Quitting Time

Evening falls, the buses stay loaded with suburban Yerevantsis who want the full good of Yerevan nights. The sidewalks cool down, stay busy, get dark. What’s new, too, is the intensity of the kissing–on the steps of the Cascade, in Lovers’ Park.

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This open passion is new, and due partly to the arrival of diasporan Armenians. They, along with other cultural winds, bring new ways, as they set up shops around the city, seeing opportunity where many don’t. It’s okay now to be at the dance clubs until late.

By 8:00, the swifts have almost all left. There’s a 10 year old hurrying home across one of the pedestrian avenues that wind behind the apartment blocks. All the other children have gone inside. They have played hard, their families expect them home.

When the frisbee was starting to blend in with the grass and the dogwood trees, my mother would call out to me, “Quitting Time, Petey!!!” My friends teased me; such an arbitrary interruption, like being hauled off the stage with a cane handle around my neck. But I accepted her indomitable logic, I ceased, I desisted, I went in. Would they, my friends, go on playing without me? Nah, we’re turning in too. It’s no fun without me, right? So we each retreated from the graying street to our clean, well-lighted places. Dusk with dignity.

Then–what holiday is it now?–fireworks, from over there, in that lot, or from up on the horizon over Nor Nork. Armenians often light up the night sky with fireworks. By 11:30, the lover’s are walking home, I’ve gone to bed.

ICU This infant, un-responsive and unable to inspire effective breath, has been on a ventilator for three weeks now. Bi-hemispheric and brainstem stroke. Would the doctors suggest to the parents that turning off the ventilator could now be a caring gesture? In the absence of any formal “Do Not Resuscitate” or end of life agreements, even for declaring brain death, such scenarios toss a delicate mix of feelings into the evening breeze, as the players guess where they will land–will the parents blame the doctors? Will the doctors know they did all they could? Will the sibling find solace with friends?

Opera Anoush, the female lead, has lost her Romeo. At sunset, she climbs the cliff to jump, her suicide glorified by the music of Armen Tigranian. From offstage comes the voice of her mother: “Anoush, come back home. Where are you, my child?“Anoush seems a bit out of it: “… how suddenly everything has changed. All things in my life are empty and void. Mountains stand alone, barren and ignored, With the shepherd boy, gone so far away.”

As the curtain closes, the audience, seated, claps in rhythm. Curtain call–she bows, the sorrow of The End imbuing her movements. She knows every sinew of this quitting time.

imageOud, Armenian Traditional: Zepuri Neman (Like a Breeze):

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Purple Crayon

“So should we not call it a ‘seizure’ when the infant has a seizure? What should we say?” In this talk for some of Yerevan’s neonatologists, I am doing my best to shatter the notion of a neonatal seizure as something you can diagnose by eye. These are fine, conscientious physicians who believe in science, who voyage to the Marzes (outlying regions) to improve neonatal resuscitation; and who, like many US neonatologists, mistakenly treat all seizure-like newborn behaviors as epileptic.

I loved Harold and the Purple Crayon, the way he divided up space so freely.

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Now, here in this Soviet-era lecture hall, I am dividing up seizures with little more than a purple crayon. “You can call it a seizure, as long as everybody knows that behind that word are 2 possibilities–epileptic and non-epileptic.” I feel the neuro-epistemology of seizures rounding a hairpin turn in the room.

A great many of us begin life with a paroxysm that you might call a seizure: we extend, we twitch, we contort, we ride imaginary bicycles, we roll our eyes. The ink runneth over in the world’s neonatal units, as we prescribe medicines for these events, even though a seizure is not always a seizure. To neglect would be a sin, seems to be the thinking; better be safe than sorry. The answer: do an EEG, and see whether the brain’s electromagnetic halo is pulsing along with those movements. But there’s no EEG at this hospital; I can’t just draw one.

Academics sub-divide as avidly as real estate developers; see, over here, I have split apart what you thought was whole! Sometimes, the academic’s intellectual avarice takes us on a frenzy of sub-division. You can imagine the sophisti-confusion. But today, I’m solid with my fission; until they get an EEG, I advise them which movements can more reliably be diagnosed as seizures, and which are the common masqueraders.

Clinic Maria, a 15 month old, former premature infant with motor delay, retinopathy. “Inke zhbtume?” Does she smile? The parents smile. It’s nice to know that, in all cultures of this planet, a smile is a smile is a smile, an indissoluble unit of behavior. And Maria has an ethereal smile. We trade waves as the discussion closes.

Matenadaran Museum; a lamb appears to be suspended amidst the branches. Look lower, there must be some misunderstanding: Abraham, his cutlass poised at his son Isaac’s throat, is looking upwards. I think he is about to change his mind. God drew a terrible line, and now is erasing it, ending this trial of faith, with the toss of a lamb.

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Recently I found myself configured in an on-line spat. O purple crayon! Symbols, and a sense of fairness–these must be the most dangerous tools God ever put in our hands. “Put it on my list of sins” was the last, despairing rejoinder. But would I call it a sin?

Song: “Put it on My List of Sins

 

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Pawning the future

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Isis

Clinic “Do you have any trouble following the rules?” The boy, 11, shakes his head “no,” but the opacity of his expression says he often feels wrongly blamed. He is having a problem with a fragile cerebral faculty, executive function, the seat of personal responsibility. You can spell it out in the acronym ISIS, which outlines how we command our own attention and doings: I=initiate; S=sustain; I=inhibit; S= shift. Many parents from Armenia’s outlying regions bring their incorrigible boys to the niartaban (neurologist). The response: a few wise words on parenting, on to the psychologist. But the parents are right: aggressive, impulsive behavior can indicate a brain problem–lead poisoning.

For post-Soviet countries, lead exposure is a pervasive health hazard. (The other is radioactive tailings from uranium mines.) So I ask my pediatrician colleagues: what about measuring lead in this boy, and others like him? The idea that an environmental pollutant could contribute to poor self-control, to this boy’s growing disappointments, is new to them.

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In the US, the clinical studies of Herbert Needleman, among others, improved the intelligence and executive skills of millions of American children, since the findings prompted mass screening of children for lead exposure. Needleman began by usurping the tooth fairy’s role, measuring the lead content of children’s deciduous teeth. We now know that any measurable lead level means the brain’s capacity for reason, for self-control, is taking a hit. Though Needleman’s reputation was attacked by lead industry “representatives,” he was a good tooth fairy, since, through standards spawned by his research, he gave back more than those children could have wished for–growth conditions to better support their sense of personal responsibility.

Armenia has the makings of a perfect storm of pediatric lead poisoning: (1) low awareness among clinicians about the potential magnitude of the problem; (2) no laboratory to measure lead; (3) government facilitates mining operations (~600 mines scattered over territory the size of Maryland, over 50% of exports) with little regulation; (4) lead, leaching out of mine tailings, accumulates in crops and water; (5) no effective legal recourse for poisonings sustained by mine-workers or communities.

When I was 11, I proudly announced that I had incorporated some of the contents of a jar marked “Benzene” into my chemistry set recipes; initiate. This is the schoolboy who, absorbed in his daydreams, thought “pay attention!” was one word; sustain. In one shocking parental lecture, I learned about the latent effects of poisons, and cancer.

What if, someday, those parents from the outlying regions learn that their ‘bad boys’ have high lead levels, and what that means? Denial, grief, anger, … regulation? To me, regulation is a core executive skill; inhibit. For others, regulation to counter lead pollution doesn’t compute. “Government action can only detract from personal responsibility!” say my libertarian friends. But I remember how I felt that day when I was 11: “My future, pawned for an afternoon adventure!Shift.

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Down for the Count

imagePolling place, election observer. I am doing my part to help diagnose the illness that has been plaguing elections in Yerevan since independence over 20 years ago. Even if there is little democracy to safeguard, it still must have its ailing homunculus at the polling place. So I go there, for 16 hours of inspection and auscultation. Democracy, as they say, is hard work. Especially when the polling place is run by a seething dominatrix–Gohar.

My first election official: a sharply wizened 40-something man stares hard at my presspass which was just recently assembled by Transparency International. His eyes have nictating membranes; his voice is rat-speak on diesel; his shoes are clearly for denting shins. But maybe I’m being defensive.

Two hours: one of the in-numerable proud white-haired ladies is shouting back at Gohar, who has repeatedly lied to us with her bold, made-up face, and her shock of in-your-face bleached hair. Gohar pivots on her red, 4 inch heels and smacks the air with disgust: nose wrinkled, upper lip retracted, eyes partly closed. I wouldn’t want to tangle with her; but I wish I had been a bit less amachel (means both shy and ashamed). Now she is walking out of the polling place with the voter list. My fellow observer nabs her, and receives a tongue-lashing, but Gohar brings back the list.

I ask to test the ink that they use to stamp the voters’ ID. After 3 hours, the stamp on my paper has disappeared. Look, the ink has disappeared. “You want ink? I’ll show you ink!” says her body, as she stamps my paper again with a juicy glob of blue-black ink. I stand down, the ink fading in my hands. As Gohar continually breaks the rules, denies, scolds, I remember Paul Eckman’s principle of lie detection: lying people often use anger to cover their lie, so that their anger becomes a “tell.” But now I see that this anger isn’t just a mask; it also effectively interferes with the moral decision-making of the person being lied to. Again and again, wishing to stand shoulder-to-shoulder with my fellow observer, I stand frozen by this woman’s rage. I wish I wasn’t so amachel.

When I was 8, my maternal grandfather, a shy, self-sanctified man, paid me the elevating sum of $5 to memorize a passage from Matthew, in the Bible. Pediatricians–at least the ones who have overcome their raw, behavioristic tendencies–know that bribery is a dubious, time-honored method of proselytizing, that dis-empowers the payee even as it “improves” him. But I still remember two cents-worth: “Even the hairs of your head are numbered.” Who the hell is gonna count ’em?, I thought. But today, as I start to love these people, I’m patient, I’m counting. I want to get the same tally as God.

Of the 854 folks who come through, folks Grandpa’s age are far over-represented; and they have additional voter recruits with them–disabled family members who look like they haven’t been outside for months. Following the 2008 parliamentary elections, there was such an infusion of bribe currency from oligarchs to poor voters that the value of the Armenian dram decreased by 4%. I suspect the rising price of a vote since then, from $10 to $40, improves the prognosis for democracy. Final count, 11:15PM: oligarch landslide. Observers’ consensus: the oligarchs paid these folks a bit more than $5.

After a day of teasing and pretend affection (“Peter-jan, you are my friend”), Garo (another bullying election official) and I come to a new understanding. “You are a doctor? what kind? I am sick” he says in his default, court jester way, his arms criss-crossing his chest. “Niartaban“–neurologist. “It’s my heart!”–again in caricature. “I can’t help you,” I tell him, “but I’ll pray for your heart.”

Oud piece: Down for the Count

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Where are you?

Doo vortegh es? Where are you? There’s something sweet and surrendering when I hear this sidewalk cell-phone refrain. As it repeats in my head with the final chores of the day, I wonder about the myth among some Armenians, that their egos get in the way of the common good, of cooperation, organization. But from what I see they track each other well, with a minimum of defensiveness or preening.

My Aunt Winnie last week completed a long farewell wave to life as we think we know it. Even in misanthropic adolescence, I would always want to know where she was. I could picture her, tracking the people around her with a loving ferocity. Her way was effervescent, and her legacy, buoyancy and resilience. My wishful mind finds her among the great flocks of swifts that have recently arrived from Africa, and that seem to have replaced the crows in the air over Yerevan.

Song (guitar, swifts) Where Are You?: 

Swifts Off my balcony, when I am not looking at Ararat, I am studying some thousand swifts like the ethologist I never was. Soaring around with their mouths open, high above the crass, empty monuments of errant oligarchs, swifts are hunting down insect lightcraft. At dinner and breakfast-time, swifts awaken on the fly (sleeping with half their brains on the wing as they do) for these diurnal feeding conventions, organizing and disorganizing like 3rd graders on a playground. Some hard-working ornithologists have deduced that swifts never stop flying except to hatch their young. Even at 70 MPH, topological rules, known to swarm theorists and swifts, guarantee friendly skies.

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Clinic Sitting at 3 desks arranged in a right triangle, 3 sets of parents confer with 3 white-coated pediatricians. The rule: keep your voice down; the conversations intercalate gently. Then, as though choreographed, all 3 sets of parents rise, thank the clinicians, and leave them to their writing. Charting is done with a similar gesture, left arm encircling the chart, right hand–“tserke“–steadily scribing. (I make the typical neurologists’ opening gambit: “is he right handed or left-handed?” The mother frowns, “normal, right-handed of course!”). Decided: the girl with strabismus does not have a neurologic diagnosis; the boy whose seizures are intensifying on carbamazepine needs a new seizure medicine; the hallucinating, twitching boy with headaches needs an EEG, admission for observation; the nervous, sleepless boy shall consume sodium bromide. Meanwhile, in our continuing hallway conferences, or around Armenian coffee and a box of chocolates, the neurologists and I are homing in on which American guidelines may be most useful here. We clinicians likewise need rule-sets to avoid dangerous collisions, to counter our fallibilities.

Marshrutka I reach a commutation milestone: I read Malatia on the bus sign, and calculate how close it will get me to Parpetsy street, and home.

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Oh, I have lists, I know dozens of bus rules, just where they go. It’s like a hobby for me, and I even ride the vans, known as marshrutkas. Twenty-one passengers–20 Armenians and one plaid Vermonter, are carefully poised and folded around each other, hardly making contact (a marshrutka is about twice the size of a Honda Odyssey). Musical chairs at each stop, as the passengers make a seamless exchange, and the drivers–smoking, chatting on cell phones, making change–instruct each other by horn.

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Home A peloton of four or five swifts, banking off my balcony at the sunset hour, is damn near combing my hair as I sit on my perch. I admire the principled ways of swifts, the way they know just where they are in space. Doo vortegh es?