McKean Rehabilitation Center
I took a red truck taxi outside of the box city of Chiang Mai to the beautiful surrounding nature where the historic leprosy hospital is set. The McKean Rehabilitation Center is enormous, acres of meadows, T-tree plantations, 200-year old ficus trees, crumbling wards, new wards, 17th-century style houses, small cottages where old patients live, and everyone moving around the campus on scooters because of its vastness. Dr. Pajon took me around on a tour. He is an elderly man with wispy silver hair and smiling eyes behind thick glasses. He has been practicing medicine for more than 50 years!
He showed me leprosy patients having reaction. We saw both type 1 (red patches, neuritis) and type 2 (ENL: erythema nodosum leprosum). One of the patients having reaction was having his hair cut by the hospital barber on the wrap around porch. I asked about how Thai leprosy patients typically present deformity. Dr. Pajon said that even through these patients frequently have reactions, they rarely develop deformities like clawing of hands, contracture, and absorption of bone. The answer to the question is very interesting, but I have decided not to post it here in public space. We visited the cottages of patients from Myanmar with active disease. Today there are very few new leprosy cases in Thailand, but many come here seeking treatment from Myanmar. I thought about Dr. Saw, my roommate in India who is the only reconstructive surgeon in Myanmar. Why are all of these patients coming to Thailand when they could go to see Dr. Saw in Myanmar?
We also visited the cottages of patients who have been here for over 50 years, from the time when leprosy was not curable and posed a huge burden on Thailand. One old man whose face knew no other expression than warmth and happiness held up his hands and smiled for the camera. He has been here for most of his life and never wanted to leave even when his family encouraged him to go home. He said he was afraid that his community would not accept him so he chose to live his life at the hospital.
One of the very kind hospital staff members drove me all the way back to my hostel in Chiang Mai. He invited me to attend the 105th anniversary of McKean Rehabilitation Center, during which we would be riding bicycles on a 22 km countryside loop together with leprosy patients. “This is incredible, and familiar,” I thought as I remembered my bicycle trip across America raising awareness about leprosy. Things always come full circle.
Into Thailand
Chiang Mai is a city of temples, yoga studios, massage parlors, and nightclubs. It is one of the easiest places in the world to make friends because everyone is looking for exactly that.
Do You Know The Heart?
I packed my things, said goodbye to Sara and the kids, and headed for Entebbe. I would stay the night there and fly to Thailand the following morning. On the Matatu to Entebbe I was inspired to write a children’s book. As I sat, squished with my things and people against the window, many different passengers boarded and dismounted every 400 meters or so. A three-year old accompanied by her mom with a new born got on. First I noticed that compared to her body, her head was enormous! She was fascinated by my pale skin. She took my arms in her tiny clammy hands and began stroking them. She told me her name was Joel.
Then she asked: “Do you know the elephant?”
For a moment, I paused, not sure how to answer. “Yes, I know the elephant,” I replied as images of elephants drinking from the river at the Queen Elizabeth Park came to mind.
“Do you know the hen”? She asked.
“Sure, I know the hen, I said, “but do you know the goat?”‘
“No, what is the goat?”
We peered out the window and sure enough, a fat goat on the roadside was visible.
“This is the goat I said.”
“Do you know the tortoise?” She asked.
I thought about the enormous tortoises in Madagascar lazily rummaging around in the dirt.
“I know the tortoise,” I said, “do you know the papaya?”
She looked confused. I scanned the fruit stands outside my window: “There!” I pointed. Joel followed my finger to the stand overflowing with papayas, bananas, jack fruits.
“The green ones?”
“Yes, that is the papaya”.
“But do you know the fish?” She asked excitedly pointing to the fish stand next to the fruits.
“I even know the fish in the great big ocean.” I remembered the St. Wally fish that had comforted me as my knees trembled scuba diving at the bottom of the ocean. His lips were so pronounced, his scales soft and grey. He had cuddled right up to me probably expecting handouts but nonetheless comforting me.
“Do you know the butterfly?” I asked.
Joel clasped her thumbs together, fanning her fingers out and beating the butterfly wings in the air. “I even know the snake,” she said as her hand shot out and began slithering over her knees. In a hushed and serious voice Joel asked me if I knew the moon. I bent my head to see the sky out the window, but there was no moon visible. I didn’t say anything because I couldn’t decide if I knew the moon. I have seen countless moons. Full yellow moons in the Ugandan villages, parcival crescent moons in the Nevada desert, blood red eclipse moons, lazy moons in a sky of stars over the ocean, cloudy moons through the thickness of evergreen branches. I only know the moon by the different kinds of light it reflects and the different shapes it makes visible. That is not the moon, so do I know the moon?
A man got off the matatu and tipped something over so that it fell out of the vehicle. It was a bucket full of hearts. They spilled out onto the dirt, rolling around. The conductor was furious! I imagined this was his meal for his family, now full of dirt and small stones. He stooped to the ground and began picking up his dusty hearts. He plopped them one by one back into the bucket. I felt so much sadness for him. Of course this was an accident, but the consequence was very sad. I asked Joel if she knew the heart. She shook here head slowly. I put my hand over her chest: “lub-dub, lub-dub lub-dub”.
“Those are cows’ hearts on the ground, and this,” I tapped her chest, “this is your heart. It beats because you are alive.”
Morgue
We asked a nurse to direct us to the Morgue in the basement of Mulago Hospital, Kampala. Mohammad was giving me a full tour of the hospital. The nurse told us to walk all the way down the corridor and open the doors on the left. The corridor felt endless as we anticipated the grisly scene we were about to behold. “Are you gonna faint?” Mohammad asked me. “I feel OK for now,” I said nervously. We pushed through the doors and my eyes fell upon autopsy sinks and sopping floors. In each basin of a sink lay two bodies. On the floor a pile of small bodies, barely covered by a sheet. The ones in the basin sinks had either been autopsied and had the long line of sutures extending from pubis all the way to the tip of the chin, or were being worked on. I watched the mortician empty a chest and abdomen of all their organs and connective tissues. A massive liver, a pair of lungs, trachea, kidneys, a small pancreas, endless intestines, gall bladder, esophagus, stomach, and the human heart. They went splashing into a metal bowel where some chemicals were added. The chest cavity was power-hosed out. The light made the chest wall almost transparent, glowing strangely. I thought it looked like a basket or a cage: ribcage.
Each organ was biopsied and examined for abnormalities. Then the mortician began suturing the two halves of the young man’s abdomen and thorax together, all the while speaking to us casually. In the effort to reposition the corpse, he suddenly pulled him forward in the sink so that his neck, open and missing esophagus and trachea bent grotesquely backwards over the ledge of the basin. When the mortician had reached the thorax in his sutures he put the forceps and needle holders down, picked up the metal bowel of organs, and proceeded to dump them back into the thorax. He poured them in just like you might pour a pot of noodles into a strainer in the sink. The organs splashed around in their chemicals as they reentered the gutted out cavity. The mortician finished suturing the corpse all the way back to his chin. I looked around the room at the dead faces in basins. They were all young. Nobody above the age of 25 or so. On the floor I suspected the small bodies covered by a sheet were children. The mortician explained that they get about five fresh bodies for autopsy each day. Every patient who dies in hospital must be autopsied. They also get corpses from outside. As the mortician began on the next body, we had had enough. We left the morgue, that grim underworld, and stepped out into the equatorial sunshine above.
Mohammad showed me the pediatric ward, the HIV clinic where he will soon be working, and oncology. I felt very sad in the cancer ward as I always do. It was even harder for me to step into the cancer ward than it as the morgue. After a very extensive tour of Mulago Hospital we went out for Indian food. It was delicious.
I said goodbye to my friend Mohammad, who taught me so much, took me on call for nighttime emergencies, and kept company when we worked together on computers in the nursing school. Back at the house Sara and I went shopping for supplies we would bring to the party. Cheese, crackers, wine, beer, ginger snaps, and we were off. It was wonderful to see how nicely the expatriate and local communities mingle. This party was quite posh compared to the ones I had attended out in the village. Everyone was dressed smartly, hair styled in dreads or other fashionable looks. Kampala is a city of young professionals.
Familiar Faces in Kampala
I wanted to buy this book, “Cutting for Stone”, that I began reading at Kagando but had to leave behind because it was not mine. Sara took me to the Oasis shopping mall where there is an enormous bookstore. My two favorite kinds of shopping in the whole world are: 1) books and 2) groceries. Actually all other shopping is stressful and somehow disturbing to me. When we were walking down the ramp in the mall I saw two very familiar Mzungu faces staring at me with a look of disbelief. It was my favorite surgeon, Uli, accompanied by the radiologist, Olga. They are both from Germany, working longterm at Kagando. Kagando is a day’s journey away by bus and I was so surprised to see the two of them here in Kampala. We embraced and then went around together marveling at chocolate, nuts, biscuits, apples, and other things that you cannot find at Kagando.
That evening I met up with my medical intern friends, Mohammad and Shariff. Mohammad is Somalian and Shariff is Ethiopian. We went out to a cozy Ethiopian restaurant called Abinet. I drank some of the best coffee I had ever tasted. It was so good that I didn’t add a single drop of milk (unusual).
TB/Leprosy fieldtrip
I I rose too early from my bed and was overcome by the awful feeling of nauseous fatigue. I rummaged around the Buluba guest house collecting my things that I had dispersed over the weekend around the room. I made an egg, ate a raw carrot, and marched with my pack and brief case over to the mess where I would be meeting the Sudanese health workers for the bus. We pilled into the bus when it finally arrived in front of the mess having stumbled over the branches and stones and piles of grass in the garden. Today I was accompanying the Sudanese on a TB/Leprosy field trip to Kampala to tour the National TB Referral Laboratory (NTRL) and the program headquarters. After a stuffy dusty bus ride that effectively lulled all its occupants to sleep, we emerged at the NTRL in Kampala. I was embarrassed to find that no matter how hard I tried to stay alert, I would invariably nod off in each of the lectures we had to sit through. Maybe it was the lack of ventilation in the room, the early morning, the long bus ride, or because I had already learned a lot of this material in India. I hoped that nobody saw my narcolepsy but after the TB talk finally finished, one of the Sudanese guys pointed it out. I was really impressed with the group of Sudanese health workers (not just because they managed to stay awake when my eyelids refused to lift) but also because they were deeply serious and committed to their work even though they cannot practice in a normal health environment because of the political conflicts.
I said goodbye to my Sudanese friends and hopped on a boda boda motorcycle heading toward my friend Sara’s house. I waited at the Little Donkey Mexican Restaurant for her children to take me to the house around the corner. While I waited I enjoyed a delicious burrito and I was surprised to discover that I had no desire for cheese. When the server asked if I would like cheese in my burrito I automatically said “no thanks”. Then I thought, this is weird, cheese used to be one of my favorite foods. I remembered a certain survey students had done at Bard about cheese and some sensitive subjects and at the time the thought of giving up cheese for almost anything was impossible. But now, nearly ten months without cheese has made me realize that it’s not important, and definitely not an essential part of my life. I think I would answer the survey much differently now. Back to the restaurant though: I saw three familiar Ugandan children marching up the hill. I smiled and waved at Sara’s kids, Innocent (15), Achai (10), and Charity (6).
