Sunday, February 1, 2015

Chiang Mai part 2, by IM Resident Joe Messana on International Rotation in Chiang Mai, Thailand

Greetings again from Chiang Mai

Kristina and I continue to soak in as many experiences as possible.  We met up with Becky Weldon, one of Dr. Walker’s childhood friends from Thailand.  She works in museum studies and has an incredible breadth of knowledge regarding the political and cultural history of the Thai people and surrounding cultures.  We went to dinner with her on Neimmenhamen Road, the hip part of town.  Later in the week we toured two different wats [temples] in the Old City: Wat Chedi Luang and Wat Pra Singh.  Becky has such insightful social commentary and descriptions of the significance of different Buddhist architecture; it was an incredible tour of the temples.  She also provided us with a book describing the history of Laos as it intersects with her family, written by her father, Dr. Charles Weldon called Tragedy in Paradise.  Kristina read it first and I’m in the midst of it.  There is such an incredible depth and social complexity/history to the area, that it is hard to fully grasp it.
            Through our travels we’ve been introduced to a philosophy in Thailand called jai yen, meaning “cool heart,”  suggesting to maintain composure and staying cool despite the situation.  This is one of the 4 brahma-viharas or heavenly abodes of Buddhism, namely equanimity (upekkha).  The others being sympathetic joy (mudita), loving kindness (metta), and compassion (karuna).  Another important phrase is kreng jai, to be considerate or not impose oneself on another person in a negative way.  I outlined these concepts in my observations in my last summary, and now they have been crystallized into concepts with these phrases.  Trying to further instill these principles will not only allow for further assimilation, but also be healthy and help cultivate the middle way.
            There is also a striking difference I observed in the hospital that is a departure from that which is found in the US.  I’ve also experienced this in India, and that is the outstanding amount of deference for physicians from patients.  Patients seem to be very much appreciative of the care they receive, and often bring gifts to the attending in clinic. 
            We continue to experience the city and go on excursions in the weekend.  We went to the night market east of the old city to watch a show of Lady boys.  This is a term for either a transgender woman or an effeminate gay male in Thailand.  They identify with either the opposite gender, or sometimes a third gender.  Lady boys are not restricted to urban areas, but are also seen in rural settings.  While lady boys, or kathoeys, are more accepted in Thailand, and there are hospitals devoted to sex reassignment surgeries, there are still a sea of social obstacles and issues that surround them.  Kristina and I made it a point to see their show in the night market, and it was extremely fun.
              The next day Kristina and I went on a 6km hike up Doi Suthep, and saw two waats along the way; Wat Pra Laat, and Wat Pra That Doi Suthep, which were incredible sites to see.  Wat Pra Laat is nested along a flat brook on the way to the top of the mountain where the latter wat is situated.  We continued our 3-4 hour hike up the mountain and finally made it to the destination.  Here, we toured the grounds, saw the outlook that oversees the city of Chiang Mai below, and circumnavigated the main reliquary three times clockwise.  This reliquary is encased in gold plating and shimmered in the evening sun.  At 5pm, the monks performed a chant outside it and then proceeded inside the temple to continue their chanting.  It was a blessing to watch.  

Sawatdee krup, by IM Resident Joe Messana on International Rotation in Chiang Mai, Thailand

Sawatdee krup from Chiang Mai!  _/|\_  (::looking like folded hands::)


Traveling half way across the world has been such a blur, particularly since I am just finishing up UICU.  It took about three days for the reality of this opportunity to sink in.  I am so fortunate to be able to have two months in which I can experience Thailand both from a medical and cultural perspective.  Upon disembarking the plane, the pervasive kindness, patience, and helpfulness of the Thai were apparent.  It is always interesting to me how different the general tone of a population is upon arriving in a country.  They are more than willing to offer assistance for whatever question or request.  There is an overwhelming degree of politeness in every conversation.  Sometimes it feels as if there is a song of “khaaAAaa” and “kruuupppp” [a polite way of ending sentences depending on gender] that rings through the city streets.  People are generally very soft spoken, perhaps not to create offensive loud noises that would invade someone else’s space.  Sometimes conversation is not louder than the level of a soft whisper.  Even if you make a loud noise by banging into something or moving a chair loudly causing a screech, one may apologize.  The pace of life is also measured.  It is rare to see someone running.  This doesn’t apply to the speed of motorcycles, tuk-tuks (like Indian autorikshas), and cars of course, but they still are considerate and will stop for crossing pedestrians.  You actually have to weave in and out of traffic to cross the street in most cases. 
            It is difficult for me to feel one step removed based on the language barrier.  In my past travels to India, Latin America, and Spain, I’ve been able to use my language skills and interact more personally.  Thankfully, people’s English skills are typically more than adequate, and they are as I mentioned extremely patient to entertain the nit-noy amount of Thai I’ve accumulated.  Thai, being tonal, is more challenging, but Kristina and I are doing our best to navigate the musical language.
            Maharaj Hospital, where we are working, is a towering series of bright white buildings just down the road from our housing accommodations.  Walking to work in the morning you find a steady train of students and residents in their pearl white ward shirts with green Thai writing over their pockets, and nurses in their traditional caps.  Street vendors are beginning to set up their stalls and preparing various types of meat from pork to chicken on portable skewer sticks.  In the hospital, Kristina and I have been rotating on the infectious disease consultation service and seeing very compelling cases (a handful of which will be deidentified and shared upon our return).  There are afternoon rounds daily, weekly journal club, and several morning outpatient clinics we attend.  Rounding includes an interesting exchange in which our experience in certain cases is shared with theirs, thus there is ongoing team-learning. 

For our first weekend’s excursions, Kristina and I sampled three different local markets.  The “old city” of Chiang Mai is a square mile surrounded by a moat with scenic periodic trees.  The moat was used for the city’s protection in times past, but now the surrounding roads are a major transit area and serve as a great daily running route!  There are 4 gates at each of the cardinal directions.  We visited the south gate market on Friday where we met Sansanee’s brother, followed by the north gate market on Saturday.  On Sunday there is a weekly tradition of a “walking street market” that is an extensive strip of tables selling crafts, paintings, foods, clothes, jewelry, lanterns, etc.  It’s full of “phalangs” or foreigners, and sometimes gets so busy the foot traffic comes to a complete stop on the street. 

We continue to appreciate and savor the experiences we are having and are looking forward to the following weeks! 

Mambo, by Med/Peds Resident Ryan Fabrizius on International Rotation in Arusha, Tanzania

Jambo from Arusha, Tanzania. I hope this update finds you all well, I appreciate all of your responses, thoughts, and prayers. This week has flown by and I have been blessed that it has been filled with great experiences, coworkers, and friends. I am becoming more accustomed to work at Selian Hospital, and continue to learn new things everyday.

This week I have been reflecting on community. As many of you have experienced, there is nothing quite like finding yourself in another culture to make you aware of your own. Though my experience of culture here in Tanzania is doubtlessly affected by my obvious "foreignness", I have been finding the community here particularly enchanting. It has been explained to me that Tanzania is made up of over 120 different tribes, each with their own history, beliefs, and sometimes language. This is thought to be a really positive for Tanzania, since there is no one tribe that can dominate the others, as has been the unfortunate reality of many other African nations. It seems, from my naive perspective, that several tribes have maintained their way of life in a way that is so obviously different from the typical city dwelling Tanzanian. An example of this is the well known Masaai tribe, prominently donning their red and blue patterned scarves, beaded ear adornments, and patterned scarification on their cheeks. As a pastoral people, they are often seen tending to large herds of cows and goats, even in relatively urban areas around Selian hospital. It is a regular occurrence for us to run into a traffic jam of livestock being tended by a young Masaai herdsman. This contrasts to some of the other urbanized Arusha residents, many from other tribes like Chaga, who have taken to city life, working as shop keepers, taxi drivers, and other urban jobs.

One particularly fascinating aspect of life here that I have seen in my limited exposure, is how these different groups interact with each other and with ousiders, like myself. A prominent display of these daily interactions occur in the greeting of one another. Each day, myself and Hope, take our scenic walk to Selian hospital and are pleasantly barraged with endless greetings. The most common greeting is "mambo", which is a sort of slang term, much like "what's up?". To this greeting, we have been learning new responses in unlimited combinations. So far, we have learned "poa" (cool), "safi" (clean), "mzuri" (good), "mcima" (well), "fresh" (fresh?), and my favorite "poa kuchezi cama ndezi indana ya fridji" (cool like a banana in the refridgerator). There is also "habari" (what's the news?) and shikamoo (I respect you), which are more formal. Then there are the many school children eager to use their English phrases, like "good morning teacher" and "how are you?". Though I can barely scratch the surface to communicate in Swahili, I can sense the rich feeling of community in people greeting each other. When I watch others great one another, it is almost never a short interaction. Honestly, I have no idea what is being communicated, but I can sense the sharing of their interwined lives. They stop to share a cup of chai, to rest in the shade, to carry their produce from the field together. 

In the hospital, I have seen how families rally to collect money for medicines and to search the countless "dawas" (small pharmacies) for the right medicines. I have seen how patients in neighboring beds support each other, like when a Masaai family cannot speak Swahili well and the neighbor will help fill in the details of whether they have received their medicines as ordered or have been taking the recommended refeeding formula. I have seen how the local doctors here will often buy necessary supplies with their own money, such as Oral Rehydration Solution, extra food, and even clothing for their patients. There is a sense of cooperation and support for one another that extends beyond family, tribe, and language. The people here have been gracious to greet us everyday, but I see that below this surface greeting there is such a richness of community here that amazes me. It challenges me to consider how I relate to others and how we as Americans (or whichever subgroup we find ourselves in) can look beyond ourselves to build stronger community with one another.

Wednesday, January 28, 2015

Jai yen yen, by Med/Peds Resident Kristina Krohn during International Rotation in Chiang Mai, Thailand

Doctors Kristina Krohn, Joe Messana, SaNat Chowsilpa and Pattraporn Tajareunmuang

The Thai ideals of sanuk (fun loving) and jai yen yen (cool hearted, or staying calm) pervade my everyday hospital experience. I find my days in Thailand are fully filled, and yet somehow, nothing seems rushed.

Fern and Jack, our two current residents, are both quick to laugh and smile. Fern's face breaks into a big grin most mornings when she sees us, "falang!, falang!" (foreigner!, foreigner!), she calls , "breakfast!" and beckons for us to follow. 

She and Jack giggle as Joe and I try out our new Thai words over fried rice and Thai tea, always encouraging as we learn names for foods, numbers, and important words like "yummy" (arroy). I think this is the essence of sanuk. Even though they have patients to see before rounds, they take the time to eat and entertain the foreigners.
Joe Messana
After breakfast some mornings we have Infectious Disease Clinic, where we see many people living with HIV, overcoming tuberculosis, beating melioidosis, or slowly succumbing to a wide range of infections from AML after a failed bone marrow transplant. Each individual is handled gracefully by Dr. Romanee, who keeps her voice at such a low calm level that sitting next to her, I barely hear her.  But the patients always seem to.

Jai yen yen.

In the afternoon we round, Jack and Fern are forced to present in English because Joe and I are here. Actually, the residents frequently present in English on infectious disease rounds anyway, so that they get some practice with English for future overseas conferences. 

Never does rounding seem rushed, jai yen yen, as each patient is seen in turn in a mix of Thai and English. And rounding is always accompanied by its fair share of laughter, sanuk.  

I hope to keep jai yen and sanuk when I return to Minnesota. 

Woman selling street food in Chiang Mai

Oli Otya, by IM Resident Matt Goers on International Rotation in Mbarara, Uganda

Oli Otya from Mbarara, Uganda! I just arrived last week and it’s been a whirlwind ever since (in a good way!). I landed late last Sunday in Kampala and woke up just as early to get started at the IOM Medical Offices. It was a bit surreal, seeing the other half of the screening exams and testing. (We always see the reports from these screens during new arrival screens at CIH). But that was only to prepare us for the road trip, and just as I was getting settled in Kampala, I was whisked away to Mbarara to start working at the camps. So far it’s been just as hectic and crazy (we’re planning on screening over 500 people!), but honestly it’s been a blast.  I couldn’t ask for a better group of people to work with.

I’m trying to keep a journal during my time in Uganda, and I’ve had a couple things on my mind ever since I arrived. One thing that I always think about as I travel is how to be a good guest. As many times as you travel or visit a country, sometimes you just feel like a tourist. You don’t fully understand how things work, where things are, or who to talk to. We have to sometimes ask what's going on to catch the cultural context and richness of a situation; but that can be difficult because it takes a level of humility and delicacy if you want to avoid seeming ignorant, rude or disrespectful.

What's more, it's always hard to transition from the U.S. to less resourced countries. Sure, the changes in the setting and personal accommodations always push you out of your comfort zone, but what’s really striking is the changes in medical resources. There’s always a change in mindset that comes with treating and working up a condition that you know will be difficult to manage in that setting. There are plenty of conditions that cannot be properly diagnosed, but one issue I’ve run across a few times is the diagnosis of Hepatitis B. IOM screens refugees for Hepatitis B prior to their departure (mainly for vaccination purposes), but if patients are positive, it’s rarely possible to initiate treatment right then and there. This is frustrating because it just doesn't sync with our view of medicine in the U.S., and while I doubt my colleagues here feel any different, their mindset has to shift to relocation in order to get these patients the treatment they need.

Another issue I came across this week was more structural. During my first week in Kampala, I came across the scene of an accident while walking to work. There were a few minor injuries, but two gentlemen were thrown from their vehicles, and we ended up staying with them waiting for the ambulance. I’m not sure what happened after they were taken to the hospital, but I found myself just as frustrated by this situation as the issue with hepatitis treatment. The road isn’t well kept, there aren’t any traffic signs, and it was easy to see the vehicle wasn’t equipped seat belts. It’s frustrating because the events leading up to these injuries were preventable, and as much as it seemed like a normal motor vehicle accident, it was precipitated by the area’s lack of resources and underlying poverty.

None of this is entirely new to me, and I've seen these sorts of frustrating things during trips before. But it doesn't take away the sting of how it makes you feel. While none of these specific incidences resulted in deaths (that I know of), I can easily imagine scenarios that do and each time I see things like this it reminds me of what Paul Farmer calls "stupid deaths."

Ultimately, I know I have little power to change large things like a country’s infrastructure or economy. But a Ugandan colleague of mine put it best: “We can ask for better.” Our partners recognize their lack of resources, but aren’t content with this norm and constantly advocate for better. That's what's incredible about working in global health. We as clinicians can have a role with the individual patient, but can also join our partners as advocates to push for larger, structural changes that lead to a better system. I’m honored to be part of that here, and I think that’s why it’s been so incredible so far (even if it's frustrating at times).

Until next time!

Saturday, January 24, 2015

Karibu, by Med/Peds Resident Ryan Fabrizius on International Rotation in Arusha, Tanzania

Karibu Jambo from Arusha, Tanzania! I am so grateful and blessed to be here in this beautiful country with a genuinely lovely people and culture. Prior to starting work at Selian Hospital, I had the wonderful opportunity to see some of Tanzania's true treasures including Zanzibar and the Serengeti National Park. With this introduction to the country, I was still in a sense of awe, a feeling of other-worldly experience at these sights I had seen in pictures but never expected to see first hand. I arrived at Selian Hospital and Arusha Lutheran Medical Center on Monday looking forward to starting the work I came here to do. 

Karibu, in Swahili, as many of you know, means welcome. I have already heard it used in a number of contexts, ranging as widely as (paraphrased in English to my understanding) "welcome to our country", "you're welcome to drink chai now", "please come into my store and have a look around", "I'll give you a ride on my motorcycle taxi", and as a response to "thank you". Though our English word "you're welcome" seems to cover many similar meanings, I have been struck by how frequently this word is used. It could be that I am so obviously a foreigner (not too many 6'8'' bearded caucasian men in this country) that I am consistently offered a welcome. But I like to think that this offer is an invitation to enter into the community here, to experience what life is like for the people who call Tanzania home, to learn the triumphs and struggles that Tanzanian's experience on a daily basis, to share in the efforts to bring high quality medical care to the community. I am familiar with the false belief that the complex social and economic problems of the developing world can be solved by benevolent humanitarians from rich countries. I sense the temptation to feel that certain people might "welcome" us foreigners to solve their problems. But I have seen a convincing glimpse of the resilience and commitment of Tanzanians working to build a country with opportunity, fairness, and help for the poor. Their Karibu is not "please rescue us"; it is, to me, "please join us in learning together" and "let us share a commitment to each other". I have seen this particularly in a few of the medical workers in the hospital here, including Joseph the pediatric registrar at Selian Hospital. Joseph has completely shattered all my expectations of what local doctors at the government hospital are like. He has a tremendous fund of knowledge about pediatrics, an inspiring compassion towards the children that he treats, and an encouraging drive to learn more in his profession. I will have more to write on him and other local doctors and trainees later.

I would like to end with a short story.  During pediatric rounds, we often see infants who have been admitted with Severe Acute Malnutrition. After a few days, children who were admitted with edema are transitioned from the initial F-75 refeeding formula to F-100, showing good tolerance of the formula and some increase in weight. When they are in need of only a few more days of refeeding in a hospital setting to minimize complications (such as return of edema, refeeding syndrome, or infection), mothers sometimes request to leave the hospital. Fortunately, care of children under the age of five years old is covered by the government (not including certain medications that must be bought at outside pharmacies), so the haste for mothers to depart seemed illogical to me.  When I asked Joseph why they wanted to leave so prematurely, he responded that "if the child stays, the mother cannot eat". There is no food service for patients (other than refeeding formulas for those with malnutrition) or families at the hospital, so they must provide their own, which is extremely difficult for families coming from far distances. When I expressed my awe at the terrible situation, he responded "welcome to Tanzania". It would be easy to take this as a fatalistic declaration of the state of health care and social determinants in this country, however, that is not how I took it. Joseph and the medical team generally come up with a plan together to assure the ongoing treatment of a child in this situation without leaving the mother to have to choose between her health and her child's. In this situation, I began to catch a glimpse of the awful reality of poverty, but a ray of hope in the commitment of people like Joseph in coming up with solutions. This "welcome to Tanzania" said to me: this is the current state of things, but we are already fighting to make it better. 

Thailand #1, by Med/Peds Resident Kristina Krohn on International Rotation in Chiang Mai, Thailand

I have rarely travelled with as much support as I have on this trip. Both my husband and my mom joined me at first for bit of tourism in Burma/Myanmar. Then I received tons of help and advice from our fellow residents (Darin Ruanpeng, Katie Anderson and Mamie Thant). And I don't have enough space to describe all that Pat Walker has done to arrange this rotation and connect me with wonderful people here.

First Darin, she went out of her way to help Joe Messana and I find housing in Thailand. Connecting though facebook with physician friends back home, I even have a computer generated map to show the cabbie when I get off the airplane in Chiang Mai! 

Then Katie Anderson met with Sheiphali Gandhi and I (Joe had to work) to give us a heads up on Thai culture. Notes to myself: don't point the soles of my feet at anyone, don't touch people's heads and don't step on money as it has the King's likeness. All very important things to know!

Katie also recommended going out of my way to climb to the 62nd floor of the Banyan Tree Hotel and fork out the money for a drink on the outdoor bar, in order to fully enjoy the view over the emensity that is Bangkok. There is nothing quite like being 62 floors up, with a drink and nothing more than hand rails between you and air.

Lastly, Mamie Thant was indisensible for my trip to Burma/Myanmar. She provided me with a lot of great historical context, and traditional foods that I needed to try. My palate may never be the same.

Now, as I sit in the airport, I find myself in a familiar state of anticipation. My husband and mom have left to return to the states. I am alone. I have done what I can to prepare myself, but as always, I really have no idea what I have just gotten myself into.

For me, travel never quite feels real until this moment. My head full of advice, but unable to do anything more than wait for the next flight. The flight that takes me to my new temporary home - Chiang Mai.