Post-BOM days...

So I am not only bathing in rose petals but drinking rose water these days... it's intoxicating, delicious -wonderful (I am not literally bathing or drinking in these ethereal creatures, don't worry -I may be a little crazy, but I haven't lost it completely!). Life is good.

Post-BOM (Basis of Medicine) life is great. I am in Vancouver, chillin' out with my sister before spending more time with the family. It is good -restful, and I can be supportive where I'm needed, and I can go into my little cocoon or cave or whatever and rejuvenate my body and mind however they need. I have goosebumps from head to toe. Because it's freezing here every time I leave the bedroom (there is no concept of central heating on the West Coast -despite the snow and cold weather that they have been getting for the last 10 years, they are still in denial about the true nature of their winters...) -I have to debate whether or not the joys and benefits of a shower actually outweigh the cost of freezing entirely upon exit from the tub and exacerbating the whatever minor infection that I'm fighting.

I've been working on planning out my holidays -which friends to visit when and where, what I'll be doing in New York, is it possible to change my Amtrak ticket to leave a day sooner, etc, etc... I realized this morning that I would really love to go to Cafe Ceramique when I get back home, and also I want to work on a new short story, and practice the piano a bit and... read... and do those things that bring me so much joy. But right now I feel exhausted and tend to have a headache most of the day, which prevents me from doing little else than napping. And it's not like I nap and then I'm full of energy. I nap and it's hard as hell to get out of bed. What is wrong with me. Am I really that exhausted from the last BOM stretch?

Anyways, time to return to the revelry of my daydreams... maybe drink some ginger and honey tea and... take a little nap.

Bathing in Rose Petals and Anticipating the Holidays!

I know my posts have been strangely infrequent of late. A lot has been going on and not exactly the kind of thing one expresses through this medium. But well. I love writing for you too, so what shall we talk about today?

I wonder if there's actually somewhere in the world where people can bathe in rose petals. Wouldn't that be a whole other-worldly experience? This image keeps coming to me and it would be cool if it existed in real life. A whole big fragrant basin of red and pink silky softness floating over the dark world below. No? It's just me?

Studying goes along. Lots of cancer out there. Simultaneously bleak and hopeful I suppose. Also, I'm convinced that we're all a little psychotic once in a while. And prenatal genetics screening really does seem mainly like another way to worry prospective parents, despite having the intention of 'educating / informing, preparing, etc...' Oh and the elusive epidemiology. Everyday I think I've got it. Then I go back to it the next day and find something that I wasn't quite as clear about as I thought I was. YouTube videos are helpful in this regard "if p is low, null must go"...

I'm ready for my break though. Vancouver with family will be lovely, followed by New York with friends. I was looking at what's on Broadway and in Lincoln Center these days... so much, so exciting! Rush tickets = best invention of life. Definitely have to see something at least one night that I'm there (although I remember with fondness that very first trip ever to New York City when I was 18 and we saw 2 in 4 nights... if it was possible, I would go everyday!)... like right now in NYC, Jude Law is starring in "Hamlet" (and apparently rush tickets for that is just $30), John Stamos in "Bye Bye Birdie"... would love to go see "South Pacific" at Lincoln Center (Rogers & Hammerstein... sigh) but that's a bit on the expensive side... anyway, anything new that I haven't already seen would be wonderful.

Also I'm already dreaming of those cookies at Levain Bakery... anyway, of course the best part will be seeing all those friends I haven't seen for the last year and half since graduation! And of course, watching lots of movies and sleeping a lot, reading for pleasure, getting some stuff done before school starts...

Well, better get back to studying (and I will probably try my hands again at the piano for my next study break... you wouldn't know I played for 15 years at the frequency of once per year that I have been playing since I quit... I really should keep that up better...)

hugs and kisses--

In the eye of the tornado

There is so much -so much to do, so much on which to catch up... feels like I'm in a wormhole getting swept to some destination and I'm just being carried to wherever it is. The control-freak in me is not a fan. But well, sometimes that side needs to just shut up and take one for the team. The team refers to the rest of me. And the team has a lot of things with which it is dealing, so hopefully a little faith will carry me through unharmed. The last couple of days have been rather zone-y for me... I've had no sense of time or space or imminence, even as I pull late nights to successfully meet my deadlines. I'm just kind of in an infinite swirl. And there is beauty and love and kindness and connection, and communion with my real self. I feel antsy and anxious one moment, and in a dynamic serenity the next; I have little appetite and little sleep... I'm so restless. Is that an existential restlessness, like knowing something big is going to happen to you or to the world, but having to wait for it even though part of you is impatiently shouting "the big thing is going to happen"... except you're not sure what that "big thing" is. Have you ever had that before?

I would like to just curl up with some hot cocoa on a couch, freeze time, and watch old Audrey Hepburn movies... just let it soothe and quiet away all the restlessness. But part of the restlessness is magical -the energetic waves, the sudden goosebumps from head to toe, the inner stillness and the inner storm. Where am I? What am I? What is all this? It's asking, it's wondering, sometimes pleading, sometimes rejoicing that the questions come so loud and clear and fierce. It's very Dagny Taggart. It's a passion that roars, but is struggling to understand itself. What is this feeling that I'm feeling?

To Feel Like a Million Bucks...

Feel our mortality. We are simultaneously living and dying everyday. If you're smart you know it, but how many of us make an effort to feel it at least once a day? Recent events in my life have brought me once again in close quarters with how fragile yet strong, how small yet meaningful our existence on this Earth actually is. For days, I could not fully immerse myself in the mundane of the routine -I mean, I've been getting done what I need to get done, but my thoughts are elsewhere. I walk around humming the shahada and various other prayers... so much of so much feels unimportant. And then I realized that certain special blessings are already stacked in my favour so might as well be pro-active about the things that are actually important to me in life -a real kind of 'co-creation' of dream-manifestation, a partnership between souls of this world and of the next... I wanted to resist the cliche, but wanting to be absolutely clear here: "God helps those who help themselves".

And so I woke up today to a beautiful, crisp sunny day in Montreal. I felt restless but full of life and beauty. And I went for my second patient interview 'practicum'... an elderly patient with a fungal infection in the lungs, secondary to HIV. Today, though, I felt like I did something useful for her, beyond 'listening to her story' (really, though, medically-speaking... med students are far from "Dr"... being a Doc is like being pregnant, you either are one or you're not one, you're never "half-Dr"). My community service internship last year volunteering with Project Genesis for social rights education and advocacy in the poor and immigrant communities in Montreal actually came in handy today. You know, doctors take pretty good histories, I guess, most of the time. But it wasn't in her chart that there was mold in her apartment and that the landlord refused to do anything about it (most likely against the law, actually)... that doesn't exactly help an immune-compromised patient! At least, I could tell her about PG and where it was, what they do, how they could help her... also finding out that she's religious but hasn't been able to practice since she's been in this country because she didn't know where the particular house of worship for her denomination was, I was at least able to suggest that someone find out and let her know / told her to ask someone providing her care if they knew / get social services involved in finding out...

So, you know, I'm not curing cancer yet or anything. But today I felt like I did something meaningful for this patient. And if today should be my last day on this Earth, I have no regrets. I'm doing my best at what I do, I make time for the people and things I love, I regularly tell the people I love that I love them (I love you!), I felt God / the infinite energy of the Universe in everything today (this is a blessing, it doesn't happen all the time... I mean, of course God is in everything all the time, but to feel it is a completely different thing!), and I have been taking some initiative in at least increasing the odds that some of my deepest desires can be fulfilled. What more can a person ask for? Productivity. Better get back to it!

A Prayer for Grandma

Dear God,

Please look after her -we love her so much. With every salty drop that blurs the world we see, bless her, lift her up and cradle her in the vast expanse of love that is your arms. And let there be music, laughter, song, joy in that place where you take her, whether it ends up being a few more moments back here or in the next. But wherever it is, everday a sunny day, every breath a happy one, no pain or suffering, just peace and light. And love. Lots of it. All around and everywhere. Her life's loves to greet her, and a Universe big enough for all the love in her heart (this one is too small). And let her hum with a twinkle in her eye and run free along the banks of the Great River, to rest only for deliciousness and delight. We love her so much, but not as much as you do. So please, look after her.

Thank you.

I have found the Holy Grail.

Well, I guess technically, I was referred to the Holy Grail -and I actually had my first sip yesterday with Elizabeth Gilbert, but these Ted Talks are seriously the shiiiiiiiiiz. I just finished watching Jill Bolte Taylor's "Stroke of Insight" -amazing. Really. It's 20 minutes of your life well-spent:

http://www.ted.com/talks/jill_bolte_taylor_s_powerful_stroke_of_insight.html

Back to ANS drugs... studying them, not taking them (take a chill ;)

The Joy of Creative Genius and the World on the Bus Goes Round and Round...

I have a real nice bundle of studying to do, but before that, I just want to say this.

I think I'm in an existential happy place right now (as in, this very moment, we're not even talking the whole rainy day), and that is because Elizabeth Gilbert (the author of Eat, Pray, Love) speaks a wonderful Truth. Not just in her beautiful memoirs (which, so, well, you know I absolutely loved it... but not because it was the best story of all the time -I fell in love with the protagonist -her writing made you love her... and I think that really takes a special kind of writer, where you fall so in love with the protagonist that you fall in love with yourself and humanity too, and it's not even about 'what happens' or 'how it happens' -you'd give your life for that character. I think every writer wishes this for their own elusive 'favourite' characters... it is the greatest blessing of the creative fairies and inspiring gods to bestow that, indeed!), although of course, as the bracketed tangent hints, there are Truths to be found there too. But I just watched a 20-min Ted Talk, "Elizabeth Gilbert on nurturing creativity" and it was... just watch it (she is a good speaker and the principles are somewhat universal, so even if writing ain't your bag, you will most likely still enjoy it):

http://www.ted.com/index.php/talks/elizabeth_gilbert_on_genius.html

Also, today I realized that the most real-world experience one can have is riding public transportation. I always notice strange and interesting characters and wonder about them -those bratty tweens who gossip and backstab (and you get to witness all this drama live, day in and day out -and you want to tell the quieter, sweet girl that her loud friend who's so popular with all the boys, though promising to talk her up to some guy she has a crush on, in reality, talks her down, revealing her precious secrets to a bunch of losers who, blatently and regularly, demonstrate that they are only and always thinking with their little head -so not worth even her puppy love) and flutter their lashes and roll up their kilts... sometimes amusing, mostly annoying and on some special occasions, heartbreaking.

Then there's that woman who's always perfectly made-up and then suddenly is not, or that 30-something year-old man all suited-up and iPhone-happy, often speaking Persian infused with Quebecois French to some mystery person on the other end, or the other scrawny 30-something year-old guy in dirty, hole-y jeans with tatoos all down his arm who gives up his seat like a reflex when an elderly man or woman gets on the bus. And also there's the most-likely schizo girl on the second bus who mumbles to herself one day, yells at strangers the next day, and makes the whole bus laugh the following day with an unfiltered soliloquey of her private thoughts and fears turned inside out and upside down... you learn a lot about yourself, about people, about the world, on that ride. Like today. It was past 2 and I hadn't yet eaten lunch, so I pulled out my bag of raw veggies and tupperware of humus in the metro. We get to Cote-St-Catherine, or Plamondon, and just as an old woman with deep smile-creases on her face and dark wrinkled hands, wearing a yellow blouse and a black leather jacket was about to get off, she taps me on the shoulder, gives me a thumbs-up and grins. I returned her smile and then probably kept smiling stupidly to myself for the remainder of the ride.

What was that for? Good for me that I'm eating healthy? Or did she recognize all the medical advertising on my very-standard, identifying "I'm a Med-2 in Canada" schoolbag? Or did I inadvertently drop the H-bomb when I pulled out my nalgene for a drink of water? Or did she like the cute hat I was wearing today? Personally, I think she approved of the veggies (and frankly, I like it better that way). But funny, eh.

Anyway, time to get on that work... I think I shall take pharm as my first lover tonight...

All the Heart's Longing in a Brief Moment

I feel tired of all this. Time for a pause, really. My glass of water is half. My stomach is full. It's already dark outside and it's not yet 7. The world feels still and yet moves too fast. One can feel alone in a room full of people, and full of comfort when actually alone. Turning on a light just made me smile. I'm trying to build a fortress around my sanctuary -keep the worries out. But they niggle and crawl and butt their heads against it. All waters should be like the turquoise and opaly Egirdir. I miss my curly, red-headed friends right now. Kindred spirits from what seems like another life ago... I miss you all at different times (consider that a compliment to your individuality).

I'm aching to write in a real way... I want the rush, the high... that feeling of entrallment and infatuation with one's own elusive characters... but here I sit and I am bound. Remind me not to love this cage -it would be such a shame to never fly, just when my wings will have grown in.

Writing on a late-night high... drunk on naught

And by naught, I mean, little sleep and lots of tiredness to the point where there is no energy left to worry about things.

I ought to write something beautiful today. It's nearly 2 a.m. and there's darkness all around me except for the light on my desk and... one another light. The rain is tinkling gently on the loft pane. I haven't really taken the time to just sit here with you and write the real write. It's hard to get there oftentimes (especially with new stresses and a tendency towards compulsive and control-freak-like behaviours under said stress), but well, there's lots of blessings. Like yesterday, I almost beat the next bus, walking home from the metro (the 5 minutes by which I lost was really such a tragedy... the longest 5 minutes of life!). Still, that means that my brisk walk home was rather impressive. And tonight I had a lovely time catching up with friends, hanging out at a new place (Pullman -on Parc above Sherbrooke -trying out new places is really one of the bestest things I think... next on the list: Byblos, Rumi, a friend's other brunch place mentioned, and 2 tapas places...).

But so, Pullman. If you like the drinkies, very nice wines for very not-that-expensive (I was designated driver, so after a sip of something white and a little fruity, I had a 7up with grenadine... yes, this is commonly known as something else, but let's save some face here by going with the 'grown-up' sounding description ;). Tapas on the other hand, on the pricey side -but worth the experience... scallops, 'the best grilled cheese in Montreal' (to be honest, I don't think I've ordered grilled cheese at a restaurant in Montreal in my life), salmon tartar thing, chocolate con churros (now this is the shiiiiiiiiz), beets with something... all very nice indeed.

I need to start working out in a serious fashion (but in order to do so, I think I will require adequate athletica to replace my 4 year-old running shoes...).

Grey's Anatomy, also good these days. Mer-Der gettin' a bit old, but lots of other juice to keep things flowing.

Remind me that I have to track down this Kashmiri philosophical romantic that I met in Dubai so that I can scoop up his lifestory and just make a character for my novel after him.

Also in the spring (or fall if the rain'll just quit), I would like to go visit McGill's Arboretum in St. Anne-de-Bellevue. There's apparently some pretty hikes around there too...

I'm flirting with the idea of going to Egypt with some friends for 2 weeks in early December after exams.

I know, such an un-poetic line on which to end this post. Well, what to do.

White Coats: Becoming a Real Almost-Doctor...

This is my carrot (and I must say, that unlike other things in life, like good food and kisses, one does not reap as much satisfaction with all that holding off and anticipation... for me, it was rather anti-climatic... there is something to be said for that 'spontaneous freshness' of creative imaginings... still, hopefully you will still find it interesting!). I was actually going to treat myself to blogging yesterday if I got all the work done that I had planned, but as it always goes, I only finished it up today (all caught up now though -let the real studying begin! I guess in a way it's good that it's going to pour rain for the next couple days and we can't go hiking up north anymore... I mean not really, I was so looking forward to that, but well, what to do!). At least I have Madonna's "Celebration" to keep making me happy here ;)

Before telling you about the big White Coat day, I just want to briefly mention that last weekend I was in Quebec City for a family medicine symposium where, not only did I get to take part in a suturing workshop and learn some basic kinds of stitching techniques (and incidentally, get filmed by the RDI crew... I didn't even realize that I was on TV last Saturday night apparently ;), but I also had the most amazing opportunity to hear the real Dr. Patch Adams speak. Yes, I will now say the most cliche thing ever: he was really so inspiring, that idealized family doctor who will do anything for his patients, who never charged any of his patients a dime (he held side jobs, essentially 'paying' to practice medicine for 39 years), goes around to underprivileged areas (of the U.S. and the world, I think) to health care facilities that don't have enough resources to adequately manage patients' pain, and provides psychosocial relief through his Clown Tours... he travels 300 days a year (doing this, giving these motivational talks too, I'm sure, visiting good friends / patients -one and the same for Patch, based on his stories) and writes over 600 letters by hand, per year to essentially fans from around the world... he's pretty much awesome. And wonderful to hear in person, standing casually before us, dressed in a clown outfit with a long greying ponytail, telling us to love ourselves and each other and not to forsake love for rigid, old-school "professionalism" and dehumanizing, patient-alienating rules in medicine (don't worry, I can take the message from this without going the extreme, but he did make some excellent points!).

And now, for the White Coat Ceremony.

Yesterday was a momentous day -I had my more formally entitled, "2009 Dr. Joseph Wener Donning the Healer's Habit Ceremony", beginning (half an hour late) with a "musical prelude" from the Medici di McGill String Quartet -a really lovely piece by Dvorak and another by Carlos Gardel -followed by intros and addresses from the Associate Dean, Dean and a family med / medical humanities doctor from Michigan / Texas (it was actually a pretty good talk -a First Nations story about the healer's journey, and the importance of virtue and love in medical practice to complement all that solid technical knowledge). The most moving though was hearing the reflections of a Med-4 at McGill talking about his personal experience being diagnosed with MS when he was a Med-1 and how the right kind of doctor with the right kind of communication skills can make the difference between a doctor who leaves their patients feeling helpless and afraid, or reassured and full of hope. It was quite touching to hear his story -so compelling (and apparently, when I react to people's stories I'm expressive enough to warrant the photographer zooming in on my face, which was kind of weird, really...).

Then we were "donned" with our White Coats -basically, 200 of us have our White Coats ceremoniously put on (2 at a time) by a big-shot McGill Medicine Faculty person and posing for a photographer... long, but, well... I guess that's partly the point. It does feel different when they put the coat on though, I'm not gonna lie. Especially because we also have our official engraved McGill nametags pinned on as well for when we go into the hospitals... it's kind of like "now, you're legit", but also "now, you better know stuff so you can help people", and frankly, people will expect quite a lot from us. That sense of responsibility was lost on no one, despite the sometimes snarky comments and making fun of all the pomp and circumstance of the ceremony beforehand... it's nice to have a tangible thing, a kind of rite of passage as we transition into real almost-doctors.

Anyway, we ended by reciting an Oath / Pledge on which a few of us from our class had worked really hard, right before the summer... okay, yes, I will just admit that I had a pretty big hand in its compilation, synthesizing the others' ideas into one cohesive message that represented all our values, to the best we could. It was a good Oath and I was very happy with it, but the real pride will be in, God-willing, being able to uphold it:

Pledge – Class of 2012

Remember the excitement of our first days as medical students? That early passion, which we surely feel again today, will be our motivation throughout our careers as we strive for excellence in delivery of care, scientific exploration and ethical conduct for the benefit of our patients, colleagues and society.

In full awareness that this journey is ongoing, recognizing our diverse talents and the value of supporting each other’s health and well-being, that we may fulfill our social and professional mandate, and

Appreciating that, through the generosity of our time, knowledge and understanding, our collective achievement will exceed our individual contributions,

We pledge, together, to our patients and to Society:

To be fully present with you, recognizing the unique fabric of your existence;

To learn from our mistakes and from you, that we may gain wisdom to adapt our methods to serve you better;

When we do meet with clinical and innovative success, to remain grounded, without pride or complacency, that we may continue re-phrasing our questions and searching for answers within the context of mutual respect, openness and trust;

To be your advocates, not just in words, but through our actions; your social struggles are ours too. We seek to transcend our differences and work together across disciplines, that we may make you well, keep you well and prevent your illnesses, no matter your background or status.

We recognize that microscopic pathologies often reflect larger social challenges. We will do our best to address those social determinants that prevent you from maintaining health and well-being.

To Medicine, we commit, both as career and vocation:

To be not the servants of science, nature, nations, personal beliefs or even our desire to preserve life. Understanding the reality of our own mortality, we endeavour, instead, to heal our fellow human beings and free them from constraint, so that they may flourish.

We embark upon this calling with humility, fervour and love for humanity.

Autopsies, Congestive Heart Failure and... Fried Bananas!

Yes, I do actually tell you how to make the most delicious fried bananas in the world, based on my mum's exquisite culinary instincts, at the end of this post...

I watched my first autopsy yesterday -coolest thing ever (so far)! It was kind of a nice surprise -our pathology small group leader at St. Mary's Hospital decided to give us a break between discussions of theoretical 'clinical cases' on athersclerosis and congestive heart failure, so that we could see not only what a real, recently infarcted heart looks like, but examine the surrounding tissue, clues from the state of the once-patient's body and better understand the pathophysiological mechanisms that lead to their death. It was fascinating. Also, you should know, it was done quite respectfully. I agree with our small group doctor -autopsies should be more regularly requested. Because even if the docs are 90% sure of the cause of death, you never really know until you go in. Sometimes it can be genetic, in which case, the whole, still-alive family can benefit from the diagnosis. Other times the first diagnosis might have been right, but reasoning how and why that particular lethal final event came about may have been inaccurate. Autopsies are important because they allow us to do justice to our patients and to their families after the end, and they also allow us to learn from our mistakes so that we can be better doctors.

These days we are learning a lot about congestive heart failure, coronary artery disease and hypertension. Something you should know point-blank about heart failure is this (a surprise to me, incidentally): all those meds (Beta-blockers, ACE inhibitors, diuretics, statins, etc...), they help alleviate suffering from the symptoms, perhaps prolong life a little bit... but ultimately, people in heart failure are going to die -the meds don't "fix" them. 50% of patients with heart failure do not live past 5 years from their diagnosis. The only way to give these people a new life is to give them a new heart. Harsh reality, and yes there are nuances... and there's reason to be hopeful in the sense that there's still 50% who do live longer than 5 years, but, well... better to know the stats and then make the best of the time one has left. It does not mean that you go around breaking bad news to people like its common, but it's important that patients are not being deluded into thinking that heart failure is just another medical condition, like the flu or even cancer, that can be overcome and then you move on with your life. You should move on with your life anyway, of course. But I'm just sayin'. Prevention, of course, is totally worth it. High LDL:HDL cholesterol ratios -bring 'em down; hypertension -bring it down; diabetes -keep it under control; getting old... well, can't do much about that... Really though, take your health seriously, so that you don't have to worry about taking life so seriously... at least you'll be there for it!

But you know -exercise, proper diet, all of this is well and good and you should do it. Some culinary delights that may be on the unhealthy side are still okay in moderation... like fried bananas, which I just learned how to make. Get butter to bubble in pan on high heat. Place cut bananas (if normal size, cut in half across and in half long-ways... if larger, cut in thirds across) in sizzling butter. Wait until they get goldeny-red (some can even get black... the more carmelized, the more yummy), then turn them over and let the same thing happen to the other side. Make sure you add a bit more butter accordingly (the bottom of the pan should not be dry). Once done, pour some lemon juice over all of it and stir them around and let simmer for a couple of minutes on low heat. If the bananas were not very ripe or over-ripe upon frying, you will need to add some brown sugar as well (when you add the lemon juice).

Taking them along with mango-peach-pineapple sorbet and fresh raspberries for dessert to a dumpling-making party later this evening. Should be delish. Well... guess I should do just a bit of work before leaving! Love you mucho...

"We're not a mistake" and "You can't earn love"

A very wise friend dispensed these grains of wisdom recently. So for all my fellow perfectionists, these are things that you probably already know, in terms of your "reasoning self", but emotionally... yeah, it can be a hard one to swallow.

We're all imperfect and we live in an imperfect world -cut yourself some slack. Making yourself perfect does not equal making yourself more worthy of love and being less perfect does not make you less deserving or less likely to receive it. Us Type-A's enjoy the idea that everything in life can be 'earned' -work hard, stay focused and you will succeed... right? Right. Except love does not work that way -whether it's love from our families, our friends, our teachers or romantic interests. Which, so, at first makes you feel disempowered right (because what the hell can you do about it right... all those 'games' are for naught)? The thing is that real love is not about power. Empowerment, disempowerment -both are moot. Yes, we may feel empowered as a consequence of love (or disempowered as a consequence of hate... just ask all those helpless women and kids in Karachi's slums)... but love itself is not about power. It's about love -that is, presence, warmth, closeness. And thank God for that because otherwise who'd help you up and hold your hand every time you fell? We can't control it all -often times this sucks, but well, what fun would life be if we controlled everything, and all of our mignons did whatever we said (even if, let's face it, we know what's best for them, for society, for the world... it's hard to care about things that are easy, or feel committed to things that are 100%-guaranteed in our control)?

So well, I do my best now (and before... these things are dynamic though so sometimes even if you think you know, you can forget) to just let it go. As they say in Pakistan, what to do.

After losing 4 lbs in 1 week, I got scared enough to up some of those calories... I mean, I'm just trying to be healthy here, really... it's just when you're not used to watching what you eat, you're more likely to err on the side of less... but you know, I'm working on it. I talk to the people I love about it. I'm talking to you about it. I still eat cookies or half-cookies if tempted by them and I try to eat when I feel hungry. Going easy on carbs and upping the veggies actually makes you feel more alive anyway. And as a good friend said to me today, in my defence, slight dietary restriction is not necessarily unhealthy, and there's just a fine balancing here that I'm working out. If you dropped 12-16 lbs and felt like a million bucks, you wouldn't want me to chastise you for it right?

Things to be grateful for today: fun lunch with good friend, soon-to-be fun dinner with other good friend, feeling confident in small group about learning some medical history-taking tips beforehand and therefore not being intimidated by small-group leader, sleeping in and feeling happy about it, sunny day, parents come back from vacation that felt like an eternity (despite having enjoyed me-time and independence again, I'm ready to not live in a big, empty house devoid of hugs... see at least, you get this latter when you have roommates!), feeling gorgeous... and MOST of all, making the time to write!

wishing you love...

Epiphanies Upon Return and Inner Demons

What a whirlwind of Life since I came back home. If Pakistan was physically, emotionally and spiritually rough... well, it didn't stop upon my return to Montreal.

First couple of weeks back, I was a royal mess. Really. I thought the extent of my "reverse culture shock" would be walking on the left side of the road instead of the right. Wrong.

They don't tell you about what really happens when you come back from the developing world, that it varies from person to person. We only ever hear about the "enlightened return" -you know, where the traveler or do-gooder or whoever, comes back with a secret kind of wisdom and understanding, strong, solid, confident, unshakable, and a bottomless well of compassion. I mean, it's who I wanted to be, that's for sure.

Let me tell you what happened to me in real life -it was humbling, to say the least. First week of school: I was more Type-A than ever, I was not able to 'rise above' with all that 'developing world perspective' -I needed to control everything. I swore at computers, ran around doing my errands like a paranoid, crazy. I felt like I regressed into old insecurities, but amplified now, with a vengeance, including a new obsession with weight, calorie-counting and prettiness. I have dropped about 1.5 BMI points, including the weight-loss of being sick twice in Karachi. I felt alone in a crowd. I felt like no one understood me, and that I didn't understand myself. I was right, at least about the latter.

See, I managed to convince myself that the emergent control-freak was because rather than feeling "enlightened", I felt an overwhelming sense of responsibility. Having seen what I saw in Pakistan, it was my responsibility to be perfect, remember every single little medical detail in my training because if you forget a detail someone will die out there because you never know if anyone else will remember that tid-bit that you should have known. So I had to be perfect on the inside... and I reasoned that somewhere in my head, I had decided that inner perfection required outer perfection... and whose body couldn't be a bit more perfect than what it is right?

Wrong again. I talked about it with my best friend, my best mentor, my sister and the Truth revealed itself to me. Since when does "a sense of responsibility" make one hate oneself, make one want to punish oneself, make one feel unworthy of love and cut off from the world? Yes, I do feel a sense of responsibility, but that was not the driving emotion behind my crazy behaviour. That was Guilt. Shame. Unacceptance. Guilt for what? That although I learned so very much working in Pakistan, that despite having met some wonderful people, having had some very special, life-changing experiences, having been blessed to be able to contribute to the work there in a meaningful way, I really, really, really did not love it. I felt no joy. I did not feel alive. It felt like a sacrifice, and I know that I am not the type to truly be able to sacrifice my whole life in this way. And now I was back, and all those feelings were so in my face, and it scared me to death because this is what I was supposed to want, this is what I thought I wanted my whole life. But I don't and I felt like a demon of a human being for that.

I do want to serve humanity still -that will never change. But I will do it in my own way. I want to help the poor, the disenfranchised, the uneducated, the sick... but I know my limits now and of course, I am still working through all of this. God-willing, at some later point in my life, maybe for a short period of time, I will be able to go back to some other part of the developing world and do more work 'on the ground'. I have my own gifts and passions. I can be a good doctor here, I can write for the world, I can effect policy level change at home and maybe in a broader context (I have, afterall, seen what it's like out there, for myself... and really, once you've seen it, you've seen it), but I don't actually want to martyr my life away in an abrasive environment that makes me sick all the time, brings down my energy, makes me feel legally vulnerable and fragile... look, see. If there is no happiness in it for you, how can you expect to bring happiness to others? Your own vessel will be empty. And that would be a fraud indeed.

So I am not fully resolved now, by any means. But I am starting to slowly chew over these early personal revelations. It helps to leave town for a weekend with friends, go out and be careless and carefree and have fun for the sake of fun -real fun, with real freedom. We are so blessed here... I can't give up those blessings. But this week, this second week, I have been embracing those blessings as much as I can.

Life surprises. It's dynamic, ever-changing -what 'is' today, may not be, tomorrow. And I find I am in awe of the mysteries that lie tucked away within myself.

My favourite part of Dubai: The ICD and more...

So good to be back home in Montreal! A great experience overall this summer though -nothing more to be said for now. The rest of my time in Dubai was pretty magical, restful, interesting and fun. I'm not really going to go into details about the rest of it. You know what they say about the number of words a picture's worth right... I actually disagree with that most of the time, but well, my last post was the words, this one's the pictures.

Above: Dubai Park across from the Ismaili Centre of Dubai.

Above: inside the Ismaili Centre Dubai (ICD) -that marble fountain was carved out of a single piece of marble, the walls and domes are all built of limestone, the architecture is in the Fatimid style, as I mentioned earlier, the coloured marble tiles in the fountain outside make the water always look like there's a breeze blowing through it even when it's still, the long hall of arches has an architectural special name (axial something?) where there's one "key stone" that if you removed it, all the domes would come crashing down, and that large room with the rectangular windows at the top is the gym for the Early Childhood learning facility inside the ICD.

At the top is Surat-Al-Fatiah which is in the reception of the Centre, the 7-sided star on the floor is the symbol of the ICD and that 7-sided dome is right above it and the only 7-sided dome in the whole world.

Of course, there's much other beauty in Dubai -below are some pics of views of the beach, Madinat Jumeirah, the Burj hotel, city views, etc...

A Tale of Beauty - Dubai: Epinephrine for the Mind and Soul

I arrived here yesterday, and am, suprisingly (for me) completely taken by this place (well, Turkey first, then Dubai -I think I'm in love with the Middle East, quite frankly). It is absolutely, utterly, stunningly, floor-me beautiful. The gulf is blue blue. And smack in the middle of a sandy brown desert, lies one of the most architecturally breathtaking cities in the world. It is very very clean, and the sun shines very hot, palm trees line the spacious, beautifully paved streets, with creamy, artfully-fused traditional-modern villas on both sides. The skyline is so perfectly unique to anything I have ever seen. Sure, the economic slow-down has made its mark here -most sky scrapers actually have cranes hanging in suspension, all work suddenly halted as money ran out and people ran away... there is also not a lot of traffic here these days and the streets are rather empty, even for these early holy month of Ramadan days.

Aunty N and Uncle S picked me up from the airport, and on the way to their home in Jumeira, I was pointed out the many gorgeous sanctuaries -the essence of beauty, kind of like seeing the thoughts and ideas that usually just result in something that is beautiful -that were the mosques on every other corner, the businesses, the villas, hotels, restaurants, office buildings, social centres, learning centres, shopping centres. I saw the Burj tower -currently, the tallest building in the world -from afar, and the Burj hotel from relatively close. This is not a land where people dream -this is a land where dreams and creative thought forms can become actual physical masterpieces.

Now I had thought that Dubai was just a ridiculously ostentatious place full of overwhelming materialism, a superficial aristocracy that mistreated and enslaved the lower classes to do their bidding... a place devoid of soul and of anything that could be truly beautiful in that existential, real kind of way. I was right about the materialism, the aristocracy, the social injustice, but utterly misguided about the beauty and soul. It's no Utopia -nowhere is, there's always room for a society to improve and grow, you know, reach its 'full potential'. But do not underestimate the value of a place where dreams become things, where human-made structures, gardens, finely cared for beaches, streets and homes and shrubs are so very beautiful that you feel the power and majesty of God, or the Universe or the Human Spirit, or whatever you believe. If you are atuned to it -this can be a surprisingly spiritually uplifting place. And it was just the kind of 'injection' I needed after the life- and self-changing traumas in Karachi.

I learned a lot in Karachi -and those experiences were absolutely invaluable. But remember how I said that these people in the squatter settlements and urban slums have these existential disturbances -addiction to suffering, inability to really reason and think about thinking, inability to love because they have never been loved. If only they saw any beauty in their physical world though, it would change their whole life. If they could see Dubai -if anyone could really, really, really see what Dubai means -then places like the villages in Thatta and Rehri Goth, Bin Qasim, could just not even exist. That's the trouble though. I think that people who are completely seduced and hypnotized by all the material excess in Dubai don't actually see that deeper, philosophical, existential beauty that is the ideas and thoughts and powerful force of action that these buildings, fountains, silky tents and gardens (thought beautiful) merely represent. And those who feel it's all fake, built on injustice and the misery of others, well, the beauty escapes them too. It doesn't mean nothing should be done about the injustice. Of course something must be done about it. But if you could see and understand the beauty, why not draw inspiration from all that, to drive positive social action? Am I wrong? There's no right and wrong. But you must come here one day.

Now I will tell you about what I've done and seen here so far. The Ismaili Centre Dubai must be the most beautiful building in the world -it was designed by an Egyptian architect couple, in the Fatimid style, built almost entirely of limestone, with marble fountains, Moroccan hand-crafted lantern-chandeliers, a 7-sided dome (heptagon) -the only one in the whole world, sky-lights in many metres-high domes made of brick and limestone, onyx engraved spiritual words that allow only the sunrise's light to bathe a small prayer room, a lovely fusion of beautiful Islamic architectural tradition and modern technology into one seamless whole that took about 25 years to achieve from the time the land was gifted to the Aga Khan to being fully built and functional.

I ran into not-too old friends from Boston who now work here after traveling and working elsewhere, as well as met with almost-long-forgotten (but evidently, not at all forgotten!) acquaintances and kindred spirits who shaped many a childhood memory and lesson.

I visited the Dubai Museum, sailed a short distance to the other side of the Dubai Creek in an abra, bought some colourful dark chocolate that I had been told was to-die-for, some dried rosebuds to add to my tea, a couple of postcards and small gifts, and a set of silvery-rose coloured Japanese pearls (yes... the adamant anti-shopper apparently did some serious kind of shopping... but I mean, this is Dubai afterall, so if I was going to do it anywhere, might as well be here... also this pearl-set is probably my first ever real 'set', and I love it and love it more because I bargained so hard for it and probably have the economic crisis to thank for my sweet deal and lovely buy!). We went to Gold Suk for that, then after coming home for a delicious lunch (cannot eat publicly here during Ramadan unless you're looking for trouble), made a little trip out to Emirates Mall, which is a mall that has a ski slope inside of it. Like a real one, kind of big, with skiing and luge. And it's -3-4 degrees Celsius in there for reals! Who would have thought you could go skiing in the freakin' cold in the heart of an Arabian desert!

Then tonight a dear friend from my childhood picked me up and took me to the Palace Hotel for the first Iftar (breaking of the fast feasting) of this holy month, where we met up with a bunch of his friends and had quite the merry and delicious time, sitting in the most luxurious place I have ever been to in my life, architecturally and comfort-wise, with intricate coloured lanterns, antique-style furniture, excellent service, fresh and tender lamb chops, tasty barbeque charred tiger shrimp, tabouleh, eggplant, red pepper and string bean Middle Eastern 'sides', mutton biryani, varieties of olives and ball-cheese, potato and meat fried kibeh-like things, smoked salmon and seasoned fish with mixed greens in a spicey salad, yummy Middle Eastern brown-noodle rice with veggies in a creamy sauce and fish in another kind of creamy sauce, and some kind of lamb or mutton curry-like thing... a lovely, gluttonous time indeed (I know, ironic, if we think about the real purpose of all this 'fasting' -well, what to do)! And then for dessert: rasberry Turkish delight, 3 varieties of baklava, a creamy cheese cake with exotic fruit on top, a dark chocolate covered date, and the best one: Um-Ali (which is a traditional dish here, apparently Hazrat Ali's favourite sweet that his mother used to make or something like that) which is kind of puddingy, but not really, creamy and delicious... a piece of Heaven in your mouth. And then ended it all nicely with a silver pot of Moroccan tea (one of the best teas in the world and it's been such a long time since I've had it!).

Then we left the comfort of AC and sat by a lovely blue blue pool, surrounded with palm trees, inside a white chiffony, silky tent, with comfy seating and strong-supportive-yet-soft cushions to hang out and relax / digest. This meant everyone ordered their own shisha -apple-apple, mint-apple, mint-mint -to wile away a couple of hours, except of course, knowing the harms of smoking any form of tobacco, and having satisfied my curiosity by trying it out a couple of years ago in Turkey, and discovering that I could enjoy just the smell of other people smoking it anyway, I opted for some lemon-water, as I listened to the stories of these mostly-new people I had just met. I was particularly taken with one character -and by 'taken', I don't mean anything silly like crushes or even flirtations (there is nothing wrong with either of these, just I was not going there...), but 'taken' as in I have decided to make one of the characters of my novel be this guy because he is that darn interesting. He's a tall, fair, handsome, wispy-dark haired Kashmiri guy, born in Kashmir but had to leave with the civil war in '89, moved and grew up in Singapore with his family, spent some time in India before moving to London for university and then now working in Dubai. But like many natives of a particular land who don't actually live and grow up there he's fully of a marvellous hopeful idealism about the free Kashmiri, blogging and writing about the necessity of free private economic enterprise in an independent Kashmir, to empower people and promote development and it all sounds like a mad man's talk to everyone else, except that it's most likely true. Not easy, but true. In his life and work, perhaps he's a realist, down-to-Earth kind of man -I wouldn't really know. And yet he talks about the beauty of the Earth of a home that was left inhabited too soon and has become a well of longing.

Then I watched the fountains and light show outside the Dubai Mall right from behind this outdoor swimming pool and tent area. And it was amazing. Like watching fireworks in water, with accompanying music and everything, and jets of misty water shooting up so high, it looked almost like it went half-way up the height of the Burj tower, and right in front of it -spectacular indeed!

But really, I would love to go to Kashmir one day, and to the Northern areas of Pakistan, in the Himalayas. There's a lot of work to be done in this world, but its beauty is infinite, and if we're blessed -which we all are, it's just up to you to see it that way (or for the non-religious, just replace 'blessed' with 'lucky' -luck is about hard work and self-perception and a positive attitude anyway) -then I think we're meant to experience the magic and beauty in our lives and in this world too.

I'm in love with all of it.

Pakistan Zindabad Day...

Yesterday was Pakistan's Independence Day -kinda crazy day in this country. The fireworks happen both the night before and the night of, the flag vendors make their money, all the kids go to school for the 'raising of the flag' and then go home and eat halva-puri, and even AKU had a flag raising ceremony followed by free brunch for anyone who wants to come and get it (you can imagine the massive numbers of families that come to AKU on this day!)... of course, there are also random gun firings (I don't think they realize that what goes up must come down... so just firing randomly in the air can actually kill someone... apparently this happens even when they do this at weddings -guests have been known to get hit by the bullet on its way down and sometimes get killed... OIP! OIP is my newly invented abbrev: Only In Pakistan -I enjoy the fact that it can be exclaimed "oyp!" and so is more subtle in its 'hidden' meaning, you see)

I, on the other hand, woke up yesterday morning with massive cramping and had to start a second round of Cipro+Entamizole... back on the dry toast and tea diet and missing out on delicious tastes in my mouth... my hunch is that it's Giardia, and probably the same Giardia from before that just never got fully cleared or I got reinfected after the last round of antibiotics which annihilated all the 'good' intestinal flora, making me more susceptible to reinfection...

I just want to say this: I am soooooooo ready to go home. I want to go home now. My family in Montreal is going up to Tremblant later today and will watch some of the August meteor shower from there at night, and I want nothing more than to be there with them... but I guess, I am here, so I am here. But I am ready to go back to wearing whatever I want, whenever I want and wherever I want -the same goes for eating. The only silver lining to my multiple Karachi-belly infections has been some weight loss (everyone keeps saying "oh! you lost sooooo much weight! so much weight!" -you'd think I weighed a ton before, even though my BMI was still in the healthy range, but hey, I'll take the compliments), which actually is good since I haven't really been able to exercise here as much as I had originally thought, and so otherwise, would not have had my usual pleasant spell of summertime body-goes-back-to-healthier-weight/shape pattern...

When I go home, I want to eat salad and mummy's home cooking. I want to eat lots of cheese. I want to go for Chinese food, and steak, and sushi and try that place, M-burger... of course, I will keep my quantities reasonable so I don't put back on all the weight I suffered so much to lose, but I look forward to having those tastes back in my mouth =)

Sigh. I feel so extremely happy just thinking about all this... really I almost wonder how much it would cost to change my ticket so I can fly home early. Although then I wouldn't get to see Dubai. And I really, really did want to see the Ismaili Center in Dubai, which looks absolutely breathtakingly beautiful in all those photos and film clips, and of course, the family I have there. So... well. Inshallah, this week will go by quickly -there are quite a few fun things planned for the rest of the week (most involve eating delicious food though, so hopefully my stomach will be up for it... like really, if you don't understand what a tragedy it is for me to not be able to eat all this delicious, but obviously contaminated, food, then clearly you don't know me well at all -I live first to eat, and then to love -in fact, I don't think I could love anyone who didn't love to eat because we would not have enough in common)

Also, I must remember that I have some excellent new ideas for my novel, which were inspired by some conversation with interesting people yesterday: ancient books hidden in the pillars of old buildings in exotic places, legend-like faith of one man on a journey by foot from far away lands to visit his beloved, spontaneous large-scale sacred meetings amidst rocks and rivers... it's all like a fairy-tale, which is perfect for my fairy-tale...

I send you my love and hugs and oh, i have so had enough of these stomach bugs... (now visualizing being able to happily eat that delicious chocolate tart and drink that mint lemonade planned for Wednesday -Inshallah, these drugs will have worked their magic by then!)

I Love Medicine -a little heroism is nice. And... back in the field.

So what I said in my last post about not being able to do OB/GYN all the time -yeah, I take that back. I totally take it back. Yesterday was one of my best days in Pakistan, and one of my best days in Medicine so far. I arrived late in the Labour Room (and so unfortunately missed experiencing Rounds) for which I have my lovely stomach to thank. But anyway, more interesting complex cases, I watched 4 deliveries (2 of them were happening in the same room at the same time, which was a bit nutso, but amazing) -also I loved watching the Head Resident stitch -after watching a total of 6 episiotomies, I know I'm no expert, but she does a really beautiful Matrice stitch -so clean and precise sewing up of the internal and external perineum -it's an Art. Also, it was wonderful getting to know the other residents, and meeting some of the consultants and attending physicians -this made such a big difference in the pleasantness of the experience. Loved it. Love it. One of the residents was actually telling me that here, most of the physicians in surgery are really humble, nice and of course, knowledgable. I was blown away, because as we all know, back home, surgeons have a pretty solid reputation of arrogance. Also so many of these young women physicians are already married and stuff, and they're my age (it's like the European system here where all doctors do "pre-med" straight from A-levels).

But I learned about PIH -pregnancy induced hypertension, which is caused by the release of vasoactive factors from the placenta + the effects of placental estrogen and progesterone. They actually simultaneously treat the labour pains and the PIH with Antinox, i.e. laughing gas (nitrous oxide)... Also, some mothers in labour are howling away in agony, and then others are perfectly quiet (just moaning a bit, saying "Ow, Ow...", I mean, that's pretty good for labour, right?)... we saw some more comlicated cases -one mother who was at gestation 40 weeks with an E. coli infection and in a lot of pain, but because her blood was infected, the originally planned epidural became relatively contraindicated (risk of spreading the infection from the blood to the CSF, resulting in meningitis), however, neither the nitrous oxide nor the narcotics (Kinz, which is nalbuphane... don't know if that's the Pakistani Dilotid equivalent or what) she was already on were alleviating her pains (and she wasn't even giving birth yet)... I don't know what they ended up doing... Then there was an epileptic woman who had just had a petit mal the morning before being admitted... and this morning I thought I'd pop in just for Rounds before going back to CHS, but apparently last night's Call had been pretty bad, with a PTL (pre-term labour), gestation of 26 weeks for a mother pregnant with twins and another woman in labour who was admitted with pancreatitis...

So, yes. Of course, some days are heaven and you're a hero, and other days, all hell breaks loose (forgive the cliche, but it is apt) and the head of OB beats down on everyone under her, and there's no time for Rounds. But it's still so exciting and I'm so looking forward to being more a part of all that. For better or for worse. It's a stronger feeling than a marriage vow I think (although, not being married, I guess I wouldn't really know...).

When I went back to CHS this morning, I was warmly welcomed back after my absence (since Friday technically because I had gone to Thatta and had not even seen my supervisor that day). However, I was quickly sent off to Bin Qasim for field work (the worst slum in Karachi). It was miserably hot, that sulfur-y sewage water smell mixed with the smell of burning garbage as we drove over in the AKU van (no AC). They seriously burn garbage everywhere.

It was hard to take today -I may have reached my limit for dealing with all this now -it's a lot and there's only so much of it one can handle before you need a serious break / must leave and get trained-up so that the next time you're in this kind of situation you're actually doing something BIG about it (even if it starts with just practicing medicine here...). But I didn't crack -I'm still here. There were lots of cattle on the road today, and of course, the token mother carrying her naked infant in one arm while juggling 2 paans in the other, and frankly handling those with more care than the kid. Makes you want to be sick, really. Most of the kids are running around everywhere barefoot (perfect for getting those worms that penetrate the skin that we learned about in Immunology). We visited 3 different villages in Bin Qasim -Lalabad (3 visits, 1 of which was not home... the person there though only spoke in Pashto so the AKU driver had to translate what the Dr was trying to ask, which was kind of interesting... apparently you really get a mix of non-Urdu languages in these poor areas... which makes the whole Town seem kind of like a mecca for poor-people-from-all-over-the-country or something), Chsma Goth (nobody home at the only visit there), and Rehri Goth (the worst off village which I had already visited).

My favourite part though was going back to baby Fatma though (whose photo you have seen in a previous blog post) who though recovered from her previous infection, was currently fighting another one (that's how it goes with these kids unfortunately)... lovely to see her much better though =) Otherwise, the stink of rotting fish and burning garbage and sewage, and the fly infestation of these parts was not at all pleasant... I'd say mind-numbing and exhausting, even the drive back through Korangi (another poor area... it's really like most of Karachi is actually poor...) and back to AKU. Like I said, how much of this can a person take without returning home with PTSD. I hope my feeling like I need to stop going into the field for now is not a sign of weakness... I just really need to take stalk, and think, and talk and learn everything I can so that I can be more helpful next time.

So ready to go back home... shopping last night was pretty good though, loving this Coke Studio music I bought (Pakistani musicians / poets /artists sing together and do a kind of 'fusion' of styles... the CDs are the songs from the music TV show here, which is very popular I believe...), as well as the Shafqat Amanat Ali CD (love his voice. love it, love it).

Well, time to go watch some 'House' and forget about my day... love you.

Oh, Babies (and moms, residents and nurses)!

Changed it up a little today. You see, I've been doing all this field work, and presentation stuff... the hands-on, but still research side of early childhood and maternal health. But I am actually going to be a doctor one of these days (inshallah), so my desire for a little in-the-hospital clinical exposure was not unwarranted. Last week's determination to find an OB/GYN doctor at AKU who would somehow get me in the Delivery Room for a couple of days finally paid off today (and I will be there again tomorrow).

Such an amazing experience! Started at 10 a.m. and pretty much shadowed the Chief Resident, Dr. A, all day. First patient I visited with her was a pregnant woman who had to be induced because she was at 41 weeks, but was also taking Metformin for PCOS throughout the pregnancy (so I did some Uptodate.com reading on this and found that women with PCOS who take Metformin have higher fertility rates than those who don't, and also lower risk of miscarriage during pregnancy!) -I watched as Dr. A drained the patient's bladder with a catheter, then stuck her gloved hand inside to do a membrane sweep (part of inducing labour, aside from IV oxytocin, etc), as well as gauge how dilated the cervix was (so cool that just by sticking a hand in there, with a little experience, you can tell whether it's 3 cm or 4 cm!). Then, checked in on a few patients with 'false contractions'... the morning was not that hectic overall, though.

However, after watching the residents share a bowl of Nihari with some naan (I had eaten already) for lunch (I really appreciated this commaradery despite the obvious medical hierarchy of things), and getting to know Dr. A a bit better (she got married in her second year of med school and had a baby in her early residency years!), things began to get a bit crazy (in a very good way, mostly!). I watched 2 babies get delivered in quick succession around 3 p.m. -for both the mothers, it was their first pregnancy, so of course they screamed, moaned, etc in all their pain (but nothing quite so dramatic as portrayed on TV and in movies in the West), and both required episiotomies (which I learned about right in the moment... I don't recall ever learning about this in Unit 3, but surely we must have... then again, Unit 3 was a big botch, so I wouldn't be surprised if we didn't!). An episiotomy is an incision made in the perineum posterior to the vulva to make the vaginal opening a bit bigger to facilitate birthing, which is then sutured up again, or 'reconstructed', immediately post-delivery (so it was cool to watch a little mini-surgery, even though no C-sections were involved).

It is absolutely amazing to see that baby's head come out of the womb, though -really one of those moments where you wonder how a whole other person just came out of a person (I know this is so cheesy and cliche, but until you've seen it, you can't pretend to really know anything about it -I thought I could before today, yet actually witnessing it is very special). And contrary to the complicated motions described in Unit 3 (first the head comes out, then the shoulders rotate, blablabla), what happened in both was once the head was out, the rest pretty much slid right out, with all the white goop and blood, etc. Then the nurse takes the little thing (South Asian babies really are smaller than White babies) and does all that rubbing, and warming, and oxygenating, and making sure none of the meconium is aspirated, etc, while the docs wait for the placenta to be expelled and suture up the episiotomy. At this time, I was surprised and grateful that Dr. A treated me like a real med student on a rotation by asking me a couple of questions -good to get a taste of what it will be like to be put on the spot all the time, except relieving that it doesn't mean anything for now.

The first questions was, "Do you know what this procedure is called?" No, I didn't, and that's how I learned what an episiotomy was, and looked it up further on Wikipedia (easier to decipher than Uptodate.com and still pretty accurate I'd say). The second question was "What are the signs of placental separation?" I hesitated, and then came my ingenius response, "The placenta comes out of the vagina?" Yup, that's what I said. Was not trying to be a smartass, but it was all that came to mind and I didn't want to seem like a total idiot (still not sure whether I had prevented this at all with that response though...). But Dr. A and the other resident just laughed good-naturedly and commented, "Oh, that's a smart answer!" (hard to tell whether they were sarcastic, or pleasantly teasing... I'll just assume it was the latter...). And then they told me what the signs were. And then I looked them up online to make sure I'd remember, and as it turns out, the Four Signs of Placental Separation are:

1. Apparent lengthening of the visible portion of the umbilical cord.

2. Increased bleeding from the vagina.

3. Change in shape of the uterus from flat (discoid) to round (globular).

4. The placenta being expelled from the vagina.

SNAP! Look who was actually right (about one of them at least!)... but anyway, I'm sure I won't forget about the increased bleeding and the lengthening of the umbilical cord (it's not actually lengthening, it's just all starting to make its way out, so you're seeing more of it -I don't think this is a difficult concept to grasp -calling it "lengthening" is just confusing, if you ask me)...

Anyway, at some point an auditor came and gave a couple of residents heck for some minor issue about one of the patient files (they apparently like to waltz in all importantly and make a big deal out of nothing... clearly, it has to be done, but it's perceived as an annoyance by the department, to be perfectly honest). And as I was told to go home for the day, Dr. A was dealing with a case of a pregnant mother (34 weeks) with an acute abdomen (most likely appendicitis or cholicystitis... which I further verified on Uptodate.com of course), and which is apparently surgically treatable without having to deliver the baby so prematurely, except of course a bit risky since surgery can induce contractions... I guess I'll find out what happened there, tomorrow!

But what a nice change today. I thoroughly enjoyed it (although I don't know if I would enjoy doing this all day, everyday for the rest of my life... I think I'd get bored without variety... this is the trend I notice when reflecting on my shadowing experiences in the NICU and Neurology as well... maybe family medicine? or pediatrics? or a general internist? But right now, I don't feel that specializing is really my scene...) and am looking forward to Day 2 in the Labour Room, tomorrow. At the very least, beats the nightmares of cruelty, rape and torture that I've been having for the last 3 nights, since my visit to Thatta. Someone today told me that I "didn't look fresh"... you try staying up for a couple hours, in the middle of the night, for a few nights in a row and then tell me how fresh you're feeling (this was not supposed to sound so bitter -it was a nice person who said it, I like her, and she means well).

Well, that's it for now!

Amidst Ancient Ruins, the Poorest of the Poor, and a Foreigner's Haven!

Yesterday was probably the 'fullest' day that I have had since my arrival in Karachi. I had wanted to blog about it last night, but I was way too exhausted, so instead, I find myself writing to you between loads of laundry, as I listen to 80's pop classics ("Wake Me Up Before You Go-Go" at the moment...) on the following afternoon.

Thatta: First-Half -a "Mega-slum"

So if I had thought Rehri Goth (in Bin Qasim town, Karachi) was in a pretty bad mess and it couldn't possibly be worse anywhere else, well, I was quite wrong. Early in the morning, one of my friends (who also works at CHS) and I left with two of the main researchers (one is working on the Maternal-Newborn Health Registry (MNH) project, and the other, on an infant Brain development study) for Thatta, which is in the interior of Sindh, near the Indus River, before it meets the Arabian Sea, about 2 hours drive from AKU.

Our purpose was to get an exposure to some of CHS' work in this very old, historic, and extremely poor part of Pakistan -apparently, there are over 400 NGO's who claim to be working in Thatta, but actually, just about none of them really do anything at all -it looks good for the NGO to say they are working in Thatta (that's how bad-off Thatta is), but since it's logistically challenging (bad roads / no roads, far enough to be a pain to commute daily from any major city, unsafe enough -gunshots, and other violence all audible and visible in this area -to actually maintain a base there...), the situation in Thatta has not changed much over the last 20 years.

We made visits in 4 different villages for the MNH project -the people here speak Sindhi, which is different from Urdu, and I loved hearing it at the first home we visited (hated it later... you know, whether or not a language makes a good impression on you really has a lot to do with who's talking... if the person speaking makes you sick, well, it's difficult to enjoying their drawling, lifeless tongue). But the first mother was warm, friendly, lively -her baby was born healthy, she was healthy, of course, she already had a bjillion kids and they lived in something that looked a lot like what we had seen in Rehri Goth -1 room made out of concrete / bricks / plaster, albeit falling apart, dirty, fly-infested (but nothing compared to what we saw afterwards)... then we visited some straw huts, huge buffalo, lazing about everywhere, massive piles of animal dung everywhere you turned, cess pools in the middle of paths, scrawny cats picking their way around, bony dogs with diarrhea, sewage water along the sides of all paths with big still ponds popping out every few meters, everyone walking around barefoot, firecracker shots, open gunshots (not at people, but just for kicks, shot up into the air), and of course more multiparity mothers, some old man raving about his spiritual intutions about rain from the overcast skies, etc...

Not far from these villages, there are vacant factories of all kinds -sugar, textiles, etc... there's a forlorn government hospital too, but women can't go there, and with the monsoons, all the flooding made the hospital pretty much inaccessible anyway... quality of care, also likely dubious... One of the homes we visited, I noticed that the mother sat on the bed, her baby was bound tightly in a piece of cloth (likely causing some rash or skin infection unbeknownst to mum) and there not far from the baby's head, a handgun lay innocently too.

The saddest of all though, was when we went to visit a mother who had a botched abortion after being pregnant for 10 months and refusing a C-section because she didn't want a surgery to come between her and her responsibilities to her zillion other kids... 5 days later, she is still bleeding and essentially refuses to see a doctor. The glazed eyes surrounded me there. The flies were very bad here. But there was one little boy, maybe 4 years-old, with flaky dry skin from head to toe, red rashes and brown and purple discolourations from infection and the flies were eating him, clung to his clothing, his skin, on his eyes, in his known, all over his mouth, as he torturously sucked on some dark brown freezie, moaning, and trying to swat at some of the flies every now and then. We asked the mother and older children if he had seen a doctor. They said he was born with skin like that (probably some genetic defect... maybe epidermolysis bullosa, or maybe some kind of skin-collagen defect, or maybe an autoimmune condition... bad eczema or psoriasis with pustules, or God-knows what -I'm not a dermatologist) and they won't take him to a doctor because they would rather use that money to feed the rest of the family. He came close and opened his mouth and began screaming, crying, his head thrown back, his arms hanging limply at his sides, tears streaming down his cheeks between the flies, the flies were in his mouth, a bunch of his teeth had already fallen out, the rest had black roots and were deformed, and his gums were obviously also affected by whatever conditioned his family refused to get treated. The pain in that cry was heartbreaking. He held his tummy and his older sister made him lie down on the woven-cot frame. He had a stomach bug too, which was also going untreated. The family seemed annoyed... short of throwing him out of their house, they seemed to almost leave him for dead. I thought they must wish him dead, and there's no way he's going to make it. He's going to die a painful, miserable death, most likely, and no one will hug or kiss or coddle him between now and those last breaths, if they ever did. When I put my shoes back on after leaving the house, I noticed little flakes of red paan inside them.

And then I suddenly understood something else, in the midst of a flare of internal rage. Maybe these mothers didn't want to not care for their children properly, but what if they didn't know how to care for them? Imagine you're a little girl born into these dirty straw slums, your mother's 9th child. No one kisses and hugs and coddles you. No one makes you feel like you're special. And while your male twin, at the age of 5 roams the streets, playing in dirty sewage water, or is told stories by your grandfather as they sit on a street curb somewhere, you're already changing diapers of your 2 younger siblings. If you were never shown tenderness and love, then how can you be expected to know what love is, what affection is when you start having your own children? And especially if you'll start having your own children when you're only 15 years-old?

Futile tears I did not cry -like I said, even my tear-ducts know that it's futile. I felt numb and I felt pain that I had to try not to feel anymore because what good would that do? I passed tissues and hand-sanitizer to my friend instead, wondering what happened to my own gentle heart... an addiction to suffering AND an inability to show love and affection, or really understand them... just glassy eyes, glazed eyes, unconscious-living in misery, filth, disease... no education (the local goons also see to it that the villagers don't get educated so that they can keep their power so the schools become barns for animals) and virtually no access to any kind of healthcare. They believe in rituals, they put charms on each other for 'protection' and they'll tell you "it's all in Allah's hands". You just want to tell them, "Allah gave you a brain so that you could use it, so please let's leave God out of this" -but there's no use. How do you reason with people who don't understand reason? You can't reason medically, you can't even reason with religious arguments? You can't reason at all, and the worst part is being at a loss to reason and explain it all even to yourself.

Thatta: Second Half (good eats and historic sites)

We had lunch at the AKU CHS offices in the main Thatta town -the chai was delicious, the fried potato slices with spices and scrambled eggs with peppers, masala and tomatoes (reminded me a bit of Turkish menemen), one tiny piece of mutton curry and a manni (Sindhi and Gujarati word for roti). It was the AKU chef who cooked everything so it was quite safe, and I only ate a little bit (and 24 hours later, I am fine ok, so don't freak out that I ate in Thatta -it wasn't street food).

Before heading back to Karachi, we made a stop at the Makli ka Khabrastan (Makli Cemetary / Historical Tomb ruins from the 14-18th centuries AD, also known as 'The Great Necropolis of Makli", which is a World Heritage Site)... although Thatta is a centre of poverty, it's also one of the big cultural / historical sites, and there are lots of ruins like these of previous rulers / dynasties in the Indian Subcontinent... they were really breathtaking -reminded me very much of when I visited the Ephesus ruins in Turkey, and sure enough the main big building was for a King who was a Turk. Although we did take photos with my friend's camera, since I don't have them yet, for now, I found some photos online that are actually similar to some of the ones we took, so you can enjoy these 2 photo collages instead ;).

The architecture is really beautiful -classic Islamic-style geometric shapes woven together into stunning archways, domes and ceilings. Tombs covered in different Qu'ran ayats, Ayat al-Kursi and the Kalima over doorways. Turquoise and Lapiz Lazuli tiling and painted designs here and there (reminds me so much of Turkish Isnik tiles... surely those must have been imported designs...).

It's nice that this beautiful little sanctuary exists in the heart of this poor area -but the sanctuary even is a symbol of the royal, the excess, the wealth even in its own time. I wonder if the people of Thatta feel that they own it, or that it belongs to them in some way. The only indication of anything would be the paan spittles on these architectural beauties. Perhaps it's fitting, but people are people. It's too bad they don't have anything -no land, no home, no nothing... nothing to be proud of, nothing that inspires love, thought, dreams, nothing that's really theirs. Maybe someone should start by showing them the beauty in this world -that belongs to them as much as it does to anyone else... I don't know. How does one light that spark? Any work here will take time and a massive committment -the reason why AKU is even allowed to intervene even in the little way we have begun to is because it has been in Karachi for 25 years, and in Thatta, acting in some form over the last 11 years... but the message is clear: We are here to stay, we want to work with you, we want to help you help yourselves; we will respect your traditions and beliefs, but we will not abandon you. That is something in which no other NGO in Thatta has succeeded -they don't act, and they can't stick it out. Trust does take forever to build though, it seems.

Friday Night in Karachi

We managed to make it back to Karachi in time for khane (just went to Noorabad Jamatkhana near AKU). Afterwards, a bunch of us piled into 2 cars and headed to the Chatterbox Cafe (with a delicious bakery called "Pie in the Sky") on Zamzama (an up-scale street in Clifton / Defence... kind of like the Karachi's Rue Laurier (Montreal), or Newbury St (Boston)...), for a farewell dinner for one of my friends who is leaving Karachi this coming week after having spent 9 months here (the same one who also works in CHS). They basically have more of a North America / European standard food (pristinely clean, salads, appetizers, a variety of main dishes and scrumptious desserts!) and prices (well, still cheap by our standards, but expensive by local standards), and atmosphere (granted the music is probably a couple years old, but still standard pop / hip-hop, etc...). It was my first time going into a place like this in the 5 weeks I have been here and it FELT SOOOOOOOOOO GOOD!!!! Especially after the day we had in Thatta. You just feel like you need to escape, pretend you're back home, pretend we don't live in a world, where I can pay 700 Rs for a nice dinner and a family of 15 has to live on probably less than $1 per day), a world where human life has no value unless it's a moneyed life...

I shared a Thai Red Curry with Prawns (also again, I am still fine today -and I ate 2 prawns so take a chill if you're freaking out that I ate seafood) and rice with another friend, had the most yummy fresh mint lemonade (made with mineral water because I'm still OCD-careful in comparison to everyone else), and a Banofee cup for dessert (this is a very sweet British thing, made with caramel toffee, bananas, graham cookies or something similar, the version I had also had chocolate syrup and an icing-y cream... pretty good, although next time I will have the chocolate tart with fudge sauce and vanilla ice cream because I had a taste, and that must have fallen out of Paradise...)

Came home around 12:30 a.m., watched one of my friends climb her favourite tree in front of Women's Residences (things like this can only be done when there aren't a lot of people around, if you're a woman)... and well, there you have it: her 'fullest' day!

P.S. Piece of Trivia: Etiquette in Pakistan
Women never shake hands with men here, women only shake hands with women (no hugging etc, most of the time unless they're your best bud), men stare all the time all the time, and women do too... when people go on dates in public here, forget PDA -even hand-holding is scandalous (physical contact between the sexes is basically a no-no); if your head is uncovered it means you're single and 'available' (if you're a woman); a lot of the prostitutes here are covered from head to toe in burkhas; and note the power of the dupata (the scarf-shawl thing that all the women wear with all their clothes): you can be wearing the skimpiest, clingiest piece of see-through material, but you're socially acceptably dressed if you've got a duputa hanging from your neck; wear jeans and a baggy T-shirt and the stares you'll get will make you wonder whether you walked out of the house naked! Also, when you're out and about, don't smile. Don't take a rickshaw alone if you're a girl. You cannot visit a cemetary if you are a girl. You cannot go to the Sunni Masjid (mosque) for prayers if you're a girl. If a woman gets raped, she can only take it to court and have it recognized as such with (maybe) consequences for the perpetrator of the crime -get this -if there are 4 male witnesses willing to testify. As Munna Halwai might say in The White Tiger, Rights? "What a f*#$ing joke!" Women, heaven forbid if you live at all, here.

Uh, let me correct myself... and Circadian Fruits of Labours Past.

So yeah, we got that World Bank funding... but having to write the official announcement for our department today, I realized that although our proposed budget was $150,000, the maximum funding we could win in the grant competition would be $40,000... still awesome of course, but just thought I'd correct myself there. This was the announcement:

AKU CHS World Bank Grant Award Announcement

On August 5, 2009, the Aga Khan University’s Community Health Science department was awarded one of 21 grants from the World Bank’s South Asia Region Development Marketplace (SARDM) fund pool of US $840,000, in Dhaka, Bangladesh.

Earlier this year, SARDM announced the 2009 competitive grant program, entitled “Family and Community Approaches to Improve Infant and Young Children Nutrition”, whose goal was to identify innovative proposals from civil society organizations across South Asia that addressed malnutrition in infants and pregnant women. SARDM considered proposals that demonstrated cooperation between families, local communities and grassroots organizations to:

• Empower women and account for socio-cultural determinants of malnutrition,
• Increase access to micronutrient-rich foods (and/or supplements),
• Develop sustainable ways of changing household behaviours to address malnutrition, despite financial constraints,
• Show and measure the impact of community-based interventions, in terms of growth monitoring and promotion, improved quality of child care, hygiene, water sanitation and the physical and social environments in which children live.

Almost 1,000 applications were submitted from Afghanistan, Bangladesh, Maldives, India, Nepal, Pakistan and Sri Lanka. The AKU CHS proposal, “A randomized controlled trial of a comprehensive community-based intervention to improve linear growth velocity amongst children aged 6-18 months in urban squatter settlements in Karachi”, was then shortlisted by a jury of nutrition and development experts as one of 60 finalists to exhibit their nutritional innovation in Dhaka.

The AKU CHS proposal, which details a plan to introduce chicken liver into the diets of babies at 6 months of age to complement breastfeeding, was one of only two Pakistani projects awarded a grant, following Bangladesh and Nepal, each with four grants, and India, with nine. Sri Lanka and Afghanistan each had one winning proposal. All projects were eligible to receive up to US $40,000 for implementation during an 18-month period.

SARDM 2009 was sponsored by UNICEF, World Food Programme, PepsiCo, the Micronutrient Initiative (MI), GTZ (Germany), and the Global Alliance for Improved Nutrition (GAIN). The SARDM regional competition is part of the larger Development Marketplace (DM), which identifies and funds innovative, early stage projects with great potential for impact on development that can be replicated. DM is administered by the World Bank and funded by many partnering organizations, awarding over US $54 million to novel development interventions since 1998 via country, regional and global competitions.

And in other news, remember when I used to be a clinical research assistant at Harvard Medical School in Sleep Med? It was a blind-women cancer study to see if blind women had a lower risk of developing breast cancer than sighted women, and if it had anything to do with melatonin levels or other hormonal patterns too? Well, 2 papers have finally just been published on our study (my name is in the Acknowledgments at the end ;). If you are curious about the first one, you may look up:

"Total visual blindness is protective against breast cancer" by Erin Flynn-Evans et al in Cancer Causes Control, published August 1, 2009 online. Or you can read the abstract of the paper posted below:

Abstract: Objective Observational data, though sparse and based on small studies with limited ability to control for known breast cancer risk factors, support a lower risk of breast cancer in blind women compared to sighted women. Mechanisms influenced by ocular light perception, such as melatonin or circadian synchronization, are thought to account for this lower risk. Methods To evaluate whether blind women with no perception of light (NPL) have a lower prevalence of breast cancer compared to blind women with light perception (LP), we surveyed a cohort of 1,392 blind women living in North America (66 breast cancer cases). Results In multivariate-logistic regression models controlling for breast cancer risk factors, women with NPL had a significantly lower prevalence of breast cancer than women with LP (odds ratio, 0.43; 95% confidence interval, 0.21–0.85). We observed little difference in these associations when restricting to postmenopausal women, non-shift workers or when excluding women diagnosed withbreast cancer within 2 or 4 years of onset of blindness. Blind women with NPL appear to have a lower risk of breast cancer, compared to blind women with LP. More research is needed to elucidate the impact of LP on circadian coordination and melatonin production in the blind
and how these factors may relate to breast cancer risk.

Well, peace out, log (which is Urdu for 'people'... the 'o' is long though, like 'low'...).