Getting Over It

Yerevan

Yerevan

I’ve returned to Vermont, but I’m not letting go of Yerevan. There’s something about this city, at once wide open to imagination, and rife with wicked problems. It’s responsibility, not disaffection, that drives the breakup–I’ve got to return to my post.  But I don’t want to get over Yerevan.

Case. 5 month old with recurrent intracranial hemorrhages–can you help us with this problem? The neurosurgeon opens up the CD for us. The hemorrhages are sub- and epi-dural, bilateral, of varying ages. The collections undoubtedly explain the child’s hypotonia, even as he looks alert, tuned in. Whatever the cause, there is no fix, other than tender loving care. The child’s brain will have to heal itself up. “Hypotonia is the least of this child’s problems” says the surgeon.

Why these hemorrhages? No known trauma or bleeding problems. But “non-accidental trauma,” as the euphemism goes, typically presents with the history “no trauma.” I suggest long bone films, an eye exam, for evidence of mistreatment. My colleague looks doubtful. “No, we don’t see this … because in Armenia, children are gold” she responds. They are gold everywhere, I think, even if parents, in non-accidental fits of physical rage, sometimes forget.

Brain injury in abused infants stems ultimately from an interaction that, while not accidental, has lost track of its intent. The caretakers’ anger blinds them to their responsibility to get over frustration, to not let a tempest in their brain’s limbic system shut down their restraining frontal lobes.  I’m sorry for the jailed parents who lost their moral compass in an emotional storm, and for their battered children.

Gohar Droshagiryan's Drawing for Like Water On Stone, animation of Dana's novel.

Gohar Droshagiryan’s Drawing for Like Water On Stone, animation of Dana’s novel.

Getting through such a storm, autonomically speaking, is a journey through some woolly peaks and valleys, and it’s a little different for each of us. You can divide us according to the alacrity with which our stress responses erupt with sweat, fear, and pounding heart, and how quickly they simmer down. If we quarrel, I may have thought things through (all right, you apologized, I accept …) before you’ve really settled down (but I’m still upset about it and we’ll both just have to deal with that until …“)? Reconciliation doesn’t happen all at once.

Case 3 year old boy, losing weight, and hakarak, aggressiva–increasingly contrary and aggressive. But his weight seems OK, and he won’t let go of the doctor’s chocolate snacks for the gait examination. Off to play therapy. Play, among other things, is a good way to learn how to go in and out of frustration in peace.

Neuro-responsibility. At what age do we lose that gold, that innocence that should assure us respect as children? And how can we verify the capacity for knowing intention that makes us responsible, culpable for our mistakes? In the 19th century, there was a trend for some poor mothers to plead temporary insanity when their babies were found murdered. And the juries were sympathetic.

Temporary insanity was a well-established legal defense in Europe–a gift of the psychologists to the lawyers you might say–when, in a Berlin street in 1922, an Armenian shot and killed Talaat Pasha, one of the primary architects of the Armenian genocide. The assassin was acquitted–temporary insanity. His defense lawyers made the case with photos and narratives of a horror whose legacy was still in its infancy. That trial brought Armenia as close as it ever came to a proper public disgracing of its frenzied murderers. The evidence gathered became a study guide for Raphael Lemkin, who later coined the term genocide.

Music. Aram, my oud teacher, has brought his duduk-playing friend Sevada so that I can purchase one of his duduks for Jeff, back home. A flute made from an apricot tree, and resonated by a bamboo reed, the duduk makes one of the most soulful sounds you can hear. Before we close the purchase, Aram and Seva play Hov Arek, Come Breeze, by Komitas, who is said to have been driven insane following his imprisonment in Istanbul in 1915. It pulls my heartstrings, this tune, and I pull back. I keep re-playing it, but I still haven’t gotten over it.

Zoom Out

image

 

Dance Dana shoots her left foot out 3 feet behind her and the young man passing by almost trips over her leg. He better watch out, the women are dancing Madzoon, “stirring the yogurt,” in a circle at the Naregatsi Center, where a hundred dancing bodies are heating up with Armenian rhythms. We greet our dancing buddies, who take our hands again.

Intensive Care. A one month old with seizures, absent corpus callosum–the problem is ultimately genetic, though chromosomes were normal. What about a DNA test? In clinical work, genetics presents a jagged coastline–the closer you come, the longer it gets. You couldn’t explore all its fjords in a lifetime.

“We have one more case for you.” This 12 year old girl’s delicate face is marred by a naso-gastric feeding tube-she has been vomiting for 20 days. No other symptoms–“the story is long, and yet with nothing else to tell” say my colleagues. I find a watchful, thin girl with no nystagmus, a normal exam. This can’t be labyrinthitis. GI workup was extensive, negative. As I coax her to sit she abruptly falls back, eyes close, pulse steady. In 3 seconds, she wakes up, fluent. “What is this?” asks the intensivist. Conversion Disorder–psychosomatic. One doctor says this is rare in Yerevan, but I wonder if he’s really stepped back to measure.

Performance Review. To teach, alas, is to judge. When a trainee seems weak, our responsibility to her future patients demands that we single her out, as we say “we don’t want you to feel singled out.” Is she over-confident, self-abnegating? It’s a Goldilocks thing, medical confidence.

We strive to pool perspectives to get the best view. Often, our impressions scatter with the coherence of bugs on a windshield–a good sign of reviewers’ independence. Wisdom of Crowds (Surowiecki) makes the point that it’s often better to trust the pooled opinion of 100 independent lay folk than that of a few experts. Can we be both?

Clinic. The parents, sitting opposite my colleague, each hold a twin. The 5 month old brothers study their doctor intently over the pleasant bodily wobbles common to their age. When their head ultrasounds were done, as premature newborns, both showed the ominous echo pattern of white matter injury that strongly predicts cerebral palsy. But their neuro exam doesn’t yet show definite signs.

So put down that reflex hammer and step back, take a look at their General Movements. This is a kind of gestalt impression of spontaneous infant behavior, introduced around the same time as the head ultrasound, though much more melodic. See the fidgety movement–good sign! The GM assessment was devised by Heinz Prechtl, an Austrian ethologist and bird-watcher, whose baby-watching methods are catching on. One brother shows ominous cramped, synchronous movement. But I’m un-sure if the parents would welcome this long view. I don’t let on.

Martyrs Day. This week the Armenian nation commemorates one of a series of massive stuttering slaughters of its people in what is now western Turkey–1895, 1909, 1915. These were the serial genocides conducted by Ottomans, who deployed some of their cruelest citizens, some even released from jail for the purpose, to kill Armenians, or lead them into the desert to starve. Frustrated by governments’ denial, historians went pointillistic, bringing thousands of accounts to international tribunals. Though you can hardly meet someone in Yerevan whose family wasn’t affected, the Turkish government dismissed these histories, as though the Armenian people were suffering an epidemic psychosomatic disorder, a confabulated Freudian memory of childhood abuse. I wonder how often in history, if ever, has an ethnic group’s sub-conscious produced confabulations of murder, persisting over 3 generations? Do nations cry wolf in this way? Meanwhile, “1915: I Remember and Demand” say the street signs. Agreeing on history sometimes requires a long hard look at the big picture.

Cameraman and Mt. Ararat at Tsitsernakaberd, the Armenian Genocide Memorial

Cameraman and Mt. Ararat at Tzitzernakaberd, the Armenian Genocide Memorial

"I Remember and Demand"

“I Remember and Demand”

Strange Territory

Arriving to Yerevan sets off dozens of soothing little clicks in my brain. Like suddenly remembering that Marshrutka #29 goes to Nora Gyugh, that my feet can trace out the steps of the Papuri dance in unison with a score of strangers, that my colleague’s office is up on Mamikoniants Street, half way down the hall on the right. There is comfort, a sense of mind and body aligning, in suddenly remembering the arrangements of streets, of the people on them, of their beautiful faces. Like a dream, or finding that some old clothes I’d nearly forgotten suit me as well as ever; it’s a perception that works like the mind’s own hospitality ethic, the one that lives in a dozen ancient cultures–make yourself at home.

With classic, joyous hospitality, Dana's cousins swooped us from the airport to a feast in their home

With classic, joyous hospitality, Dana’s cousins swooped us from the airport to a feast in their home

Travel also re-arranges geography in a pleasant way: when I’m here, Yerevan moves closer to Vermont than it was, or seemed to be, when I was in Vermont. So it may be with other kinds of fields–the intellectual kind. A trainee in child psychiatry joins me weekly, in clinic at UVM, and I strive to extend hospitality, make her feel at home by focusing our discussions on the psychological dimensions of the cases. Opportunities for this kind of intellectual hospitality arise when we see cases like one I saw last week in Arabkir Clinic, Yerevan:

Clinic. He is 10, and sits with the emotionless stillness, the poise I remember from Armenian children at this age, even though their brains have just cranked through a programmed developmental revolution, the kind that changes the furniture arrangements. I hear that he was referred here by a logotherapist–a speech therapist.

My colleague turns to me and asks whether in my work as a pediatric neurologist I see referrals for stuttering. “Not since the last time I was here.” She laughs, that happy-side-of-despairing laugh, for this referral signals a mis-understanding in her medical ecosystem, and she explains as much to the mother. But then there’s more–he can’t feel his palms. Just like that, the chief complaint around which the encounter should orbit has just re-positioned by 1000 light years. We don’t de-brief, historicize the numbness–but get right to brass tacks. Well nothing that sharp really. We check his nervous system.

The neurologist breaks a wooden swab and tests him–sharp vs. dull–through his face, shoulders, neck, arms, and finally his palms. He pauses longer, but identifies the sensation correctly throughout. Dismissed.

This is a scene I recognize: one care is addressed, and another swims to the surface, and none of the concerns speak of any serious pathology, just bewildering phantasms emerging in a Sisyphean interview. Why this tsav–hurt–that our tools can’t heal? We merely predict that it will pass, and then it does. But not before the parent leaves our office wondering, “an artifice of my child’s mind? Why?”

Back in Vermont, discussing such cases with my child psychiatry trainee, I venture that, perhaps for both the child and his parent, this un-satisfactory transaction exemplifies what the psychiatrist Chefetz has identified as the mind’s imposition of a “phony coherence that is better than confusion”: for the child, if they are at the doctor’s office, there should be a reason; for the parent, being a medical puzzle may make more sense than their child’s confusing somatizations.

At the end of the day, my child psychiatry trainee confides that she feels more comfortable here in Neurology Clinic than she had expected. Success! But then, I want her to be more daring, to venture further with her curiosity into Neurology’s dark forests. Curiosity, like music, signals a sense of safety, of security, and sometimes inviting curiosity, nudging it a little, can catalyze that safe feeling. Especially if the music is from the heart, if the questions come from wonder at the strange territories around us.

Save the Children

Mashtots Poghotz Walking the streets of Yerevan, Charlie Chaplin often turns up on T shirts and storefront posters. Maybe it’s because Charlie’s side-kick, Jackie Coogan, helped to raise millions of dollars for starving Armenian orphans in a 1920s media blitz organized by Near East Relief. The campaign was so effective that you probably heard their meme relayed via your parents’ parents: clear your plate, remember the starving Armenians.

Near East Relief, ancestor to the Peace Corps, retained artists, actors, singers, even made a film, to make their pitch. The campaign proved how well photos and films that depict sad, beautiful faces can compel a critical bit of behavior change: donation. The millions that were raised in this un-precedented effort helped thousands of survivors of “death marches,” like Dana’s grandma. They came south and east, from Western Turkey into Syria, through the mountains.

Lecture Hall, Yerevan State Medical University The largest congregation of pediatric professionals I’ve seen is convened on a Friday to hear New York child psychologists, talking heads beamed over to a large screen in the hall. The discussion is about losing our children to media–to computers in particular. The Americans (ironically enough) are emphasizing what these clinicians already know: the animations and interactives that pour out of the US, among other sites, are endangering family relationships.

As in the US, a high percentage of Armenian children and adolescents continually focus on those pocket computers that we label innocuously as “cell phones.” Toddlers aren’t exempt: television stunts their language development in dose-dependent fashion. I doubt there is a pediatrician practicing in the US today who hasn’t been out-competed by such a machine in her attempt to have a discussion, to build a relationship, with a young one. I know the seated maestros of “World of Warcraft” and its like possess an extraordinary suite of skills, but I don’t want to play, so I can’t relate.

Questions from the audience: “Can you tell us in what ways social media have been studied or used to improve children’s health?” “We now label cigarettes for their negative effects on health; what do you think about doing the same for video games?” “We hear your advice to guide parents to restrict kids’ video game hours, and TV, but how should we do this? We are trying to guide parents and it doesn’t seem to work. What really works?” Stunning, insightful questions that set the experts to spin: “Clearly, we need more studies … No studies have been done … ”

One happy picture of parenting shows us simply admiring the old-fashioned child’s play, the kind that doesn’t rivet their attention through micro-chips, from a distance. A nice way to convey the principles of self-determination–competence, autonomy, relatedness–all at once to ones we love. Interventions for parents of kids with behavior problems like ADHD borrow this approach, and have parents narrating, extolling, though never influencing the play itself. “Avoiding boredom is one of our most important purposes.” (Saul Steinberg) A milestone! You’ve rescued yourself from your own boredom! thinks the watching parent. Meanwhile, these machines fit into the lonely caves of our boredom like a key in a lock.

In Dana’s book (Like Water on Stone), set a few years before Near East Relief flew into action, there’s a moment when a three year old is alone at home, waiting for her brother, fighting off boredom by swinging her feet. In 1915, she lives far from the electronic media networks that will soon help rescue her.

Song: feet up, feet down

Future Selves

image

Clinic, Yerevan This 7 month old was fine until the last 3 months: decreased visual interaction, increased flexor tone, keeping hands fisted. MRI shows leukodystrophy, and my colleague’s first thought is metachromatic. Or Krabbe–how is the head growth? The interview takes place standing, in one corner of a colorful, windowed playroom. The parents smile at how his gaze reaches for me as I say his name. Repeatedly, during the interview, he seems to grow sleepy, then he revives, as though it’s important to stay present.

Another family watches from the other side of the room. Perhaps they are related?  But they keep their distance, 15 feet. As I come to realize that they are in fact the next consultees, my mind scrambles to reconcile the dissonance of the confidentiality breach. Aha!– they are like family. It’s in the gravity of their gaze. If there is curiosity there, it isn’t morbid; if there is empathy there, it minds its fences. Though the two families have never met, I wonder if they know what I know: after this meeting, they are like family.

The confidentiality practices in Armenia stir a bit of anxiety in me, but I’ve been keeping that to myself (until now). As an ethical principle, confidentiality doesn’t just protect us from social hurts in the here and now (e.g., stigma, gossip). It also protects our future selves from pigeon-holing, from financial disadvantage, from getting nudged into a ditch somewhere down the road. Of course we may be our future selves’ worst enemy, under-estimating and abusing them with static expectations (“I always … I never …”).

We move over to the family across the room; now they are lit with the first family’s gaze. Their articulate, economical responses to my colleague’s questions are no more ruffled by their neighbors’ attention. Hemiparetic, she reaches her right hand across the front of the doll’s house to open its side door, playing seriously while her parents talk. Her seizures have significantly reduced on Depakene. She is 4, and just now starting to relate to peers. Her condition– infantile hemiparesis—was first described by Freud before he turned to other brain problems.

Later, the first parents come un-announced to my colleague’s office. Their faces look beautiful together as they gaze at the translucent MRI film: grandfather, rough and stubbled; tidy, composed grandmother; laconic, equanimitous mother; her infant child, eyes also searching. Their joint attention transcends the image of disaster they behold.

I have a strong impulse to photograph them … if I ask, they might feel they have to assent … they have enough to worry about … will others see their beauty in a photo, ricocheting around the planet? … it’s not like I’m family.

I leave that office turning over my inhibitions, with a new ambivalence about confidentiality rules. “Treat people as if they were what they ought to be, and you help them to become what they are capable of being” (Goethe). And what if we ought not to defend our future selves so carefully? I still think of that family, looking through an MRI towards a window they can’t see; maybe they are like family.

image

“OK, you take my picture”

Comforts of Home

“All right, I’ll bite, what’s the gooseneck in the bag?” asks the customs lady. I explain. “You brought your oud all the way to Armenia and not your wife?” She’s coming a little later. She admits me, an oud-toting pediatrics professor from Vermont looking for a donut.

image

Even donuts have family back in the old country. It is cousin to the ponchig, which you can eat under an umbrella at a window-front bakery back in Yerevan. Ponchigs can be had–and have them you will if you can–at just 150 dram, sweet fried things with custard under-bellies passed to you through a window marked with strange letters by a woman with dark eyes and clear plastic gloves. As you eat the deltoid pastry, breath through your nose, not to inhale it, and watch the fine sugar drift away in sweet convections, melting on the  sidewalk under you in the 90 degree heat. This jet fuel can get you through the morning and then some. My translator warns me not to eat such things, as the frying oil may intoxicate me with free radicals. They have those here? But I can see her sadness as she conveys this teaching. She misses eating ponchigs.

“You never know when you leave the house, you might come home by a different route,”  (James McMurtry); I think he means the traveller has changed, more than the route. After a fretless 15 hour trip across the stratosphere to Boston, I am at Braintree’s midwestern-quaint bus depot. Little evidence of trees, but the brains are neighborly. A brown lady with a welcoming smile sells me some coffee and a donut.  The donut line-up has changed, as these things must always change, lest we hordes of donut-eaters grow bored. Our attention, battered by fluorescent lights, diesel fumes, and faux-vinyl seating, wanders easily. I scan the steel-rack slopes for a donut whose olfactory character may take me all the way home, like a salmon, swimming up the tributaries, deciding which way to turn. There’s a right answer, and many wrong answers.

I choose a donut dressed up as a piece of lemon cake. Wrong. Outlandishly yellow (# 43?), with a bullet-proof jacket of sugar and a belligerent dash of yellow flavoring that I suppose must be called “Natural” (like Plutonium!), its Armenian clansman would scarcely recognize it. Still, it shall be my ponchig, for the while. I am what I eat, and I am loyal, if no longer fully natural. Some day, Dunkin’ Donuts will recall its ancestry and serve ponchigs. Meanwhile, I’m trying to make better choices.

Sitting high in the Megabus, I stare out the picture window, eyes drinking, as we enter the White, and then the Green mountains. A geographic birth canal–shaggy, fog-smoked foldings of earth–weaves past and around me, until I am abruptly delivered into my academic ecosystem, there to re-join a circle of patients, families, colleagues, administrators, directors, friends from Africa who keep the place organized. My oud-pegs are a little tight from the change in humidity, but–even part ponchig–I love home. I know it’s comforts.

Guitar: Comforts of Home

image

image

Crossing Over

image

“And your husband, is he Armenian too?” ask the ladies as they make lavash. “He is not Hie, but he has an Armenian heart.” How they smile! My blood–now that is another matter, separated from my heart by some kind of genetic moat. Or can my Armenian heart change my blood, the way a wine cask seasons wine?

Maybe that’s what their smile says. image

We are sitting with Vergine, a venerated folklorist and Yerevantsi scholar who has also compiled a massive tome of eyewitness accounts of the genocidal atrocities. Dana sings her Armenian folk songs, remembered from 40 year old recordings of George Mgrdichian, who introduced the oud to America, and to me. Vergine writes down lyrics she never heard before:

Yerkenk barenk miatseen, Vor mer tsegh getar mena Let’s sing and dance together! So our race can continue!

Vahan an American-Armenian professor here, turns over the grapes from his farm outside of Yerevan to his friend Mavrik, who makes wine out of them. Mavrik, while showing us how to distill vodka from mulberries with a still on his shaded porch, explains how mixed up Armenian blood has become. image   Ethnic marms disdain the notion of romantic inter-marriage, calling it bad fiction. Meanwhile, my eligible (well, not exactly eligible!) sons in the country for 2 weeks, and they receive at least 4 recommendations to marry an Armenian!

After a marvelous Spring in Yerevan, I’m pulling up my stakes, preparing for a different kind of crossing over. The joy of travel seeks novelty at first, then it backflips, and revels in similarities. Here I have seen new kinds of humility, of resilience, of professional dedication, of national pride, and of gratitude. I leave wondering, how can people, nations, hold together over what we hold in common, and still celebrate differences? Nature relentlessly mixes us up, crosses over our chromatids, separates and re-joins us.

Returning with me are memories of heroic clinicians working with generosity and competence for a pittance; and of new music, new ways to move with it. I am odar (foreign), but I identify with the love of Armenians for their own particular ways–a love I hardly knew as an American. This love, knotted like a carpet (the word carpet is Armenian for knotted), itself becomes a treasure. It binds together, like family; and it has an ambivalent boundary, unsure of its own porousness, of how to stay pure.

I want to see that boundary melted with beautiful cultural fusions, with people helping each other to heal. Then, I want to go into the heart of the village, see the fathers holding their daughters’ hands, dance the Tzakhadzor, sit with the doctors and the families, and listen to the old women’s stories. Our planet’s heart has many chambers.

Bell at hakhpat monastery

Song: Our Big Trip: Our Big Trip