“Springtime For Hitler”

23 August 2020

[Above photo:  My view. Two small ferries in the foreground, a small freighter carrying sand in the middle, and the recently-launched fishing fleet, perhaps 30 large boats, to the rear. The view always changes, always engages me.]

[NOTE: When you receive an alert for my post, click on the green emblem and it will bring you to the most recently edited version, complete with photo.]

My students decided we should meet for breakfast on Wednesday.  I went an hour before clinic opened and walked along the damp sidewalk across the busy street from the hospital.  I’d been given directions of sorts and a name, Tin Tin Aye, of the mohinga shop where we’d meet. After asking several people and receiving puzzled looks, one fellow brightened and pointed down the road. My accent isn’t so bad; I think people just aren’t expecting me to speak in Myanmar. I was the first to arrive and sat down on a plastic stool in the little shop, open on two sides and with a very low ceiling. It is part of a “chain” of 3 mohinga shops of the same name scattered about Yangon. Eventually 4 of the 6 students appeared and we removed the see-through plastic barriers set on each table, selected what fried delicacy we wanted in our mohinga, and slurped away as we chatted. It was a good way to start the morning.

This week’s Trump Truism. Upon the release of the Senate Intelligence Committee final report about Russian interference in the 2016 election, Mafia Don said, “This is just a continuation of the most hideous witch hunt in the history of our country.” I agree. He truly is the “most hideous witch.”

We’ve seen an 11yo girl in clinic who presented with psychosis and seizures. Her mother states she was normal, doing well in school and with a good cohort of friends until 6 months ago. She was seen by our pediatric neurologist who obtained an MRI of the head which showed diffuse calcifications in the brain, including the basal ganglia. She was being managed on low dose antipsychotics and antiepileptic medication.  They thought she might have Fahr Syndrome, a genetically-determined disorder with similar symptoms and basal ganglia calcification.

She seemed to be doing quite well until a week ago when she had 3 days of fever and a recurrence of her seizures. Because of the recurrence, I wondered about an underlying autoimmune encephalitis and sent her for a spinal tap to check for antibodies. The doctor who saw her at Yangon General Hospital obtained some blood work, as well, and her calcium was very low, her phosphorus very high, and a subsequent assay for parathyroid hormone was very low. Thus, she has hypoparathyroidism and has been referred to an endocrinologist. The cause may still be autoimmune and lab results for that are pending.

I’d never heard of Fahr Syndrome and have never seen, or heard about, a case of hypoparathyroidism.  Somehow, even with fumbling, we arrived at a correct diagnosis. Her treatment will be Vit D and calcium which can be very helpful for symptoms but also can lead to kidney stones. Newer treatment is available in wealthy countries; parathyroid hormone is now able to be synthesized but it isn’t available here.  Perhaps this is too much Medicine for this blog. But it was so interesting for this psychiatrist, seeing things now that I last thought about in medical school for the Pathology final exam (1963-64).

An 11 yo boy was brought to our clinic by an NGO worker. He has been awakening at night, screaming the equivalent of “Mom, Mom!” He sleeps in bed with his 18yo brother who he loves—the callow older youth doesn’t reciprocate. Our patient witnessed his mother being stabbed to death by her boy-friend 4 months ago. How to help?

He is HIV+ and has taken antiretrovirals without side effects for the past 3 years. His mother previously was a sex worker. He currently lives with his half-sister (same mother), her husband, their 4 children, the husband’s parents, and his brother. That’s ten people crowded into a dilapidated shack in a massive slum in South Dagon. And all that is keeping this leaky boat afloat is a singly betel nut stand operated by the half-sister and her husband. Each day after breakfast, the boy is turned loose to roam the slum all day, not allowed to return to the house until supper time. He did go to school and did quite well prior to Covid; it provided some structure to his day.

The boy was initially shy but quickly warmed to my student and clearly enjoyed himself. He appears of at least normal intelligence and can both read and write basic Myanmar (and Arabic numerals, as well).

Wanting to meet the half-sister and support whatever efforts she could muster on his behalf, we arranged to see her. The NGO worker drove me and my student followed in his car. We met her in a tea shop; it was not “high tea”, as you might guess. The area was a typical slum—it reminded me of the outskirts of the Limbe Market or of Ndirande in Blantyre—with falling-down shacks crushed together, large pools of standing water, and plastic and paper waste littering all. The dengue must be fierce, with all the mosquito-breeding ponds.

She was an attractive woman, well-groomed and simply dressed.  Initially she was wary, as would be expected. However, she met my eyes throughout. I brought her a shopping bag with a large bottle of cooking oil, a sack of rice, a packet of dried shrimp, and a large box of chocolate-covered cookies, for which she was appreciative. She helped us with the context of the child’s life. I wondered aloud about how difficult her mother’s death must be for her. After the mother was stabbed, she was carried to this woman’s house where she died. [I’m not sure why an ambulance wasn’t summoned but it probably was wise as she could die surrounded by her family, at least.] I offered that if she felt unhappy and wanted to talk about it, she was welcome at our clinic. I doubt we’ll see her; a visit to a psychiatrist here is freighted with ideas of madness, as in most countries. It also makes no sense to most people, who don’t recognize the possible benefits. She is 26yo and looked about 50yo. That she chews betel nut contributes to it, since betel stains your gums and teeth a dark red so they appear to be rotting away. But her life had worn her down.

The NGO worker will bring the boy in to see us weekly. I was reminded of Japhet, a 12yo boy in Malawi who’d been attacked by a neighbor with a panga knife (machete), nearly killing him until a bystander intervened. On our third visit, my “treatment” was to have him draw a picture of the attack, after which  he shrieked and ran out of the clinic. He was back the next week, however, and was no longer dissociated. I saw him weekly to chat for 3 months after that. He went on to do well in a local boarding school. After establishing a supportive relationship with the current boy, perhaps we’ll follow that example.

We saw the girl in clinic Wednesday who had regressed and became mute when her mother, upon returning from the Thai border where she was working in her brother’s fruit stall, gave birth. She’s improving slowly but is still mute.  She is clearly very intelligent. We’ve attempted to decrease the secondary gain she gets from her mother and grandfather for her “illness”. She no longer breast feeds her mother or suckles on the nursing cat, happily!

After the family left the clinic, three of the students were sitting together and began to laugh. I asked what was going on. One of them, a very quiet, sweet woman who is the girl’s therapist, said, “I just want to slap her on the back of her head and tell her to snap out of it. Is that countertransference?”  I howled.

I was impressed with the DNC 2020. Decency, inclusion, kindness, science, optimism. And I suspect the platform will move us forward a big step, if it is enabled. Seeing the fires in California and reading the Covid, economic, and White House news makes it all seem like the End of Days.

An international cabal of Satanists, pedophiles, and cannibals, you say?  That has the makings of great costumes and a hilarious musical, like a combination of Guys and Dolls, Lord of the Flies, and The Producers, underpinned with shadenfreude.  Can they top “Springtime for Hitler”?  I am sure some clever librettist is already working on it. Sarah Cooper could star as Mafia Don. I think we need to honor both Kaleigh Mcenany and Sara Huckabee Sanders, as well, giving them each the “Distinguished Dissimulator Award”. “The Joy of Imprisonment” could catalogue those moral stalwarts, “the finest people”, before, during, and after their incarcerations. What, Nero fiddled while Rome burned?  Humor is serious work, I submit.

I’d best stop. This is compelling fun and I have a lot of work to do today.