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.


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.