A Day of Healing at a Clinic for Native Americans
Barely thirty, JWE, now sits in front of you, a wasted life, his limbs a metaphor for that waste. Bites from bed bugs all over. He requests calamine lotion.
R foot disabled by Charcot. Painful to move, dislocation of the bones of the ankle joint I suppose.
I was determined that he is seen regularly by us. The Podiatry Nurse had picked him at his home and bought him over to the clinic ( Point 1).
Basing our concern on the friendship we have with this nice man, sit and chat with him.
He produces two prescriptions from a cardiologist from City: Atenelol ER 25 mg , one half to be taken each day.
The Diabetes educator tried to break the tiny tablet into two, was unable to ( Pont 2). The Pharmacy agreed to break the tablets into two for this young man suffering with neuropathy and general muscular weakness.
The Podiatrist attends to his feet, he needs operative correction and she makes the necessary arrangements for them to be done at Sioux City.
I ask him for his telephone number, I have two cellular phones, he says proudly, I shall call you on both phones at the same time to remind you to come and see us next month.
He has been prescribed 35 units of NPH (a longer acting Insulin ) in the morning and in the evening and 20 units of Humalog (a quick acting insulin) before Lunch and dinner. Whoever prescribed that did not have any idea of his eating habits.
He, likes many Indians has hardly any breakfast, so the Insulin in the morning makes him feel weak by mid morning, he has to grab whatever he has, usually something undesirable, to make him feel better. Lunch is a small affair and if he takes the Humalog he feels drowsy all afternoon. The evening meal is a substantial one and he takes his insulin before dinner and the fast acting one after dinner. Occasionally he wakes up feeling weak .
Cut down on his Insulin in the morning, Omit the pre lunch Insulin if he is having a small lunch and ask him to take his Insulin before dinner.
A commonly made error is the incongruity between Insulin dosage and the requirements of the individual body, in this case a man who does not eat breakfast or very little at lunch.
Bug Bites may not be a medical emergency but it is a social one. Calamine lotion is not the treatment for the situation, first soap to clean the skin , and look into the housing situation, where does he sleep, how can we find out the status of the bedding he sleeps on, how can we help. (Point 3)
Point 1
Just because the Nurse thought of picking him up, he was able to have his foot cared for. There are people out there whom we can help. But how can we help if they don’t have access to us?
Point 2
How many of us know the shapes and colours of the prescription medications we write for and ask patients to do superhuman feats that we ourselves cannot do. Just because he is a patient it does not mean he does not have any human rights.
This first patient of the day, was an example of Human Rights Violation at the level of Health and at the same time an example how social care can augment the outcome of a poor patient.
Point 3
Knowing fully the personal habits and hygiene of the place of residence is extremely important. As carers of human beings, we must make sure that we are not adding to the already present social structural violence in their lives.
Patient 2
Age 43
Type 2 Diabetes since age 35.
Why do you think you got Diabetes?
It cannot be hereditary, since my mother who is in her late sixties was just diagnosed with diabetes and I have had diabetes now for eight years.
I am convinced that it is the food that made me diabetic. (Point 1). I was eating everything and anything and paid no attention at all to the quality of food.
Now going on for eight years with Type 2 Diabetes, controlled with one oral hypoglycemia agent.. Eventhough he works in the clinic area, he has not been seen by any provider for more than one year. His A1C is 7.0.
Doctors tend to forget that patients also have their view of the world and explanations of why they get ill. It is one of the fundamental themes of cross cultural medicine, that patients from various cultures, even from the same country, such as USA, have different explanations on why they get sick. If you are unwilling to accept and negotiate through the model (called Explanatory Model in Anthropology), you would become less effective, you are not out there to demonstrate your pathophysiological knowledge, you are out there to take care of the patient and relieve him of his illness and suffering. You are not at war with your patient, and don’t try to assert your superiority ( a complex) by insisting that only your explanatory model, the western medical model based on body as a machine metaphor). If the patient believes that his hyperglycemia was caused by food he was eating, and you don’t believe him; and you make that clear in your action or words or facial expressioins, he also has very little interest in believeing your pathophysiological explanations of insulin resistance or insulin secretion. We are not here to prove who is right and who is wrong, but try to find way s communicating with the person sitting in front of you and alleviate his symptoms Curers, which of most of the health care providers are, want certainty; healers want relief of suffering. This is not about doctor patient relationship, that is very much dependent upon the personality of the provider. As my UmonHon teacher once told me: you cannot make a good doctor out of a bad person.
Patient No 3
If you work with Indians long enough, you begin to understand the importance of symbolism in their lives. As one Lakota Elder remarked: we live in a world of symboiism, we only need a hint to understand.
One such thing happened to me today.
As I was leaving the Blue House ( the house where I stay when I come to work with the Indians), a whiff of air made a photo tumble down from its position in the shelf. I looked at the photo. I t was a photo of Marcia
C an assistant to D(director of Diabetes Programme) had called this patient at home. (point 1) to remind her of the appointment with me. She said, I clear forgot, I thought it was for next Friday. Eagerly she was at the office within fifteen minutes.
My sugar is up today, and she would give an explanation. ( remember to believe in their explanation, and not arrogantly deny saying, one piece of cake wont make the sugar go up by 100 points). But it has been coming down.
Her blood sugars have been acceptably normal in the range of 150 post prandially and with a a1C of 7.5. that was early last year.
Her closest friend of twenty five years died in March of last year. We have been friends for a long time, she said, I could see how she struggled to complete her nursing degree while she was still in an abusive relationship. Her son was a toddler then, thank God her father stepped in and helped her and she could finish her studies and become a nurse. We would sit around and talk about things, she was the only person that I could open up and tell everything.
Patient came to the clinic in June 2007. Her Blood sugars have been running high, and A1C was elevated. This time it was close to 9.5 (point 2). The provider looks at the numbers and increases her insulin and tells her to come back in two months time.
Everytime someone mentioned her name, my eyes will well up, my patient continued. I was crying and feeling very sad. I was not depressed but I needed an explanation.
She returned to the clinic in august of 2007, the response of the provider was to increase the insulin once again. She did not wish to follow the advice, as she had recently begun to see the mental health counselor and was seeing a ray of hope in the world of her sorrow.
On her next visit and the subsequent ones, the blood sugar had come down, the A1C showing a congruous decrease.
How are your sessions with the counselor? She is a good friend of mine, and a very traditional woman.
She has really helped me. She talks to me about understanding this loss and I feel that when the ceremony for the anniversary of death comes around I would no longer be sad at the mention of her name. but I will never forget her and I will always remember her, my dear friend.
I began relating to her sadness. When Ruggles Stahn, an excellent colleague and a kind man, died in a plane crash in Minot North Dakota during one of his trips to the various tribes, tears would well up in my eyes each time I heard his name. A Indian Elder told me, take his favourite food, go to a secluded area, preferably under a tree and call to him and speak to him, tell him that it is time for him to go, on his journey and leave you alone. Tell him that he will always be in your heart and that he is in a better position after his journey to be of help to you and look after you than where he is now. I prayed for him and miraculously enough, despite the fact that my love and admiration for him never decreased, the welling up of eyes did go away, go away it did very quickly.
I then invoked a Colombian writer, a favourite of mine, Alvaro Mutis, who once wrote: when someone dies, until all the person who knew and remember that person, he or she remains alive in our hearts. It is only after all of us have died that the person finally dies.
The mental health counselor helped me accept her physical loss. I am very grateful to her. I also thanked the counselor in my heart.
Looking at the blood sugar and A1C in a chronological fashion, one thing is very obvious. Her blood sugars were acceptable before the death of her friend, it went up and went up, and once she began counseling with the Mental Health Counsellor, it began to come down and I am confident that once that ceremony is over, her blood sugar will return to its previous self.
I always try to bring in the spiritual aspects of life to the encounter. There is no need for proseletyzing since an average Indian patient is on a much higher plane of spiritual awareness than an average person that I encounter on my visits to the United States. I was delighted to hear that she attends the Native American Church regularly, and that her husband is a Roadman for the Church. I was happy as I had just watched a documentary about Huichol Indians and their Peyote collection rituals. (at the Museum of Antrhopology in Mexico City).
I an Endocrinologist trained in the purest of the western tradition (London, Melbourne, Washington University and University of Miami in the USA), firmly believe that it is the counseling by the Mental Health Professional that has brought her relief: not only emotionally but physically as well.
And do you know the name of her of friend she so much mourns about?
Marcia
Point 1
Our clinic is not run along the models of a fee for service medical service clinic found in the non Indian world. Giving a patient an appointment slip or sending a letter has very little value in our world view. What I learned from long years of working with M is as follows: You can tell a patient that you would like to see them, in one month or two months and if possible even give a date.
The week before or on Monday or Tuesday of the week if the clinic is to be held on a Friday, someone has to call and remind the patient that she or he has an appointment on Friday. That is still not enough. This patient came to the clinic, because Crista called her and reminded her of the forgotten appointment.
I would have missed a great spiritual experience if she had not come to the clinic.
Point 2
Fifteen years ago, Dr Mohammed A, asked me what is the necessity of having a psychologist on the Diabetes programme? We can take care of their diabetes, we have medications and why do we need a psychologist? They are not crazy.
Unfortunately, fifteen years later that kind of thinking still persist. Working with the UmonHon Indians, it has afforded me a chance to practice medicine as it was practiced among them before the European came and we can practice healing like everyone in the world deserves but don’t have access to.
We have access to their world but we don’t utilize it. They come to see us and we see only the paper and the number before us.
Whenever there is a sudden change in the measurements: whatever it is, weight, TSH levels, A1C levels, remember, the usual cause is emotional upset in their lives. Instead of just reaching out for the prescription pad and writing more of the same medications, just enquire a little bit about their lives, and try to find out from their social and cultural life what has changed.
And respect it and offer help if you can. Some of you may think that I have I am doing injustice to the patient not to increase Insulin or other medications when on paper or on algorithms one must increase it, I am sorry, I never increase any medications for patients under my care unless I speak to them of their emotional, family and social and many cases spiritual life.
I am allotted 30 minutes with each patient and it is sufficient to touch all the subjects to gain a good understanding.
To imitate Eugene Delacroix, it is the relief of grief and suffering you rendered that people remember you by.
Lunch at Azteca Bar and Grill in W village. The outside temperature was hovering around 30 degrees F.
Let us go to W village to eat but we have to be back by 1 pm, said M. Sorry there is not enough time to go elsewhere to eat, apologizing knowing my propensity for edible food.
Three of us colleagues, D and M and I got into the car and we were at the restaurant in W villatge. It is a metaphor for the mixture that is this country in that in the middle of the state of upper plains, in a town where majority of the people are native Americans, there is a Mexican restaurant! Also tells us about the future demographics of this country.
The Burritos are oversized, like a Mexican migrant to the united states, perhaps an allegory. It was tasty enough. It was prepared by Esperanza, I went to the kitchen and said hello to her. I was told of her by the a nurse working at another Indian clinic.
It is a nice time to be together, eating together with people you work with. I don’t have time nor occasion to socialize with them as they live about 30 miles away from the clinic and when I am here I stay very close to the clinic.
Patient no 4
During the lunch time, I was told that a patient is bringing her sister to see me, even though there was no medical indication for that visit. M said, she was a little angry when she left the clinic the other day, so you can calm her down.
More about the sister later on, first about the patient.
I have known this patient and her family from the very beginning of my visits to the UmonHon country. It is obvious that her family has a genetic proclivity for metabolic diseases in that most of the members of the family have diabetes, young and old and even the eight year old grand daughter has Acanthosis Nigricans.
She had come to see in October last year. She had just been to see the Nephrologist and received what she termed, the “death sentence”. The nephrologist authoritatively told her, your kidneys are only functioning at 10 per cent of its capacity and soon you would need dialiysis.
She had somewhat expecting the news but the brutishness with which the news was delivered unnerved her. She realized that she needed the services of the doctor, and would soon become dependent upon him for continued life, and the thought depressed her. She also has a sister in a similar stage of advanced kidney disease.
She wanted to know, in October last year, what I thought of her proposed trip to Oregon. She has been invited by a friend to spend a month or so with her in the Oregon countryside. She cherished the thought of being able to go once again to the land of mountain and river and waters. I saw the pleasure of anticipation in her face and said to her, that I fully support her visit to her friend and made sure that she had enough of the medications she needed. Even at that time I noticed that she had left the nephrologists office very little medications, not like many others at her stage of disease with multitudes of medications.
She spent two months with her friend and also with her other sister who was living there in Portland, Oregon. Each day they ate fresh food, conscious of the additives in food and try to eat less meat and more fruits and vegetables. They kept each other company and she had a delightful time and returned only a few days before this visit to see me in the clinic.
She definitely needs to be under the care of a nephrologist. We are fortunate enough to have a nephrologist on our staff, Dr A. So first it was to make sure that she will make an appointment to see him and follow his advice regarding ways to keep dialysis at bay.
She had been concerned about her blood pressure, but it was an acceptable 130/58. She was very happy to hear about that. She felt relaxed and began to relate stories about her visit to Oregon. She had thoroughly enjoyed the visit. She ate fresh food each day and the salads and fruits were much different from the ones she was used to eating in Nebraska. She felt healthy, went for walks and had a general sense of well being. She is now back and ready to face the future with regards to her illness. I told her that she has to be under the are of Dr A and she agreed. We talked a fair bit of time about her family and ways of maintain her good health. She agreed to make an appointment, and was very happy when I told her, even if the nephrologists are looking after you, I still would like to see you and talk to you. She went outside to fetch her sister.
Patient no 5
G
She looks like how Indians used to look like. Tall, smooth long black hair, thin . she smiled with caution on meeting me for the first time.
I broke the ice by telling her, let me tell you about my two brothers who live in Portland Oregon (Point 1). We talked about Oregon life, the food culture there and she is a naturalist in that tries to eat as pure a food as possible and keep well.
After we reached the plateau of comfort, she wanted to begin talking about the reason for her visit.
She has been infected with Hepatitis C virus, which was documented 17 years ago, eventhough she feels she has had it at least for twenty years. On enquiry why she may have or how she may have gotten the infection, the only connection I could make was to a blood transfusion in 1985 after the birth of her last child. But he is not Hep C positive, so I explained to her that she might have gotten the infection form transfusion but it would have spared her child and she remembers the transfusion being given after the birth of the child. Every year as part of a national study on Hepatitis C, she goes to an university and is checked over by a Gasteroenterologist, Infectious Disease specialist, Hepatologistm an Oncologist. Obviously she is under some national study, she said she has been on four different studies as part of the control to study the natural history of the virus.
What has triggered fear in her was a recent visit to the Hospital. The doctor who saw her, a first time encounter, on seeing the levels of the virus, RNA based measurement of type 1a virus, said that her levels were at 5.9 while the normal (?) levels were given as under 1.9. What she heard from the doctor ( I was later on told that the doctor did not say this) was that her liver was failing and that she needs immediate interferon therapy. Interferon therapy is a very aggressive form of treatment and people feel very sick on that. Her own son had received it and was sick for almost one year but benefited from it in that he is now virus free and part of the US Armed forces. She was referred to the Hepatologist but the health committee of the tribe denied her that recommendation since the doctors reviewing the results found that it was not necessary. The only information transmitted to her was that her referral has been denied, which she felt that would be insult to injury if she really needed treatment and consultation at the University Hospital.
I felt that what all she needed was an explanation of the well status of her infection. All of us are infected with many viruses and that alone does not make us sick or label us as being diseased. The history of hepatitis C virus is complex and the first good news is that she has had this infection for more than twenty years. We talked at length about the stories about patients who have received treatment with interferon. This is a society that fears taking risk and that believes that life is a risk free business. The best news I could give her was that her liver function tests were absolutely normal. If she is worried that her viral activity has increased one of the main organs affected would be the liver and as far as we can see the liver is functioning well. She seemed happy to hear that. I encouraged her to continue her good habits of eating well (in this isolated community that is a tall order) and find ways of finding calm in her life. She is very clued into the life of a new age person from the west and she with her family support should not find it too difficult to adjust back to the life in her reservation. She will be living with her sister and in fact, they could support each other emotionally. I don’t even want to go into the financial hell these people live under. The structural violence against them is beyond imganiation.
When I was in the Kalahari desert, I was at a remote area, near Tsumkwe, a town where a lot of the bushmen lived. I was surprised to see large bottles of Fanta and Sprite for sale at the petrol stand. Soon I realized the reason, I saw a group of young Americans, members of the peace corps assigned to the area. When we met, they proudly said, we are Americans, we are peace corps people, and what do you do?
I said, I am an Austrlalian, I do Peace Corps work in your country with the native people of your country. This reduction of the romance of their job to the Nebraska reservation did not set well with them. They soon said good bye and left. Romancing the Coca cola, I suppose.
Point 1
World view is the way we look at the things around us, finding comfort when there are intrusions into our daily lifes by other geographies, or people among other things.
When an Indian, who has never met me, looks at me, he might put me in his world according to his ideas or constructed ideas about people who like me or people who do work like me, doctors.
It is very important to place yourself in their world view, in their world that they can easily understand you.
When a new patient comes to see you, it is so important not to launch directly into the medical complaints or questions that brought them to you in the first place.
By finding common ground, if they have a familiar name, asking them whether they are related to your friends with the same name, or in this case, this lady has just arrived here from Portland, Oregon. It is a city where two of my brothers live and it is a city that I happen to like very much. She has some nostalgia about leaving the place of her residence of the past few years and she lit up when I told her that my brothers live there. That opened the conversation and it flowed very easy from then on.
It is also important, in immigrant countries like Australia and USA, not to begin the conversation with comments such as:
If you think they look oriental asian, don’t begin , Which part of Vietnam you come from
The most polite form is to ask: are you an American or are you an Australian? Then he might tell you which part of the world he or his parents came from and he wont feel that you are prejudging you.
I have met many Mexicans along the border who refuse to speak Spanish eventhough they cant speak English well either and who insisted that they are Americans and they know nothing about Mexico.
One day at restaurant Merida, a laid back fellow walked over to me and wanting to be friendly, asked are you from Guinea Bissau, when I answered an emphatic NO, he pursued, are you from Papua-New Guinea. So this guy obviously knows nothing about Guinea Bissau nor Papua New Guinea and I lost interest in a conversation with him.
It is very important not to create friction when meeting a new person for the first time, whether in the consulting rooms or at the airport check in lines. Most of our interactions are less than five minutes in duration in real life and why rub anything against the person in that short period. It is far easier to be pleasant in those five minutes or less.
Consultations on the Corridor
Patients 6 & 7
It is nice to be able to take your gaze away from laboratory tests and concentrate on the patient. When I saw JW at the hallway, I made a note of the fact that she looked rather puffy. This is also an advantage of coming regularly to the same place but you are not there all the time, so that the changes in the place: the bodies of the people among them is easily noted. It is as if the brain has the last image of the person stored and compared it with the new image and give you a comparison
She suffers from insomnia and it is worse when her thyroid hormone levels are not adequate. She is on a high dosage. The laboratory tests have been done, and the provider came to say: the thyroid is low and you need more.
My thoughts were, why? This is the difference between anthropologically oriented thinking and medically oriented thinking. The former asks WHY and the latter asks WHAT? Your thyroid levels are low, so it can be corrected with an addition of thyroid hormones you are already taking. The WHY question is , why is her thyroid hormone low. It was this kind of questioning that made me realize about three years ago, there is a connection between pesticides and the increasing prevalence of hypothyroidism in this country.
What could make this young lady’s thyroid function go down? Even in the best of times, there is only about 75 % absorption of the medications and there is a slew of things that would interfere with its absorption: Tums and Iron Tablets, both of which she is taking. It is better to take thyroid medication by itself in the morning , so that a better absorption is guaranteed. Also like many other minerals and trace elements, the American diet now lacks in iodide. We tell them don’t eat white bread and don’t put salt on your food, both good source of iodide and Americans don’t favour sea kelp and other sources of iodide.
She eats bread three times a week and does add salt to the food. We cannot yet point the finger of blame. I wonder we could propose this scenario. Does lack of sleep compound the problem of absorption? Making the stomach more acidic? Or the tension of not sleeping? There has to be a connection since her insominia disappears once she is adequately replaced.
In the busy atmosphere of the day, I forgot to go back and counsel her. I have to make sure I call her over the weekend at her home and talk to her.
In this small clinic, there are quite a few women who are hypothyroid. And in my opinion, autoimmunity perhaps reveals the proclivity, but certainly some chemical entering the body from outside and blocking the uptake of iodine or the manufacture of the thyroid homone is to blame.
A few years ago three womencolleagues were diagnosed as hypothyroid within a short period of time. That is when I began looking into the association with an ecological agent and hypothyroidism. While the thyroidologists agree that the prevalence is increasing, they are looking at the body for an answer, rather than outside. Plastics, pesticides, artificial food are the candidates.
One of those women, a few months complained about her hair falling off and a small adjustment of the dosage had corrected the problem. Today she comes to talk, take the necessary blood tests, the results of which would be discussed on my next visit.
She is only on about half the dosage necessary for her age, sex and weight. Over the years I have become friends with her, and I had the misfortune of telling her teenage daughter when she came in for a school physical that she has type 2 Diabetes . while she was at school and living at home, her management of her metabolic alterations were exemplary and once she got a scholarship and went on to the university where she is a senior student now, the behavior has nothing but disastrous.
The preparation of Indian children to face the wider world is not well understood. In these isolated parts of the country, they are comfortable when they are growing up eventhough facing racial insults and discrimination, but not a psychological ones. This young lady went to the metropolitan university and was surrounded by petite blond haired fair skinned ladies of higher economic milieu, and suddenly she subconsciously adopted their modes. She wanted to be slim, lithe like them and nothing would stand in her way. She wanted to be different and she was out to prove it. Tattoes and a miscarriage and loss communication with her family and her tribe followed. What aspects of being suffered? In this mental dilemma about her cultural identity and body identity, she completely forgot to look after her diabetes. Once she was a paragon of diabetes care, when she was one of the best cared for students out of the five who had been diagnosed with type 2 diabetes at her school (now the number is even larger), but at the university, she ate to her hearts delight to imitate her friends, kept long hours and drank. As a result, her blood sugar has never stayed anywhere near the normal levels for the past three to four years.
The mother tries what is good for her daughter, but the daughter does not listen. She takes all sorts of approaches all are met with a hard wall of refusal. Finally she tells her, when your feet are cut off, don’t come back here to this house, I will put you on a wheel chair and send you out, when you are blind, I am not going to say to you, oh my baby , come back to mother I will look after you, I will send you back out there.
Full of tattoes, piered skin, she wants to study law. How can she go back into the society which she subtly rejected by taking on this personality and identity? It is a great worry for her mother and usually our consultation period is spent on talking about her daughter. Always she leaves happier than when she arrived. She is not a patient of mine, she is afriend and I happen to be an Endocrinologist with some knowledge of the thyroid diseases.
Patient no 8
I always look forward to his coming to the clinic, very positive attitude and takes your word very seriously. He had an accident at work and was sent to neurologist and rheumatologist in Sioux city. The neurologist at first said he needed a rheumatological consultaition and the rheumatologist thought an injection into the knees would be of help. At that time, TT, took out my card and gave it to him, please send all your reports to my doctor. All of a sudden the rheumatologist realized that this is not just an Indian with workers compensation but there is an organization behind him. Believe it or not, the rheumatologist changed his mind, and sent him back to the neurologist who now proceeds to diagnose the condition as diabetic neuropathy. And suggests high dosages of steroid therapy intramuscularly which he gave six times during a period of two months on various visits. You knew you would get neuropathy, since you have had diabetes for twenty years and you should have looked after the diabetes, admonished the neurologist with a latin sounding name. just because you are from another culture it does not automatically make you culturally sensitive. Greed and avarice are the prime motivator here and not the welfare of the patient. In towns like Sioux City, and Yankton where there are more plastic surgeons and orthopedic surgeons than family practitioners, this mentality of wild west medicine exists, since there are no checks and balances if they were close to a medical centre or under the gaze of doctors associated with teaching and keeping up with the literature. (medical that is, you cant expect most of the doctors to keep up with the literature of the English language). TT was good at taking are of his diabetes, his A1C was acceptable and the blood sugars were well controlled and he was not on insulin.
The next month after his first injections, his blood sugars began climbing up, first into the two hundreds and then three hundreds and after the second series of steroid injections, they went up to the five hundreds. He was not told that this might happen and on his first visit, the neurosurgeon had whispered to his nurse, please make sure that I have their medical histories the next time, since on his first visit he was not aware that the patient had diabetes, making the referral to his friend the rheumatologist who works within the same organization in tax free south Dakota, on the border to the town of Sioux city.
It took a full two months of checking the blood sugar four times a day and taking 10 units of regular insulin for the blood sugars to begin to come down. Even now it is in the high two hundreds and I told him that as the steroids begin to wash away, his blood sugar will come back to the old levels. I did notice that the intramuscular injections were rather high in steroid content. M kept in touch with him and he dutifully calls on the phone and comes regularly to the appointments. I want to show him that with diligent care, by taking blood sugar readings four times a day and acting upon it, his blood sugars will come down and that hopefully no permanent damage would be done to his body.
He is builder by trade and somehow or other the conversation came around to the house I own within the reservation limits. He came over one weekend during my visit few months ago and took a good look at it and recommended several things. I wouldn’t mind keeping the house, which now houses all my books collected in this hemisphere and the parapharnelia of travels. He and his friends would donate their time to repair the house and all I have to do would be to get the material and pay for the transportation. I have gladly agreed to that.
The last patient of the day, I did not recognize her by name. As I entered, even her face was not that familiar even though I have seen her around. Finally finding a way to place ourselves in each others world, I realized that one of my patients ( the lady with the thyroid problem) had sent her mother to see me. And the place I had seen her would have been in the corridors of the clinic at the Winnebago Indian reservation.
She lamented about the fact that she used to have good skin, and took good care of herself and her good looks, now the physiotherapist advised to wear comfortable but unfemininie shoes, despite the use of creams her skin is dry. The introduction to our consultation was much more cosmetological, the place where she gets here nails done. She had been feeling lethargic and devoid of energy, and at the request of her daughter had come to the clinic to discuss whether or not she had problems with her thyroid gland. She receives all her care at the Winnebago clinic and since I was going there the next week, and it is easier to order thyroid function tests there, I told her that we would continue our consultation there and I would order the thyroid function tests. She had some symptoms of hypothyroidism, but some crucial elements were missing. I will see her next Monday.
When I finished with her, I noticed the clinic had emptied and when I returned to the doctors area, the lonely podiatrist was packing up.it was a Friday evening and the beginning of a nice long weekend of rest for me. Very rarely I spend a weekend here in these parts but when I do it is full of rest and relaxation and an opportunity to write.
Todays clinic is what a clinic should be for me. Socio cultural and psychological consultation mixed in with the endocrinological aspects which does not take primary role. Good working relationship with my colleagues who make my consultaion with the patient easy and facilitative. Lunch with colleagues to take time off and talk about other things.
When I was a child, I used to read poems of Omar Qayyam of Nishanapur, a mystic Persian poet. He had lamented about the rotating doors of the consultation rooms of the doctors and the despondent patient returning to the tavern after their consultations. This was in the 12th century. That stuck in my mind long before even I had decided to study medicine.
Pablo Neruda, that Chilean Bard, the greatest poet of the 20th century had written a poem which I read when I was a student of medicine ..I forget in which country it was that I read him first, Australia , England or America..
Here it is:
How much does a man live, after all?
Does he live a thousand days, or one only?
For a week, or for several cernturies?
How long does a man spend dying?
What does it mean to say “forever”?
Lost in this preoccupation
Iset myself to clear things up.
I sought out knowledgeable priests,
I waited for them after their rituals,
I watched them when they went their ways
To visit God and the Devil.
They wearied of my questions.
They on their part knew very little.
They were no more than administrators.
Medical Men received me
In between consultations,
A scalpel in eachhand,
Saturated in aueroycin,
Busier each day.
As far as I could tell from their talk,
The problem was as follows:
It was not so much the death of a microbe-
They went down by the ton,
But the few which survived
Showed signs of perversity.
They left me so startled
That I sought out the grave-diggers.
I went to the rivers where they burn
Enormous painted corpses,
Tiny bony bodies,
Emperors with an aura
Of terrible curses,
Women snuffed out at a stroke
By a wave of cholera.
Thre were whole beaches of dead
And ashy specialists.
When I got the chance
I asked them a slew of questions.
They offered to burn me.
It was all they knew.
In my own country the dead
Answered me, between drinks:
“get yourself a good woman
And give up this nonsense.”
I never saw people so happy.
Raising their glasses they sang
Toasting health and death
They were huge fornicators.
I returned home, much older
After crossing the world.
Now I ask questions of nobody.
But I know less every day.
Barely thirty, JWE, now sits in front of you, a wasted life, his limbs a metaphor for that waste. Bites from bed bugs all over. He requests calamine lotion.
R foot disabled by Charcot. Painful to move, dislocation of the bones of the ankle joint I suppose.
I was determined that he is seen regularly by us. The Podiatry Nurse had picked him at his home and bought him over to the clinic ( Point 1).
Basing our concern on the friendship we have with this nice man, sit and chat with him.
He produces two prescriptions from a cardiologist from City: Atenelol ER 25 mg , one half to be taken each day.
The Diabetes educator tried to break the tiny tablet into two, was unable to ( Pont 2). The Pharmacy agreed to break the tablets into two for this young man suffering with neuropathy and general muscular weakness.
The Podiatrist attends to his feet, he needs operative correction and she makes the necessary arrangements for them to be done at Sioux City.
I ask him for his telephone number, I have two cellular phones, he says proudly, I shall call you on both phones at the same time to remind you to come and see us next month.
He has been prescribed 35 units of NPH (a longer acting Insulin ) in the morning and in the evening and 20 units of Humalog (a quick acting insulin) before Lunch and dinner. Whoever prescribed that did not have any idea of his eating habits.
He, likes many Indians has hardly any breakfast, so the Insulin in the morning makes him feel weak by mid morning, he has to grab whatever he has, usually something undesirable, to make him feel better. Lunch is a small affair and if he takes the Humalog he feels drowsy all afternoon. The evening meal is a substantial one and he takes his insulin before dinner and the fast acting one after dinner. Occasionally he wakes up feeling weak .
Cut down on his Insulin in the morning, Omit the pre lunch Insulin if he is having a small lunch and ask him to take his Insulin before dinner.
A commonly made error is the incongruity between Insulin dosage and the requirements of the individual body, in this case a man who does not eat breakfast or very little at lunch.
Bug Bites may not be a medical emergency but it is a social one. Calamine lotion is not the treatment for the situation, first soap to clean the skin , and look into the housing situation, where does he sleep, how can we find out the status of the bedding he sleeps on, how can we help. (Point 3)
Point 1
Just because the Nurse thought of picking him up, he was able to have his foot cared for. There are people out there whom we can help. But how can we help if they don’t have access to us?
Point 2
How many of us know the shapes and colours of the prescription medications we write for and ask patients to do superhuman feats that we ourselves cannot do. Just because he is a patient it does not mean he does not have any human rights.
This first patient of the day, was an example of Human Rights Violation at the level of Health and at the same time an example how social care can augment the outcome of a poor patient.
Point 3
Knowing fully the personal habits and hygiene of the place of residence is extremely important. As carers of human beings, we must make sure that we are not adding to the already present social structural violence in their lives.
Patient 2
Age 43
Type 2 Diabetes since age 35.
Why do you think you got Diabetes?
It cannot be hereditary, since my mother who is in her late sixties was just diagnosed with diabetes and I have had diabetes now for eight years.
I am convinced that it is the food that made me diabetic. (Point 1). I was eating everything and anything and paid no attention at all to the quality of food.
Now going on for eight years with Type 2 Diabetes, controlled with one oral hypoglycemia agent.. Eventhough he works in the clinic area, he has not been seen by any provider for more than one year. His A1C is 7.0.
Doctors tend to forget that patients also have their view of the world and explanations of why they get ill. It is one of the fundamental themes of cross cultural medicine, that patients from various cultures, even from the same country, such as USA, have different explanations on why they get sick. If you are unwilling to accept and negotiate through the model (called Explanatory Model in Anthropology), you would become less effective, you are not out there to demonstrate your pathophysiological knowledge, you are out there to take care of the patient and relieve him of his illness and suffering. You are not at war with your patient, and don’t try to assert your superiority ( a complex) by insisting that only your explanatory model, the western medical model based on body as a machine metaphor). If the patient believes that his hyperglycemia was caused by food he was eating, and you don’t believe him; and you make that clear in your action or words or facial expressioins, he also has very little interest in believeing your pathophysiological explanations of insulin resistance or insulin secretion. We are not here to prove who is right and who is wrong, but try to find way s communicating with the person sitting in front of you and alleviate his symptoms Curers, which of most of the health care providers are, want certainty; healers want relief of suffering. This is not about doctor patient relationship, that is very much dependent upon the personality of the provider. As my UmonHon teacher once told me: you cannot make a good doctor out of a bad person.
Patient No 3
If you work with Indians long enough, you begin to understand the importance of symbolism in their lives. As one Lakota Elder remarked: we live in a world of symboiism, we only need a hint to understand.
One such thing happened to me today.
As I was leaving the Blue House ( the house where I stay when I come to work with the Indians), a whiff of air made a photo tumble down from its position in the shelf. I looked at the photo. I t was a photo of Marcia
C an assistant to D(director of Diabetes Programme) had called this patient at home. (point 1) to remind her of the appointment with me. She said, I clear forgot, I thought it was for next Friday. Eagerly she was at the office within fifteen minutes.
My sugar is up today, and she would give an explanation. ( remember to believe in their explanation, and not arrogantly deny saying, one piece of cake wont make the sugar go up by 100 points). But it has been coming down.
Her blood sugars have been acceptably normal in the range of 150 post prandially and with a a1C of 7.5. that was early last year.
Her closest friend of twenty five years died in March of last year. We have been friends for a long time, she said, I could see how she struggled to complete her nursing degree while she was still in an abusive relationship. Her son was a toddler then, thank God her father stepped in and helped her and she could finish her studies and become a nurse. We would sit around and talk about things, she was the only person that I could open up and tell everything.
Patient came to the clinic in June 2007. Her Blood sugars have been running high, and A1C was elevated. This time it was close to 9.5 (point 2). The provider looks at the numbers and increases her insulin and tells her to come back in two months time.
Everytime someone mentioned her name, my eyes will well up, my patient continued. I was crying and feeling very sad. I was not depressed but I needed an explanation.
She returned to the clinic in august of 2007, the response of the provider was to increase the insulin once again. She did not wish to follow the advice, as she had recently begun to see the mental health counselor and was seeing a ray of hope in the world of her sorrow.
On her next visit and the subsequent ones, the blood sugar had come down, the A1C showing a congruous decrease.
How are your sessions with the counselor? She is a good friend of mine, and a very traditional woman.
She has really helped me. She talks to me about understanding this loss and I feel that when the ceremony for the anniversary of death comes around I would no longer be sad at the mention of her name. but I will never forget her and I will always remember her, my dear friend.
I began relating to her sadness. When Ruggles Stahn, an excellent colleague and a kind man, died in a plane crash in Minot North Dakota during one of his trips to the various tribes, tears would well up in my eyes each time I heard his name. A Indian Elder told me, take his favourite food, go to a secluded area, preferably under a tree and call to him and speak to him, tell him that it is time for him to go, on his journey and leave you alone. Tell him that he will always be in your heart and that he is in a better position after his journey to be of help to you and look after you than where he is now. I prayed for him and miraculously enough, despite the fact that my love and admiration for him never decreased, the welling up of eyes did go away, go away it did very quickly.
I then invoked a Colombian writer, a favourite of mine, Alvaro Mutis, who once wrote: when someone dies, until all the person who knew and remember that person, he or she remains alive in our hearts. It is only after all of us have died that the person finally dies.
The mental health counselor helped me accept her physical loss. I am very grateful to her. I also thanked the counselor in my heart.
Looking at the blood sugar and A1C in a chronological fashion, one thing is very obvious. Her blood sugars were acceptable before the death of her friend, it went up and went up, and once she began counseling with the Mental Health Counsellor, it began to come down and I am confident that once that ceremony is over, her blood sugar will return to its previous self.
I always try to bring in the spiritual aspects of life to the encounter. There is no need for proseletyzing since an average Indian patient is on a much higher plane of spiritual awareness than an average person that I encounter on my visits to the United States. I was delighted to hear that she attends the Native American Church regularly, and that her husband is a Roadman for the Church. I was happy as I had just watched a documentary about Huichol Indians and their Peyote collection rituals. (at the Museum of Antrhopology in Mexico City).
I an Endocrinologist trained in the purest of the western tradition (London, Melbourne, Washington University and University of Miami in the USA), firmly believe that it is the counseling by the Mental Health Professional that has brought her relief: not only emotionally but physically as well.
And do you know the name of her of friend she so much mourns about?
Marcia
Point 1
Our clinic is not run along the models of a fee for service medical service clinic found in the non Indian world. Giving a patient an appointment slip or sending a letter has very little value in our world view. What I learned from long years of working with M is as follows: You can tell a patient that you would like to see them, in one month or two months and if possible even give a date.
The week before or on Monday or Tuesday of the week if the clinic is to be held on a Friday, someone has to call and remind the patient that she or he has an appointment on Friday. That is still not enough. This patient came to the clinic, because Crista called her and reminded her of the forgotten appointment.
I would have missed a great spiritual experience if she had not come to the clinic.
Point 2
Fifteen years ago, Dr Mohammed A, asked me what is the necessity of having a psychologist on the Diabetes programme? We can take care of their diabetes, we have medications and why do we need a psychologist? They are not crazy.
Unfortunately, fifteen years later that kind of thinking still persist. Working with the UmonHon Indians, it has afforded me a chance to practice medicine as it was practiced among them before the European came and we can practice healing like everyone in the world deserves but don’t have access to.
We have access to their world but we don’t utilize it. They come to see us and we see only the paper and the number before us.
Whenever there is a sudden change in the measurements: whatever it is, weight, TSH levels, A1C levels, remember, the usual cause is emotional upset in their lives. Instead of just reaching out for the prescription pad and writing more of the same medications, just enquire a little bit about their lives, and try to find out from their social and cultural life what has changed.
And respect it and offer help if you can. Some of you may think that I have I am doing injustice to the patient not to increase Insulin or other medications when on paper or on algorithms one must increase it, I am sorry, I never increase any medications for patients under my care unless I speak to them of their emotional, family and social and many cases spiritual life.
I am allotted 30 minutes with each patient and it is sufficient to touch all the subjects to gain a good understanding.
To imitate Eugene Delacroix, it is the relief of grief and suffering you rendered that people remember you by.
Lunch at Azteca Bar and Grill in W village. The outside temperature was hovering around 30 degrees F.
Let us go to W village to eat but we have to be back by 1 pm, said M. Sorry there is not enough time to go elsewhere to eat, apologizing knowing my propensity for edible food.
Three of us colleagues, D and M and I got into the car and we were at the restaurant in W villatge. It is a metaphor for the mixture that is this country in that in the middle of the state of upper plains, in a town where majority of the people are native Americans, there is a Mexican restaurant! Also tells us about the future demographics of this country.
The Burritos are oversized, like a Mexican migrant to the united states, perhaps an allegory. It was tasty enough. It was prepared by Esperanza, I went to the kitchen and said hello to her. I was told of her by the a nurse working at another Indian clinic.
It is a nice time to be together, eating together with people you work with. I don’t have time nor occasion to socialize with them as they live about 30 miles away from the clinic and when I am here I stay very close to the clinic.
Patient no 4
During the lunch time, I was told that a patient is bringing her sister to see me, even though there was no medical indication for that visit. M said, she was a little angry when she left the clinic the other day, so you can calm her down.
More about the sister later on, first about the patient.
I have known this patient and her family from the very beginning of my visits to the UmonHon country. It is obvious that her family has a genetic proclivity for metabolic diseases in that most of the members of the family have diabetes, young and old and even the eight year old grand daughter has Acanthosis Nigricans.
She had come to see in October last year. She had just been to see the Nephrologist and received what she termed, the “death sentence”. The nephrologist authoritatively told her, your kidneys are only functioning at 10 per cent of its capacity and soon you would need dialiysis.
She had somewhat expecting the news but the brutishness with which the news was delivered unnerved her. She realized that she needed the services of the doctor, and would soon become dependent upon him for continued life, and the thought depressed her. She also has a sister in a similar stage of advanced kidney disease.
She wanted to know, in October last year, what I thought of her proposed trip to Oregon. She has been invited by a friend to spend a month or so with her in the Oregon countryside. She cherished the thought of being able to go once again to the land of mountain and river and waters. I saw the pleasure of anticipation in her face and said to her, that I fully support her visit to her friend and made sure that she had enough of the medications she needed. Even at that time I noticed that she had left the nephrologists office very little medications, not like many others at her stage of disease with multitudes of medications.
She spent two months with her friend and also with her other sister who was living there in Portland, Oregon. Each day they ate fresh food, conscious of the additives in food and try to eat less meat and more fruits and vegetables. They kept each other company and she had a delightful time and returned only a few days before this visit to see me in the clinic.
She definitely needs to be under the care of a nephrologist. We are fortunate enough to have a nephrologist on our staff, Dr A. So first it was to make sure that she will make an appointment to see him and follow his advice regarding ways to keep dialysis at bay.
She had been concerned about her blood pressure, but it was an acceptable 130/58. She was very happy to hear about that. She felt relaxed and began to relate stories about her visit to Oregon. She had thoroughly enjoyed the visit. She ate fresh food each day and the salads and fruits were much different from the ones she was used to eating in Nebraska. She felt healthy, went for walks and had a general sense of well being. She is now back and ready to face the future with regards to her illness. I told her that she has to be under the are of Dr A and she agreed. We talked a fair bit of time about her family and ways of maintain her good health. She agreed to make an appointment, and was very happy when I told her, even if the nephrologists are looking after you, I still would like to see you and talk to you. She went outside to fetch her sister.
Patient no 5
G
She looks like how Indians used to look like. Tall, smooth long black hair, thin . she smiled with caution on meeting me for the first time.
I broke the ice by telling her, let me tell you about my two brothers who live in Portland Oregon (Point 1). We talked about Oregon life, the food culture there and she is a naturalist in that tries to eat as pure a food as possible and keep well.
After we reached the plateau of comfort, she wanted to begin talking about the reason for her visit.
She has been infected with Hepatitis C virus, which was documented 17 years ago, eventhough she feels she has had it at least for twenty years. On enquiry why she may have or how she may have gotten the infection, the only connection I could make was to a blood transfusion in 1985 after the birth of her last child. But he is not Hep C positive, so I explained to her that she might have gotten the infection form transfusion but it would have spared her child and she remembers the transfusion being given after the birth of the child. Every year as part of a national study on Hepatitis C, she goes to an university and is checked over by a Gasteroenterologist, Infectious Disease specialist, Hepatologistm an Oncologist. Obviously she is under some national study, she said she has been on four different studies as part of the control to study the natural history of the virus.
What has triggered fear in her was a recent visit to the Hospital. The doctor who saw her, a first time encounter, on seeing the levels of the virus, RNA based measurement of type 1a virus, said that her levels were at 5.9 while the normal (?) levels were given as under 1.9. What she heard from the doctor ( I was later on told that the doctor did not say this) was that her liver was failing and that she needs immediate interferon therapy. Interferon therapy is a very aggressive form of treatment and people feel very sick on that. Her own son had received it and was sick for almost one year but benefited from it in that he is now virus free and part of the US Armed forces. She was referred to the Hepatologist but the health committee of the tribe denied her that recommendation since the doctors reviewing the results found that it was not necessary. The only information transmitted to her was that her referral has been denied, which she felt that would be insult to injury if she really needed treatment and consultation at the University Hospital.
I felt that what all she needed was an explanation of the well status of her infection. All of us are infected with many viruses and that alone does not make us sick or label us as being diseased. The history of hepatitis C virus is complex and the first good news is that she has had this infection for more than twenty years. We talked at length about the stories about patients who have received treatment with interferon. This is a society that fears taking risk and that believes that life is a risk free business. The best news I could give her was that her liver function tests were absolutely normal. If she is worried that her viral activity has increased one of the main organs affected would be the liver and as far as we can see the liver is functioning well. She seemed happy to hear that. I encouraged her to continue her good habits of eating well (in this isolated community that is a tall order) and find ways of finding calm in her life. She is very clued into the life of a new age person from the west and she with her family support should not find it too difficult to adjust back to the life in her reservation. She will be living with her sister and in fact, they could support each other emotionally. I don’t even want to go into the financial hell these people live under. The structural violence against them is beyond imganiation.
When I was in the Kalahari desert, I was at a remote area, near Tsumkwe, a town where a lot of the bushmen lived. I was surprised to see large bottles of Fanta and Sprite for sale at the petrol stand. Soon I realized the reason, I saw a group of young Americans, members of the peace corps assigned to the area. When we met, they proudly said, we are Americans, we are peace corps people, and what do you do?
I said, I am an Austrlalian, I do Peace Corps work in your country with the native people of your country. This reduction of the romance of their job to the Nebraska reservation did not set well with them. They soon said good bye and left. Romancing the Coca cola, I suppose.
Point 1
World view is the way we look at the things around us, finding comfort when there are intrusions into our daily lifes by other geographies, or people among other things.
When an Indian, who has never met me, looks at me, he might put me in his world according to his ideas or constructed ideas about people who like me or people who do work like me, doctors.
It is very important to place yourself in their world view, in their world that they can easily understand you.
When a new patient comes to see you, it is so important not to launch directly into the medical complaints or questions that brought them to you in the first place.
By finding common ground, if they have a familiar name, asking them whether they are related to your friends with the same name, or in this case, this lady has just arrived here from Portland, Oregon. It is a city where two of my brothers live and it is a city that I happen to like very much. She has some nostalgia about leaving the place of her residence of the past few years and she lit up when I told her that my brothers live there. That opened the conversation and it flowed very easy from then on.
It is also important, in immigrant countries like Australia and USA, not to begin the conversation with comments such as:
If you think they look oriental asian, don’t begin , Which part of Vietnam you come from
The most polite form is to ask: are you an American or are you an Australian? Then he might tell you which part of the world he or his parents came from and he wont feel that you are prejudging you.
I have met many Mexicans along the border who refuse to speak Spanish eventhough they cant speak English well either and who insisted that they are Americans and they know nothing about Mexico.
One day at restaurant Merida, a laid back fellow walked over to me and wanting to be friendly, asked are you from Guinea Bissau, when I answered an emphatic NO, he pursued, are you from Papua-New Guinea. So this guy obviously knows nothing about Guinea Bissau nor Papua New Guinea and I lost interest in a conversation with him.
It is very important not to create friction when meeting a new person for the first time, whether in the consulting rooms or at the airport check in lines. Most of our interactions are less than five minutes in duration in real life and why rub anything against the person in that short period. It is far easier to be pleasant in those five minutes or less.
Consultations on the Corridor
Patients 6 & 7
It is nice to be able to take your gaze away from laboratory tests and concentrate on the patient. When I saw JW at the hallway, I made a note of the fact that she looked rather puffy. This is also an advantage of coming regularly to the same place but you are not there all the time, so that the changes in the place: the bodies of the people among them is easily noted. It is as if the brain has the last image of the person stored and compared it with the new image and give you a comparison
She suffers from insomnia and it is worse when her thyroid hormone levels are not adequate. She is on a high dosage. The laboratory tests have been done, and the provider came to say: the thyroid is low and you need more.
My thoughts were, why? This is the difference between anthropologically oriented thinking and medically oriented thinking. The former asks WHY and the latter asks WHAT? Your thyroid levels are low, so it can be corrected with an addition of thyroid hormones you are already taking. The WHY question is , why is her thyroid hormone low. It was this kind of questioning that made me realize about three years ago, there is a connection between pesticides and the increasing prevalence of hypothyroidism in this country.
What could make this young lady’s thyroid function go down? Even in the best of times, there is only about 75 % absorption of the medications and there is a slew of things that would interfere with its absorption: Tums and Iron Tablets, both of which she is taking. It is better to take thyroid medication by itself in the morning , so that a better absorption is guaranteed. Also like many other minerals and trace elements, the American diet now lacks in iodide. We tell them don’t eat white bread and don’t put salt on your food, both good source of iodide and Americans don’t favour sea kelp and other sources of iodide.
She eats bread three times a week and does add salt to the food. We cannot yet point the finger of blame. I wonder we could propose this scenario. Does lack of sleep compound the problem of absorption? Making the stomach more acidic? Or the tension of not sleeping? There has to be a connection since her insominia disappears once she is adequately replaced.
In the busy atmosphere of the day, I forgot to go back and counsel her. I have to make sure I call her over the weekend at her home and talk to her.
In this small clinic, there are quite a few women who are hypothyroid. And in my opinion, autoimmunity perhaps reveals the proclivity, but certainly some chemical entering the body from outside and blocking the uptake of iodine or the manufacture of the thyroid homone is to blame.
A few years ago three womencolleagues were diagnosed as hypothyroid within a short period of time. That is when I began looking into the association with an ecological agent and hypothyroidism. While the thyroidologists agree that the prevalence is increasing, they are looking at the body for an answer, rather than outside. Plastics, pesticides, artificial food are the candidates.
One of those women, a few months complained about her hair falling off and a small adjustment of the dosage had corrected the problem. Today she comes to talk, take the necessary blood tests, the results of which would be discussed on my next visit.
She is only on about half the dosage necessary for her age, sex and weight. Over the years I have become friends with her, and I had the misfortune of telling her teenage daughter when she came in for a school physical that she has type 2 Diabetes . while she was at school and living at home, her management of her metabolic alterations were exemplary and once she got a scholarship and went on to the university where she is a senior student now, the behavior has nothing but disastrous.
The preparation of Indian children to face the wider world is not well understood. In these isolated parts of the country, they are comfortable when they are growing up eventhough facing racial insults and discrimination, but not a psychological ones. This young lady went to the metropolitan university and was surrounded by petite blond haired fair skinned ladies of higher economic milieu, and suddenly she subconsciously adopted their modes. She wanted to be slim, lithe like them and nothing would stand in her way. She wanted to be different and she was out to prove it. Tattoes and a miscarriage and loss communication with her family and her tribe followed. What aspects of being suffered? In this mental dilemma about her cultural identity and body identity, she completely forgot to look after her diabetes. Once she was a paragon of diabetes care, when she was one of the best cared for students out of the five who had been diagnosed with type 2 diabetes at her school (now the number is even larger), but at the university, she ate to her hearts delight to imitate her friends, kept long hours and drank. As a result, her blood sugar has never stayed anywhere near the normal levels for the past three to four years.
The mother tries what is good for her daughter, but the daughter does not listen. She takes all sorts of approaches all are met with a hard wall of refusal. Finally she tells her, when your feet are cut off, don’t come back here to this house, I will put you on a wheel chair and send you out, when you are blind, I am not going to say to you, oh my baby , come back to mother I will look after you, I will send you back out there.
Full of tattoes, piered skin, she wants to study law. How can she go back into the society which she subtly rejected by taking on this personality and identity? It is a great worry for her mother and usually our consultation period is spent on talking about her daughter. Always she leaves happier than when she arrived. She is not a patient of mine, she is afriend and I happen to be an Endocrinologist with some knowledge of the thyroid diseases.
Patient no 8
I always look forward to his coming to the clinic, very positive attitude and takes your word very seriously. He had an accident at work and was sent to neurologist and rheumatologist in Sioux city. The neurologist at first said he needed a rheumatological consultaition and the rheumatologist thought an injection into the knees would be of help. At that time, TT, took out my card and gave it to him, please send all your reports to my doctor. All of a sudden the rheumatologist realized that this is not just an Indian with workers compensation but there is an organization behind him. Believe it or not, the rheumatologist changed his mind, and sent him back to the neurologist who now proceeds to diagnose the condition as diabetic neuropathy. And suggests high dosages of steroid therapy intramuscularly which he gave six times during a period of two months on various visits. You knew you would get neuropathy, since you have had diabetes for twenty years and you should have looked after the diabetes, admonished the neurologist with a latin sounding name. just because you are from another culture it does not automatically make you culturally sensitive. Greed and avarice are the prime motivator here and not the welfare of the patient. In towns like Sioux City, and Yankton where there are more plastic surgeons and orthopedic surgeons than family practitioners, this mentality of wild west medicine exists, since there are no checks and balances if they were close to a medical centre or under the gaze of doctors associated with teaching and keeping up with the literature. (medical that is, you cant expect most of the doctors to keep up with the literature of the English language). TT was good at taking are of his diabetes, his A1C was acceptable and the blood sugars were well controlled and he was not on insulin.
The next month after his first injections, his blood sugars began climbing up, first into the two hundreds and then three hundreds and after the second series of steroid injections, they went up to the five hundreds. He was not told that this might happen and on his first visit, the neurosurgeon had whispered to his nurse, please make sure that I have their medical histories the next time, since on his first visit he was not aware that the patient had diabetes, making the referral to his friend the rheumatologist who works within the same organization in tax free south Dakota, on the border to the town of Sioux city.
It took a full two months of checking the blood sugar four times a day and taking 10 units of regular insulin for the blood sugars to begin to come down. Even now it is in the high two hundreds and I told him that as the steroids begin to wash away, his blood sugar will come back to the old levels. I did notice that the intramuscular injections were rather high in steroid content. M kept in touch with him and he dutifully calls on the phone and comes regularly to the appointments. I want to show him that with diligent care, by taking blood sugar readings four times a day and acting upon it, his blood sugars will come down and that hopefully no permanent damage would be done to his body.
He is builder by trade and somehow or other the conversation came around to the house I own within the reservation limits. He came over one weekend during my visit few months ago and took a good look at it and recommended several things. I wouldn’t mind keeping the house, which now houses all my books collected in this hemisphere and the parapharnelia of travels. He and his friends would donate their time to repair the house and all I have to do would be to get the material and pay for the transportation. I have gladly agreed to that.
The last patient of the day, I did not recognize her by name. As I entered, even her face was not that familiar even though I have seen her around. Finally finding a way to place ourselves in each others world, I realized that one of my patients ( the lady with the thyroid problem) had sent her mother to see me. And the place I had seen her would have been in the corridors of the clinic at the Winnebago Indian reservation.
She lamented about the fact that she used to have good skin, and took good care of herself and her good looks, now the physiotherapist advised to wear comfortable but unfemininie shoes, despite the use of creams her skin is dry. The introduction to our consultation was much more cosmetological, the place where she gets here nails done. She had been feeling lethargic and devoid of energy, and at the request of her daughter had come to the clinic to discuss whether or not she had problems with her thyroid gland. She receives all her care at the Winnebago clinic and since I was going there the next week, and it is easier to order thyroid function tests there, I told her that we would continue our consultation there and I would order the thyroid function tests. She had some symptoms of hypothyroidism, but some crucial elements were missing. I will see her next Monday.
When I finished with her, I noticed the clinic had emptied and when I returned to the doctors area, the lonely podiatrist was packing up.it was a Friday evening and the beginning of a nice long weekend of rest for me. Very rarely I spend a weekend here in these parts but when I do it is full of rest and relaxation and an opportunity to write.
Todays clinic is what a clinic should be for me. Socio cultural and psychological consultation mixed in with the endocrinological aspects which does not take primary role. Good working relationship with my colleagues who make my consultaion with the patient easy and facilitative. Lunch with colleagues to take time off and talk about other things.
When I was a child, I used to read poems of Omar Qayyam of Nishanapur, a mystic Persian poet. He had lamented about the rotating doors of the consultation rooms of the doctors and the despondent patient returning to the tavern after their consultations. This was in the 12th century. That stuck in my mind long before even I had decided to study medicine.
Pablo Neruda, that Chilean Bard, the greatest poet of the 20th century had written a poem which I read when I was a student of medicine ..I forget in which country it was that I read him first, Australia , England or America..
Here it is:
How much does a man live, after all?
Does he live a thousand days, or one only?
For a week, or for several cernturies?
How long does a man spend dying?
What does it mean to say “forever”?
Lost in this preoccupation
Iset myself to clear things up.
I sought out knowledgeable priests,
I waited for them after their rituals,
I watched them when they went their ways
To visit God and the Devil.
They wearied of my questions.
They on their part knew very little.
They were no more than administrators.
Medical Men received me
In between consultations,
A scalpel in eachhand,
Saturated in aueroycin,
Busier each day.
As far as I could tell from their talk,
The problem was as follows:
It was not so much the death of a microbe-
They went down by the ton,
But the few which survived
Showed signs of perversity.
They left me so startled
That I sought out the grave-diggers.
I went to the rivers where they burn
Enormous painted corpses,
Tiny bony bodies,
Emperors with an aura
Of terrible curses,
Women snuffed out at a stroke
By a wave of cholera.
Thre were whole beaches of dead
And ashy specialists.
When I got the chance
I asked them a slew of questions.
They offered to burn me.
It was all they knew.
In my own country the dead
Answered me, between drinks:
“get yourself a good woman
And give up this nonsense.”
I never saw people so happy.
Raising their glasses they sang
Toasting health and death
They were huge fornicators.
I returned home, much older
After crossing the world.
Now I ask questions of nobody.
But I know less every day.
