The Mystery of Resilience
We are sharing a series of journal entries that were sent to us as an essay submission for our website. The author, JH, includes the following message: The following entries from my journal along the Burma-Thai border were first shared more than 18 years ago. On the advice of a respected teacher, they were distributed only on paper, so as to protect involved parties while raising awareness. Later, when the Internet became available, many of us still hoped in our hearts that these descriptions would soon become obsolete. Finally, I offer these words here in realizing that certain details remain far too accurate. May they bring benefit. Please forgive my youthful ignorance and arrogance. Errors are my own.
“I want to know in my bones what nudges a person to risk the market at night, checking stalls and corner shadows for those who might need help.”
Burma Border Journals #2
One medic brought in this funny clump of vegetables, rubber banded together and cut flat across the bottom. The green stalks of varied heights and slightly floppy at their tapered ends made the greenery look like a multi-colored jester’s hat, white at the hat band, rhubarb colored in the middle, and resembling giant leeks at its tips. This bouquet was placed upon the table where we interview and write patient histories. I asked him, “You like this vegetable?” “Oh yes, like very much,” he says. “This vegetable from Burma, from Karen State?” “Oh yes,” smiling. “Does it grow on trees or up through the ground,” using finger motions to illustrate carrots poking up through dirt. “From ground, yes, in jungle.” “Is it special?” “Yes, special vegetable.” “Is it food or medicine vegetable?” I ask because I’m thinking of a woman I know who works with sea gypsies of the Southern coastal Burmese islands. She was burned from hot tea on her abdomen, not by the locals but on the airplane, to a degree that one would expect to scar. Their elder took her to find a broad light green leaf in the forest, placed this directly onto the injury, and instantly all pain disappeared. No scarring ensued. So the medic, regarding his favorite vegetable, says “food, no medicine.” The young male nursing trainee also present chimes in “For normal people it is food, for him magic medicine, ha ha.” He said this with a jibe and grin, making the moment as ridiculous as the placement of a vegetable centerpiece in the exam room. It felt so gladdening to share in their good-natured laughter. Instantly we were friends. This is why the other twenty-three and one-half hours in the day are not spent writing.
I want to know why some shut down their hearts like fortresses in the face of pain, while many here find compost for flowering, fodder for the fruit of enormous compassion. There are people whose walls could knock you over and then those who emanate a glow when giving gifts, but language cannot approach the contrast. I stick to my half an hour of designated writing time because when the mystery becomes object, understanding is lost.
I want to know how it feels to have been offered refuge in a third country and to say no, preferring instead to sleep and eat communally at the clinic compound so that one might better serve people medically. I want to know in my cells the energy that brings paint to the canvas, brings images to the eyes of this world, that moves a man to stay and paint when he has been invited to Europe and East Asia to display his art. I want to know in my bones what nudges a person to risk the market at night, checking stalls and corner shadows for those who might need help. I want to know how a man I met rears seven orphan children as his own. He finds work for them when they fledge his tiny home. Not everyone knows that he does this or that he gives away all earnings, except a small amount covering basic food and rent, but they do perceive his kindness. Thus he receives gifts enough to live in this manner. He has a master’s degree that doesn’t count in other countries; in this second country he works like a servant. He ran a private school until the universities were all shut down; then obviously there was a decline in student incentive to attend. Here they are physically safer, but if the boss fears the departure of a likeable gardener, washer woman, or maintenance person, wages are withheld for months, preventing anyone from going anywhere. I want to know empathically how he continuously opens his heart, not knowing if he will ever go home in this lifetime.
Had to postpone those deeper questions for a while to read up on Neurology. First there was a teen-aged girl who presented as an outpatient with complaints of left-sided total body numbness and weakness. After performing and eliciting an unremarkable neurologic examination, I expected we would all speculate amongst ourselves as to the etiology of her symptoms. In medical school we had always fashioned some list of differential diagnoses, prioritized them, and then proceeded to rule out all but the most likely conditions. In this case, however, it became apparent that I, having led our group of three, one newly graduated medic, one medic-in-training, and myself, through the exam, was now expected to proclaim the diagnosis. Although the university will not actually be mailing me the MD diploma for twenty more days, there was nothing to do but step up to the responsibility and vow to myself to review the Neurology chapter of the Oxford Handbook of Tropical Medicine at my next convenient chance. The patient was sent home, that is if she had one, as she complained of no functional incidents and the face numbness was ipsilateral to the bodily decrease in sensation. The following neurologic cases were not so straightforward in diagnosis and clinical decision-making; I was grateful for the presence of both the chief Adult Inpatient medic and a foreign consulting physician.
The second such patient was a sixteen then eighteen then twenty-three-year-old female, depending upon the translation steps required for various providers, from Karen to Thai to English and what seemed like the whim of the moment. She had endured low back pain for two years in Bangkok while working illegally, and upon return to Burma two months prior to admission she had developed an ascending asensate bilateral lower limb paralysis. These deficits had reached, by what we understood as two weeks prior to her arrival at the clinic, the level of T- 12 and had led to urinary and fecal incontinence as well. The causes of such symptoms that come to mind include infectious myelitis, spinal or paraspinal infection by tuberculosis, tumors such as lymphoma or multiple myeloma, and disc prolapse. We were rather concerned about the likelihood of a tumor given the insidious course and inquired as to the possibility of obtaining magnetic resonance imaging (MRI). Evidently, that modality is not employed in this province or those surrounding it. Computed tomography (CT) was our next hope, though not ideal for the diseases we hoped to rule out.
The hospital in Chiang Mai, five to six hours away by bus, does have CT capability, but again this would require four thousand Thai Baht. Each Inpatient Department (IPD) receives a fixed monthly allowance for sending patients to such procedures, but allotment is usually preferential toward young children with straightforward cases, a high pre-test suspicion of some treatable diagnosis, and an excellent likelihood of recovery. Priority is also given to sick parents who have many family members to care for. Plus, it would be unwise to use up the funds so early in the month; what if someone sicker shows up in three weeks, or tomorrow? This patient is not expected to be included in the monthly chaperoned pick-up truck journey, for the above reasons and also because of the uncertain but probable long duration of disability. Acutely, such symptoms would constitute a surgical emergency, but they have been present for well over the forty-eight hour window. Besides, nothing is really a crisis anymore along the Thai-Burma border. We will, however, refer the young lady to MSF for TB testing. The question that remains is why the young woman, reportedly lucid and verbal, seems afraid to utter a single word and so defers fearfully to her ever-present husband in every single response to our inquiries.
The third neurologic case involved a young man with fever, headache, malaise, and some tingling sensory disturbances in the bilateral lower extremities. He presented five days ago also complaining of aches in his back and buttocks. His legs weakened progressively over the first three days of his stay. He now fails to plantar flex or dorsiflex the feet more than say 1/5 motor strength, yet sensation to light touch is completely intact. Any paresthesia has completely resolved. So, acute afferent motor neuron symptomatology resulting in effectively flaccid paralysis of both lower legs; I had never seen anything quite like it. Both older men with whom I stood flashed on the diagnosis instantly as a classic case of a certain childhood disease no longer common in the developing world. Polio. Some countries don’t report.
May this writing heighten awareness about the plight and great beauty of the people from all parts once called Burma. May it bring benefit to all who are described herein and to all who read it. May you be truly happy.