Cartman

5 July 2020

[Above photo: Another amazing temple from 12th century Bagan.]

I’m not sure why it took me so long to notice the similarity. I suppose it’s because I haven’t watched South Park for decades but isn’t DT represented perfectly by Cartman? An ignorant, vengeful, foul-mouthed, impulsive bully, a school failure who enjoys torturing others? My god, he’s ruined another, if minor, pleasure—laughing at Cartman’s antics.

Our new clinic works amazingly well. We are in a large conference room with an open stage and a 30’x40’ open area in the back. The conference seating in between is on numerous immense matching overstuffed leather couches and chairs, obviously from an earlier era, as half of the metal upholstery button caps have fallen off.

It is a pop-up clinic. On Monday and Wednesday at 9AM we unlock the double doors and set up two portable child tables, two portable regular-sized tables and chairs, two cloth-on-metal -frame screens, two large blue foam pads in front of the child tables, a grouping of chairs on the stage for psychotherapy, and our box on wheels. In the latter are charts and charting materials, toys, art supplies, etc. Because the entire conference room has a green felt floor covering (no shoes allowed), the sound-proofing is pretty good.

Today, however, there is a conference in the conference room so we have moved to the cardiology clinic wing of the hospital. We were given only one small room with a table and three chairs so we have imported several other tables and are using the large waiting area to see our patients. Built with economy and ease of maintenance in mind, it is all hard, flat surfaces, maximally reflective of sound. We have our box on wheels and at the moment a psychotherapy session is happening with a 15yo teen in the one private room and two intakes are happening in the waiting area. I was prepared to do a Zoom therapy session with my one patient, sitting in a corner of the waiting area, but it is much too noisy, so I have rescheduled.

Since people’s lives are so precarious, interpersonal boundaries seem very porous, and most people live packed closely together, our clinic environment doesn’t seem to faze anyone. In addition, or perhaps primarily, people who come to us are so desperate for help that they overlook the material deficiencies. We learn and do good work.

We saw a fascinating 9yo boy with episodic vomiting that has put him in the hospital 11 times. He was brought to us from the Defense Academy hospital. He is intellectually disabled and cannot attend school. He was presumptively treated for tuberculosis on the basis of enlarged abdominal periaortic lymph nodes, so common is tb in his area. His mother beats him sometimes. He has become dangerously dehydrated at times, with a serum sodium of 150meq/L. Curiously, he has an apprehension before he begins to vomit, his body stiffens, his toes curl, and his feet dorsiflex tonically, and he has an outburst of aggression each time immediately after the vomiting ceases. While it may be that this is Cyclic Vomiting Syndrome, it also could be a Temporal Lobe Seizure disorder so we are working him up for both. And seeing if we can get the mother to stop beating him.

After clinic on Wednesday, my students drove me to Wake ‘n Bake, a durian shop. By that, I mean to say that is all they sell. Durian puffs, durian pillows, iced durian in coconut milk, and so forth. Year round. There is an adjacent storage room with racks full of durian. You either love it or are disgusted by it. We all love it and the groans of satisfaction from our packed booth would have suggested an orgy to a blind observer. Of course, we had to take off our masks to eat it.  One student called her husband, who was nearby, to join us. The sign—”No firearms. No durian.”—in hotels is pretty ubiquitous. More people globally are killed by falling durian in a year than by sharks, a fact.

I have seen more rats—both dead and alive—this week than ever before. Fresh roadkill, ancient flattened roadkill, and alive and scurrying across the road or the sidewalk immediately in front of me. One consistent fact, they are all huge. No timid little hickory-dickory-dock rodents; they are hefty, dark gray, solid beasts. I wonder if they are out more often in daylight now because they became accustomed to fewer cars and people, given our self-isolation for the past few months.  We need more cats.

We continue to have very few cases of Covid-19 here—about 300 confirmed for the country. Myanmar has been very conservative, strictly limiting international and local air traffic, as well as travel within the country.  Mingaladon International Airport is essentially closed and has been since late March. Many townships don’t allow people from adjacent townships to enter. People still wear masks in public, although more variably in Chinatown than in other areas. I cannot explain the lack of spread.  The hospitals have seen very few cases and there have only been a handful of deaths. With the crowding and poverty, I’d expect to see higher numbers; perhaps they will come soon. I have gradually relaxed my guard, although I still wear a mask in public and wash my hands frequently.  I don’t wear a mask when doing psychotherapy or at lunch with my students, however. Or with close friends at their homes. The latter have been very careful, mostly working from home.

I am enviously imagining my sister, her daughter, and the latter’s son all enjoying the beauty and tranquility of Beach Island for two months.  Next year for me, although who can tell? Maybe there will be a tsunami or a storm of durian. Perhaps the US borders will be closed to travelers from Myanmar. It is all such a strange time.

I have accepted another patient.  It is difficult not to, as it was in Malawi, since there is no one as qualified to see him. He is 15yo and was adopted by a single mother at 4 months of age after his mother and father abandoned him in the hospital. At first he was quite anxious about seeing me; by the end of the hour he was asking if he could come 2x/week! I think we’ll make progress with motivation like that. I’ll not take on any more, although I could clearly have a thriving practice here to support myself. At my age, I don’t think I should take on new, long-term cases.  The situation is somewhat different than in the US. There is an abundance, at least in the Bay Area, of good, younger people to see them.

The California Medical Board sends out a quarterly report. I often glance through to see if any of my acquaintances are in trouble. Usually it is “acts of negligence” and “failure to maintain accurate and adequate medical records”. There are few flagrant sexual violations, surprisingly, given how riven the analytic community has been with them at times. A fair number of “excessive prescribing of narcotics” and “prescribing without prior examination” or “prescribing with intent to divert”. Then there are the curious ones: “driving while intoxicated and performing an act forbidden by law”. Obscene stand-up comedy? Oral sex? Bestiality (which is, curiously, legal in Russia and Angola)? Or this doozy: “No admissions but convicted of three felony counts of obtaining and unlawfully using the personal identifying information of another; and charged with having a condition affecting his ability to practice medicine safely, dishonest acts, prescribing with intent to divert for self-use, and false representation.” How can you not admit to these things when caught red-handed? Or this: “No admissions but convicted of one misdemeanor count of inflicting a corporal injury resulting in a traumatic condition upon a person; one misdemeanor count of using force and violence upon the person of another; and two misdemeanor counts of violating a protective order.”  He sounds more like a Mafia enforcer than a physician. How did he get through medical school? Why did he want to? Why not just go directly to your local capo and enlist, saving the repayment of all those educational loans? I do, always, think of the cascade of problems that lands on their families.

As my friend, Jeff, once said to me, in the wake of 3 members of the Boston Psychoanalytic Institute having had sexual relationships with their patients: “We are so fragile.” Such strong feelings, ghosts from our past, are activated in therapy, it is amazing that it doesn’t happen more. I have certainly had my Id stirred many times in the course of a long career. Happily, I could always step back and be curious about it. In all humility, I’m lucky that the stars weren’t in alignment for such a transgression. We are fragile, men more than women, it seems.

Knowing how exercised, how filled with adrenaline I can quickly become in an argument about our Dear Leader, it was a good and sobering lesson to see an interview yesterday with Bob Woodward from 1 ½ years ago at the occasion of the publication of his book about DT, Fear.  I watch stuff when on my elliptical trainer; it allows me to run much further, distracting me from my fatigue. In the Q & A period at the end, an impassioned woman with a trembling voice implored him to say something about Trump; he quickly said, “I don’t want to respond to that kind of question.” He talked about the need to de-polarize our country and that calm, thoughtful discourse was more likely to succeed at that than strident confrontation.  We must calmly stick with the logical, the critical thinking part of dialogue to avoid polarization. We need to talk with each other and listen to each other based on facts, not scream at each other fueled by feelings. Women pulling pistols in parking lots and women calling police to report attacks by birdwatchers are based on hysteria, which only will go badly. The same with shouts, accompanied by fists, of “White Power” by old men in golf carts. Cars driving into protestors. Police killing black people has a more sinister, if similar, irrationally fearful basis.

DT’s Mt. Rushmore antics are true to form. Fear and division are all he knows, since he seems incapable of the character, discipline, or motivation to study and learn otherwise. He is, like Mike Mulligan and Mary Ann (his steam-shovel) in my favorite book from childhood, digging a nice deep pit with 4 square sides and 4 square corners for himself. Maybe, like Mike, he can set up house there. It may match his capabilities better than Trump Tower or Mar-a-Lago.  They could be re-purposed for low-income housing for the poor, including blacks and immigrants.