On loneliness

It’s 923pm and I’m alone in a WiFi-connected bar in Chiang Mai with a fake-strawberry daiquiri, watching the green Facebook chat icons change and trying to block out the sound of Pink Floyd’s Wish You Were Here.

This is without doubt the highlight of my week.

It’s been a bad 10 days, starting with a needlestick injury sustained on a Friday evening when I was in the middle of giving Hepatitis B immunizations to a group of young children from shelters in the local Burmese migrant community. They were in a long line, like a conveyer belt moving on fast-forward.

It all happened in an instant; by the time I’d snapped off the glove and seen the red streak on my thumb, the child (‘the source’) had already scampered off into the squealing crowd. I spun around and yelled, “Who was that child? Get that child back here!” to the bewildered staff and an audience of over a hundred wide-eyed kids. Someone handed me a Band-Aid. Someone else unhelpfully called out “Don’t worry, it’s OK!!” Disoriented, I went out the back, stuck my hand under the bathroom tap and tried not to tremble. One of the shelters is for HIV positive women and children, and in that moment I had no idea where this elusive 6-year old was from.

Over the next 72 hours – the window for PEP[1] – I went into calm, clinical doctor-mode in an attempt to restore a sense of control. I downloaded the relevant forms and tried to do a thorough risk assessment. This involved tracking down various staff members and questioning them about the child – her medical history, her mother’s history, whether she had been screened for blood-borne viruses or not, whether her status was known. The language barrier made it difficult. None of the answers were very clear or complete and it was hard to determine what sort of documentation existed, if any, but from the fragments I managed to piece together it sounded very low risk. No alarm bells.

After some deliberation, I decided to subject the little girl to a rapid HIV test anyway so I didn’t have to wait out the 3 months thinking about it.[2] It was negative, as expected. But then on the way back from the clinic, celebratory KFC ice-creams in hand, a staff member cheerily mentioned there had been some confusion over whether this child was the real ‘source’, or not. The rest of my ice-cream went in the bin.

At this point there was nothing much left to do. The window for PEP was about to close. The likely source – by almost all accounts – was negative.[3] Even if there was a remote possibility it was a different child and that they had HIV,[4] the risk of transmission would only be 0.3% – even less given it was an IM injection, with a fine bore needle, through a glove.

The facts were in. As far as I could tell, on balance, it had been the right decision to not take PEP even with this added element of uncertainty. But I was unnerved. At work, I felt isolated, self-conscious, under threat. Word had spread, and colleagues kept coming up and making awkward needlestick injury jokes, I think in a misplaced attempt at comfort, which I did not find amusing. Things I had previously found fun or interesting took on a sinister edge, like not being able understand what anyone else in the office was saying. My filter had changed. All of a sudden I was intensely aware of being dislocated, stuck on the edge of Burma, without a real job.

Left to my own devices, thoughts started fermenting like a sickly dark ale, and the seed of doubt re: the source sprouted into a weed, entwining itself around the frayed edges of my mind. I started questioning whether I should have taken PEP, even though there was no clear indication. I replayed the incident over and over, wracking my brain in case I had missed something. I felt more and more on edge. I also started thinking more about my failed relationship, disturbed by a long-forgotten sense of being alone-in-the-world.

To take my mind off things I took to drinking cheap wine out of a plastic cup in my room, in bed. One night, having fallen asleep next to a damp acidic patch of red-purple, I woke up at 3am with a searing epigastric pain that felt like someone was stamping out a cigarette inside my stomach. In the morning, I poured the rest of the wine down the sink, drank a litre of milk, and made a mental note to avoid espresso shots and spicy Thai salad. I figured this might also be part of a general stress reaction – a brief bout of physical and psychological reflux – and that the other symptoms, like the pain, would soon settle down.

On Wednesday night, I woke up again at 3am – this time feverish, with sore glands. Half-consciously, I palpated the sides of my neck. Then I froze, suddenly hypervigilant. Non-specific viral symptoms. Acute HIV seroconversion. Disease. Death. A rushing flood of dread.

That was the tipping point. Anxiety escalated like a nuclear chain reaction into full-blown panic and the next 3 hours were spent alternating between thrashing around googling in the dark, inspecting every body part for other telltale signs (rashes, generalized lymphadenopathy, mucosal ulceration, thrush) and lying very still, like a lone witness, paralysed as HIV molecules invaded my bloodstream. In the morning I woke up terrified and exhausted and the adrenaline was still pumping.

As my stress levels went into overdrive, so did my body. On top of the viral feeling I lost my appetite; I developed diarrhea; my bladder became even more agitated than my mind. I felt waterlogged, miserable, weighed down by fatigue. I started re-living break-up trauma, like a reactivated herpes virus that had been lying relatively latent in a ganglion only to erupt into a painful, disfiguring emotional coldsore as soon as my defenses were down.

The remainder of the week was spent holed up in the air-conditioned womb of the Hazel café, glued to the Internet, checking my temperature and researching the latest innovations in the treatment of HIV/AIDS and Hepatitis C. Every 15 minutes I ran out to squat in the adjacent public toilets where I would try to avoid getting sprayed by my own catecholamine-laced urine while fending off large, silent, predatory, indifferent mosquitoes. Sometimes I would just sit there and sob into my watermelon shake listening to Joni Mitchel’s Both Sides Now on repeat, having initially put in earphones to escape a terrible cover of Just the 2 of Us (what is up with background music?).

Inevitably this implosion had social consequences. It didn’t help that I don’t yet know anyone in Mae Sot well enough to be able to comfortably reveal anything much other than the charming/interesting side of my personality, and that this side had unfortunately gone AWOL leaving behind a walking can of human repellant – jumpy, pale, distracted, avoiding eye contact with the latest round of volunteers at the guesthouse. This set up a pernicious cycle of stress – isolation – stress – isolation that I didn’t know how to contain.

I tried to be rational but seemed to have developed immunity to reason (maybe that’s why my glands were up??) so repeat attempts at applying it to the situation only made things worse. I tried to distract myself by clinging to close friends via G-chat, WhatsAp, Viber and Skype, which provided some emergency relief and was very comforting, even life-affirming, but the effects would wear off soon after the conversations were over. I tried doing mindfulness-meditation exercises but struggled to embrace the idea of ‘being in the moment’ – every moment was bad and I just wanted to escape them. At night I swallowed sleeping tablets to turn off my brain, like pressing the power button of a jammed laptop for a forcibly long time.

I went down, down, down into the rabbit hole.

Two days ago, on the advice of the NGO coordinating my placement, I took a flight out to Chiang Mai to get baseline blood tests at an international hospital.[5] I went straight there from the airport. The hospital was big, white and shiny and I found it soothing in its order and sterility, its crisp, environmentally-unsound A4 checklists, its unrelenting Fordism: it felt like home. I was registered, triaged, referred to Internal Medicine, given a routine blood pressure and weight check by a harassed, dumpling-shaped nurse (I’ve lost 4kg), seen by the doctor, sent for venepuncture, then instructed to come back to the waiting area in 2 hours for the results.

When I returned at 7pm there was some sort of delay. The Thai nurses seemed nervous when talking to me [6] and wouldn’t let me open the envelope sitting on the front of my patient file. On high alert, I decided this meant I already had HIV. My hands went numb. I felt like I was on an acid trip. I paced up and down trying not to faint, which made them more nervous, which made me more nervous, and so forth.

When I finally saw the doctor and she read out the results (negative), I felt the blood returning to my head. And as I walked out into the busy street rubbing my tired, twitching raccoon eyes I started filling up with a clear, liquid relief, almost as irrational as the panic attack before it.[7]

The jury is in: loneliness is bad for your health. This is something that I thought about a lot working in A+Es in London, where the global epidemic has hit pretty hard. The little old lady found unconscious on the floor by a carer at 8am after falling out of bed in the night; the unemployed 21-year-old from Europe who tried to hang himself 3 times with an extension cord. These clinical presentations can seem like indictments of neoliberal capitalism, with its rampant individualism, youth-obsessed consumer culture and economic inequality leading to an influx of sick and injured patients at the “downstream” end. The dark side of development.

The effects of social isolation are more diffuse and insidious than the immediate or practical consequences, or even its impact on mental health. But they’re real, very physical and very potent, trickling down from the emotional-cognitive level to the cellular, biochemical one and back up again. In this feedback loop of misery, loneliness hurts the mind and the body, blurring the arbitrary line between them. The mechanism, in a nutshell, is stress. Although the exact pathways are not yet well-established, when the body is stuck in ‘flight or flight’ mode, adrenal glands working overtime for prolonged stretches of time, the brain doesn’t do well. One prominent theory is that stress-induced immune dysfunction leads to low levels of chronic inflammation, which leads to an increased incidence and severity of diseases ranging from atherosclerosis to the common cold. Neuroscientists are testing out the hypothesis that inflammatory markers are implicated in the aetiology of depression through impaired neurogenesis – new adult brain cell formation. More specifically, there is evidence that stress in the form of perceived social isolation – feeling lonely, rather than being alone – can have impacts on the body independent of any overlapping depression. When someone is lonely they feel more threatened, less connected, and studies have linked these anxieties to cardiovascular disease, infections, even premature death.

For what it’s worth, over the past week I think my lonely mind has been making me sick, quite literally. I have felt mentally and physically inflamed – the end result of a constellation of risk factors exacerbated by an acute stressor (the needlestick, etc.). I can almost visualise the negative biochemical messengers hurtling along my nervous system, the cytokines swarming to the lining of my bladder, stomach and intestines, lowering my pain threshold, zapping my energy reserves, fricasseeing my neurons and inducing a slight psychosis.[8]

It’s interesting that being in Chiang Mai is making me feel better. I’m staying smack bang in the middle of the tourist district, which is like an eco-hipster Garden of Eden filled with Hill tribe coffee, sidewalk foot massages, lilting guitar music and young firm bodies walking around in singlets rubbing aloe vera into their sunburn. My level of social isolation is pretty much the same; if anything, it’s increased. And yet I feel suddenly lighter, able to distract myself, content to wander amid all this activity without the risk of being attacked by a rabid, malnourished dog. I don’t think this is just because of the (meaningless) test result. Everything is more familiar here. I’m no longer culturally isolated and as a result feel more connected to my surroundings, more in my element. Not without irony, this element happens to be an alienating First World consumption-driven one – I have been spending a lot of time in Boots, Starbucks, Burger King and shopping centre complexes, and if I found myself on a tube now, as opposed to earlier in the year, it’s possible I would weep with gratitude.

This leads me to conclude that loneliness-induced stress is not just to do with an absence of high-quality one-on-one interactions or direct social supports, but is also about losing that sense of being a part of something wider, rather than an outsider with your damp nose pressed up against the window glass.

With this feeling restored, I’m no longer lost in my own neurotic wreck of a head. As a result, I’m no longer obsessing about my relationship status, or my HIV status. The stress is draining away, and in 24 hours my body has almost returned to its (albeit slightly anxious) baseline.

Technically, the process isn’t over. I still have to wait and get a repeat blood test at 6-weeks post-exposure, and again at 3 months. On the upside, it’s likely that by then I’ll want an excuse to leave Mae Sot and plug back into this familiar world for a few days – to hang out in Boots and burn my tongue on overpriced Starbucks lattes – at least until the one on the border starts to feel bit more like home.


[1] Post-exposure prophylaxis (PEP) – any preventative medical treatment started immediately after exposure to a pathogen in order to prevent infection.

[2] The time it takes for 97% of cases to seroconvert; negative tests before then don’t exclude HIV infection.

[3] I didn’t give a s*** about Hepatitis C at this point because there’s nothing you can do about it (no PEP); as a health worker, I’ve been immunized against Hepatitis B.

[4] For those readers that know me, I later established that there are only 2 children of that age living in the HIV positive shelter at the moment, and that everyone from that shelter had been immunized in the morning session anyway. Also it turns out all children in every shelter are screened for HIV etc. as part of the standard client intake procedure. And finally, the 6 year old child that was tested had apparently gone home that night and reported to her mother that she had ‘hurt the doctor’, which pretty much clears up the doubt about the source (all this information took a lot of time to amass – a painstaking process).

[5] which, for some ridiculous reason, I had initially protested again (“What’s the rush now that the PEP window has closed? Why can’t I get them done at Mae Sot General?’). Ugh.

[6] In retrospect this makes sense (I think I was a freakish sight by that point, not to mention a relatively tall one).

[7] At this early stage I would only have tested positive if I had been exposed to HIV before the needlestick injury (which I haven’t been, as far as I know).

[8] In terms of those infernal, badly-timed viral symptoms, a stress-induced upper respiratory tract infection would probably have been a more sensible provisional diagnosis.

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1st vs 3rd World Expectations

After a bumpy start in Reproductive Health (ehehe), Ive been spending Wednesdays in the Surgical Department – a concrete block towards the back of the Clinic, to the left of the sea-blue plastic water tank.

Surgical Department

Thongs (flip-flops) of all sizes are heaped up outside the doorways in accordance with Buddhist shoe-removal etiquette. There is a 40-bed ward, two procedure bays, an outpatient clinic, a small, air-conditioned operating theatre and a staffroom (like all public hospital staffrooms) filled with stray chairs, unstable piles of notes, watermarked textbooks, empty bottles of Coke and Red Bull and a PC that looks like a grey rock stuck to a desk. This one also has a litter of indifferent kittens huddled in the base of the bookshelf with an entourage of fleas – less familiar, although no more disturbing than some of the things I’ve stumbled across on top of NHS staff lockers.

Entering a surgical inpatient ward barefoot is a disorienting sensation. After two or three times you start to get used to it, and to the curry bowls and green banana bunches everywhere, the cats (graduated from the bookshelf) and the patients lying in rows on wooden beds, all in the one room, with relatives mingling in the aisles. It’s a large, airy space, like how I imagine makeshift war hospitals might look like, with missing ceiling tiles and noise from a lone TV buzzing in the background.

Most of the admissions are for treatment of conditions like infected ulcers and burns and chronic cellulitis, or for post-operative care following on-site hernia and hydrocele repair. There are also occasional swathes of young men presenting with severe penile infections caused by unsterile injections of coconut oil into the shaft. How word hasn’t got out yet that this is a bad idea, I don’t know.

In the outpatient clinic I’m paired up with one of the medics, a Karen man who’s been studying or working at the Mae Tao Clinic for the past thirteen years. Together we assess patients with an array of wounds, work injuries, dog bites, abscesses, sprains, lacerations and lumps, mostly in the neck, breast and groin. They tend to stream through the door, one by one, in either a light trickle or a patient tsunami.

One young man walked in the morning after accidentally mangling his index finger with a machete while cutting down stems in a field (or something). He was joking around with his friend and seemed to have no trouble accepting the fact that there was a bloody stump where half a finger used to be – not something stitches could fix.

I thought back to the last severed finger I had come across, in a London A+E a few months before. A middle-aged woman had stuck her hand through her neighbour’s letterbox and had one of the tips bitten off by an overly zealous housedog. What happened next was difficult to follow. She called for help and somehow 3 friends appeared and managed to sidestep the dog, retrieve the fingertip and put it into the neighbour’s freezer, directly on ice (this is the wrong thing to do btw – readers take note!). Then when they arrived at the triage desk, bewildered and flushed, they realized the finger was still in the freezer and the ambulance had to turn around and go back for it, sirens blazing.

More drama ensued. To cut a long story short, my whole day was taken up with this finger, not least because while I was on the phone arranging an urgent referral to the plastic surgeons at a specialist hospital in the unlikely event they could somehow reattach it, the wide-eyed patient and her not-so-helpful but well-meaning posse jumped the gun, presumably in a fit of collective anxiety, and raced out the door without telling anyone, without clear instructions or a trackable mobile phone. And they forgot to take the finger. Again.

I remember wrapping the poor, frostbitten thing in a shroud of sterile gauze and noticing it looked very dainty and well tended-to. A perfect nail painted an inviting shade of coral, with a glitter sheen.

It would make sense that First World fingertips get more attention than the ones on the Thai-Burma border (except when they’re in the freezer or on a hospital desk). The loose phenomenon is one of Adaptation  – of priorities, expectations and distress levels falling in line with the resources at hand (ba-doom).

This is something that’s been on my mind a lot since moving to the edge of one of the least developed parts of Asia, where I happen to find myself spending a lot of spare time reading articles and blog posts related to current debates on the connection between happiness, expectations, and reality. Like this one: Why Generation Y Yuppies are Unhappy. And this one: Fuck You. I’m Gen Y, and I Don’t Feel Special or Entitled, Just Poor.

Some incipient thoughts on the psychology of 3rd world expectations:

There is a undoubtedly a positive side. Deprivation can bring out remarkable levels of human resilience (from experience, the converse is also true). And even observing it can instill a sense of perspective that is difficult to maintain in conditions of saturated affluence. Almost every morning at the clinic, often while fumbling with a cold thermos filled with mixed fruit frappe, I walk past another young man with both arms missing, likely an old landmine injury. Things like that make you remember – or realise – what matters. Fingertips and spilt fruit frappe don’t make the list.

There is also a disturbing side – the apparent resignation, or passive acceptance of a miserable status quo. Unlike a distal phalynx, the penis is a near-universally revered and undeniably useful appendage. Yet some of the young men who wander over to the procedure bay for their daily dressing changes seem almost resigned to the fact that theirs looks like it’s about to drop off. Maybe it’s just because I can’t read their anxiety, or maybe they don’t understand the potential long-term consequences. Maybe on discharge they’re planning to go out and start an awareness-raising/prevention campaign, with flyers and street theater, to alert other men in the community to the dangers involved.

It’s hard to tell.

Photo Essay – Saturday morning in the market

fwatermelonman4

I have to confess I haven’t cooked anything – not one thing – since moving to Mae Sot six weeks ago.

Once I went to Tesco Lotus and bought some items with the view to cooking them, but when I got home hungry I unwittingly bit into a raw mackerel, then spat it out on the floor, then spent the remainder of the evening cleaning up mackerel juice and scrubbing my hands instead of cooking (or eating). And that was that.

For budget reasons though (and to avoid diabetes/high blood pressure/obesity), I will need to start. To get the ball rolling I decided to take a Saturday morning class at Borderline – a store and gallery that sells handwoven crafts and art and makes very good Burmese vegetarian food – and learn how to shop in the local market.

My guide, Bo Bo, was a man in his early thirties from Shan State who (like many here) is planning to go back to Burma sometime in the next few months. He was calm, friendly and very fit, with both arms covered in tattoos.

Bo Bo explained that the market is divided into three parts – first Thai, which blends into Burmese, which blends into the Burmese-Muslim covered market.

We mainly shopped in the open-air Burmese stalls.

market umbrellas

   As someone with pale skin, I was struck by the high levels of sun sense amongst the locals. The methods depend on which part you’re in: baseball caps, loosened headscarves, warm glowing umbrellas, thanaka cream, those conical Asian hats designed to protect from sun and rain while toiling in rice paddies, etc. I think the Burmese ones are made of bamboo. They’ve also (like many things here) been known to double as a political symbol.

eam made from ground bark, and one of the main ways I tell whether to say 'mingalaba' (Burmese hello) instead of 'sawade ka' (Thai).

This woman has Thanaka on her face. It’s a distinctive yellowish-white cosmetic suncream made from ground bark, and one of the only ways I decide whether it’s better to say ‘mingalaba’ (Burmese hello) instead of ‘sawadee ka’ (Thai).

Thai man in a cap

Betel leaves, pressed into intricate whorls, can be found everywhere. They’re used to wrap up the wood-like areca nut (‘betel nut’) along with tobacco, spices and lime, a calcium-containing substance that’s meant to aid digestion. This little bundle (a ‘betel quid’) acts as a mild stimulant, like drinking a cup of coffee.

New leaf – betel leaf

New leaf – betel leaf

Chewing betel quid is a widespread habit in Asia. It’s believed to have medicinal properties but has unfortunately been linked to a number of diseases including gastritis, kidney stones, birth defects and oral cancer.

Most ironically, it’s rumored to be good for dental hygiene – this has not been my impression. The dentition here is not good. The leaves deliver tannins which stain a deep dark red, and some of the patients I’ve seen give the impression that they have a mouthful of blood and rust and are chewing on shards of their own rotten teeth.

Betel nut – deceptively pretty

Betel nut – deceptively pretty

Lime

Bags of lime. Hmn.

But betel was not on our shopping list (although, despite the carcinogens, I am curious to get a betel buzz and watch my spit turn red).

Some essential ingredients, whether you’re Thai or Burmese, Buddhist or Muslim (or even farang [1]): rice, dried chilies, limes, eggs and a wide variety of fresh vegetables.

rice fresh vegetables and mangoes

dried chilies

limes Eggs and dried fish

Another new fruit…

Custard applies on a cart – like a pile of sweet grenades

Dragon fruit – more exciting on the outside

Dragon fruit – more exciting on the outside

And some more familiar ones.

pineapple

Pineapple patterns

Bananas

Incandescent banana bunches

 

 

 

They somehow seem more vivid scattered around in the morning market heat, as opposed to ordered and spaced out in an air-conditioned supermarket.

 

 

 

 

 

I was so drawn to these watermelons that I asked to buy one so I could take a bunch of photos without feeling too awkward.

 

 

 
N.B. not the lightest fruit

 

 

 

Somehow I ended up with four, that ended up in Bo Bo’s backpack. I don’t think he was too thrilled. Watermelon is not the lightest fruit.

 

 

Fermented fish paste, or ngapi, is a staple of rural Burma/Myanmar, especially the Irrawaddy Delta. I noticed it was a recurring thread in the autobiography ‘Little Daughter’ by Zoya Phan, a young Karen woman who was forced to flee her village at the age of 14 when it was attacked by the Tatmadaw (the Burmese Armed Forces). She is now a prominent activist living in the UK, where she has political asylum, and remains a vocal critic of the current Burmese government.

Fish paste seemed to be one of the few points of continuity for her and her family when they were living for many years in refugee camps in Thailand.

fish paste

Karen comfort food – kind of like my cold Milo or macaroni cheese (except they don’t smell like putrefying flesh)

Other hallmarks of the daily Burmese diet.

Ingredients for the national dish, pickled tea leaf salad (otherwise known as လက်ဖက်သုတ်). In Burma, they don't just drink tea!

Ingredients for the national dish, pickled tea leaf salad (otherwise known as လက်ဖက်သုတ်). In Burma, they don’t just drink tea!

Banana stems (note the scale – they’re huge!). One ingredient in mohinga, a popular breakfast that consists of fish soup with rice noodles and fresh herbs (and other things). It’s up there with tea leaf salad as far as iconic Burmese dishes go.

 

 

 

 

 

 

 

 

 

As a child of divorce, I have 3 little half-siblings aged 7, 5 and 2 years old. For some forgotten reason I call the middle one “Froggie” and when I first saw frogs in the market it sparked the idea of compiling a photo scrapbook of the creatures in Mae Sot to send to them.

fish 2 atzsnail

aturtle 3 aturtle eel

But then I realised it would be like sending them a documentary on Guantanamo Bay.

Or a DVD of The Shawshank Redemption.

Or a storybook version of ‘Tales from the Crypt’.

Maybe it’s time to come up with a new nickname.

It’s a well known fact that Asians aren’t squeamish when it comes to their dead animals. Surrounded by buckets of slime-covered gizzards, beaks and feet and lone pulpy eyeballs, and bloody white entrails slopping out all over the place, I thought back to the neat little plastic-covered bundles of light pink chicken breast at the Herne Hill weekend farmers’ market.

In the Western world, where everything tends to be highly sanitized and over-packaged, there a lot of distance between us and the things we eat. I, for one, have never so much as seen a live headless chicken let alone slaughtered my own cow. And Anglo-Saxons like our meat very dead, in pieces (not all the pieces) and preferably a bit cute-looking.

Chicken ballerina

A chicken foot stretches out daintily into the warm air, like that of a tired ballerina.

Asians also like to eat insects. But it seems Westerners are the odd ones out again – in fact we’re behind the food 8-ball.

Entomophagy – the human consumption of insects as food – is common in most parts of the world, in almost every culture, on every continent. It’s even currently being explored as a potential way to solve global food insecurity. And (like sushi in the 90s) it looks like it might just be starting to become ‘trendy’.

High protein, low-GI, crunchy and salty, a solution to malnutrition and global warming….what more could you want from a snack?

Mae Sot is a major Thailand-Burma trade hub. According to Bo Bo the fish here comes from either the freshwater Moei river, tracing the border, or the Andaman Sea in lower Burma, south-west of the Bay of Bengal. The source affects the level of saltiness so it’s important to ask about it before you commit (N.B. this is not going on my expanding list of phrases-to-learn anytime soon).

bshopper

Decision time

row of fish

“Salt- or fresh-water?”

Dried shrimp

Heaped trays of sun-dried shrimp, shrunk down to thumbnail size. A handful is often thrown on the top of Southeast Asian dishes.

Another random reminder of being in a border town.

Army men with flowers. These guys seem pretty chillax at least.

Thai army man with flowers

Mae Sot is adjacent to Karen State, Burma. Armed conflict between the Karen National Union (KNU) and the Burmese government is the world’s longest running civil war. Over the years it has spilled over into Thailand in fits and starts, mainly in the form of masses of displaced villagers. From what I understand, the fighting has been at a relative standstill since 2012. As it’s not an international conflict, I wonder what sort of role the Thai security forces have had (in Mae Sot at least).

menu

 

After collecting enough fruits, vegetables, herbs, grains and fermented things we ended up in a Burmese tea shop located down one of the side alleyways.

Bo Bo and I had a very interesting Q+A about the history of tea and coffee in Burma and how it mirrors the political and economic upheaval of the past century.

 

I think the same must be true of the food. From what I can tell it’s infused with the complex myriad identities of this fractured country and its 60 million inhabitants – roughly two-thirds Burman and one-third ethnic minorities – living at the edge of Southeast Asia, squished in between two rising global powers India and China, and still struggling with the reverberating effects of their colonial and military-coup-dominated past. Although luckily it would seem the British had more of an influence on drinking habits than on the food.

cup of Burmese tea

All this makes a Saturday morning shop in the market more thought-provoking than a trip to Coles or Sainsbury’s.


[1] Foreigner in Thailand – generally a white person

The way to work

IMG_4493

I am relieved to be out of London. In the last months before leaving I was starting to lose it. The tipping point – on top of shift work, erratic sleep and general life upheaval ­­– was the commute.

443px-Brixton_Tube_2006-04-22I was living in the South and working as a locum doctor in a handful of A+E departments strewn over the city. Unfortunately the one with the most regular shifts was in the Northeast, bordering Essex, which meant a minimum of 90 minutes travel time each way. This was divided into 10-minute frenetic spurts on various buses, tube lines and underground tunnels, and one unreliable train.

Most of this was spent glued to my iPhone, engaged in a futile struggle to vanquish my ‘To Do’ list – sending emails, tapping out texts till my thumbs seized up, making calls to various unsympathetic office workers about things like tax codes – and checking the minutes as they ticked away.[1] At the end I would walk for 6 minutes beside a highway, past rows of concrete blocks and through a car park, before taking a deep breath in and passing through the automated hospital doors. After evening shifts I would run back up through the dark empty streets, sometimes still in my crumpled green scrub bottoms. If I missed the last train I would take the dreaded night bus and arrive home at 3am, disheveled and exhausted.

There has been research into the effect long commutes can have on mental well-being. The effect on mine wasn’t good. After six months my neurons were irritated. My already-elevated stress levels went up, and my irritability threshold went down ­– to a disturbing new low.

Brixton_Tube_Station

I found myself holding back impulses to knock elderly people aside when they moved too slowly or push tourists down the escalators when they strayed haplessly into the wrong aisle. I threw small internal tantrums when something obstructed my way (like the Pret-a-Manger checkout person at Liverpool Street Station taking too long putting my avocado wrap into its paper bag). I forgot to think what I looked like, stalking up and down underground platforms like an agitated panther in aqua-coloured Nike sneakers, sucking down flat whites and staring at the departure board with dark-ringed, narrowed eyes. I felt alienated, isolated, surrounded by incoherent noises, concentrating only on dodging human traffic and other obstacles to my final destination – like a caffeine and cortisol-fueled lemming in a warped, urban-jungle-themed video game.

IMG_2359   IMG_2357   IMG_2366

In Mae Sot, at the eleventh hour, the transport arc of my everyday life has changed dramatically. For the past 3 weeks I’ve been bike riding to work – and everywhere else – and if I pedal firmly it only ever seems to take 10 minutes. And it’s not a coincidence that I no longer feel a homicidal antipathy towards my fellow man (or elderly woman).

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In the mornings I leave the guesthouse and whiz through the warm air fragrant with fish sauce, garlic and burnt sugar, listening to birds tweeting and loudspeaker announcements from the Buddhist temples (loud, but better than squealing tube brakes). Everything is covered in foliage, like a small, inhabited jungle. My mind feels like a dehydrated plant that’s been transplanted from an arid, hostile environment into a cool, watery, reed-filled one. Things go past in a blur, but it’s a slower, greener, softer blur. Not a sensory assault.

There’s still traffic – cars, trucks and motorbikes leaving smoky trails of exhaust fumes, other bikes with passengers sitting sleepily on the back with their feet dangling just above the road – but a lot less of it.

Like a stop-off at Brixton, I pick up a coffee from a shop on the side of the road past the main roundabout. After chatting with the guy in my limited Thai/apologetic English I ride away with an espresso shot in a cup overfilled with ice-cubes suspended in a plastic sling tied to one of the handlebars, with cold drops splashing on my ankles as I swerve to avoid centipedes inching along the road and bump over rock-filled mud puddles.

London commuters get stuck in the rain, but in South-East Asia it’s more of a big deal, and as September is the tail end of the wet season there’s at least a brief shower every day.

In the first week I was caught unprepared in a sudden downpour. The rain fell in loud, straight streamers, and I was drenched within seconds. After that I started traveling with an industrial-looking waterproof laptop sac, a small umbrella, and a rain-poncho fastened to the rear rack.

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The CBO[2] I’m working at, is located in a Burmese residential area on the edge of a vast field of rice paddies. At the turn-off from the tarred road the traffic disappears and lone battered rickshaws coated in faded red paint rattle past goats and stray chickens and children on their way to school. I ride past small corner shops, washing lines and a series of stained and dilapidated concrete fences, through some more puddles, to the entrance of the office.

IMG_3105    IMG_4472    way to work photo

On my second day there, the one doctor on staff, who runs a mobile medical clinic and various other programs, took me to buy the bike from an outdoor warehouse beside the Moei river, on the border. It’s not very wide and on the other side you can see where Burma/Myanmar begins. The experience was very different to buying a bike from Argos.[3]

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There was an endless expanse of bikes and bike parts heaped up in different sized-piles, in various stages of assemblage and decay. A group of young men and their small, sprightly assistants – boys that looked about 7-10 years old – pulled out a tall-sized frame from the end of a long row and asked me to pick the various bits that I liked from other bikes – a seat, handlebars, front basket – for them to swap. Then they changed the tyres and fastened on a rusty but effective lock and a generator-powered light. They worked quickly, with a fervent collective concentration (and seemed a lot more engaged with the process than the Argos employees).

As I marveled at how much better it was to go shopping here, I had to remind myself of the situation they were in – displaced and undocumented, living in poverty, most likely without much chance of getting out. Six weeks ago there had been severe floods in Mae Sot and hundreds of bodies were rumored to have washed up on the riverbanks, but no one knew how many because there had been no official count.

IMG_2863I left with my new (recycled) hipster-looking bike, 3000 miles away from the immensity of London, feeling lighter. And a bit uncomfortable. Even though it’s a lot to do with being in a small town, there’s a dark lining to this expat/‘voluntourist’ contentment – the immense relative wealth, the heightened sense of one’s own freedom, the sometimes-morbid fascination.

Other observations in the streets on the way to work – a man with no legs pushing himself beside the gutters on a skateboard (also stuck in the rain); a young child with wasted limbs, contorted with spasticity, being steered through traffic in a rusted makeshift wheelchair by a teenage girl – make it difficult to get too carried away with the ‘Life is better here!!’ feeling. Maybe, in a process of apathetic evolution, the effect will wear off, like it has with the mentally ill and homeless people outside London’s stations.

But I’m not spending 3 hours a day/night stuck on a hurtling tube, on my iPhone, or in my own head. And this can only be a good thing.


[1] I tried listening to music and podcasts, as per Google’s advice on how to improve your commute, but it was harder to concentrate on the tube/tube/train transfers, so I stopped

[2] Community-based organization

[3] In retrospect a very ill thought-out and regrettable decision. It was also not as cost-effective as I’d hoped, mainly because after the bike was assembled (by me and a helpful customer at the store), it squeaked and wobbled and felt too unsafe to ride, or to sell or give away (M. called it a “death-trap”).

Day 1 at the Mae Tao Clinic

Aung San Suu Kyi

In the midst of all the leaving-London mess, I hadn’t really thought about what I would be doing for my once-a-week placement at the Mae Tao Clinic.[1] And so my first day there was a daunting one.

The clinic is a sprawling, plant-filled complex of one-story buildings located just off the Asia highway, outside the center of Mae Sot. I was dropped at the entrance by a tuk tuk and jumped off the back in my grey hospital skirt outside a row of dark, shed-like food stalls with roofs made out of corrugated iron and dried leaves.

I instantly felt inappropriately dressed – although the skirt was knee-length (as per advice from the ‘Volunteer Orientation Manual’) almost everyone else was wearing a longyi. Tugging self-consciously at my waistline, I wandered in and around and tried to figure out how to find the ‘RH OPD’ (Reproductive Health Outpatient Department). This was only piece of information on ‘where to go’ I had discovered on trawling through my inbox the night before.

I followed some dusty signs with uterus drawings on them, passed an open-air delivery ward where a baby’s slick black head was crowning, tentatively stepped into a large room filled with pregnant-looking women, and introduced myself to someone sitting in a small office who seemed to vaguely register who I was. She sent me into another room where I was adopted by one of the health workers and sat down with a jolt for row after row of consults in the antenatal clinic.

Having no real O+G experience aside from medical school, I had to concentrate hard to remember/pretend to remember how to take an antenatal history, measure a fundal height, feel a cervical os, and determine estimated date of delivery (EDD) with that cardboard wheel-calendar thing. The health worker – a very patient, slender, seemingly sweat-proof woman in a clean, light-coloured shirt – seemed to figure out quickly that I was essentially useless, and relieved the awkwardness of the situation by both acting as a translator and telling me what to write in the notes. She was very good-natured about it, smiling and twittering quietly in clear but broken English in response to my frequent questions. The patients seemed bemused whenever I spoke directly to them – this was a bit disconcerting. 

MTC fanThe room was sticky with heat and I tried to position my plastic chair directly under the fan. Embarrassing moments included not being to find the fetal heartbeat 3 times in a row, then being asked to interpret a bedside ultrasound (I could barely make out the gestational sac in that swamp of inscrutable grey lines). And as the day went on I felt more and more uncomfortable, partly because I was dehydrated from all the sweating, and partly because of the pressing question: what is the point of me being here when I don’t speak Karen or Burmese, don’t know anything about O+G, and am only going to float in, ill-equipped, saddled with a mild but ridiculous white-saviour complex, for one random day per week?

I was relieved to be sent out for a break. I bought a longyi – a sarong-like tube of material that goes down to the ankles – from a makeshift hospital store that was dark, dank and covered in dust. For lunch I had a fluorescent orange chunk of fried chicken thigh, a small plastic bag full of noodles and some water from a flimsy bottle that tasted like chemicals. I swallowed it all in front of two expectant dogs, then stood under the shade of a large tree in the middle of the main passageway holding a green apple, feeling faint and staring blankly into the heavy air. Lost in a blur of human activity.

The Mae Tao Clinic was started by Dr Cynthia Maung when she was a young doctor fleeing the brutal repression by the Burmese military in the wake of the 1988 student uprising. From its beginnings in a small, run-down shack, it now provides an extensive range of free health and social services to an estimated 150,000 refugees, migrant workers and other displaced groups living on the border. Around half travel to the clinic from the Burmese side, where healthcare is essentially non-existent. Many belong to ethnic minorities (mostly Karen).

As I stood there eating the apple, I thought about how it was less sterile here compared to other hospitals I’ve been in – both literally and metaphorically.

MTC sinkThe toilets have splintered wooden doors with rusted locks and a plastic bucket floating in a dark pool of water for a flush. There are dregs of rice blocking the sinks, and cracked eggshells in the gutters. The soap is diluted. Gloves are scarce. But people seem more connected – less alienated and scared – with healthcare being this intertwined with everyday life. As per the website, the MTC is “not just a workplace…it is also a home” – there is an on-site orphanage, and 95% of the staff have themselves been displaced from Burma.

I went back to the RH OPD after lunch less naïve and more reluctant. The afternoon session was much the same, except the health worker wasn’t there anymore and none of the others paid me much attention. I spent some time taking blood pressure and walking in and out of different rooms, and attempted to communicate with staff and patients but didn’t get very far without intensive help. And when my longyi fell down while listening in vain for another fetal heartbeat, I decided to give up.

I left early, back on a tuk tuk through the searing afternoon heat. At the guesthouse I collapsed under my anti-mosquito tent and fell asleep in the dark with the air-con on.

I’m strongly attracted to the MTC, the buzzing humanity of the place – but one day a week won’t be enough to get the hang of things, let alone contribute anything. And I should probably ask to be moved somewhere other than the RH OPD (or anywhere else RH-related).

I remember now reading something about the problem with short-term overseas volunteering, but I didn’t pay much attention at the time. It suddenly seems very clear: I am here asking the MTC for help, rather than the other way round.


[1] The rest of the week will be spent working at a community-based women’s organization

In Mae Sot

In Mae Sot, in bed, trapped inside a bright blue anti-mosquito tent with the fan blades beating overhead. Outside it’s dark and raining. Swollen drops are tapping loudly on corrugated iron but everything else is strangely quiet for a Saturday night, aside from a lone chirruping gecko outside my window (at least I hope it’s a gecko and not a vocal cockroach).

Arrived here at 6am. Almost missed the night bus, but managed to dart in and out of the 7-eleven at Moh Chit station just before it left, and was momentarily stunned by the refrigerated rows of weird, artificial, packaged Asian foodstuffs, miniature bottles of potion-like soft drink, and lychee-flavoured poppers. A flashing daze. Then climbed onto the “VIP” bus, inhaled a sticky rice pork burger, levered back the (extremely comfy) chair, and passed out.

When I woke up, small mountains covered with thick jungle-forest were becoming visible on either side of the road, quiet in the aquatic early morning light. At the bus station I was bundled into the back of a tuk-tuk and flew past monks and small apprentice monks wading through the mist with their alms bowls, swathed in burnt orange, a faint sweat in the air.

Mae Sot is small and messy, and enchanting. The leaves here look like they’re on steroids. Stray dogs trot purposefully through the town – one growled and ran at me tonight but I managed to stay still and it didn’t come too close (N.B. expensive rabies vaccine course – a sensible decision).

The roads are lined with dusty food stalls and displays of strange, sodden-looking pink and green tropical fruits with spikes and fuzz and dark tendrils. Also noted several giant painted chicken statues – curious as to their significance.

In other news, it has come to my attention that I can’t speak a word of Thai, or Burmese (except an imperfect, apologetic, big-eyed ‘thankyou!’) and that this is problematic. It seems that in the midst of 30kg of overweight/obese luggage I forgot about language being an important part of… medicine, and daily life…

At least I managed to find a photocopied version of a Lonely Planet Thai-English phrasebook in a corner of the guesthouse.

And with that, dâi way-laa norn léaw [it is bedtime].