is a good money-maker for the Yangon PD which they don’t want to disturb, safety be damned. The locals know the score so only visitors unfamiliar with the bridge exit get fined. Kind of like a one-time toll, unless you are a slow learner.
I was dropped off on the corner nearest my apartment, tan thi in hand. This is a fruit I have never seen before. It comes in a padded shell a little larger than a softball. I couldn’t wait to try it and was….underwhelmed. Amazingly juicy and with the appealing (to me) appearance and texture of jellyfish, it didn’t have enough flavor to merit the work of mining it. Similarly with rambutan, those bright red hairy fruit. Good lichee, mango, or mangosteen suit my taste. I like to try them all, however.
I’ve enquired about a week-long liveaboard dive trip in the Mergui Archipelago in Lower Burma in November. I first was certified at 65yo and have only dived 20-25x since then and not recently but I feel fit and simply love it. Plus, all I have read about these 804 mostly uninhabited islands is alluring. The diving is supposedly wonderful. Being aged and missing 15% of my lung volume, I think I’ll limit myself to 25 meters maximum; also, the colors and light are better in the shallower water. I’ll join Divers Alert Network for emergency evacuation insurance, and check with the dive folks at Duke University to see what they think. And I’ll join a fitness gym in a hotel to work up to it. It’s too hot to jog here. I suppose I could buy an exercise bike for my apartment.
Here comes the rain! A platitude these days.
A Psychiatrist in Myanmar 