Anger in America

      Last Wednesday was one of those rare perfect summer days: Blue skies with low humidity, clear air. I was rounding at Baystate Medical Center. As I passed a line of cars waiting to enter the parking lot at 3300 Main Street, the outpatient center, I heard a driver shouting out his window:
    "Stupid jackass!"
    Had I done something wrong?  Who was he shouting at.  Did the recipient of his anger even know it?    It was really just disembodied vitriol wafting through the summer air.
    At the end of a busy day, with the usual stresses of our needy and often poor patients and their complicated lives, I was rushing to meet up with a group from the Northampton Cycling Club for their 5:30pm ride.  So I was wasting no time zipping up I-91 N.  I passed a car in the left lane, doing about 73mph in a 65mph zone.   Before I could look in the rear view mirror again, there was another driver on my tail.  I turned on my right hand turn signal, but he was impatient.  He zipped around my passenger side, and cut me off as he passed into the left lane, waving his middle finger at me out his window.
      As I've said previously, there was no road rage in Bhutan.
      If you had road rage, you would probably fly off a cliff to your death.  The Bhutanese look with bemusement at the frequent road closures that occur on 3000 meter mountain passes, with large Indian trucks passing within inches.   Bemusement and patience.
     So it was not with anger but with curiosity, more than anything, that I thought about Americans and American drivers as I was driving towards the Academy of Music in Northampton.   Why are so many Americans so bitter, indignant and resentful?  Why the rage?   Do they know how fortunate we are, to live in a country with all the material comforts one needs, in a free democracy, with roads going anywhere we want, working toilets, no civil war, endless forms of entertainment, a relatively safe and stable society?
       I write relatively safe, because it is a society where anyone, no matter how crazy, can get their hands on guns that should only be available to the military, and shoot up  - in close succession - an historic black church, a military recruitment center, and a movie theater.   In Bhutan, where even the police don't carry guns, such shootings are of course unheard of.  (There was one isolated episode, in the last ten years, where an abusive father owned a gun.  He threatened to kill his son. The young man took the gun and killed the father.  This story is known to everyone in the country, because it is the only case of gun violence in recent history.  It is used as a cautionary tale)  These (almost always) venomous white males are like the cankers exposing the underlying infections of racism and paranoia, all too prevalent in this country.
        This is not to say that Bhutan, home of Gross National Happiness is utopia.  It's recent history of persecution and virtual expulsion of tens of thousands of ethnic Nepalis, in the vain attempt to maintain ethnic purity - some say to prevent annexation by India or China - is shameful.  Alcoholism is rampant, and with it unreported child and spousal abuse.  And I found pockets of random violence.  Young street toughs, high on the drug of choice - glue - would occasionally beat up the unarmed police! And among the male college students with whom I met, in their "hostels" to talk about typical teen topics - their residential advisor got them to talk about their senseless fist fights during and after football matches during which they would bloody each other.  But the boys would laugh about these fist fights as soon as they were over.

  The caretaker of our apartment, whose cell phone was stolen by a gang of youths, said, in describing the event:  "It was funny, actually."!  There is, in the words of Milan Kundera, an incredible lightness of being among even sad events in Bhutan.
       Whether it is their Buddhism, or the fact they love their enlightened king, or their isolation, or the fact that modernization is so new to them - probably all of them - there is not the constant undercurrent of anger, cynicism and violence which pervades the United States.
       

Half the citizens of Bhutan were rehearsing for the celebration of the King's 60th birthday

         And what is constantly weird to me is what Americans choose to get angry over:   It is the "asshole" that forgot a turn signal, or didn't turn fast enough.  It is our President, for doing his best to make health insurance available to millions more people.  It is doctors for "poisoning" kids or "overloading their immune systems" with lifesaving vaccines.  
         But where is the outrage directed against the energy companies that are responsible for causing climate changes that is already killing many thousands and may kill millions?  Or the growing obscene gap between rich and poor in this country?  Or the fact that the richest country on earth permits so many to get sick, go bankrupt and die without a rationale, affordable health care system available to all?   There is appropriate indignation over the killing of unarmed black people by police (and citizen murderers like George Zimmerman).  But African Americans have shown remarkable restraint in the face of the violence directed against them.
              The perfect example is the nobility of the families of the black Christians who were slaughtered in the AME Church in Charleston by a white racist terrorist. (Yes, he meets the definition).  Their expressing their forgiveness of this young man, only days after the murder of their spouses, parents, and siblings is the kind of the kind of dignity, generosity and superiority of spirit that all Americans need to learn from.
         It is consonant with the teachings of all the great world religions from Buddhism to Christianity.
As the rabbi at the Manhattan Jewish renewal synagogue Romemu said during a service we attended only a week after the Charleston church shootings, those killed were like the martyrs of old in Judaism, practicing their faith with an intensity and honesty and courage few of us have, while inviting a stranger into their midst.
          It is their kind of faith, as much as learning from the lessons of Bhutan, which can provide an antidote to the epidemic of middle finger waving, ranting, raving and killing in this country.

     

            Traditional Bhutaneses Medicine Expressed on the Leaves of a Lotus Tree
       
          I'm attending a conference, established 18 years ago by my mentor, Karen Olness.  Dr. Olness wears two hats.  Wearing her hypnosis hat, she and her colleague Dan Kohen literally wrote the book on pediatric hypnosis. Her accomplishments in this field add up to more than any of us achieve in a lifetime. But she wears a second hat:  that of an expert in international health - specifically, helping out children after humanitarian disasters.  After decades spent helping out kids and their families after wars, floods and famine all over the world, she established this conference, "Management of Humanitarian Emergencies:  Focus on Children, Women and Families.  A Course in Disaster Preparedness."
         Fortunately, Bhutan has not seen the kind of humanitarian emergencies that have risen geometrically in the last few decades.   But with the total number of people at risk for humanitarian emergencies at 2-3 billion, with 50 countries either facing long term humanitarian crises or at serious risk of them, with over 51 million refugees in the world, the largest since World War II, and natural disasters in the United States happening on a regular basis since the first really big one - Hurricane Katrina, it makes sense for a pediatrician to learn how to help out.   And the earthquake in Nepal, which killed 9000 people and left 3 million homeless, occurred on the same narrow Himalayan seismic shelf which Bhutan sits on. The earth is folded up like an accordion in this region.  
           Since bringing her husband and young children to a refugee camp in Laos in the 1980's, then establishing the first pediatric residency in that country, Dr. Olness began Health Frontiers, an NGO that specializes in tending to the psychological and emotional needs of children and their families affected by natural disasters, war, and famine.  The faculty and participants here reflect her selflessness, creativity and courage.  I've become friends this week with Dr. Hem Sagar Rimal, the first developmental pediatrician in Nepal, his wife Archana, the only psychologist in their hospital in the east of the country, and Raj Pandey, a neonatology fellow here at Rainbow Babies and Children's Hospital.  Raj's town, in the Gandaki district, was at the the epicenter of the earthquake.  He flew back a week after the quake to help out. 
           Over dinner at a restaurant in Cleveland's Little Italy with the three of them, Raj recounted farms being cut up into slices with big rifts down the middle, and advising villagers on how to start rebuilding homes. 
         "Do you have an engineering degree as well?" I asked.
         "No," he smiled.  "It's called being a doctor in Nepal.  I take care of premature infants here," he said "but back home I took care of a 91 year old woman.  If there is no one else you do what you can."
         And what does he want to do next?   His dream is to establish a system of primary care medicine in his home country.  As in most developing countries, there is only acute medical care.  "So people wait until they are too sick to seek care, or go to emergency facilities" Raj explained.  (Sounded like the health care system in too much of the United States, still, I thought)  He wants to help build a system where preventative health care will be paramount.

         Dr. Hem as vice principal of the Nobel Medical College Teaching Hospital organized relief efforts in his area.
         "But the communication was very bad," he said.  "We had neurosurgeons and all sorts of specialists, only to find that the government was flying all the victims to Kathmandu."
         He and Archana most wanted to talk about their two sons.  As specialists in child development, they thought it was not surprising that their younger son mainly showed fear after the earthquake, but their older 16 year old son, mainly wanted to DO something.  Rather than study for his final exams, he insisted on organizing relief efforts among fellow students, that resulted in truckloads of supplies being sent to earthquake victims.
        When Dr. Hem described this to the group in the lecture hall, his eyes glassed over with emotion.  This is the only time I saw any of them display outward grief over the destruction and suffering they had witnessed.
        Dr. Hem and his wife preferred to talk about the previous four weeks.  This was their first trip to the United States.  They had been to Los Angeles, San Francisco, Las Vegas, Louisville, New York, and Washington before coming here.
        "What is your favorite city?" I asked.
        "Well we really liked visiting the White House," he said. "but our favorite place was Las Vegas."
        "Las Vegas?"  I asked "… do you gamble?"
        "No," he replied. "But we loved the way the city rises out of the desert, with the mountains and the sun in the background."
        And they were enchanted by the Grand Canyon.
        "That was fabulous," he and Archana said.

        They were mostly interested in hearing about my life, and my travels and work in Bhutan. In passing, I described the incidents (depicted in a previous blog) about the nursing students who laughed over the obese girl's crying when I showed the film "Fed Up", and the young man with cerebral palsy, who laughed, along with his friends when he fell walking to the hospital.   They looked at me with curiosity.   
            I said that one of my Bhutanese friends explained that since, in their Bhuddist tradition, they believe life is suffering, we need to be able to laugh at ourselves when we endure pain or sadness.  I immediately regretted telling this story, for obvious reasons. 
          "We are not like that," they explained --- a response which gave me more admiration for the good humor and generosity of spirit they displayed in the face of so much adversity.
           We talked about the history of Bhutan and how many people of Nepalese origin were expelled from the kingdom.  
           "60,000 of them were accepted by the United States" Dr. Hem said - a laudable gesture which led to other countries welcoming them as well.  
           The ethinic Nepalis from Bhutan are "more Nepali than the Nepalis" he laughed.  I told him that the Irish say this about Irish Americans in our country.
           He seemed to harbor no resentment towards the way his countrymen were treated in Bhutan.
           "They (the Bhutanese) are our brothers and sisters," he said.
And he said that the Nepalese people greatly appreciated that the government of Bhutan, led by its prime minister had sent a delegation to their country with one million dollars (US) in aide.
         
          But Bhutan was also busy this past month achieving a milestone, according to a facebook post by my friend Namgay Dorji. The kingdom set the Guinness World Record by planting 49,672 saplings in 57 minutes!  These 100 volunteers, working at breakneck speed, broke the previous record held by the Indian state of Assam. How each of these volunteers planted about 496 trees in one hour is anyone's guess!

           Our lectures have concentrated on disaster relief, but all the speakers have acknowledged that long term reconstruction, building of infrastructure, and maintaining a safe and healthy environment are what is needed in the long term.   Bhutan's policy of Gross National Happiness is the perfect example of this philosophy.


       

      

     I''ve been home almost three months now.   But as my good friend Ed Perry, who is the reason I ever learned about Bhutan, said "this trip stayed with me on a deep level".
        It's the middle of a snowstorm "of historic proportions" and work is called off.  My wife has CNN to listen to the constant news, amid commercials for drugs like humera ("may cause lymphoma and susceptibility to certain fungal infections, Call your doctor now!")  The news, of course is all about the storm.  Lots of warnings:  not only against driving, but even walking outside.  "Because the ground may be uneven".  I was just out shoveling our walk, which evidently was a dangerous thing to do.  And there is no coastal flooding or massive power outages, yet… but who knows what may happen in a few hours.  
         I think of Michael Yapko's definition of anxiety: Using ambiguous information in the present to make the worst projections about the future.
         We could think about how we might lose power soon (and for us that means losing water since we have a well with a pump) or we could enjoy the plump cardinals at our feeders, and the antics of the acrobatic squirrel hanging upside down on our expensive "guaranteed" squirrel proof feeder, enjoying himself on the nuts and seeds spiked with special red pepper powder from the Amherst Farmers Supply, also "guaranteed" to keep these voracious critters away.
         "Must be Mexican squirrels you have" the woman at Hadley Garden Center laughed, when I went there yesterday to buy some burlap and twine to cover my last unprotected rose bush.
          I plan to pay attention to the bird feeders and not the TV.  But millions of housebound northeast Americans will spend the day with CNN overdosing them on angst and apprehension.  Instead of ads for humera, the pharmaceutical companies could more profitably show ads for the serotonin reuptake inhibitors and other anxiety drugs rake in billions of dollars for them every year.
           The last phone call I made last week had to do with a patient with chronic dizziness. Her mom wanted a referral to a pediatric neurologist.  In children, chronic dizziness, unless it is really vertigo (a sensation of the world spinning around you, as if you are in the center of a merry-go-round) is almost never a sign of a significant medical disorder.  As with this patient, it is often related to stress.
          I thought of patients in Bhutan.  Dizziness, called giddiness there, is quite common.   In fact, according my fellow volunteer, Dr. Allen, who increased the number of psychiatrists in the country from one to two, depression and anxiety in Bhutan is usually manifest  as dizziness and other somatic symptoms.  (See previous posts).  
         Dizzy patients don't get to see neurologists there, because there are none.   They may be seen by the one Bhutanese psychiatrist, who may diagnose them as having a seizure.  This diagnosis is tough to prove there, because electroencephalograms, or EEG's, are not available.  Patients will either get put on one of two anticonvulsants available, or the one antidepressant available (an older medication called amitryptiline) and told they WILL GET BETTER.  And they usually do, often in one day.
          Why could I not cure my patient so easily? I worked with her for over a year, having specialists "rule out" organic illness (there were other somatic complaints as well).   I sent her to therapists.  I employed clinical hypnosis to try to help her calm herself.  I reassured her.
          What is different about Bhutan?   Is it just that doctors are still viewed as gods there, which makes the placebo effect so much stronger?
           Could it be that the daily news there was more focused on the fourth king's 60th birthday celebration, than local weather calamities? They certainly have bad meteorologic events:  a big earthquake caused significant damage to about a quarter of the buildings in the country several years ago, late monsoon rains virtually ruined their rice crop two years ago, and rains and the increasing snow melt from global warming regular wash out roads throughout the country.
           Could it be the Buddhism that pervades all aspects of their lives?
 I'm reminded of two incidents:   I showed the movie "Fed Up" to nursing students there.  It is about the obesity epidemic in the U.S.  I brought it there to show this hard hitting film to whomever would watch it.  There are virtually no fat people in Bhutan.  There are also no fast food chains, and almost no processed foods and "food products" - basically just food:   rice, vegetables, fruits, meats.   "Fed Up" focuses on the story of three obese kids in the U.S.  One of them is a sad 12 year old girl, who is often seen crying as she talks.  By the third time she appeared, the nursing students in the audience began to chuckle, and even laugh out loud.
         Why are these otherwise kind, polite and sensitive young people laughing at this poor girl?, I thought.
          These nursing students invited me to their annual talent show, which turned out to be a wonderful evening of Bhutanese, Tibetan, Nepali, Hindi, Bollywood and hip hop dance and song.  As I was walking through the gate of the JDW National Referral Hospital, on my way to this talent show, I saw a young man with a slow spastic gait, walking ahead of me, with the help of a walker and two friends.  He probably has cerebral palsy, I thought.  Suddenly he tripped and fell on the divider under the gatehouse to the hospital.  He and his friends broke out in laughter, and continued to laugh as he struggled to get up, with their help.
      "May I help you?" I asked.
      "No sir, thank you" they said.
      I asked Kenley, the perceptive and well read physiotherapist who hosted us at his country home above the town of Punakha, home to the beautiful historic dzong situated on the forks of the male and female tributaries of the Punakha Chha (river) about these incidents.
      "In Buddhism, we are taught that suffering is part of life," he explained.  "So we must accept it. One way to accept suffering is to laugh.

                             Jomohlari, in Jigme Dorji National Park.  This area gets some serious snow.

       Part of the problem in this country is not that people are anxious all the time, but they get anxious about the wrong things.  It is amazing to me that with each 24-7 coverage of each storm or other "extreme weather event" with which the U.S, and the world is increasingly hammered with, there is no mention of why these "events" are becoming so common and so extreme:  Global climate change.
       There is cursory analysis of climate change in the media now, but not while these storms, floods, and fires are happening.  Why?   Is it thought to be in bad taste?  Not even the environmental groups, like Bill McKibben's 350.org.   Instead of concentrating on issues which are far away and abstract for most folks, like the Keystone Pipeline, why not focus on the weather outside?   And to remind people that this snowstorm is not because of the earth getting colder, but because the earth is getting warmer, melting the Arctic ice cap and shooting all the frigid air that is released down our way?
          In Bhutan, by contrast, where people are remarkably equanimous about day to day weather events, concern about climate change is everywhere, front and center.  The tiniest villages I trekked through had signs about the latest climate change news posted in health centers. They know it is a health issues.  There is a national climate change council.  Mining it's extensive copper reserves is outlawed because this would disrespect and damage the earth. Bhutan preserves two thirds of its forest land as forever wild. Lumber may only be used domestically.  There are even concerns about the number of trees cut down to make prayer flag poles (prayer flags are as common as Red Sox caps in Boston).   Plastic bags are outlawed.  The government has plans import thousands of electric vehicles, even though there are no recharging stations in any of the far flung towns, save the capital, Thimphu.  
       And since this tiny country is dependent on the melting Himalayan snows for the hydroelectric power that supplies all its electricity -- sale of which is its major source of income, outside of tourism, they have reason to worry about global warming.  And they have done much to address it.   According to a minister in the department of natural resources,  Bhutan is already "carbon neutral".  We have much we could learn from them.
   
         Of course, they have much they could learn from us. About pediatric intensive care:  Maybe Karma, Kinley, Ugyen  and the other children from Decholing, Pelethang, Khangdang and other districts of Bhutan would be alive if they had the medicines, personnel,  and technology we have to treat infections, shock, and brain injury.
         The extent of the problem of alcoholism, which is probably the biggest cause of morbidity and mortality in Bhutan, is just being recognized.  Chithuen Phendey Thokpa, whom I met at my former guide and friend Namgay Dorje's house (where his wife made a delicious feast for me, served up in their small but comfortable apartment) is a prominent contractor who had just met with the king to discuss development issues.  A recovered alcoholic himself, he had joined the first chapter of AA in the country.  But he said that it should not be called AA since no one is anonymous in Bhutan; people "know each others business", knowledge which they usually use to help each other.

                                            Namgay Dorje, his wife and two children

       Chithuen pointed out that Bhutan is not necessarily happier than anywhere else.  The king (K-3) established a policy of GROSS national happiness, he explained. "It's from the perspective of the whole country; it's not on the individual level."
         I met a mother named Pema, mother of Kenzay, whom I saw in the OPD.  The OPD is not a happy place, overall.  It is dark and dirty.  Long queues form outside the little offices called stations.  Patients may have travelled for two hours, to wait in these lines, just to have blood tests results read.
But I never saw people complaining.   Pema spoke excellent English because she and her family had moved to the Bay Area of California, and were back here visiting, when Kenzay got sick.  (Health care is universally free to all, visitors and residents alike).   She acknowledged that she preferred the healthcare system in the United States.  "It's much more modern. They know how to find out what's wrong with you and treat you.
       But where do you think people are happier?  I asked.
       "In Bhutan," she said.  "People are always running around in the U.S.  They're always anxious about this and that.  There is never enough time just to be together."