Two Observations

Two observations on this trip so far:

1) I forgot that fruit on this side of the earth tastes phenomenal.

2) I found myself being less patient with people when faced with misunderstanding. (Haven't i supposed to have become more patient-centered?)

Security during a rushed connection: A laptop in your bag?

Me: No. Is whudder ok?

Him: What?

Me: Whaudder.

Him: (makes a face)

Me: (frustrated) Wa-ter.

I rememberd whose country I was and felt ashamed of my american attitude and accent. I found Aresh and Kyle and we are on last leg of our flights.

India After Ten Years

Dearest IHP,

I am thinking of you today. I think about you a lot, but today I am coming back to India today for the first time (apart from a weeklong wedding rush) since our trip.

Some of you have been back in this part of the world many times and for much longer periods of time, and I haven't even left the airport. Nonetheless, I wanted to share what it has felt like for 10 minutes after 10 years.

I'm on the bus from the international to domestic terminal in Mumbai for my transfer to Kolkata. Airports all look the same minus the language on the signs. This one also happens to have a less sterile smell than Houston or Chicago.

It's dark out, about midnight their time. I forgot that we drive on the left side here. I envision the bumper-to-window-to-wheel-to-arm traffic pulling up to MG road from the high rises in the tech belt in Bangalore everyday. I flash back to an accident Belinda and I had on bus. No one had been hurt, just yelling and broken glass. Flashback to the moped accident with Lindsay in Vietnam where someone had been seriously hurt, to feeling helpless. Could I, would I do more now? I read about central line technique in the ICU book on the plane, would that have helped?

We keep driving and I see construction to our right. It's something that looks like an unfinished terminal serving as a hanger for Jet Airways. Would we have that in the states? Would we have runway workers sleeping under it?

On the same side there is a wall. In front of it are layers of barbed and even thicker ones on top. Behind it, there are corrugated iron roofed houses.

In my head, I start asking questions: how much to people pay to live there? Why not build them apartment buildings? Employ the unemployed to do it. Who could do it better, corporations or the government? Or, do these people want to stay in their homes. I find that hard to imagine, but then think back to the singing women protesting the dam in Kerula.

Do we have an equivalent to this in the US? Probably. Did I ask these kinds of questions on IHP? Probably, but it's been so long I can hardly remember. 

I had a hard time leaving home. I cried when I kissed Olivia and fought with Dave. I worried about my parents and grandparents. I was emotionally labile from exhaustion with the flu. It was harder than I ever remember it being.

It only took a few hours without my phone to start to read more than I have in a while, to start to observe in a different way and to write. 

I am grateful for this experience and for the chance to share it with you and see what you think. What has your experience been like traveling-- those of you who do it for work, Jack, Al? Those who have spent prolonged times here like Volps, KJ?

Love you very much,
Sash

On Call

14 hours in

machines hum

People bustle in coats

on white,

Fewer than before

the shift change.

Gliding, sometimes slipping.

The sensation in our feet

makes us wonder

if we can enjoy what we came here to do,

Which is ski.

To the man with flowers that I met on my way out of the ICU

To the man with flowers that I met on my way out of the ICU:

You came up to me and told me how grateful you were to all of the doctors in this place, for how well they treated you and your wife.

You were holding bright red, maybe pink and yellow flowers with gold ribbon in clear wrap. You had grey hair and a kind smile. I said something like, "That's so wonderful, I am glad you had a good experience," and then looked to my left. 

My attending physician was far enough down the hall to have already looked back and yelled at me with his eyes to hurry up.

I am sorry that I could not stay and talk. Sharing that moment with you made me feel warm, and I want to thank you for that.

For the rest of the day, I endured a lecture on efficiency.

Despite our common intentions, I observe so many contradictions in medicine. Care, but don’t care too much. Follow 11 patients and get enough sleep to make good decisions about their care. Lecture a patient on diabetes, gorge on donuts in the break room, and then roll your eyes at the patient who won’t lose weight.

Three months into my third year of medical school, I am not sure what to make of this. I know that I still want to stop in the hallway and say thank you to the man who tells me about his wife’s care. I know that I one day hope to perfectly manage 11 patients and get enough sleep. I also know that I love sweets and don’t know how to talk to patients about their weight.

I guess this is why I am a still student.

The Things I Carry

We read an excerpt from Tim O'Brien's book The Things They Carried in class the other day. I have powerful memories of reading this book my sophomore year of high school. While we cannot compare medical school to war in any way, we were asked to use this chapter as a model and write about what we carry as third year students. Here is what I carry:

I carry my stethoscope, my reflex hammer and my tuning fork, but sometimes just a book. I carry my id, gum, tums, and chapstick. I carry my tattoo to remind me of the bigger picture and the desire for anther one, but also the knowledge that I will get through without it. I carry my language(s) and the taste of olivier, my mom's bread and my dad's grilled eggplant. I carry what it feels like to be outside in my backyard and the sensation of my grandmother's kiss.

I carry my frustration and anger at stubbornness and the tugging reminder that we are all human.

I carry my breath, sometimes heavier than other times. I carry guilt. I carry a headache. I carry my friends.

Zinzi

Zinzi, The Sangoma in Zwelathemba, South Africa

Photograph taken by Valerie Halls, April 13, 2006.

During my junior year of college, I had the opportunity to study healthcare in India, China, and South Africa. The experience taught me more than I can put into words, but one story has shaped and continues to inform my perspective on medicine.

I met Zinzi on a hot afternoon. We walked to her house through what appeared to be an empty township called Zwelathema, 120 km northeast of Cape Town. It was not empty however. The residents hid indoors out of reach from the unbearable sun.

            The sunlight followed us into Zinzi’s shack through uneven slits in the corrugated iron walls. It cut through the dusty shadows and illuminated the strands of thick white beads that hung around her neck. A faded floral curtain separated the room in which we sat from a slightly larger space that served as her bedroom and her kitchen. The smell reflected the piles of small trinkets, animal hides, twigs, roots, fruits, empty cans, and strings of beads on the walls and in corners.

Zinzi shifted her large body as she scattered and arranged objects on the sheet that covered part of her dirt floor. Her beads clinked as she moved and she grunted as she sat back on a short stool and crossed her legs. She looked us over, 32 American students and four professors, and began to tell her story through a translator about how she became a Sangoma, a traditional Southern African healer.

Zinzi speaks to IHP group, Miriam translates

Aleha Aziz, Belinda Dobson, Derique, Emily Wheelis.

Photograph taken by Valerie Halls, April 13, 2006.

Zinzi was a churchgoer. She fell ill with sores all over her body, and the sickness kept her from going to church. Soon thereafter, her ancestors began to speak to her in her dreams, telling her that her body will heal once she becomes a Sangoma.  At first, she did not listen to them. She did not want to believe that they were real.  One night, she fell asleep in her bed and woke up by a bush far from her home; her ancestors had brought her there. They told her to find a hare on the other side of the mountain, to slaughter it, and to make it into an offering.  She went to the other side of the mountain and was not afraid because she knew that her ancestors would protect her. She knew which hare to capture. She slaughtered it, and she made an offering. 

In a short while, the dreams returned and a few nights later she woke up in a shallow river. Once again, she followed the orders of her ancestors and made an offering to them.

 Then for a third time, her ancestors called on her in her sleep, and she woke up in a cave. After performing the rituals that they called upon, she knew that she had to accept her calling as a Sangoma lest the ancestors become angry.  

She kept a bone and the skin of the first hare that she slaughtered, and she uses them as charms.  She says that these items helped her body to heal, and they help her to heal others. 

Zinzi now heals others.  She does not charge money for her service unless the ailment is healed.  If “the patient” does not get better, she either continues to work with him or she sends him to the “white doctor.”  The medicines that she prescribes come in the form of potions, herbs, recommended foods, and through the performance of healing rituals.  The combination of specific healing methods that she uses depends on the complaint of the individual and on his ancestral background.  In her rituals, Zinzi hears her ancestors with the help of her African beer, and sees the signs that they send in other ceremonial items. She quenches the thirst of her ancestors by making offerings of homemade Brandy.

She performs a form of fortune telling called bone throwing.  Her client takes a pile of her special collected charms in their hands, blows on them, and drops them.  She reads the arrangement into which they fall as insight into the seeker’s past, present, and future.

The Voices of the Ancestors

Zinzi

Photograph taken by Daniel Seeman, April 13, 2006

We sat and listened to Zinzi’s story. We may have interpreted the voices of her ancestors’ as auditory hallucinations, her night adventures as sleepwalking, and the disappearance of her brandy as evaporation, but we understood the importance of her role in her community. She listened to people’s ailments, she gave them faith amidst their troubles, and she served as a liaison between her community and the “white doctor,” who many of her patients would not trust or go see on their own.[1]

I cannot help but think that if she were in another context, Zinzi would be considered mentally ill. Had she disclosed the same story to a psychiatrist, he may have diagnosed her constellation of symptoms as Schizophrenia. [2]

In 1956, Ethnologist and Psychoanalyst George Devereux wrote about a case similar to that of Zinzi’s in his article entitled "Normal and Abnormal: The Key Problem in Psychiatric Anthropology."  He commented on how the behavior of a shaman may appear dissociated and could be interpreted as a sign of schizophrenia.  He asked, “Was the shaman normal or was he instead ‘really’ schizophrenic but merely labeled differently?”[3]  Devereux and another researcher, Julian Silverman, assumed that the experience of a shaman is schizophrenia, but expressed through different cultural symbols and interpreted as normal by the shaman’s community. [4] 

This interpretation did not sit well with my understanding of Zinzi. One of the reasons for diagnosing a mental illness is to treat it. What would be the purpose of diagnosing Zinzi as mentally ill if she were functional in her community? If her “symptoms” bring more purpose than suffering, do we call them a disease?

At a time when the cracks in mental health care in the US are seeping into the public eye, Zinzi’s story reminds us that the way we define and treat mental illness is entrenched in our own history, and that to fix it may mean to take a step back and redefine it.

In a series of longitudinal studies, the World Health Organization found a higher prevalence of schizophrenia and negative symptoms such as social withdrawal and apathy in urban areas of more developed societies.[5] What could we learn from Zinzi’s culture that could help us better accommodate people in our society with similar symptoms?

History reveals that definitions of disease change over time. Cervical carcinoma in situ becomes high grade dysplasia. Homosexuality ceases to be an illness. As science dives deeper into understanding the biological mechanisms behind mental illness, we must not forget to consider the role of the culture that surrounds it.

Trinkets line the Floor
Photograph taken by Valerie Halls, April 13, 2006.

---

   Adapted from senior thesis on global perspectives of mental illness, published in May 2007. This version was originally published in USF MCOM Wellness Bulletin, Vol. 4, No. 2, April 2013. http://health.usf.edu/NR/rdonlyres/B43E3CE8-EECC-4550-BC82-06785DBCE502/0/Bulletinv4n2_Web.pdf

Notes and References:
[1] Apartheid in South Africa fostered an environment of distrust between traditional healers and medical doctors.  The conflict increased in intensity and publicity with the country’s growing epidemic of HIV/AIDS.  Recently, activists and practitioners on both sides have aimed to bridge the gap of trust and understanding.  One Sangoma was quoted in Nature magazine saying, “Both play vital roles in healing the majority of AIDS-afflicted South Africans…ARVs (antiretroviral) are the only medical intervention available to alleviate the physical effects of AIDS. The traditional healer, in addition to using herbs, also works on the spiritual level, which is an essential part of the African healing process that Western medicine does not address.” Zinzi shared this belief.  Under her beads, she wore a white shirt with a red ribbon. She has attended conferences that address the divide between doctors and Sangomas, where she learned the signs to look for in a person with AIDS.

[2]According to the DSM-IV-TR: “Schizophrenia is a disorder that lasts for at least 6 months and includes at least 1 month of active-phase symptoms (i.e., two [or more] of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms).”

Allen Frances, M.D., chairperson.  Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association. (2000), p. 298.

[3] Horacio Fabrega, Jr., “Conceptions of Human Behavioral Breakdowns,” in in What is Schizophrenia?, ed. William F. Flack, Jr., Daniel R. Miller, and Morton Wiener. (New York, NY: Springer-Verlag New York Inc., 1991), 128.

[4] Julian Silverman, “Shamans and Acute Schizophrenia.” American Anthropologist, New Series, Vol. 69, No. 1. (Feb., 1967), pp. 21-31. (Accessed March 16^th, 2007).

 [5] Hopper, Kim. “Interrogating the Meaning of ‘Culture’ in the WHO International Studies of Schizophrenia,” in Schizophrenia, Culture, and Subjectivity: The Edge of Experience, ed Jenkins, Janice Hunter, and Robert John Barrett. Cambridge, UK: Cambridge University Press, 2004.

Baking with Quinoa Flakes

I accidentally ordered 4 boxes of quinoa flakes from Vitacost while studying for my last big exam. 

One can only eat so much quinoa flake for breakfast oatmeal-style, so the chance to make granola bars proved an ideal opportunity to use them. The result was better than I expected.

Here is the recipe:

Banana Raisin Soft Granola Bars

2 cups rolled oats

1 cup quinoa flakes

2 ripe bananas

1/2 cup whole almonds

1/2-3/4 cup raisins

1/2 tbs cinnamon

1/2 tsp ginger powder

1/2 tsp nutmeg

1/4 cup coconut butter (1/8 cup for mixture, 1/8 cup to butter the pan)

2 tbs honey

1 tbs maple syrup

1 tsp vanilla

1 tsp salt

optional: 1/4 cup almond butter (to drizzle on top)

Directions:

1. Preheat oven to 350 deg F.

2. Coat 8x8 pan with coconut butter.

3. Mix the rest of the ingredients together in a bowl.

4. Spoon mixture into pan.

5. Pat firm and dry with your hand.

6. Optional: drizzle almond butter on top.

7. Bake for 20-25 minutes or until edges start to turn golden brown.

8. Flip over onto cookie sheet and let cool.

9. Cut into granola bar slices, serve, or save in the fridge.

10. Enjoy!

A Plug for Fluid Intention in Yoga Class

Now, come back to the intention that you set in the beginning of class.

Shit. How often does that sentence catch you off guard, thinking about that woman across the room who doesn't like you, wondering whether the farmer’s market next door sells fresh eggs, or blowing that tiny ant off of your mat? What was my intention?

In the busy world we create for ourselves, we strive for peace and transformation in our hour-long once-a-week yoga class. Why can’t that transformation take a different form from the one we felt when we looked out into the ocean after a week-long yoga retreat?

My intention had been to focus on my breath and to take that focus into my work that afternoon. I felt disappointed that the awareness of my breath didn’t last longer than the first two minutes of class. Then again, I hadn’t just been thinking about that woman across the room, I had been asking for the compassion to forgive her. I hadn’t just been planning out my breakfast, I had been taking in the smell of grilled cheese or whatever it was wafting across the garden-turned-studio. I hadn’t just been blowing off the ant…ok, maybe I had been.

Just then, as I continued to not focus on my breath but analyze my thought process from that morning, my awareness of my breath came back, deeper than it had been all day. It lasted right up until I started to draft this piece in my head.

Nevertheless, it was a reminder that those thoughts had meaning, that maybe I had to set them free, or dust them off my mat if you will, before I could find my breath underneath.

.

In a world in which our high expectations often leak onto our yoga mat, acceptance of the fluidity of our intention may be a good place to start in that search for breath.

Lives and Knives: Future Doctors of America?

I stumbled upon this 30 second clip by Johns Hopkins medical students today.

It got me wondering-- what does the American public think when they see their future doctors getting down?

     a) I am glad that my doctor had a life when he/she was young.
     b) I would rather not know what my doctors do outside of the office.
     c) Why aren't they studying?

It's not hard to find more of the many medical student videos out there. Some are full of inside jokes, while others display serious talent, like this one.

In full disclosure, I am one of those medical students, part of the Glee club at the University of South Florida Morsani College of Medicine.

So as my good professors have taught me to ask, how do you feel?

My Friend Justin on Living with a Gay Man

“...I may have to come sleep on your couch sometimes.”

“Why? You’re afraid he’s going to hit on you?”

“Well, yea.”

“Justin, you have a girlfriend.”

“I know. It’s just…”

“I’m not afraid my lesbian friends are going to hit on me.”

“Maybe it’s a guy thing.”

“Maybe…”

Maybe it’s not. My guy friends who grew up with gay friends embrace their sexuality, joke about it the way bros joke about pounding a beer. They pound beer together.

So no, it is not a guy thing. Please stop using your gender to excuse ignorance. Thanks.

Flash Mob at Boston's Faneuil Hall for Mike Bhaiya & F. Eastman

February 2011

When I was little, I used to close one eye and look at my nose and wonder if other people could do the same. Today was the first time I did that in a while, while accommodating for the cranial nerve exam.  Nose, I am sorry I have neglected you all of these years. I promise to accommodate more to see you.

TALKING TO THE FAMILY 

- John Stone (1936-2008) -

  

My white coat waits in the corner

like a father.

I will wear it to meet the sister

in her white shoes and organza dress

in the live of winter,

the milkless husband

holding the baby.

I will tell them.

They will put it together

and take it apart.

Their voices will buzz.

The cut ends of their nerves

will curl.

I will take off the coat,

drive home,

and replace the light bulb in the hall.

Ode to the Red Moleskine

I found this unpublished draft from February 2011. Love it :)

I just saw a tall, lanky intellectual type on the #1 bus with a red moleskine. I smiled because I thought about the symbolism that Lauren, Amy, Lindsay and I created around the book. This will be the year of the red moleskine, the year of adventure, love, and passion. We got the passion right, but it came in a completely different form than we probably expected.

This has been, and still is, a year of transition for us. Whether in love or career, school or family, there have been a lot of unknowns. Some have been scary and some have led to transformation.

What this has been is a year of support for one another, and for this I am so grateful. We don't need to all have the same journal to be there for each other, but it doesn't hurt :). I love you guys!

If she had seen that sunset, she would have wondered how the world would end.

Meeting Dave

He wiped the salt water off my skin with his shirt.

Laughter floated above the hurt,

The deeper and the shallow into which I leapt

To impress a boy, or so he says.

My first attempt at poetry since eighth grade

Bumps over slush

Hard seat bumps over Mass Ave on the way to hear.
Before and after misty drizzle.
Soft steps through slush
in waterproof boots with enough wet between 

my toes to make me shiver.

Deep cinnamon touch to my coffee reminds me of the slush,
The yellow bumps, the mist,

But not the talk.

Silence and thoughts in a snow storm

On a night like tonight, the steady silence of the snow only occasionally gives way to the sound of slush under the tires. I pass by the intermittent buzzing of power lines, hear a siren in the distance, and feel a gust of wind against my face as I turn corners.

The concept of experiencing something fully comes to mind and for a moment it feels like my entire brain is taking part in seeing the snow on the black backdrop. Quietly, my mind starts to tip-toe around on its tiny feet, weaving and creating.

Roshni told me that she can’t imagine not believing in god. Isn’t god a concept created by those wandering little feet of our minds? As a concept, it is useful when things do not make sense, but it makes more sense to me to try to understand what doesn’t make sense rather than to cover it with a blanket. Sometimes we need a blanket. Roshni also told a story about how her friend’s sister calls her friend at very timely moments in her life after she has dreams about her. Is coincidence and fate the same thing by a different name?

Slush, wet boots, gusts of wind against my cheeks, power lines, darkness and quiet. I walk towards a police car, no two, blocking a small dead end street off of High St. At the end of it, a tree has fallen over power lines and onto a car, probably breaking the roof. Neighbors stand around. Only one house does not have power; the one with the broken car.

I feel myself breathing faster. I notice the sound of my sleeves swish-swashing back and forth against my body. Where did that silence go? If feels like it never existed even though I know it is there. I realize I have been holding my breath. I am scared that I won’t be able to write this down when I get home. I take out my phone and record myself, pausing often. When I listen, I hear myself sniffling in the cold.

It amazes me how physical stress can feel, how it can change what we sense in the world around us. What was stress before we had a word for it?

I felt happy leaving work, like everything was right-- I had finished what I had to do, I discovered twitter, weekend plans were falling into place. But the happiness seemed superficial, it lacked the act of experiencing. I saw the snow, I heard the silence and the cars and my footsteps. Maybe creativity comes in the absence of worry.

Lauren got me a red moleskin. Or rather, I finally got the red moleskin that Lauren bought me for my birthday in July. Assuming that the book has symbolic significance of self-realization and carpe-diem, I could say that maybe it wasn't meant to be until now. I nearly finished the last of my favorite Tibetan journals last week and then spilled tea on it, so it seems like it's time. College was the era of recycled paper journals from B&N, half page notebooks, and IHP journals. After college was the time of the little Tibetan books, and now may be the time of the moleskin? We'll see how it goes.

Zoe and I had a great talk about "imaginal worlds" last night. It's something that her myth and magic professor from Brown has taught her about, and reminds me of Greenfeld's idea of culture. Maybe culture is a web of shared imaginal worlds? Does culture shape how we act or is it just a manifestation of our emotions that would happen regardless of culture? Someone can be angry at their mom, at injustice, or at a shitty driver, but it's all still anger. I'd assume that the physiological processes in the body and the brain are the same. However, culture and traditions do affect what you do with that anger. Some people might be raised to react, others to suppress, and others to channel. See this article called Culture and the brain in the Tufts Alumni magazine for a summery of some the research that's done on this. I also highly recommend an article in the New York Times Magazine called The Americanization of Mental Illness. It offers some interesting ways of looking at how experience and the processing of emotional stimuli can vary depending on culture.

Enough of this for now. Day 1 of feeling more fulfilled at work is going well, good practical goals and good mindset. Thanks :)

I'm going to try to do this-- to keep a blog. I can't promise anything, but I'll try my best to post observations and descriptions of my time here in Chile. So far, I'm still a little sleepy, so my perception isn't as sharp as it could be.

While driving the 17 km from the airport, I smiled at the sight of cows and was reminded of IHP when I saw slums partially hidden behind a poster reading the words, "Estamos construyendo Mombacho Urbano limpio." Quien lo esta construyendo?

I imagined that the city might actually be working with residents to improve the condition of their neighborhood, but I couldn't help but be skeptical because of the reputation of similar "city beautification" projects in other cities.

As we drew closer to the city, I was awed by the mountains that tower over it in nearly every direction like watchful guardians. Under their gaze, the streets fill with an orderly bustle. I find it less chaotic than what I remember of Buenos Aires, but then again, this is day one and I've seen maybe 1 1/2 streets total.

Our neighborhood is actually rather fabulous-- wide streets lined with tall trees. Amy met me with a wide smile and endless delightful conversation since then. We made our way to Oh! Salad for lunch, past the fresh flower stands and hippie-jewelry dealers on the sidewalk.

Amy is off to a meeting this afternoon, giving me a chance to check in with email and to acclimatize. My plan is to buy some groceries (and flowers), make dinner, and then catch up with Amy over a bottle wine before starting our work tomorrow.

I feel comfortable here, excited about actually interacting with the city and with people, and for getting to know the country. And from here I move onward…