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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”

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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.

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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

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Crossing Over

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“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?

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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

Art Meetings

June 15 In 2 hours, Turks, Azerbaijanis, Georgians, and Armenians, will simultaneously sit down and, for 24 hours, write stories and draw comics according to an on-the-spot assignment. (Armenia’s First 24 Hour Comics Event ) They must improvise, they must imagine, they must stay awake. Thank you, actual art (project organizer); thank you Democracy Project of the US Embassy (funded the project); thank you, Dana (project doula). The center of the action is Gyumri, still hollowed out from the earthquake, but with a vibrant art school. Many artists will check in remotely from their home countries via internet. Together they will suffer sleep deprivation, revel in creativity, and meet a deadline.

Guitar–Meet Me in the Rain (in 10)

Since I learned that the physiological necessity of sleep concerns neural waste removal, I have become something of a nag to my spouse about adequate sleep. “You can’t just keep piling up those dishes!” I tell her, feeling the poetic justice. So you’re a dolphin, or a swift, and need to keep moving? All right then, sleep half your brain at a time. But now this: 24 hour comics. Let the dishes pile for a while. The Caucasus needs its artists to meet, to push its envelopes.

Transport in metch (on the bus) A fellow passenger hands me her kopeks (coins) to give to the driver, as I’m sitting nearest to him. “Me-hat?” (one fare?) asks the driver. Yerek hat (3) she answers. I pass back the change, kopek bucket-line. Eyebrows raise a quarter-second, a fraction of surprise. I’m an odar, not the usual model for this little role.

Sometimes I think Armenia is even more ethnically homogeneous than Vermont. Now, in June, Americans with ostentatious backpacks increasingly punctuate the sidewalks, bickering over their blackberry vodka, explaining crosswalk rules to each other. I see it-their faces may look Armenian, but they aren’t. But hold on here–condescension towards my own compatriots? Reflexive xenophobia by proxy? Anyhow, what’s an Armenian face? Sometimes it is dark as cocoa, sometimes freckled and fair. These people are as diverse as Argentineans. Will the real Armenian please stand up? All rise.

Bari Ghoompe Two dance groups jammed over at the history library last night. For the closing photo, I crouch in the back row. It’s the young man next to me–he doesn’t want me to dwarf him. Having struggled in vain to interpolate some of his taller brethren between us, he’s up on his toes. I can bend.

With only a week left, I am opting for taxis, whisking around the city from rim to rim, fitting in a few more meetings, catching my Oud lesson. Aram and I do this mostly in Armenian. Since we both strive to speak in music, linguistic limitations have minimal impact. Do you use do-re-mi-fa? Che (nope). Do you read music? Eye-oh! (yes). Handipenk. We meet.

Mikhail Zlatkovsky, cartoon

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Protected

Clinic-the villages Aida, the lead physician, is good-natured, blustersome, and almost 5 feet tall–“I am short, but I know a lot!” The interview goes according to her agenda. She tells me of their scrupulous immunization practices, handed down from a higher, scientific authority. Aida sends us off in her jovial way–“Thank you for coming, and thank you for not eating our chocolates and drinking our coffee!”

Haemophilus influenza, diphtheria, tetanus, measles, mumps, rubella, pertussis–germs to which children, infants, and expecting mothers have a special vulnerability–they won’t find a toe-hold here. Armenian parents, like many Vermonters, have a history of skepticism about this kind of protection. But here they are increasingly accepting of vaccination, partly because all vaccinees can expect a house call within 3 days. I might have considered this excessive, but the clinicians say their patients avoid immunization complications because of the careful checking.

When Tavid, now 25, emerged from his doctor shot visit 20 years ago, he exulted, “I feel so clean!” That protected, connected, microbially righteous feeling, like he was wearing a new coat of arms.

Sarian Museum Sarian, who designed Armenia’s coat of arms decades ago, stands with Monet and Chagall among painters. He wrote about how a feeling of connection to the earth depends on knowing, and loving, a specific landscape and community.

Life is an island. People come out of the sea, cross the island, and return to the sea. But this short life is long and beautiful. In getting to know nature man exalts the wonder and beauty of life.

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Travelling, Tavush and Lorry Marz We’re at home in these mountainous, forested, northeastern provinces–Armenia’s little Vermont. At Haghpat monastery (also part university, part caravansary, part fort), the swifts are raising their young inside the 1100 year old walls of the sanctuary. Tiny beaks show in the portholes of round gray nest-walls as the parents arrive with treats. The monasteries are built at the tips of mountainous promontories, soaring over the green zor (valleys). Their approaches, and the people, treasures, and manuscripts within, were protected by walls 20 feet high and 4 feet thick. Those marauders’ were determined.

Monastery swifts:

In the valley below, stream frogs court in strange amphibian phonemes I’ve never heard:

Sanahin village, a few miles away, has a monastery and a museum with an actual MiG fighter jet in front, because it was designed by one of Sanahin’s native sons, Artem Mikoyan.

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A grand niece–a real Mikoyan–shows pictures of Artem’s illustrious brother, politician Anastas Mikoyan.

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Among other accomplishments, Anastas averted World War III, and brought ice cream from America to the Soviet Union. Stalin: “You, Anastas, care more about ice-cream, than about communism.” I like your priorities, Anastas.

Cascade, 9PM An outdoor dance event, last friday of every month. A young man asks, “you want to join?” He takes my right hand as I join the circle. It turns out I know this dance better than him. “Oh, you know this one!” But he’s catching it from me, and I feel the safety of belonging.

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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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?