17 July 2019

[Above photo: Waterfall at a shrine outside Pyn Oo Lwin]

I’ve returned from a 5 day trip to northern Shan State. Yesterday, Tuesday, was the Full Moon of Waso  and Friday is Martyr’s Day so I cancelled classes for this week. We’ll have clinic on Wednesday and Thursday, as I don’t want to interfere with the momentum of referrals and follow-ups, and those psychiatrists who are local can come in to run it. The idea of a 1-3 week holiday during the year for government workers, including physicians, is unheard of.

Before I left Yangon I wanted to pay Jose for the carpets I bought—small, stunning Afghanis—but when I arrived at his home, my wallet was missing. That gave me pause, since it meant that for the time being I couldn’t withdraw money from ATM’s or charge anything. I walked it back and my best guess was that the wallet fell out into the mud as I paid a taxi driver and rushed to get my umbrella up in a downpour; I was visiting a Dutch psychologist who has been involved with child protection here for years. The other possibility was that I somehow left it at the library. Since I wear a longyi, I have no pockets and am not yet confident enough to stick it in my waistband like the younger crowd. So I keep it in a zippered pocket in my backpack with my phone and surplus cash. Stupidly, I had both of my ATM cards in it. I have friends to borrow from in the short term, I can get dollars to convert to kyat from the Embassy, and can have new cards sent by Linda via DHL within a couple of weeks, all a nuisance for me and others.  Still, it was unnerving, just as I was setting out on a trip.

The next day as we pulled up to the UniMed 1 cafeteria, Dr. Gyi’s phone went off. I’d left my wallet on a bench in the lobby of the library and a student turned it in. All intact, even the $100 bill I keep for emergencies (like this one!). When I returned home I took everything out of the wallet except my Visa, one ATM, my Maine driver’s license, and the $100 bill. Was my Unconscious expressing some ambivalence about the trip? Was I just impulsively, inattentively rushing? I didn’t feel great anxiety after the initial discovery I’d lost it, but when I retrieved it, I became aware how much I was holding in.

Dr. Thura Lin, one of my students who lives in Mandalay, took me under his wing, picked me up in a taxi, and the driver got us to the bus station after an hour of wild riding on unlit back streets in a downpour to avoid the traffic mess. Thura had a bite and I had a beer in a little dive he uses at Aung Mingalar Bus Terminal, and at 9:15PM we boarded a huge, new, comfortable bus. An aisle wide enough to dance in. Two spacious, comfortable seats on one side of it, one on the other. A polyester throw. Footrests. Snacks and bottled water. We slept for four hours, stopped for a toilet and mohinga break at a large, open bus stop dining room near Nay Pyi Taw, and then slept another 5. A little 3-wheeled motorcycle taxi zipped us to his childhood home, where I had tea and met his 3 sisters, father, and 12yo nephew.

Dr. Thura had planned an outing for us. His uncle drove us to Pyn Oo Lwin, nephew in tow. The town is at 1300 meters and was founded in 1896 by the British for their officers to escape the Mandalay heat. We toured caves, temples, and waterfalls, a pretty standard itinerary in Myanmar, had lunch, and they dropped me at my hotel and returned to Mandalay. My hotel was a kilometer out of town and set in lush gardens. It was very Bernard Maybeck-looking, with lots of dark wood, open beams, etc.

I went for a walk on a path beside a nearby lake and a jogger started a conversation with me. He is a 51yo retired school teacher who lives off the interest of his savings, drives a $100,000 Mercedes, and was involved for 4 years in something shady which he said he finally couldn’t stomach. Despite the alarm bells, he was an interesting guy and we had supper together while he told me tales of his travels. He’s been to Italy several times, and Oktoberfest 3x. More to the point, he has trekked and climbed a lot in Myanmar and gave me a list of great-sounding possibilities here.

The next day I walked to, and through, the National Botanical Gardens for 5 hours. It was magnificent and well-maintained by the Burmese since the British left. Wonderful formal flower beds, massive timber bamboo and teak groves, two enclosures with Takin in them, and so forth, all around a long lake. Takin are an Eastern Himalayan ungulate found in Bhutan, China, and Northern Myanmar. They look like a small bison crossed with a wildebeest.  The aviary, a net-covered acre of trees, had interesting birds, but seemed miserably confining. The butterfly and beetle museum was astounding to me, especially as I am finishing Half Earth by EO Wilson about the current massive extinction of species worldwide.

I walked a few miles to the main market, having only one dicey encounter with a pack of 5 angry dogs. A woman came out of a nearby house and they, recognizing her, slunk away. By now it was drizzling but I had my trusty umbrella. Pyn Oo Lwin is known for its sweaters; I’m not sure why as they are machine-made but I got a great thin wool one for $3 and a heavier woolen turtleneck for $5. Hard to resist, no bargaining. I secured my seat on the train for the next day and taxied back to the hotel for the evening.

My cab arrived on schedule at 7:15AM the following day and took me to the train station. This train line was built by the British, opening in 1903. It contains the Gowteik Viaduct, which was the second highest bridge in the world when it was constructed and remains the longest in Myanmar. The train cars are likewise of ancient vintage. As the journey to Hsi Paw started, the track was so uneven that the train rocked back and forth violently, tossing luggage into the aisles. The viaduct is a marvel and we crossed it at walking pace. Trains are, for me, the most interesting form of travel, although sailing is a close second.

There was chatting among the passengers, both Myanmar and foreigners, and I saw a couple I’d supped with a month or so ago, travelling the same route. The bushes beside the track scraped the side of the train and whapped leaves off into the permanently opened windows.  It was green beyond imagination. I felt like I was bathing in chlorophyll and realized how much I’ve missed it being in Yangon.

I didn’t take the time to explore Hsi Paw, another British hill town and site of a Shan prince’s “palace”, a large, colonial-style house. The town is set in a valley ringed with mountains and surrounded by rice paddies. I was whisked in the back of a truck to Mr. Charles’ Riverside Lodge, 2 ½ miles out of town. Mr. Charles, himself, was there to greet me, a genial and clever hotelier. Now in his 70’s, he lets his daughters run the place and they have extremely high standards for staff, food, cleanliness, etc. My cottage had a deck 30 feet above the river amid banana trees and other lushness. I didn’t want to leave, sitting at the pretty teak-slab table on the deck, reading. However, I decided to take a trek the next day and arranged for a guide. More later, in Part 2.

I think the surprisingly progressive agenda of “The Squad” is frightening to many, although it all seems way overdue to me. The bickering among the Dems doesn’t worry me as we’ll have only one nominee at the end and everyone, hopefully, will get behind her. I think it is not surprising to have such struggles, given how ambitious and necessary the agendas are.  A demagogue is extremely dangerous, however, so we cannot screw this up.

7 July 2019

[Above photo: A massive storm cloud approaching over Yangon, exploding in rain 10 minutes after the picture was taken.]

I reached out to someone I met at the Peace Corps swearing-in ceremony I attended a few months ago and, lo and behold, I finally have a social network. He, Jose, and his wife, Irene, are directors of two different NGO’s, and their neighbor, Kelly, who is within 15 years of my age, is also a PC alumnus and the director of a large NGO.  They have all spent their lives in and out of conflict zones in Benin, Bangladesh, Sri Lanka, and Myanmar, doing this work for 20-30 years, and they know how to have fun. We had a poker game last night with three others, including a Pakistani carpet merchant who is a long-term friend of theirs, and laughed ourselves silly. The title of this post is a 7 card game, 9’s and 3’s wild and if you have a 4 you can draw an extra card. It generates a massive pot so, even if stupid in the world of serious poker, it is very exciting. We ended, happily exhausted and with money redistributed to the two who actually played throughout with strategy, with a single round of “Indian Poker”.  Everyone puts a card on their forehead so you can see the others’ but not your own and you bet for the high card. Not much thinking there.

My history of playing poker is a dismal story. I lost $5 in a game in my freshman dorm in college at a time I didn’t have $5 to lose. The evening was enlivened by a visit from two young Cambridge locals. One of our number had maliciously tossed a couple of milk cartons full of water from the 3^rd floor suite onto the sidewalk close to where the two were standing. Up they came, one with a blackjack and the other with brass knuckles. It was their mistake, as two of our number were, as freshmen, stars on the varsity hockey team and were very happy to mix it up. No blows were landed but one of the visitors was suspended off the floor against the wall for a few minutes while he cooled down.  I watched, breathless.

4 or 5 years ago I was invited to a poker game in Petaluma, California (45′ north of Berkeley) where I was consulting briefly for Seneca Center. Their psychiatrist, who they all adored, had dropped dead while taking a stroll. The leadership and staff were in grief so it was difficult for me to break it to them that just because he felt that Celexa (an antidepressant) was “very helpful for these kids”, it didn’t justify him putting them all on it.  Plus, he gave mood stabilizers in the absence of Bipolar Disorder. Clearly a failure of his imagination and understanding of attachment behaviors.

Anyway, I drove north to the evening game and realized that it had been ongoing for many years. All the participants were seasoned players, even the woman who dropped in briefly for one hand in which she cleaned me out while one of the other fellows asked me impatiently,  “What are you doing?”.  I realized that they were helpfully refilling my wine glass at regular intervals and no one else was even sipping theirs. I dropped $90 and learned three good lessons. If you want to lose at poker, drink. If you want to lessen the pain of losing at poker, drink. Finally, if you don’t know who the patsy is, it’s you.

Last night after a few impulsive moves at the beginning in which I lost half my stake, I settled down and played with some strategy and discipline, gaining back most of my losses. Less than the price of a movie at Reel Pizza in Bar Harbor for 5 hours of hilarity. My luck was pretty awful, in addition to my play, but both improved a bit as the evening advanced. The blatantly manipulative trash talk kept us howling. “Man up! You can do it. He’s bluffing again.  See him and raise him.”

One of them directs an organization that works with refugee children, so he invited me to accompany him to look at kids in several camps in two major conflict zones, in Rakhine and Kachin states. I can’t go on the proximate trip in 3 weeks because of my teaching but I can go at the end of my stay. I’ll think about how to gather information on post-trauma symptoms in the children and their parents and ways to address them.

It is slowly dawning on me that we may not get therapy rooms—ie rooms with doors— in which my group of students can learn. I’ll keep trying, but there seems to be major resistance to securing them among the powers that be. The students have learned how to do a proper assessment on everyone and what a good management plan would look like, as well as the difference between bad and good medication practice. I am teaching them, currently, a time-limited therapy called “Interpersonal Therapy” which is evidence-based, manualized, and used world-wide as one of the WHO mhGAP treatments.  They also are learning Play Therapy, principles of behavior management, and the theory and technique of Psychodynamic Psychotherapy, as well as elements of CBT. Psychodynamic psychotherapy is my drug of choice but it is also the most difficult for them to learn and to do well.  After we read some papers, I’ll do a presentation or two, and we do role plays, there is often the question, “Professor, but what is the therapy?” I remind them that this is not removal of an appendix or writing a prescription, that listening, understanding, and deepening the patient’s understanding of themselves in a special kind of conversation or helping them to alter their responses is the therapy. I do love the way they begin a case presentation or lead the discussion of a paper: “Professor and my colleagues…….”.   They are respectful but unruly, a combination appealing to me . I may change my first name; I’ve gotten used to “Professor”. It has a gravitas that “George” lacks, since the latter recalls 41 and 43 and Mad King George.  There is Curious George, however.

We read and discuss theory, do role plays, and occasionally have the opportunity to work with a patient several times in our one room with a door that closes (I suppose we could use one or both of the bathrooms, but that would present interesting transference and play therapy issues.).  We may have to settle for no supervised ongoing psychotherapy experience for them for the present time.  I won’t participate in developing the curriculum for the year-long course in Child and Adolescent Psychiatry they plan to start in January unless I am promised that there will be reasonable psychotherapy facilities. Since psychotherapy isn’t currently done in psychiatric training or practice here and since resources, both money and space, are very limited, I can understand the minimal motivation to secure the same. But Child and Adolescent Psychiatry is largely a matter of intimate talk and play with adults and kids, not the writing of prescriptions, so confidentiality is crucial. If they want a decent program here, they must create the spaces for it.  You don’t do surgery in a large open room with people walking through.

When I head down Anawrahta Street on my way to the bus each morning, every week or two there is a sudden collective look of fear and a scramble of the fish, meat, fruit, and vegetable vendors.  At first I thought I was not noticing an imminent deluge but later realized that the arrival of the police has triggered the activity.  I imagine that vendors are not supposed to block the roads or the sidewalks with their stands and wares. But they all do, making roads impassable on 17^th and 18^th streets and the sidewalk nearly so on Anawrahta.  When the police arrive, they all scuttle about, dragging their stalls, mats, umbrellas, carts, etc. full of whatever back to the sidelines. The police cruise slowly, menacingly by in their little Suzuki truck, and the whole game resumes.  I am tempted to do in-depth interviews with a vendor and write their life story. I imagine it would be full of poverty, oppression, deprivation, loss, abuse, death, and sadness, but perhaps also joy and love and laughter, although likely not in equal measure. It would be a very interesting but voyeuristic experience.  Perhaps if I were a more talented writer it could be a part of something that would help to change their lot.  So many fascinating directions in which to travel through this life; the difficulty is choosing which star to follow.

Before July 4^th, I’ll admit I had fantasies that a soldier in one of the two stationary Abram tanks, trucked to the Mall in order to bolster his fragile bone-spurred draft-dodging image, would throw caution to the wind and sacrifice himself and the Lincoln Memorial for the greater good. The Blue Angels might have assisted. But the crowds were too great a liability to support even my fantasy.  I want to help them see the light, not plunge into infinite darkness.

 

30 June 2019

[Above photo: Dr. Thura Lin in front of  a clever marketing approach, if your dream is to have “Singapore imported bedroom accessories.”]

I finally returned to the National Historical Museum Saturday after my massage. I’d visited floors 1 and 2 the first week I was here but never returned. I’d heard that the ethnic costumes on display on the top floor were wonderful so I walked up 4 flights to start there. They were amazing!  The male and female garb was of colorful locally woven fabric and remarkably varied from village to village among the same group (Shan, Kachin, Kayin, Chin, Rakhine, and others). The Atha women looked like they’d be the most fun at a party—stunning outfits with colorful miniskirts and lovely woven gauntlets for their calves (Leg warmers? I don’t know this stuff.), and lots of metal adorning all. Girls just wanna have fun!  There also is a glorious collection of ancient and traditional musical instruments: harps, stringed instruments and xylophones in the shapes of crocodiles, “banjos”, “violins”, and many types of flutes. One common type of flute had 15 pipes of different lengths, all bound together and played simultaneously by a man and a woman, reportedly to make both masculine and feminine sounds simultaneously. How they managed to share one flute, I have no idea but the Freudian implications are obvious to a beginner. The English on the displays was pretty bad—several carvings of a “Lion seizing”. I suppose they can have fits but who would memorialize it so?

Being on the top floor when a massive rain flooded down, it was impossible to hear anything else. After the rain slowed to a normal pour, I dashed across the parking lot through ankle-deep water to the museum café and had a burger and coffee. The sun then appeared and I walked home in the sparkling aftermath. It scrubs the air clean. Despite hours of pre- soaking in bleach and soap and diligent work with my nail brush,  I cannot manage to clean my shirt collars as thoroughly.

When I was running errands yesterday—getting a large bottle of melatonin tablets for stock in the clinic, some bright stickers for the parents of unruly children to use on behavioral charts, and a bottle of cracked pepper and some Worcestershire sauce—I noticed, for the first time in the upscale supermarket checkout line, the cigarettes. Two types were available, Lucky Strikes from British-American Tobacco and another brand from a Chinese tobacco company. Each carton, and pack, of the Lucky Strikes had a large color photo of a dying man with a tracheostomy and a nasal oxygen cannula (not sure why the latter except for effect). The Chinese cigarettes had the same of a human tongue with a massive cancer on it.  It seems you can effect some public health measures with an authoritarian government that we cannot.

Sidewalks here are interesting. They all have a 2 foot wide, 3-4 foot deep concrete storm water sluice running on the house side.  Generally, they are covered by removable concrete pads; occasionally the latter fail and there is a hole to fall into but mostly they are intact. There appears to be little, if any, building code enforcement.  If a person wants a large back-up generator for their house or apartment, they mount it in the middle of the sidewalk, permanently. If they want a guardhouse outside an embassy, a private residence, or a local police enclosure, it may span the sidewalk. Trees, also, are allowed to grow right through the sidewalk. All block your way, forcing you to walk in the street. You just wander along. People cross the road without respect to the traffic or the lights. The bus drivers with the new #37 yellow buses race each other in pairs. They are like teenagers with their first car, jerking along, accelerating and braking like crazy. We all hang on for dear life. Then you get one who slows a bit, opens the door, and suddenly speeds up. You have to time your exit perfectly. I’ve switched to #21, as they are old buses and just chug along steadily, completely stopping at each bus stand.

I went to the US Embassy 4^th of July celebration. It was at the Lotte Hotel, which I discovered is new, massive, and elegant. It took an hour in a taxi to travel what is a 15 minute ride in normal traffic.  En route we were passed by 3 shiny black Mercedes with national flags flying—I recognized the ones from India and  Indonesia—so I guessed the celebration wasn’t going to be an intimate gathering. Traffic flow halted 3 blocks away so I paid the cabbie and walked the remainder. Lining the sidewalk to the door there must have been 50 Myanmar soldiers lounging about, no doubt to scare off a would-be bomber.  Inside there were plentiful and very tasty hors d’ouvres and, wonder of wonders, Anchor Steam beer. It is my favorite, a San Francisco original. It was sold during the gold rush, no ice was used (or available) for its manufacture, and it was open-brewed on rooftops for the cooler air, hence the “steam” rising.  I asked where I could buy it in Yangon. “You can’t. They flew it in for this.” Our tax dollars at work.

There were many more very elegantly dressed Myanmar couples than Americans. There were large banners proclaiming the “2019 US Embassy Independence Day Celebration”.  An MC announced the formal parade of the Ambassador and his wife and their Honored Guest, the government Minister to the Counsellor of State (Daw Aung San Suu Kyi) and his wife up onto the stage.  The wives looked bored, but perhaps I was projecting. Both men gave short speeches, but the level of conversation in the ballroom was so high that much was lost to me.  I did get that the Ambassador chose rock ‘n roll as the very American theme for the evening. An honor guard of 4 US Marines, carrying flags of Myanmar and the US, marched in, ramrod straight. We heard the US and Myanmar national anthems. I hope we can ditch “the bombs bursting in air” some day soon for “Oh beautiful, for spacious skies, for amber waves of grain”.  The Marines did a few slick, well-synchronized moves to turn around and marched out. As they passed I wondered what those well-fed 20-something year olds thought, and understood, of the whole show. Then a local band played rock and roll covers.

I did meet another Fulbrighter, Hollie Hix-Small, who is here with her husband and son. She’s teaching Early Childhood Intervention. Hollie knows her way around and worked for George Soros for some years in unnamed former Soviet satellites. She’s a smart, modest, and lovely person and I like her husband and son, as well. She grew up in Grants Pass, Oregon, for those of you who know that little nidus of Trumpism on Interstate 5. But her mother was a school teacher, which I increasingly think of as the noblest profession. I also chatted with a terrific UK-trained psychologist who has moved to Myanmar with her husband to be near her family. Her mother is Irish, her father Myanmar. I had her visit my class so they could meet her and for her to talk about her work.  Their reaction, after she left: “She’s very smart and she’s very beautiful.” Both true and happily married.  I also met two women from US AID and hope to enlist their help to spend our tax dollars more fruitfully.

I asked if they would fund a nationwide conference with follow-up local meetings to develop and implement a plan addressing school bullying. Myanmar, it turns out, is the only country of 96 surveyed by WHO where all parameters of school violence and bullying have increased between 2007 and 2016. The causes are unclear. I wonder about the combination of an authoritarian government, a sense of powerlessness and hopelessness about economic betterment among most of the population, authoritarian parenting, and high rates of intimate partner violence and corporal punishment, the latter both at home and in schools. To be researched, I hope. Even when bullying doesn’t lead to suicide, which it does, it can cause serious and lasting damage to the victims. And if not identified and assisted, bullies often have sad lives, with antisocial behavior, substance abuse, failed intimate relationships, and incarceration at a significant rate. And there are many well-studied programs that can effectively reduce school bullying. It’s fun to have a project. Another project.

My modest paper on puerperal psychosis was finally published. Whew! It’s available at <mmj.mw>, the Malawi Medical Journal. I can see it would get easier with practice but it took about two years and a lot of effort and I had virtually no data collection and certainly no statistics with which to wrestle. I’m glad it is done and hope it spares a new mother or two, and their nursing newborns, from being put on antipsychotics.

The debates yielded galvanizing, I think, performances by the two women, Elizabeth Warren and Kamala Harris. What a ticket that would be!!  Is he trembling? The rapist?  However would he deal with two smart, educated, and competent women?  “Not my type.”

I saw an ad for “Absorbent Pads” on the side of a truck.  It showed a white-haired couple in a big fluffy white bed with gleeful smiles as they looked at each other.  Why are they smiling so? What would their thought bubbles say? “I’m wetting myself and I don’t care?” DT’s behavior is so heedless and infantile, the ad brings him to mind.

23 June 2019

[Above photo: A young woman, thanaka-smeared, throwing small dishes on a primitive electric pottery wheel in Twante.]

I’ve wearied of feeling like a slacker because I haven’t studied for my weekly Burmese language lesson. It was similar in Malawi, where I was so incredibly busy teaching and seeing patients that I had little energy or motivation to study Chichewa.  I’d go to our weekly group class at the French Cultural Center and sit with my eyes cast down, praying I wouldn’t be called upon. It gave me empathy for the children I’ve seen who found academics difficult or otherwise didn’t do the work; a dread builds up beginning two or three days before the class when you realize that you can hardly recall the last lesson, let alone be able to use what was presented spontaneously in conversation.  Given my mild hearing loss, my life-long difficulty with auditory discrimination, the tonal nature of spoken Burmese, the total lack of cognates, and the fact that after 5 months of study I can speak some but can understand nearly nothing except prices in the market and brief phrases on taxi rides, I figure I won’t achieve conversational fluency at this rate in the next 5-6 months. So I’ve called off my lessons for now—-possibly forever. It is a great weight off of me and I still will chip away at trying to learn more but without the pressure. Whew!

We visited two schools for the deaf on Friday, punctuated by a great lunch at Thai 47. This time I successfully used my professorial prerogative to demand that I pay. The first school was founded in 1918 by Mary Chapman, a wealthy British do-gooder who really has done good. It is a wonderful and going concern with regular education for K through 4^th grade, assistance for the children to continue in the local public schools, a beautiful new 5 story hostel where they can live, a large indoor gym/sports facility, a training college with a 1 ½ year curriculum for Special Ed teachers, and all manner of extras for vocational training: a coffee shop, a gift shop, a massage studio, a beauty parlor, and a large room for tailoring and crafts, all set in a woodsy area in the midst of Yangon. The children looked happy and cute and were very friendly; apparently many do not feel well-treated when they go home on weekends and are eager to return to school and to see their friends. I bought an amazing box woven out of discarded instant coffee packages—You know, the kind that are so tough you cannot open them—in the gift shop. And a red, black, green, and yellow string bracelet and a bottle of homemade shampoo. I returned the next day for a shiatsu massage.

The massage was done very professionally and upon completion I felt nearly new. But during it, the pain made me want to cry out at times. I thought about it on the spot and decided that life has a lot of pain for most of us and crying out really isn’t much help unless you are attempting to change something. I didn’t want the masseur to stop what he was doing, as I assumed it would loosen my tightness. And it felt unbecoming to scream in this peaceful room where others were likewise being tortured, but in silence. An hour of the most thorough massage I’ve had cost 7000kyat, less than $5. I signed up for next Saturday, although I may change the time if I decide to travel.

I braced myself for our visit to the government school after lunch, given how awful the government Boys Training School had been. But I was pleasantly surprised. While more modest in appointment, and it is only 5 years old, the atmosphere was cheerful, the children appeared happy, and the teachers were animated and engaged. I suspect that the leadership of each institution, above and beyond the funding and the population of children, has a lot to do with how they function. The Boy’s Training School was led by a dispirited man whereas both schools for the deaf were led by upbeat women. Also, it always improves a system to have a training mission; it reminds us to do our best, always, given the responsibility of teaching others.

I wondered what my reaction to the deaf children would be.  Meeting a handicapped child can stimulate sympathy. I wanted to inoculate the students against this but didn’t need to. They responded to the children as if they were children, not handicaps. I’ve heard blind adults say they view their blindness as a blessing, because it heightens their other senses and helps them to adapt in unique ways.  Think of George Shearing, Ray Charles, Art Tatum, Stevie Wonder, Doc Watson, Reverend Gary Davis, Blind Lemon Jefferson, Sonny Terry, and countless others. While it is perhaps a reaction formation, I can understand why many of them say they fear being sighted, as it would expose them to a world for which they aren’t prepared.  

I recall when taking Erhard Seminar Training (EST)—-Remember that?—as part of my Family Medicine Residency at San Francisco General Hospital in 1973, during the recruitment meeting in the Masonic Auditorium a man wondered if he might receive a special discount since he was blind. “We can talk about that afterward”, said the charismatic, gold-bechained, open-at-the-neck-shirted leader, “but I want you to know I don’t feel sorry for you.” It seemed gratuitous and cruel at the time but he was making a point in response to the man’s plea for special treatment. There weren’t, I might add, many particularly valuable points I extracted from the several weekend trainings, other than that stress can trigger panic and psychosis in vulnerable people. Witness the man who charged at the exit doors, blocked by large men and tables, screaming,     “Let me out!” Or the other man who stood up and repeated many times in a dreamy voice, “Away with the old, in with the new. Away with the old, in with the new.” I think the man who peed on the carpet in our hotel ballroom simply had a full bladder; we weren’t allowed to exit the room during the “seminars”.

A 15yo girl, an only child, was brought to clinic by her parents 2 weeks ago because she wasn’t interested in school and just wanted to draw anime on social media. She lived her early life in Papua, New Guinea where her father worked. She was homeschooled by her mother. Neither were allowed by the father to leave the house as he felt it was dangerous for women and girls to be out and about unescorted (by a man). The girl has been sleeping in bed between her parents since birth.  Co-habitation in the parental bed, even if there are other rooms in the house, is surprisingly common here. We gently suggested that the girl be given a bed in her own room to see what might happen. Lo’ and behold, she came in with her mother this week looking happy and assertive. She’s sleeping on her own, doing her schoolwork, willing to limit her animation to an hour a day on weekdays and two per day on the weekends. She’s even interested in joining a badminton club to play with friends on the weekend. I think she has hope she might be allowed to grow up. Another one saved! The students are so funny, being pleasantly surprised by the often dramatic changes wrought with simple measures. Use other methods of discipline than beating your child; get him/her out of the marital bed. I suggest to them that it always isn’t so easy. I have added a question to the Assessment Form, “Where does the child sleep?”

DT is enjoying yet another accusation of rape as detailed in New York Magazine. I worry it may further nudge him to distract us by starting a war with Iran. It’s strange, he equates bullying impulsivity with decisiveness, groping with masculinity. Our politicians have little incentive for peace, as they raise election money from industries that flourish during wartime. Election finance reform and eliminating the Electoral College must be central to the Democratic platform. The latter was perhaps helpful when we were a small, rural population but no longer. I cannot wait to get back and get to work for this election. Senator Susan Collins’ time ended for me well before her calculated dithering Brett Kavanaugh endorsement but that underscored her finale. And good ol’ Mitch is currently the least popular senator in the country. The times they are achanging—we hope!

16.6.2019

[Above photo: Rushing for cover in a downpour on the Yangon River.]

I was playing some Bob Dylan and heard the above line, which inspired me to skip off Friday to Twante. To get to Twante you take the ferry to Dalah, then hire a taxi or motorbike to drive you the 40 minutes into the Delta (of the Ayeyerwaddy River). When the British were here the Delta Region was the rice bowl of Asia, exporting more rice than any country in the world. After WWII and the economic policies of Ne Win, it all collapsed. Cyclone Nargis in 2008, which devastated the Delta, hasn’t helped.

I was firm with the hustler at the ferry terminal in Yangon that I was going to take the bus, not ride a motorbike; seeing his commission vanish, he did as well. When I arrived in Dalah a man approached me to hire his motorbike. No, I said, I was taking the bus, thinking about my unease riding on the back of the motorbike in Bago in shorts and flipflops with no helmet. “There is no bus. It is closed.” I doubted him but not wanting the hassle of finding the depot, I settled for his offer, donned his ineffectual helmet, and climbed on the back. “Pyay pyay,” I said, Slowly, slowly. He was obliging. As we left Dalah he stopped and we had to walk a block or two. “I don’t have a helmet. Police ahead. 3000kyat fine.” So we walked past the police, who seem to be very tolerant and just wanted a little respect for their authority, mounted up, and drove on. In 10 minutes an incredible downpour covered the area; we dismounted and sheltered in a 6×6 shed with a Buddha shrine inside. After it subsided in another 10 minutes we drove on but this time when the rain poured we kept motoring.   A motorbike 30 feet in front of us screeched to a halt, nearly crashing,  as a lazy dog wandered across the road, oblivious. People on motorcycles get killed hitting deer all the time in California; a large dog could easily do the same here.

After we passed the main Dalah garbage dump, the countryside was all brilliant green rice paddies, teak trees with their huge leaves, and little homes on stilts with standing water underneath. I can only imagine the number of mosquitoes and, thus, risk of dengue and malaria in this area in a month or two. Dengue peaks in September in Cambodia, I recall.  I think seasons are similar with Myanmar.

We drove directly to the pottery which was the draw for me in Twante, other than the trip.  It is the pottery manufactory for most of the Delta. They make small and immense pots, the latter for rice and water. The clay is mined from the local river bank. The pottery is in a series of large, connected, ramshackle wooden sheds with no windows and no artificial lighting—dark. There was a kick wheel next to which a man squatted to combine coil and throwing techniques, making large flower pots. A woman did the kicking. Another young woman was working on a primitive electric wheel in a separate dark shed, making candle holders.  There were two large walk-in wood-fired kilns, one of which was cooling after 3-4 days of firing. There were assorted people glazing and finishing pots and ceramic grill bases. It looked like steady work for low pay but with pretty good craftsmanship.  The atmosphere was a bit dreary and I couldn’t help comparing it with the lacquerware manufactory in Bagan where the products were much finer, more expressive, and varied.  It would make the job more appealing to me, if not more remunerative.  I bought a vase with a glaze the green of the paddy fields for $1. 

The drive back was even more beautiful along the channel where Twante is sited. Several long-tail boats were tearing by, looking nearly submerged.  They are constructed with very little freeboard for these generally calm Delta channels and rivers.  We passed one bus during our 1 ½ hours coming and going, so there must be some bus service.

As I re-boarded the ferry, an immense, very dark cloud approached, the skies emptied, and visibility was nil on the Yangon River. Huge container ships vanished in the rain. I decided to stay dry by riding the ferry back and forth across the river until the deluge subsided but when we arrived at Yangon and the last passenger left the ferry, the rain lightened and I stepped off. I walked up Pansodan Lan and treated myself to pizza and gelato at Sharkey’s, a local eatery. I don’t think I’ve had pizza since Malawi—Linda’s homemade was better than Hosteria or Jungle Pepper. Sharkey’s was pretty good but not up to the standard of the Cheeseboard in Berkeley.

The upshot is that I’m going to change my language lesson from Saturday to Wednesday after my work and start taking Friday-Sunday local trips. I can drag my computer along to prepare lectures, if need be. I’ve been very focused on doing a solid job here but think this won’t affect my ability to do that. I want to begin with exploring the Delta.  It’s not high on most people’s list but I like everything aquatic and the Delta is nothing if not that.

Human depravity knows no bounds, it seems. We saw a 17yo girl who ran away from her step-grandmother’s home, took a bus to the end of the line and refused to get off, so the bus driver took pity on her. He took her home for his wife to feed and to sleep for the night, then took her to the district administrative center. She was subsequently sent to the local Girls’ Training School. Because of her story, she was referred for forensic evaluation to Yangon Mental Hospital and then to us.

She lived with her mother on the Thai border for the first 6 years of her life.  Her mother was a sex worker and the patient never knew her father. Her mother died of AIDS 10 years ago. The maternal grandfather took her in. It was hardly a blessing because her step-grandmother beat her regularly and the step-grandmother’s now-25yo son has been raping the girl 3x/week since she was 7 or 8yo.The girl has primary amenorrhea so hasn’t gotten pregnant, thankfully.  The biological grandfather died a year ago.

When we interviewed her, she was tiny and extremely skinny, perhaps accounting for her amenorrhea. She has no hips and no breasts. Her face was very childlike. She missed her mother a lot and had nightly “hallucinations” of her mother calling to her. I wrote a report to the Medical Board, being very clear in several places that she was not psychotic and should not be given antipsychotics, as can happen here at the drop of a hat. One of our female therapists will see her in psychotherapy, she’ll be evaluated for her eating disorder, and, hopefully, they can find a safe, stable home in which she can live with a warm and loving woman to whom she may attach. It is so grotesque, more so to continue on and on for years, denying that she is a child and a human. I lack animal empathy, I guess, but I wouldn’t feel as bad if she were a sheep or a goat, which is how she has been treated.

On the other hand, I had supper with a young academic linguist, Justin, from London at the French Institute last night.   He has been teaching an intensive 3 week course in Burmese annually for a number of years. He scrutinized the SDQ survey instrument I am trying, still, to get certified for our use. He had good suggestions, including that the translation into Burmese that we have is much too formal for most people to fully understand and that people may be much more receptive to an audio message than a written one. No reason we couldn’t translate the form again into more colloquial language, have a Burmese read each question into a recording device, and play it back for parents to answer. Brilliant! I’ll keep hammering away at it. At the end of supper, two nannies arrived with his darling 1 year old daughter who was so happy to see him.  I don’t know about primal sin but there certainly is good and bad behavior in this world, with some extremes of each.

Which brings me to Elizabeth Warren. The woman is a fierce and knowing force for good. I’d love to see her debate DT, who would be reduced, as he was with Hillary, to trying to physically intimidate her in debates, distract from the issues, and call her silly, rude names.  She has a record of being very effective both before and during her Senate career.  She is very much in touch with the needs of the poor and working people, having grown up the same. I just hope people aren’t scared off by her strength, as she seems so genuine and brilliant and direct. There are others I like but she stands out for me. If worse came to worse and the Dems go for Biden, which I doubt, Biden-Warren would be quite a ticket. Or Warren-Harris. Or Warren-Buttigieg.

There is some hope in America. I want to return home and canvas! The Bugger may be even more outrageous by November 2020. Hopefully, he won’t begin a war with Iran; probably the Saudis bombed the tankers, wanting us to try to crush Iran for them, giving DT the pretext for a really large distraction.  “We cannot waste our time talking about obstruction and collusion. We are at WAR!” The Ghost will simply slink back to the rock out from under which he crawled, with wife in tow.  “I would never crawl under a rock without my wife. What if there was another woman under there?” Don’t you wish, obviously!

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 3^rd 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.

2 June 2019

[Above photo: A photo of a photo at an exhibit at the Goethe Center. Chin tatoos were outlawed by the government so only old people now have them.]

It is difficult for me to imagine that my time here is ½ done. Weeks seem to pass in a trice. The abrupt change of weather helps as a reminder of time passing. Frequent squalls, lightening storms that scared my language teacher, Pwint Phue Wai, yesterday, and a cooling 5 minute drench this morning all are in sharp contrast to the seemingly endless scorching sun and clear skies of March through mid-May.

The rain encouraged reclusive denizens of the deep roadside gutters to sing out.  As I walked from the 37 bus on Pyay Road to Yangon Children’s Hospital this past week a booming, throbbing choir accompanied me. Bull frogs, well, perhaps cow frogs, I have no idea. Some were about 3” long and medium-pitched but there were some granddaddies, basso profundos, as well. I paused to watch the smaller one’s puff out their cheeks before each croak.

I keep the glass door to the kitchen closed and the kitchen windows open when I am at home. Two days ago a house sparrow, true to her name, came in. After a bit of confused fluttering about she found the open window and exited. Last night as I walked up the street to dine with Ruth at Sule Shangri La, an elegant hotel, I noted that the latest crop of fried grasshoppers for sale along the sidewalk were immense—3” long or more. Not just a single crunch and swallow. Several bites. More than I can do. Chicken feet was my risk cuisine for this quarter. One of the students pointed out, as I was gingerly nibbling on the feet, that I looked afraid of it; of course I was! Why isn’t entirely clear to me. Something about my brother’s chickens when I was 5yo. Put me off boiled eggs for about 70 years, as well. I feel the same wariness toward the grasshoppers. Walking the mile home from supper at 10PM last night I saw many families and other groupings at impromptu restaurants set up in the street under tarps with tiny tables and tiny stools. It looked so lovely, people laughing and enjoying each other’s company. Then I noticed the many broad-shouldered dark shapes scurrying to and fro—ratus norweigicus, perhaps. Everyone looking to enjoy a meal.

One of my favorite memories is when Nate and I were biking in Provence. He was 15yo, I was 55. We were staying at a 16^th century farmhouse on an island in the middle of the Rhone, across from the Palais du Papes in Avignon. We biked in the dark down empty roads through fields until we came on a restaurant. It was another beautiful ancient stone farmhouse with a pea-gravel front yard set with tables and twinkling lights strung between the trees. Large groups of families and friends were eating and drinking. We parked our bikes and had a splendid meal.  The chef asked us into her house to tour it, including the kitchen, which was a certain thrill. And across the river the lights shone on the Pont d’Avignon and Palais du Papes while we ate. Magic, created by the people and their relationships and augmented by the setting.

I would ordinarily never intentionally go to a meal at a fancy hotel. At least here where the little hole-in-the-wall places on second floors have so much atmosphere, good prices, and great food. At the International School Yangon gala two months ago I won a free buffet for two at the Sule in the raffle, so I asked Ruth to go. She teaches at the school and had invited me to the gala. It was pretty spectacular with every kind of meat, fish, shrimp, salad, soup, pastry, dessert, etc., all prepared and seasoned wonderfully. Neither of us ate lunch, in preparation. And we spent 3 hours cruising through, like one of those 7 course French meals with 7 paired wines. We chatted away. Her daughter, an art teacher in Kansas City, Missouri, is a real adventurer, working for several years all over the world as a teacher, following in her mother’s footsteps. She will visit her mom here in 3 days and they’ll travel around, so Ruth is pretty excited.

It is interesting how differently waitstaff behave. At Sule, they are incredibly trained, always there but unobtrusive. It seems like such a strain to serve [relatively] rich people and have to submerge your personality. Come to think of it, when she cleared the table she dropped the fork from my dessert onto my trousers, which chocolate mess I had to scrub out. I cannot believe that it was other than chance, although clearly I wonder if her unconscious was at work, expressing some dissatisfaction. No, it was pure physics and, subsequently, chemistry. Contrast the waitstaff in Try, a place near my apartment on Lamnidaw Lan where I go for sushi and miso soup. The guys in the kitchen get riffing and laughing and shouting so loudly that normal conversational tones in the restaurant won’t work. It sounds like a locker room—not DT’s type—where kids are being raucous, snapping towels and commenting about one another’s sexual prowess or lack thereof to great hilarity. I don’t know why the creationists have such trouble with Darwin; we are so incredibly close to the apes, although we are more warlike.

I listened to a wonderful commencement speech by David Foster Wallace. I’m late to the party and many of you have likely heard it. It is at Kenyon College in 2005. He talks about finding meaning in our lives and our natural narcissism, egocentricity, and how it isolates and blinds us. And how the struggle to overcome it brings us satisfaction and much closer to each other. And how we can, in fact, choose what to think about. I highly recommend it in these days of gazillionaires who need to accumulate more and more, never satisfied.

Also, Nicholas Kristof’s reprint in the Saturday NY Times of his article from 2017 encouraging us to treat guns as we do automobiles is a wonderful and sensible nostrum. His graphs of gun prevalence and gun deaths—and who dies—are staggering. Graphs really can pack a punch. It prompted me to write another Letter to the Editor about how we’ll never truly realize our democratic values until we get Big Bucks out of the election-equation. The rich will always be able to connive, to tip the balance in their favor, and to secure it, tipped.

There now is a dark cloud, like a carpet, covering my part of Yangon. The rain has picked up again and the humidity is fierce. The Bay of Bengal is washing Yangon clean. I have a leak in the roof but, since it isn’t my place and I can conveniently put a bucket under it, I am not in the least worried as I would be if I owned it. Although the temperature is only 77F, with a predicted high of 84F today, I may have to use the air-con as I washed my sheets and they won’t dry with a humidity of 95%. Why did I wash my sheets? I have to keep up the pretense of civilization here. Pretense it is, as I haven’t washed them in a long time. They aren’t, however, aromatic as I shower before bed each night. Still.

Many of the kids we see—-whoa, the rain is really pouring down now—are so responsive to attention and to when their parents stop beating them. It is very different with the traumatized kids I saw at Seneca Center, whose family life was often entirely chaotic and destructive. The children here have intact families who just believe that beating is the way to discipline. It causes an Adjustment Disorder, so when the beating stops, their behavior/depression often resolves promptly. It gives my students a very optimistic view of the efficacy of therapy, which isn’t bad when you are starting out.

I must have some breakfast. I just got off a video call—imagine that, a video call!—with Linda and her grandkids, James and Amelia. They are so cute and sweet and developmentally spot-on.  Linda’s off to Malawi for a month in 2 days, moving the midwifery ward project along nicely.

There’s hope for the world if we can just get this crook out of the White House. Hooray for William Weld, who has signed up for a potentially very stressful year fighting off DT’s scabrous attacks as they both seek the Republican nomination. Weld’s entry is clearly a fundamentally altruistic gesture, a falling on the sword for all of us. Wouldn’t it be fantastic if he actually won it? As is, he may be able to gore the bull enough to further cripple him. Arouses my hostility, that pres does.

26 May 2019

[Above photo: A snapshot from my deck of the evening sky during the rainy season. ]

Yesterday on our trip to the University of Medicine 1 cafeteria I suggested that we eat somewhere else for variety.  Kyi Min Tun, who was driving, read my mind before I had the thought and had already planned an outing to a place he knew from student days.  We were heading down Lamnidaw Lan just before the train overpass near the University when he turned right into a dusty yard. A little restaurant sat in the back serving authentic Shan food. It has been there for 18 years. Clean, modest, quiet, inexpensive. I’d never seen, or eaten, any of the dishes and were they amazingly good! Steamed fish in banana leaf. Fermented pork with rice steamed in a banana leaf. Shan noodles with a wild, goopy, soft-tofu sauce.  Steamed chicken feet with a spicy, lime dipping sauce. And more.

The conversation turned to the film we’d seen the day before, Daddy and Papa, about gay men adopting children. A friend of mine who is a gay dad and a documentary film maker used the occasion of their first adoption to explore the issue, complete with footage of Anita Bryant on one of her rants. It stimulated a lively discussion in our class and I was able to correct some misperceptions. No, they are not simply recruiting children for sex.  Yes, the studies so far show no difference in outcomes of child adjustment between gay and straight parents. Gay marriage is too new to be able to speak intelligently about its comparative longevity.  And, no, there is absolutely no increase in homosexuality in the children of gay men as compared to the children of heterosexual couples. And pedophiles share common qualities with adult rapists, not homosexual men.

Hnin Aye slyly inserted that pigeons are the birds with the highest percentage of gay males, a suspect fact.  More fascinating to me than avian homosexuality is the reaction to it:  “Homosexuality in animals is seen as controversial by social conservatives because it asserts the naturalness of homosexuality in humans,” How burdened and constricted, if true.  She also encouraged me to try the chicken feet. I ate one, found it pretty strange nibbling on little fat flavorless fingers, and don’t feel a need to repeat the challenge. I was then told of “Home Chicken”, skinny, flavorsome free-rangers vs. “CP Chicken”. The latter are the huge, bloated, fatty things we buy in the supermarket, named after the CP Corporation, a huge, bloated Thai multinational enterprise with branches throughout Myanmar. I was assured that CP Chicken lacks flavor and is filled with fat, hormones, and antibiotics, which I doubt not. Home Chicken is called Local Chicken in Malawi, and makes for a dry, stringy lunch. I seem to be cooking suppers for myself, mostly, and haven’t bought chicken, eating lean pork, shrimp, and fish. It was fun, the 5 of us in this tiny place feasting for about $3 each. It’s certainly not in the guide books and I would never have found it.

Last night was the wildest sunset ever. The sky was deep orange, with thunderheads and lightening all around. I could see it was pouring rain in the northeast of Yangon. The night before it had poured in the northwest of the city, according to one student who stays there. No real rain in Chinatown, however. I keep waiting to try out my new, larger and sturdier, umbrella.  No rain dances.

We saw a just-ten year old girl who lives 3 hours away,  referred to us from the neurologists.  She is an inpatient at Yangon Children’s Hospital while she is being worked-up. A normal, bright, happy child with good friends who did well in school, 7 months ago she began to withdraw from her friends and family, having auditory and visual hallucinations, fearing others might hurt her, not talking, and withdrawing from school. The neurologists, who have considerable experience, want to rule out Anti-NMDA Receptor Encephalitis but think that she has Childhood-onset Schizophrenia. Never having heard of Anti-NMDA Receptor Encephalitis I read about it, and reviewed Childhood-onset Schizophrenia (of which I recall having treated 2 cases, total) last night and think that she has the former. She was a normal, social kid with no gradual cognitive or social decline or other manifestations suggesting Schizophrenia until, suddenly, it was upon her. The crucial difference is that most NMDA is highly treatable with immunosuppressives whereas Childhood-Onset Schizophrenia is a life-long disease with progressive deterioration. They’ll do a lumbar puncture, get antibodies, and make a decision. I’ll push them for a trial, at least, of immunosuppressives. The stuff I am learning!

On a cheerier note, two students started play therapy with the girl who’d been molested in her pre-school.  They had little confidence or idea of what they were doing, despite my teaching. To learn to do therapy all must read about theory and technique but can only learn it by supervised doing. Anyway, I quietly observed, as did other members of the class.  It seemed awkward to me since I am accustomed to being alone in a quiet room with a child, but the girl was focused on her play and seemed oblivious to us.  She developed play themes of attack and defense, of drowning and being rescued, of being rewarded and admired, and of running away and being found, always engaged with the therapist. Afterwards, the class gathered around and we tried to make sense of it. Of course, since we were just beginning to see her, we could mostly observe and note, try to help the two students conducting the therapy to not interfere or moralize—-“You shouldn’t punch him. He just rescued you from drowning.”—and remind them of their role(s) as containers of her feelings. We’ll see where it goes but I am excited to get them started at last.  I’ll videotape the sessions so we can review them as a group.

I met an Australian, Harry Minas, a Psychiatrist in Public Health at the University of Melbourne, who is consulting with Dr. Tin Oo and others as they develop a National Mental Health Policy for Myanmar.  It is thrilling and I have been assured that Child and Adolescent Mental Health is included. I can’t really advocate to be on the committee, although it would make sense to have a Child and Adolescent Psychiatrist on it. I was told that they’ll be writing a Curriculum for a year-long Child and Adolescent Psychiatry Diploma course, equivalent to a US Child and Adolescent Fellowship, which they want me to edit. I’m tempted to teach part of it but I also want to create my life in Maine so perhaps I can do a couple of months here. In any case, Harry is a terrific and interesting guy who will help them and who I wish lived here. He’d be a fun friend.

How ironic that I should be preparing my lectures on ADHD for the class and I demonstrate, to myself, a perfect example of it! I went shopping this morning for enough meat/fish and vegetables to feed me for several days. I bought from various street vendors on Maha Bandoula and 18^th streets. The entire operation, from leaving my apartment to returning took less than 30 minutes and I now have enough pork, prawns, and fish to last a week, as well as a variety of fresh vegetables. As I was soaking the veges in a bit of bleach for 5 minutes, I prepared the protein to store, trimming the pork, splitting it into smaller portions, and freezing it.

Then I realized the fish wasn’t cleaned. Nor was it scaled. So I set to work, feverishly, scales the size of dimes flying all over the kitchen, in my hair, on the floor, amongst the condiment jars. At some point I realized this wasn’t the smartest way to do it but forged ahead. The long and short is it took about an hour to gut and scale the fish and then clean up the mess. I could have done it in the sink with minimal scatter in 10 minutes. That’s why there is a fish cleaning station on the beach at the Skeleton Coast in Namibia, a concrete trough with fresh water, far from floors and counters and dishtowels. Talk about impulsivity and a failure of executive function.

I am disciplined enough that I can force myself to focus and work creatively. A patient I saw for several years came in with a new haircut one day. When I didn’t comment, being hyperfocussed on what she was saying, she accurately stated, “You wouldn’t notice if I came in wearing a burka.” Alternately scattered and hyperfocussed, often very inefficient and having to re-do things, I work much harder than I need to. In the past when I’ve wondered idly if I had ADHD, it seemed like an excuse I was giving myself and I dismissed it. I think it is part of why I enjoyed my psychotherapy practice so much; the work welcomed my hyperfocus and I enjoyed not going in seven directions at once. As if my handwriting wasn’t enough of a tipoff. I was the only kid in 2^nd grade whose handwriting was so bad that I had to copy a page from a Shakespeare synopsis every night as we learned cursive. It still is nearly illegible. Just imagine, with a little Ritalin I might have been a contender. Ha, ha. Is that from Requiem for a Heavyweight?

Good god! Today provides the second of two incredible downpours in two days. Most impressive is the lightening and thunder; the latter is almost simultaneous with the former, indicating proximity.  So close, the thunder sounds like a howitzer shot, crisp, cracking, and fearsomely loud. Makes a penthouse dweller wonder why he hadn’t snugged up on a lower floor in the middle of the building. I am a bit reassured by taller buildings some blocks away, often with metal structures on top, so I will just unplug all my electronics and hope for the best. Kit Cowperthwaite, who lived in Denver and was a few years my senior, was hiking with his girlfriend on a summer day in the Rockies when an afternoon electrical storm hit, blasting him out of this world. I also recall a tale of a hiker sheltering in the stone hut on top of Mount Whitney during a storm when a lightning bolt hit the hut, throwing him across the room.  Like being on a sailboat in mid-ocean, I am respectful—sometimes terrified—of Nature’s dispassionate, unselective fury.

It does recall my terror at my mother’s loud dark moods when I was a young child; I suspect it felt just as dangerous as the lightening. Surely a good Shan couq  swe—their equivalent of matzoh ball or chicken noodle— soup would calm the troubled spirits.

19 May 2019

[Above photo:  “Call me an electrician!” “You’re an electrician.” ]

I’d forgotten how lovely it is to awaken and open the front door and kitchen windows and have a cool breeze waft through. It’s 5:45AM and 82F and I feel human again. The temperatures, even without rain, are heading into the low 90’s and high 80’s for the next 10 days, a dramatic change.. I’m not sure how it works, as the rains haven’t really started, but I love it. 82F feels positively cool! I’ll begin to plan some weekend trips. That has been a spell of hot weather.

I’m hitting my stride in teaching here. I have knocked myself out preparing a zillion lectures, etc. but now that I’ve modified the schedule to a more reasonable pace, I can see some light, not feel like a beast of burden, and begin to smell the flowers. Like Linda looked at Mile 24 of the NY Marathon.

I studied Burmese in bits and pieces every day last week and come lesson-time, it showed. I’ll never be fluent but I can make my way around handily. The lack of cognates makes it so much more difficult.  Trying to learn sounds unmoored by the familiar is interesting. I wouldn’t have thought my old brain could do it but immaturity has its benefits!

It was interesting, as I prepared the lesson on Learning Disabilities, to read the relevant chapter in the textbook. It must have been written by speech pathologists, linguists, or learning specialists of some sort. Finally learning about semantics, phonemes, transparency, symbol registers, decoding, orthographies, etc. and comparing them across cultures reminded me how miraculous an animal we are, able to develop so many highly varied, comprehensive, and sophisticated ways of symbolic communication. Our alphabet has 26 abstract characters. The Chinese have thousands of tiny pictures. Writing goes right to left, left to right, top to bottom and bottom to top. Some ancient Greeks wrote in a zig-zag fashion as if plowing a field. Some Egyptian hieroglyphics were written in any direction—you could only tell where to start reading by studying the animals, which were looking to the beginning.

I once saw a fireman who was very bright but illiterate. He was up for promotion but had to take a written exam and was in a state because he couldn’t think of a work-around. Compound illiteracy with poverty and lack of educational opportunity. The difficulty of it, let alone the shame and embarrassment, is staggering in this world.

It has been amazing to see how children shape up when their parents, and grandparents, stop hitting them. It is such common practice here and some children just hunker down, take it, and avoid their elders’ ire, I guess. Others identify with the aggressor and pass on the lesson, creating a very difficult path in life for themselves and those around them. Parents do seem to get it that their children learn all too well from them how to solve problems. When the hitting stops, the children are so much happier. The students love it that such a simple and obvious suggestion can turn an assaultive child around, no pill indicated or required.

I’ve been excited about getting the Strengths and Difficulties Questionnaire (SDQ) officially certified in Burmese. It is used by WHO worldwide and is certified in 60 languages. The process was started about a year ago and then dropped. The author, Robert Goodman, in London said they were stopping the project because of lack of follow-through here. Jim Harris, a professor at Hopkins who has been involved in Myanmar, pleaded to keep it on life support. I kept everyone informed as I sought  two people to do the back-translation. I had my students do it but then learned that the translators must have British English as their mother tongue. The British Embassy was less than helpful. The American Embassy folks didn’t know anyone. Save the Children didn’t. All the Brits I’ve encountered here shook their heads. Finally, a substitute teacher at International School Yangon volunteered to do one. While she worked on it I was referred by a new friend to a Professor of Linguistics and Burmese at University of London. Success felt within sight! I submitted the first back-translation and had the door slammed in my face. It wasn’t up to their standards; they were no longer going to consider a Burmese version, Linguistics Professor be damned. Burmese children be damned. Infuriating. I realized that 1) I had entered a process that was nearly moribund from neglect and, 2) the SDQ people were being ridiculous or got up on the wrong side of the bed or weren’t getting along with their intimates or something. I’ll continue to try to get two high quality back-translations and perhaps maneuver to have an NGO like UNICEF submit it. It was a disappointment—still is—as I’d been anticipating its use to survey the mental health needs of children throughout the country. There are other solutions, of course, so I must let go of that bone.

Today shall be a day of great productivity! It’s only 6:50AM and I’ve almost finished a draft of this. Two lectures to prepare, Encopresis and another topic as yet undetermined. The roster of readings for the journal club. Study a bit of Burmese. Read more of The Couple’s Guide To Thriving With ADHD and Opening Up By Writing It Down. Supper at Jing Hpay Myay Kachin with my friend, Ruth, a schoolteacher. Buy some mangoes for breakfast on the way home. Call my sister-in-law, Pat, and nephews, Keith and Gordon. Fall into bed, ready for next week. Oh, do my little weight routine.

I did get my haircut yesterday, which was a treat as I had gotten shaggy. I also did a bunch of grocery shopping, buying all the shrimp this guy had for about $4—probably    1½ kg. I froze some but had a luscious stir fry of shrimp, garlic, onions, and fermented black bean sauce with a side of steamed asparagus and garlic scapes in a vinaigrette.  I finished the meal with some of the local lichee, a variety now in season. They are bigger than regular tan lichee, which we also had in Malawi. They are rosy-hued and covered with bumps, easy to peel, and impossibly juicy. Beats going out. Still, I miss Linda’s cooking a lot, especially the breads and pasta—well, how she makes a great meal out of nothing, air and grass clippings.

We should stop giving DT any media coverage. No photos, no videos. Simply note policy statements. Ignore all his outrageousness and refrain from all the public speculation it provokes. Again, as with his election, the press gives him limitless free publicity, no matter that it is negative. Our public outrage fuels him and his base base. It does nothing to improve anything. We have gotten hooked on it, cringing at his provocations and enjoying our outrage.  Cynically, it sells papers/TV ads, etc. It isn’t newsworthy and plays directly into his hands. Put him on page 8, if you must.

12 May 2019

Above photo: Cute teenage girls enjoying a fruit smoothie and a selfie at City Mall St. John.

This has not been my favorite week here. The mid-term exam went smoothly, most of the students did well, and everyone learned something, myself included. Like the double meaning of grasp—I used it as “to understand” but one of the students understood it literally “to take ahold of”. I had a couple of questionable questions. Is putting a large, violent, intellectually disabled man with autism on 7 medications an example of “wishful thinking” or “polypharmacy”? Both. Admittedly, it was a pretty simple question, but I was making a point. Some of the students’ mistakes derived from losses in translation. Several of the students are caring for young children, so when the electricity went off the night before the exam they had to sit up most of the night and fan the little ones, who couldn’t sleep in the heat. Overall, however, they are beginning to understand Child and Adolescent Psychiatry.

We saw a 14yo girl who had a difficult birth, leaving her with Intellectual Disability. Four years ago she began to have complex partial seizures. A year ago she was switched from carbamazepine (an anticonvulsant), because it was no longer controlling her seizures, to topiramate. Shortly thereafter she began to have disruptive behaviors, auditory hallucinations, and paranoid delusions, although her seizures were controlled. She was then put on two antipsychotics at high dose, gained a lot of weight, and is somnolent. She doesn’t have language although she is bowel- and bladder-trained. Somewhere along the way a CT was done which demonstrated bilateral calcifications in her basal ganglia, her cerebral cortex, and her cerebellum. A presumptive diagnosis of Fahr Disease was made. Fahr Disease, epilepsy, and topiramate have each been associated with psychosis. And she is in the right demographic for the beginnings of schizophrenia. A perfect opportunity for us to use our critical thinking skills, which I have been drilling into the students. We’ll try to get her on a single antipsychotic and have the neurologists switch the topiramate to another anticonvulsant. I’d certainly never heard of Fahr Disease.

On the following day we saw another girl, a 6yo, who was developing normally with her motor, social, and language milestones up to 24 months. She then gradually lost speech and the use of her lower limbs and developed persistent stereotypical (not purposeful) movements of her upper extremities. She was a cutie and appeared to relate somewhat but clearly was very compromised. Her skull circumference was below normal, as is common with Rett Syndrome. Rett used to be considered a subtype of autism but 4 years ago its genetic origins were discovered. It was one of those rarities I read about in my Child Fellowship but then forgot, never having seen a case. This sort of thing happens in developing countries, where the most severely ill come to your office. In the US, they’d be seen at a child development center in a medical school. [On re-reading this, I realize we are in a child development center at a medical school and I’m the professor!] She’ll have a shortened life span, marked by disease progression and a massive burden on her parents. She’s getting kind care and is involved in physical therapy. We’ll monitor her every few months, helping the mother to manage her complications as they arise.

I took the students to lunch at Shan Yoe Yar, a lovely traditional restaurant, to celebrate seeing the exam in their rearview mirror. The Shan food was so good—-a soccer-ball sized meringue, browned on the outside, filled with a mix of seafoods and vegetables, yummy spicy shredded beef with intense garlic sauce, and two types of fish. One had a tamarind sauce and was heavenly. The waiter took lots of photos with our phones, as the students always love to do. Maybe the historic uncertainty of life here, with poverty, infectious diseases, natural disasters [Cyclone Nargis in 2008 killed 138,000 people!], and capricious military oppression, encourages making permanent records of good times.

Toward the end of journal club on Thursday, my nose began to run like a hose. I’ve had a sore throat, as well, for four days and feel yucky so I sit in my aerie and work, read, or watch the circus in Washington, DC. I have a huge smart tv with fast internet and cable service so I can immerse myself in electronic media all too easily. Especially the YouTube segments with Colbert, Trevor Noah, Seth Meyers, John Oliver and all the CNN talking heads. I was sneezing and dripping so much that I cancelled my language lesson, as well as supper with a friend. I feel passive and unproductive, having watched so much TV.  Seeing all the maneuvering of the various factions in our capitol is like intense foreplay but with no actual delivery of the goods. I just don’t want us to look back and have taken a major misstep so that this destructive bigot gets elected for 4 more. The temptation is to react to his repeated provocations but then it, also, isn’t smart to let them simply wash over us. I trust Nancy to lead us—smart, tough, principled, and with years of experience. We cannot count on the ‘Pubs to defect, so long have they been in bed with him now, all damp from his near-constant golden showers, this man for whom incontinence is a fetish.

I vow today not to turn on the TV for 24 hours. One day at a time. Cold turkey is my way. A simple decision—-“No”.

I summoned Beethoven String Quartets this morning to lift me out of my pixel-induced sludge of mind. As soon as one began, I felt cleaner and more alert. Not narcotized, like some music can do.  I have had the immense pleasure of hearing a lot of live classical chamber music in my life, especially when I lived in Boston and NY, but in Berkeley, Aspen, Marlboro, Tanglewood, and Bar Harbor, as well, and each time it feels like a small miracle.

Here’s the additional piece, after my cold and watching too much TV, that has me unsettled. I encountered three small young boys in my building when I came home Thursday from work. They were riding the elevator up and down. Two were dressed in monk’s robes. They got off the elevator and begged for money.  When I refused, they begged for one of the mangos I was carrying.

I recognized one of the boys, who had harassed me a month ago on the street. I gave him a bit of money as one does to monks, but he wanted much more money and refused to leave an ATM enclosure where I was attempting to withdraw some kyat for the week. He followed me up the street, under my feet, demanding. I am certain that he has been physically abused, as he was fearlessly provoking me to do the same, which I resisted, of course. Children from awful home situations are often put into monasteries for care.

When I got onto the elevator on Thursday, one of the other boys held the call button so I couldn’t close the door. My blood was boiling but I restrained myself, using my foot to firmly pry him away from the button. Ten minutes later, putting away my groceries, my doorbell rang several times, clearly them. I didn’t answer. At 9 that night the doorbell rang again; it was a man with his wife and daughter, a tenant in the building, saying, “Keep the [main front] gate locked.”, referring to the boys who he had also encountered. He was visiting all the apartments in the building.

Talking with three young doctors about a project the next morning, one suggested that they were not monks. Street children will often get an old monks’ robe to legitimize their begging. Moreover, they said that burglars often use street children to case a target.

It isn’t a big deal, really. I am [relatively] rich, marked in a big city with a lot of poverty, and I’ve lived in high-crime cities in the US and Malawi.  It’s just that the balloon of unreality with which I had surrounded myself suddenly popped and I must take notice.  Also, that the repetition compulsion and the power of projective identification in a child is so powerful that I’d have to make a firm, conscious decision not to whack an 8yo hard, that he could arouse such strong feelings in me which run so counter to all I teach and believe, leaves me a little breathless.  In touch with my humanness, I guess.

On Monday I’ll talk with the landlord to suggest: 1) a gate for my front door like all the other apartments lower in the building; 2) that he tell all the tenants, officially, that we are to keep the front gate locked.