Picking up the pieces

I think it is safe to say my life has drastically transformed since last I wrote two years ago. I moved to a new place (read: across the South China Sea), moved into our own cozy little apartment, started work in a great environment with great colleagues. Just as everything seemed to be happily going according to plan, life took a turn for the ugly. Familiarity and proximity bred distrust. Ugly words were spoken, discontent were unearthed. Eventually, I had enough of the abuse and moved out.

Living alone after sharing my life with someone for so long hit me pretty hard. If you had suffered break-ups before you would be able to empathize. Overnight, I went from the top of the world to the bottom of the barrel. One moment I was a happily engaged woman and then suddenly I wasn’t. You can say returning the ring was the hardest…and the best thing I ever did.

“The true victors in life are those who, enduring repeated setbacks and challenges, have sent the roots of their being to such a depth that nothing can shake them.” – Daisaku Ikeda

So as you can imagine, I hit rock bottom pretty hard. It took an embarrassingly long time and plenty effort to recover my sense of self and worth. Looking back, I identified several valuable lessons that helped me pull through.

Accept grief. Grief is a most natural reaction and we totally should embrace it. It’s okay to grief the loss of your past life–after all, those were some really good memories and times. Denying yourself grief will only make things worse for yourself and impede further self healing.

Take one day at a time. Things won’t get better overnight, but–take this from me–they most definitely, absolutely will. You just need to give it time. You will emerge from this mess stronger, more resilient and better. This will pass. Looking at the big future can be intimidating so don’t. You don’t have to, at least not now. 

Don’t look back. This is hard, but you’ve got to learn this. Looking back in anger and regret will not do you or anyone any favors. It is done. Do NOT seek him out. You can’t change anything that happened, but you can change yourself.

Remove all reminders. This is also pretty hard–after such a long time together, everything reminds you of that person, or a happy memory together. Time to Marie Kondo him out of your life honey. I’m talking Facebook photos, profiles, vacations together, memorabilia, movie tickets, clothes. Disconnect from all links on social media. Thank him for the memories, and dispose. 

Envision your better life. This is the law of attraction and you absolutely need to do this. Imagine yourself in a better place, as your better self. What do you want to be? Imagining that better place is the first step to getting there.

Introduce something new. I picked up running and fitness videos (Hey there Jillian), and made a resolution to cook my own dinner everyday. I grew flowers on my balcony. Changing up my routine gave me something to look forward to everyday.

Take care of yourself. There is no point in further punishing yourself–you’ve already suffered enough. Treat yourself to a good meal once in a while. Eat well. Exercise. Take a short trip, a sojourn of sorts. Do something meaningful for your community.

Remember your loved ones. Often times we are so wrapped up in our own grief, we forget that the people who love you are grieving too. They grieve to see your sadness. Keeping in touch with the people you love will give you the support you need.

Looking back, things were tough but I wouldn’t wish it any other way because I wouldn’t be where I am today. The day you stop looking to the past is the day you start moving forward. It may be difficult to believe it now, but we humans are resilient creatures–things will get better. You will get better. 

Good luck.

Memory

She waits until the woman in the nurse’s garb leaves the room, then reaches under her bed. For a moment she forgets what she is searching for, until her fingers, knobbly with cold, close around the familiar drawstring purse.

Briefly she holds it close to her chest, then empties it onto the faded draw sheet. A thin wad of cash, folded in half and bound with a worn elastic band, addressed “For Tommy“; a faded photograph of a young Marine she didn’t recognize…and twenty-three smooth, oblong blue pills.

She may not remember what she had for breakfast or who came by to visit yesterday, but she very well remembers why she hoards them.

Her memory stirs. A tricycle, rusted from use and rain. A little boy, not so little anymore, crying because his mother wouldn’t buy him that blue bicycle he saw in the store today. A pang of regret. Tricycle, tricycle, tricyclic.

A voice floats up from the hollow void that was her mind, sympathetic and faintly authoritative. “-not only helps with the phantom limb pain, but with the dysthymic spells as well.” She had insisted she didn’t need them, but Michelle (Martha?) wouldn’t listen. “Just remember not to take too many at once.”

She really ought not to be so unsentimental about saying farewell to this tiresome experience called life, but she has lived with this emptiness for far too long. Her problem lies, it seems, in her inability to remember why she was sad in the first place.

Gently, she sweeps them into her cupped palm, then reaches for the glass of water.

A jarring noise and she leaps, nearly knocking the glass off. Again it comes, from the phone on the night table. She waits until the fourth ring, then gingerly plucks up the receiver. “If you are looking for,” she pauses, trying to remember her name, then gives up. “Well, she’s not at home.”

“Betsy?”

Like a great gush of water, they rush towards her. A tornado of memories stirs to life with a force that leaves her breathless. They are fragments, weathered with time, but piecing together like a quilt, of duvets of sweeping green hills, of the smell of pine after a wash of rain, of a cottage with neatly trimmed shrubs, and the scent of freshly baked cinnamon bread wafting out into the yard.

“Betsy, baby?”

She glances down. She is in a yellow frock, familiarly creased in the left hand corner where she had so carelessly mended a tear with a needle when she was six. Her favorite frock. There are ribbons in her hair, and a daisy behind her ear. A figure, distant but familiar, approaches, her face hooded. She feels nothing but love and warmth.

Had she already swallowed those pills?

“…M-mother?”

The voice on the other end sighs. “Betsy, I’ve been worried sick about you.”

“Mama.” She sees her clearer now, in her favorite checkered apron, carelessly humming to the McGuire Sisters as she moves about the kitchen.

“How have you been, my little birdie?” 

“I’ve been, I’ve been-” Her eyes welled, her hands shook, like how Grampa’s used to when he forgot his medicine. “Mama, I’m so tired. I want to go home.”

“But you are home, darling, with your family.”

No no, mama, you don’t understand. She clutches the receiver so hard her arthritic fingers hurt. Her chest swells with words unspoken and years of regret and longing. She is babbling, like how the little girl in the yellow frock used to babble.

“There are so many things I want to tell you, about James, about the divorce, about-” she glances back down at the picture of that handsome young Marine, his smile so much like her own, and a long forgotten name leaps triumphantly to her lips accompanied by a fresh well of grief. “About my little Darren.”

She could almost hear her mother smile, and deep down, she knows mama understands. She swallows.

“Mama, I’ve missed you so much.”

She feels her mother’s love enveloping her, squeezing her tightly. How had she longed to feel one of her hugs again.

“I have been and will always be with you. My sweet, sweet Betsy.” 

Suddenly, she is pulling away, receding into the distance. Panic seizes her. She is trembling uncontrollably, like a frail leaf in winter. “Mama, please don’t go-”

Before the grief could seize her, she is awash with an overwhelming and pure love. A familiar voice, so boyish and full of youthful ambition. An impish smile, then a loving hug. “Mommy.”

She sighs, and does not resist.

At dinnertime, the nurse finds the old demented lady slumped heavily into the nightstand. She smiles when she sees the familiar polaroid in her lap. “Thinking about your son again, Mrs Coop?”

It is then she notices the unmistakable unmoving gaze fixed in the distance, the cool skin left behind in her quiet, unremarkable departure. The old woman’s face is relaxed in an eternal smile. It is whispered that the coroner later recovers from her clasped fist, stiff with death and time, twenty-three perfect blue pills.

 

The disease of disillusioned doctors

I write this in a period of my life where morale sits on an all-time low. I struggle to stay afloat in a hostile environment that seeks to suppress growth and nurtures a not-too-unfamiliar culture of fear through intimidation. Hierarchical tyranny runs rampant like typhoid in the 19th century. The burden of defensive medicine and a duty to answer to the bosses sitting atop the heap of exhausted MOs leaves tempers running short. It is ugly to watch colleagues getting verbally, emotionally torn apart.

We exist in a medical culture that has become strangely inattentive towards patients’ needs. “Jom, ibu. Let’s get a line in for little Nurul here.” “Can we take her for a shower first, doctor?” “Why don’t we do that after getting the line in,” I try to coax, placing precedence on how fast I can send my blood samples so that the reports come back before my MOs can shout at me–over the comfort of my two year-old patient running a fever of 40 degrees. The art of medicine has eroded to diagnoses of “pneumonia” (because there is “perihilar haziness“), “URTI” and “presumed sepsis”. Start antibiotics, take a blood culture, trace the CRP.

Returning from a much-needed break, I realized in many ways I have become the doctor I feared to be: insecure, disillusioned, sometimes dismissive of the pains my colleagues and patients are going through, if not because it is exhausting enough that I have to shoulder my own. Stretched thin and emotionally drained, I find myself in a vicious whirlpool of dysthymia and self-neglect, wondering what am I doing with the best years of my youth.

Recently I aired my grievances to a senior colleague of mine whom I greatly admire. “You need to look at the bigger picture,” he rebuked, not unkindly. How? I thought. How do I do that if I live every moment in fear, in dreaded anticipation of being shouted at for something I missed, or for the fear of messing up in an environment that made a sport of ratting out our flaws?

My awakening came in the most unlikely form, in a mamak stall hidden away in Kota Tinggi, Johor, during my recent sabbatical.

While waiting impatiently for my maggi goreng ayam, just a table away, a group of foreign workers sat down for their evening meal. On their plates were a huge heap of plain rice with a dash of curry and a hard boiled egg. No vegetables, no meat.

“Should we buy them some chicken?” I whispered to my companion.

“Maybe they’re vegetarian,” he replies, half-convincingly. Both of us felt the sympathy, both of us had the means, but the self-consciousness was more paralyzing.

In the end those workers left, satiated by their meal of simple sustenance, and we did nothing. Soon my maggi goreng ayam arrived, and I wondered what good I have done to deserve any better life than those men in such harsh living environments so far from home. I was in a privileged position to do something yet I hesitated. My own fear to act left a hollowness that ate away inside me.

In Youth: A Time for Construction, Daisaku Ikeda says, “(…) there may be occasions when your sincere intentions are completely rejected or you may be laughed at or ridiculed. But letting the fear paralyze you is foolish. The thing that matters is what you want to do. You must have the courage to follow your own instincts when it comes to helping people. Your life will expand only as much as you take action on behalf of others.”

Another passage that touched me deeply, also by President Ikeda,

“Our true selves shine and the inherent strength of our lives wells forth when we exert ourselves for others. This is human nature. And this is the way of life Buddhism teaches.”

How strange that this simple truth, nurtured from a young age thanks to wonderful parents, the importance of exerting for others’ happiness, could be so easily shrouded by the fog of my problems.

How do we battle a system that strips our medical vanguards of their humanity, leaving their faiths and morale as sterile as the operating field? It is by recognizing that our environment is essentially a reflection of ourselves, and challenges are actually opportunities for growth. “To shift one’s thinking and see things from another perspective is the first step to changing both oneself and one’s environment.”

This is the time for me to look beyond myself, to rise above my fears and have the courage to fight the sufferings around me. Having been air-dropped into the field of suffering, into the field of medicine…one could not be in a more fortuitous position to fight for the happiness of others.

In time, my own happiness will follow.

Perhaps this was what was meant by the bigger picture.

NAR

My grandfather was recently issued a No Active Resuscitation (NAR) status shortly after being admitted for septic shock (under high flow mask and an unstable GCS score), ripping an equally enormous shock through the family. After issuing dozens of NARs in the past few months, it was the first time I found myself on the other (read: wrong) side of a NAR order. I was ignorant of how harrowing an experience it was…until now.

Discussing NAR decisions with families is perhaps one of the more memorable training I’ve had in my first few months since starting work. NAR is an advance directive which dictates that life-saving chest compressions will be withheld should the patient’s heart stop beating. It is not making a value judgment on someone’s life; rather, it acknowledges the futility of active intervention and instead emphasizes on the patients’ comfort in their last moments.

Unlike in more progressive parts of the world, NAR remains in some local hospitals such as mine a debatable option rather than a clinical decision. This decision lies more with the family than with the management team’s authority. This presents some challenges as many families are not ready to bear the ‘responsibility’ of signing their loved one’s ‘death sentence’–a common misconception.

To most of us drowning in work, obtaining a family’s consent to a NAR/DNR (Do Not Resuscitate) order brings about some relief, much to our shamelessness. “At least we don’t have to CPR him,” we will crudely point out. Culturally from casual observation, Malays consent more readily with the NAR/DNR order. “Ini memang kehendak Tuhan (this is God’s will),” they would say. Another I hear often, “Terpulanglah kepada doktor. Buatlah yang terbaik untuk dia.” Everyone else…not so.

Throwback to a patient I hold in dear memory. This Chinese uncle was a few days from his fifty-fifth birthday when he was found unconscious at work. A massive heart attack had left him in a coma, ventilated through a breathing tube and tethered on powerful drugs for his dangerously low BP. The team was willing to risk streptokinase, a primitive treatment for heart attacks but, unfortunately, the only option we could offer.

“I’ve got a bad feeling about this,” his eldest daughter said quietly to her siblings, but finally consented to the risky treatment anyway.

Reperfusion was successful, even though Uncle developed some gum bleeding during streptokinase infusion. Things seemed to be looking up. Even his daughter was cheerfully keeping up a conversation through the early morning hours while I went about my work. I remembered she was telling me where to find the good food in Batu Pahat when the staff nurse came to me with troubling news. She’d just drawn up 200cc of fresh blood from Uncle’s breathing tube.

We hurried to his bedside. Uncle was tossing around restlessly. Clots in his breathing tube was compromising his oxygen levels. Then, suddenly, in a dramatic moment, Uncle stretched out his hand towards where his wife stood, as if he knew she was there…and then his heart stopped.

My MO arrived shortly, hair rumpled and bleary eyed with the exhaustion of a long lousy day. He took one look at the double inotropes, then at the blood gurgling in the tube, then at the dilated nonreactive pupils, and shook his head in exasperation. He retreated for five minutes and then came back in, still shaking his head. At that point, I could feel the bones crunching under my palm. So sorry, uncle.

“Can we counsel for DNR?”

“I just did. His family refused.” 

Fifteen minutes later, and Uncle still showed no sign of life.  “Look, why don’t you go try?” my supervisor suddenly suggested. His frustration was evident–it really was a hopeless, futile situation.

Just outside the drawn curtains, Uncle’s daughter had her arms around her mother. I drew up a chair next to them and sat down, frantically searching for the right words. My limited experience with NAR counselling could fit a pinhead and with room to spare. Later, I realized I didn’t need any of them.

“He didn’t want to come to the hospital,” Aunty was saying, weeping. “Deep down, he knew.”

On the other hand, his daughter kept her composure, her back ramrod straight, her tears gathered but unshed. “What now, doctor?” she asked with unnatural calm.

I hesitated. A fragile moment. “We will try for another five minutes.”

“And what do we do after five minutes?”

“We will make a decision.”

By this point, Aunty’s body was shaking uncontrollably. His daughter took a deep breath.

“What would you do if you were in my position, doctor?”

Looking back, I wonder if I sounded as gentle as I intended. “Miss, if I were you, I would let him go–peacefully, painlessly.”

Back home, her siblings slept on, unaware that their beloved father was slipping away from the living, or that their stoic eldest sister was struggling with probably one of the biggest decisions in her life and feeling very alone in that moment.

Finally, a tear fell, betraying that brave young lady’s inner turmoil as she came to terms with the enormity of the words she was about to say.

“Okay. Then we stop now, doctor.”

I wished I knew her name. Memory of that young lady’s courage stayed with me til this day. I hope she lives with the knowledge that her decision demonstrated nothing but overwhelming love for her father…and has inspired nothing but awe and quiet admiration from this inexperienced and impressionable house officer.

The Beauty of Impermanence

When I was a child, I was struck by a wonderfully meaningful quote in an otherwise innocent Japanese animation film, Hayao Miyazaki’s Tales from Earthsea. The hero cries out to the anguished villain, “Life is precious because we know we are going to die.”

The hard truth in those words terrified me. Growing up, I struggled through one change to another, tolerating itches of old wounds healing only for them to be torn fresh open again when it was time to move on. This time, it was the pain of moving on into a new environment after you’ve finally settled in your present one. It’s like the first day of school all over again. New friends, new teachers to be afraid of, new cultures and new tricks to learn.

All our lives, we struggle against the reality of impermanence. A young man despairs as he watches his father’s mind decline with dementia. A housewife laments the loss of her prenuptial beauty. A husband and wife watch as their son leaves home for the war wondering if it’s the last they’ll ever see him again.

Our struggle with impermanence will always be our great source of suffering. Peter Pan is nothing if not a child who dreaded change, likely a manifestation of J.M. Barrie’s own fears as an adult confronting the realities of life. We grasp onto people and things as if they would last forever. Without delving too much into Buddhism–because, after all, impermanence is the essence of this religion–I invite you to ponder on this great undeniable truth. Impermanence, in less ominous terms, is change. We all dread change. It is uncomfortable. Unpleasant. But to the young father struggling to put food on the table, or the terminally ill patient laboring from one painful breath to the next wondering when would be his last, impermanence can be a comforting friend.

This, too, shall pass.

These four simple words have the ability to comfort the most downtrodden of souls and to sober up the happiest of men. Rather than making us depressed, perhaps it serves better to help us better cherish each moment we experience, each person we meet, no matter how beautiful or vile. This day will never happen again. Would you put in effort for every fleeting moment, for every passing soul, if you knew this was your only opportunity to do so? I hope so.

“The only constant in life is death.” I was reminded this by a senior not few days ago. Life is as fleeting as the drawings in the sand after the waves recede. If we can remember that life is like a river, ceaselessly flowing towards its inevitable end, then perhaps we can remember to admire the riverbank and the mountains and all the beauty it has to offer–and the exhilaration of the journey as we bump our way down towards the gulf of life.

Your river is what you make of it. Would you like to be like the Thames, or the Ganges, or the Rio Grande?

Perseverance

Tough and exhausting don’t begin to describe it. You begin fearing the call of your name, because it always either means something needs to be done or one of your patients have a problem that you don’t really know how to deal with right now. You escape out into the corridor, glad for a moment’s peace, only for your phone to ring and a nurse on the other end telling you that the blood pressure of that sleepy old aunty in the corner of your cubicle is dipping dangerously low. You look forward to the end of your shift, only to have new cases to attend…and attend to them you must, even if you’re due to be off in fifteen minutes.

Colleagues can be scathing. Calculative. You try not to fall into the same shortcomings–you’re above that!–but it’s hard not to whine when your colleague leaves you undone tasks as he quickly sneaks off at the end of his shift. More blood cultures! More bloods to chase! Referrals to make! You wonder how you got through five years of grueling medical education only to arrive here with a gloved finger stuck up this old lady’s gut hole manually scooping out rock hard stools.

Your nurses comment that you’re smiling all the time, but you’re not as unbent as they think. In fact, you have loss all sense of what the word “pleasure” actually means anymore. You can’t remember the last decent meal you had. Meals are sustenance, not indulgences, because you’re too tired to notice the delicious platter in front of you, and all you want to do right now is to crawl under the covers and forget all the screw ups you wished never happened today.

Two months on, and you’re hurrying towards the lab, urgent bloods gripped in one fist, the waistband of your pants in the other, because none of your pants fit anymore. Your watch dances loosely from your wrist, despite threading the clasp through the last hole on the band.

The final hours close to dawn are the hardest, as you struggle not to fall asleep even as you shove needle after needle into your patients’ arm. Damn, missed that vein again. Gotta break her skin again, even as you ignore the wet, pained hiccups bubbling from her lips. Work dogs your heels even when you’re catching your breath in the still quiet of your room after a messed up night call.

You begin to have nasty thoughts. “How did he get so fat? He’s like a whale drinking the entire ocean drowning himself.” Despite all attempts at civility, you finally lose your patience with your patients–“Why did you even come to the hospital if you don’t want to listen to our advice?”–a few sharp words later, the regret and shame hits you like an oil tanker. That was beneath you. You really shouldn’t have said that. Now go apologize. But there are discharges to be done, bloods to chase, and that delirious grandmother with the difficult lines yanked out her branula again.

Stumbles are inevitable, but that don’t mean they hurt less. Lessons are learned the hard way. Mistakes haunt. By the end of the day you’re all purple and there’ll be new bruises tomorrow, just you see. But you pick yourself up, and you soldier on.

Desperately you wonder why the hell did you choose this life for yourself. you really can’t take another day like this. And then suddenly you look back and you’re amazed that two months have passed, and you’re still standing. You’re not doing half as bad–sure, there are low moments, but you look up and see the grateful smile of the elderly gentleman whom could barely manage a word through his breathless gasps when he first came in, whom you saw through day after day of excruciating medical therapy…to see him actually walking out of the ward on his own two feet is nothing short of amazing.

You glance over to your colleague who has been particularly nasty towards you and you realize he or she is probably going through the same mental and physical torment you’re feeling. You are grateful for your supervisor, whom in rare displays of sympathy and compassion, tells you to stop whatever you’re doing and go grab something to eat before you burn a hole in your gut. They’ve been there, they’ve probably made the same mistakes. Work can be hard, but kind colleagues and seniors make life a little bit less unbearable.

The harder the wind howls, the deeper the roots take hold. You are stronger than you think you are. Now fix those shoelaces, take a deep breath, and run on.

The issue with death

There is a herald of death in my hospital. A chubby young man, brazen and ruddy faced in his adolescent vigor, steals around the corners, slips up beside the grieving relative, and, in his discreet own way, proffers a business card. Ah Huat Coffins and Coroners.* The nurses tell me that he would beat to the hospital forensic team, peeking around drawn curtains even before the bodies have cooled.

Growing up, unlike many, I never had much fear for death, thanks to my mother’s frank and candid attitude towards the frequently avoided taboo topic. She would drag me along for funeral services when no one else would go, either because it was Hungry Ghost month or because the unfortunate person passed away during Chinese New Year. She always coaxed me to look into the open lid. “He looks like he’s sleeping,” I would comment. “Her make up is done just right,” she would declare, or, “Did they puff up her cheeks with injected chemicals? She looks much younger.”

I owe a lot too to my brother, who introduced me to the Discworld universe at an impressionable age, where Death is not a feared entity, but instead is immortalized as a cat-loving, human-curious skeletal figure that SPEAKS IN CAPITALS and prances around the universe on the back of a horse named Blinky.

Fast forward to current days, I find myself dealing with death with unsurprising regularity. Managing the acute/subacute cubicle is like handling your own personal ICU. Infusion pumps, ventilators, monitors beeping, running for ABGs, patients collapsing at the most inconvenient of times, malignant oxygen saturations. However, the difficult aspect is dealing with patients’ relatives and their anguish. I am reminded on a daily basis that life is finite–that we are, in the end, mortal.

“How long does he have left?” they would ask. It took me a while to realize that they actually wanted to know how long they had left with their dying loved ones. After all, only the living grieve.

For such a profound experience, death is surprisingly prosaic in writing. Informed by staff nurse cardiac monitor showed asystole, we would document in clinical notes. Attended stat. Active resuscitation commenced. No ROSC. BP unrecordable. Peripheral pulses not felt. Pupils fixed and dilated. No spontaneous breathing. Death pronounced at 2.14am. Cause of death: aspiration pneumonia. 

I remember pronouncing death for the first time. He was a Chinese centurian whom I regretted not getting to know better. He must have been a wonderful man, a devout husband, a patient father, an indulgent grandparent. His loved ones choked up the sidewalks of the ward day and night, waiting anxiously for the moment when he would draw his last breath, as he mumbled incoherently in his delirium.

He eventually stole away in a quiet moment in a still afternoon, when everyone had finally gone home. He must have known it would be better this way. Let them remember me in my better days, he must have thought. Uncle was a hundred and one years old.

“Can he still hear us?” Another tough question I regularly get. Most times I do not trust my tongue to lie, so I give a non-committal nod. That usually suffice. People would believe anything they want to hear. I have come to believe this is an important cathartic process of dying for the people left behind. Whatever peace you want to make with him, now’s the time.

Just this morning, I attended to a middle aged lady found unconscious at home. Nothing could’ve prepared her family for the massive heart attack she had. As we furiously pumped away at her chest, sweat stinging our eyes, the curtain slipped in the breeze, revealing her son, eyes rimmed and bloodshot with grief, hands clasped in earnest prayer to whoever was listening. “Please don’t leave us,” he begged. “Why do you have to leave now? I want you to meet my future wife, my future children. I want you to see me succeed in life. Please don’t leave now.”

I glanced down at grey lips gaped but unmoving, eyes that gazed but did not see.

We finally ceased resuscitation efforts after 45 minutes. When I finally emerged, the man was on his knees, shoulders shaking in ragged sobs. Unbidden thoughts of my own beloved parents arose, as I watched a man losing his.

“Come,” my supervisor said. “Let’s get back to work.”

But I need a moment, I thought, heart racing as my own eyes prickled at the onslaught of emotions.. Numbly I wrote as my supervisor dictated, but my mind was a thousand miles away. All I could think of was my own family, and what I would give to see them again.

“One day you’ll wake up and there won’t be anymore time to do the things you’ve always wanted.” – Paulo Coelho

The only certainty in life is death. So wake up, and live.

*Not their real name

Guide to the Rohingya Crisis and Rohingyas in Malaysia

Speaking to people, I realized many are not initiated to the plight of Rohingyas in Malaysia, or Rohingyas in general. This has impelled me to writing a short introductory piece in hopes of shedding some light on their situation.

Source: AFP

The recent and ongoing humanitarian crisis of Rohingyas stranded off our Malaysian and Thai coasts is a dramatic escalation of events as a result of Thailand’s recent strict crackdown on immigrant camps. Remember The Star’s headlines on finding over 50 bodies in a grave site at the Malaysian-Thai border? It is believed to be part of a human trafficking network detaining Bangladeshis, Rohingyas and other Burmese ethnic groups until they can pay for passage into the countries they are fleeing to. Thailand has since stepped up on their efforts to catch these smugglers, resulting in thousands of smuggled Burmese and Bangladeshis being abandoned at sea.

I have chosen not to comment on Malaysia’s rather ignoble decision to turn away these people in their time of need. That is a discussion on regional politics and Malaysian’s humanitarian stand i.e. a discussion for another day. What I would like to highlight is that this is just the tip of the iceberg.

A protest in front of Thailand’s Myanmar embassy in Bangkok. (Source: Reuters)

Since 1974, the Rohingyas, a minority Muslim community, have been stateless and denied citizenship in Burma, among other generation-long conflicts such as military rule, forced labour and dispossession. They are not recognized as citizens because of lingering perception from colonial rule that they are “migrant Bengalis” and thus not a genuine native ethnic group. They are denied basic education, healthcare and public privileges. Political reforms in recent years have also granted authorities licence to crack down on these communities. They are essentially a voiceless people; even Nobel prize laureate and political activist Aung San Suu Kyi refused to comment on this issue.

Seeing no future and fearing for their lives and future generation, hundreds of thousands of Rohingyas have taken to seek protection as refugees in neighboring countries. Many have to fork out huge sums of money–thousands of US dollars–to be guaranteed passage into Malaysia and Thailand. The journey is a precarious one, overcrowded vessels with little sanitation and water, with many perishing along the way. Their willingness to take such a risk is a clear indication of the depth of their desperation for sanctuary and a better future.

Source: Chiangrai Times

Source: Chiangrai Times

Initially, the refugees in Malaysia were well-received by the Malaysian government. There were even promises of legal work visas. However, as repeatedly warned in Game of Thrones, words are wind. As expected, these plans securing a semblance of a future for refugees in Malaysia were dashed by corruption claims, and they were never spoken of again.

There are now two solutions for refugees: (1) Integration into local communities, with basic rights granted to refugees, or (2) Resettlement to another country.

Unfortunately, Malaysia, for some reason unbeknownst to me, did not sign the 1951 Convention on Refugees, which grants refugees protection, civil and economic rights as well as conformance to local laws.

This leaves refugees in Malaysia, 90% of which are Burmese, indistinguishable from illegal migrants and no better off than they were back home. They are vulnerable to arrest, detention, abuse and deportation. I have accounts of refugees getting pulled off the streets by policemen and, if they cannot afford the bribe, getting detained in detention centers for indefinite amounts of time and eventually dying in captivity.

They are denied work permits and even if they secure a job, they are frequently abused and exploited of their salary and rights. When cheated by their employers, they have no one to turn to for support.

What protects refugees in Malaysia is registration under the United Nations High Commissioner for Refugees (UNHCR). Never heard of them?

Angelina Jolie is synonymous with UNHCR. Rings a bell?

By possessing a UNHCR refugee card, they are protected (to a certain degree) from the authorities. Unfortunately, not all police officers are aware of this. Often UNHCR officials have to search through detention centers for wrongfully detained victims when refugees report their families missing from home.

The refugee card does not grant them employment or appropriate wages, nor does it grant them affordable healthcare or formal education. Many refugees do not have the UNHCR card due to inaccessibility or fraudulent “middle men” issues–such as false fees and extortions. The UNHCR is working tirelessly to improve the situation for refugees in Malaysia, but so far the Malaysian government has remained inconsistent and apathetic to their plea for cooperation.

If there is a shred of hope to be found, it is that Malaysia did sign the Convention on the Rights of the Child, which subsumes protection for refugee children.

But what is the definite solution to these people’s refugee states? Currently, the only way out is Option No. 2: resettlement to countries that have signed the Convention on Refugees. Most refugees, if lucky enough, would eventually be resettled in Australia, the United States and Canada. This is an effort the UNHCR focuses its resources on, while trying to improve their daily situation locally by working with NGOs to provide basic healthcare (mobile clinics by Tzu Chi Foundation Malaysia, ACTS, Health Equity Initiatives and COBEM, among others), basic education and skills training.

UNHCR, with its very limited regional fundings, also tries to provide basic accommodation. Malaysia does not house refugee camps, so these refugees stay in squalid shelters with limited access to clean water and electricity. Employers illegally house them in crowded quarters–agar mediums for public health catastrophes.

I had the good albeit very limited experience dealing with refugees, having signed up as a UNHCR volunteer providing education for refugee children in hopes of prepping them for eventual resettlement. Their situation is deplorable. I watched as 15 preschooler children scrambled excitedly over a box of twelve color pencils, ashamed that back when I was at their age I demanded for a new set when one color goes missing.

I watched a teenage boy sit in with the preschooler class learning ABC and 123, yet instead of feeling embarrassed, he was eager to lap up all the knowledge I had to offer, happily giggling along as I taught them the name of colors through drawing caricatures of Batman and Superman. An eight year old got hold of my “buku conteng” filled with medical school revision and began copying letter by letter in hopes of learning new words.

Next, I went to the primary one class, where children clad in an assortment of school uniforms (because policemen were less likely to pick trouble with school children) greeted me excitedly. To my surprise, their range of vocabulary was impressive for children without consistent education. They could grasp the concept of plants germinating from seeds, herbivores and carnivores. They could follow instructions. I did not need to “dumb down” my English or adopt “baby speak” in order for them to understand. They are intelligent, intuitive and eager learners. Why should they not deserve the same opportunities as us?

In the refugee school I visited, there were days when the students would gather but no teacher would come, because volunteers were scarce. When I arrived, their faces lit up, as if they hadn’t seen a teacher in days.

So if some of you are feeling overwhelmed with helplessness by the recent refugee boat crisis, I assure you there are plenty of ways to help. Get in touch with UNHCR by their official website and sign up as a volunteer. Get acquainted with their plight, and open up your world.

This is the opinion of the writer and in no way officially affliated with any organizations or agencies.

Book review: Damned Nations: Greed Guns Armies & Aid, by Samantha Nutt

“Most of us come into this world amidst a frenzy of pain and emotion and unpredictability, and too many of us leave in the same way.”

I came across this book by pure luck and I can say I’ve never been luckier in my life. It was basically plucked off the shelves in a suburb library to make up the number of books I was loaning (because if you are allowed to borrow six books, by the Gods you borrow no less than six books.)

Three days and 200 troubling pages later, I glanced up from the final page a changed person.

Books which I can solidly admit to be life changing are few and far in between. This is one such book.

If I could have my way, I would include this as a compulsory read for all medical undergraduates.

Samantha Nutt, M.D. narrates her experience as an aid worker in conflict zones for the past fifteen years. The chapters are aptly divided by the war-torn regions she has worked in, namely Somalia, Haiti, Iraq, Congo, Liberia and Afghanistan. It is more a commentary than a memoir as she keeps the focus tight on issues assailing humanitarian work rather than glorifying her contributions and promoting War Child, an international humanitarian NGO she founded.

Nutt is perceptive of the real problems behind humanitarian aid and the detrimental state of current affairs. She expertly distills otherwise convoluted interconnections between international power play, grass root aid efforts and local culture into simple, easy-to-digest words. Adopting a no-nonsense approach, she does not hesitate in taking a hard hitting stand on these atrocities, waging humanitarian wars that would span decades with a tireless passion and iron will.

She openly criticizes how disaster crises are seized upon as publicity opportunities and how organizations fight for space to set up their tent when providing relief, only to leave when the world loses interest in these disaster-stricken areas, leaving no long-lasting impact. She suggests that there are many small, lesser known organizations that deserve more support and urges readers to donate responsibly and know where and what their money is going into.

By putting forth issues which are rarely seen by the world, Nutt shows us the way to be a better aid worker, or a wiser donor.

There are plenty of moving personal accounts with fellow relief workers, the victims she is fighting for and terrifying encounters with the local militia.

One riveting encounter was during a spontaneous visit to one of Somalia’s resettlement camps as a UN aid worker.

Curious to find out why the local womenfolk would rather make the miles out to a stagnant creek to collect water rather than utilizing a new drinking water pump set up in the center of their settlement, she is suddenly ambushed by a group of shot-up, drunk adolescents toting AK-47s.

“You journalist?” they asked, holding her camera.

“No, no journalist. Doctor. Children here in camp very sick. I can help.”

“You UN?”

“Yes, UN.”

“The UN help no one in Somalia.”

“I want to help.”

“Then leave Somalia.”

A notably poignant recollection is her friendship with Margaret Hassan, a UK-born Iraqi front lining humanitarian work for more than 25 years. She was working under Care International and was a vocal critic of UN-imposed prohibitions. A champion for the Iraqi people, she notably brought leukaemia medicine to cancer-stricken children in Iraq. 

In October 2004, Mrs Hassan was kidnapped. Hundreds of protesters took to the streets of Iraq. Even then al-Qaeda leader, Abu Musab Zarqawi, appealed for her release, although Hassan never claimed allegiance to anyone but the people of Iraq.

A month later, Al-Jazeera received three videos from her captors, one of which was released showing Hassan begging then PM Tony Blair to withdraw British troops from Iraqi soil. The second, Al-Jazeera reported, showed Hassan being prompted to recite a text with false claims that she was spying on Iraqis. The third, which was never released, showed Hassan executed by gunfire.

Her killers have not been found until this day. Her body remains missing.

Nutt enlightens the readers with various difficulties faced by aid workers, including a struggle to restore a felicitous identity blemished by constant military presence. “For aid agencies on the ground in Somalia (…) the stubborn image of foreign soldiers storming the beaches of Mogadishu brandishing the latest American artillery under a relief banner had damaged local relations,” she writes. This robs the “aid community” of the politically neutral and protected stand they needed to operate from.

She points out also these impoverished war-torn countries are able to gain easier access to the weapons market than to vaccinations, clean water and shelter. 73% of all global arms-transfer contracts belong to developing countries, with exponential sales growth observed in the small arms market—rifles, machine guns, hand grenades.

She documents how the needs of Somali civilians no longer take precedence over the abject violence that rages across its barren, bullet-riddled expanse, as international aid consideration wanes in this country that is more interested in squabbling among themselves than actually saving the people.

“War, and the pursuit of war, destroys us. It turns teenagers into killers, neighbours into génocidaires, and politicians into executioners. War is humanity at its most primitive, despite our attempts to dress it up, distance ourselves from it through technology, and frame it in acceptable terms. (…) In the end, all wars are only one thing: people killing people.”

My personal favourite section is her open criticism on “volunteer tourism” or voluntourism, a booming profiting industry for idealistic eager foreigners who are enticed by promotional pictures of volunteers handing food packets to smiling doe-eyed children with bloated, ascitic abdomens. What many are unaware of is how commercialized volunteerism has become.

Perhaps this is because I share a similar apathetic disapproval with Nutt for such ventures.

As Nutt succinctly explains, these attractions make a spectacle out of poverty. Funds are directed to serve the clients, providing clean sanitation, comfortable accommodations and good food, with little or none going to fund the impoverished communities. It’s for people who are deterred by reputable volunteer organisations which require all volunteers to undergo proper rigorous screening and training programs before allowing them on the field. “These are programs open to anyone willing to foot the bill,” Nutt writes.

Local conditions are sometimes even maintained in a perpetual dismal state to lure more donations from your pockets. Volunteers arrive eager to “make a difference”, upload a few dozen Instagram photos doing “humanistic work” and forge bonds with the local children, only to sever them without second thought when their ride back to the city arrives. These temporary bonds, forged with lonely orphaned over a span of a week or two, are routinely severed and could be nothing but detrimental to their social and emotional well-being. Imagine yourself, impoverished and orphaned, seeing two-week cycles of these blemish-free cheerful foreigners showing bits of kindness, only to never see them again in your life, while they return to their comfortable homes gushing about their unforgettable, eye opening experience in “the jungles.”

Nutt writes it best,

“Repeated short-term attachments can leave young children with feelings of abandonment that impede their social development. Visitors to these programs often come away with a sense of how friendly and happy these children were, and it is common to see photos and promotional videos on voluntour websites of foreigners ferrying affectionate children about on their shoulders and backs. But what creates an extraordinary experience for the visitors—hyper-friendly pre-schoolers who make them feel immediately wanted—is a symptom of the children’s repeated psychological trauma. It is normal for young children to be cautious, even mistrustful of strangers. That children in these programs are so emotionally indiscriminate should be heeded as a warning that voluntour programs are failing children.”

While the author acknowledges that these opportunities are great early exposures for young people to humanitarian work, admitting that she herself had similar beginnings, she can’t help but entreat for more ethical, responsible, meaningful and sustainable development. These communities don’t need another latrine dug out for them; they need jobs, training programs, formal education. “With every school built by well-meaning Western volunteers in villages in Africa, there is one less opportunity to provide employment and skills training to young people from such communities, who are also desperately seeking such experiences.”

Nutt exposes the pressure under which aid organizations are compelled to show donors tangible results, like a new classroom or a new latrine, taking away much needed attention on more urgent, sustainable causes like investing into education, legal justice, microcredit start-ups, helping countries establish self-governance. With such an approach, we’ll always be wiping away the mud from the flood, without finding solutions to the flood itself.

Amazingly, despite the bleak issues it touches on, the book is never defeatist. If anything, it seeks to empower the reader with new perspectives, and offer realistic solutions to existing issues. Nutt dedicates the last chapter to highlighting ways in which the reader can effectively make a difference.

So if you aspire to venture into the field of aid work, or you want to help responsibly, Damned Nations is the book for you.

Dealing with MLM and How to Politely Decline People

*Explicit language alert*

Rather recently I had the misfortune of being one of the targets of a good friend for a business “project” which turned out to be another classic pyramid/MLM scheme. She had invited me out on a pretext that we were just catching up after 2+ years.

The SO and I intuitively had a hunch that something was a tad off course and agreed beforehand to walk right out if it was (1) some religious convert campaign or (2) multilevel marketing recruitment.

Turned out to be harder to do than I thought.

We arrived at the meet point to find a bunch of strangers waiting for us. The polished manners, flashy smiles and overly friendliness was enough to set off alarm bells right from the quick introductions made. No one should be that happy to make my acquaintance, I thought. After about twenty minutes of saccharine-coated trash talking and preamble, they finally dove into this “exciting new business venture”.

Ah well.

While I left that encounter feeling rather crushed that my friend had exploited our friendship for profit, I do understand he/she meant well and was probably pressured by the more senior members in the team to contact personal acquaintances.

As this article on Forbes.com stated, “MLM companies have been a frequent subject of criticism as well as the target of lawsuits. Criticism has focused on (…)  encouraging if not requiring salespeople to purchase and use the company’s products, potential exploitation of personal relationships which are used as new sales and recruiting targets.“

Frankly I just felt bad wasting their time trying to convince me when my mind was already made up. I would’ve saved them the trouble if my buddy had told me up front what this was all about

What I found rather difficult was finding a nice way to let these salespeople know that I’m simply not interested. It took a lot of effort to resist turning confrontational and biting back every smart-ass retort that came to mind as:

1. I was already feeling bummed I got tricked into meeting them that evening,
2. I was wasting my Friday evening on this (when I could be wasting my Friday evening at home doing nothing)
3. We were getting increasingly hypoglycemic from delaying dinner for this
4. These people were becoming more insistent with every polite decline I gave them.
5. Making their approaches personal, e.g. “Your friend was very thoughtful for inviting you out tonight to listen to us (when I wouldn’t have come out at all if I knew what this was about, but I was too polite to point that out); she wanted you to have the same opportunity” They took advantage of my reluctance to cause any offence or upset to my good friend.
   Also, this statement came up quite often, “There are plenty of successful doctors out there who do this for passive income.“
6. One can’t help but feel that there is plenty left they’re not telling you. Cash backs and passive income? I’m way too much of a skeptic to buy that sort of thing.

I found myself increasingly beleaguered by their passive aggressive approach and insistence that I signed up now. The resistance I put up at various points in the meeting without resorting to rudeness included:

1. Appealing for more time to think it over before making a decision, and then distracting them by asking if I can apply later or by some other way.
2. Quoting my mum, who really actually did warn me never to be pressured into signing anything in any circumstances.
3. Emphasizing repeatedly that I’m not comfortable making pressured decisions and “I hope you’ll understand that”
4. Acknowledging their time and effort in offering me this wonderful new opportunity, but “I really need time to think about it”
5. Pointing out that while this is a great idea, not everyone will thrive in it. (ie I have ZERO business sense)
6. Repeat each of the above at least three more times.
7. There was even one instance where I let my bitch side slip through and challenged them with a difficult, uncomfortable question that left them a little unsettled. They recovered admirably after that.

By the end, I was a hair’s breadth away from turning into Malcolm Tucker from The Thick Of It.

At the end of the day, I applaud them for their persistence and unfazed spirit. Now if we can just channel that same tenacity and passion into worthy causes like obliterating nuclear weapons or racial and gender equality, or fighting for a transparent and meritorious government, the world might just be heading in the right direction.

So, here are some ways I thought would be good to try the next time you catch yourself in such a tricky situation, MLM,  or otherwise. The basis of it is to keep things friendly and and always end the meeting on a positive note.

(1) Explain politely that you’d prefer to keep relationships away from business. “Sorry, I don’t mix friends and work/business.”

(2) Suggest that you know someone who is genuinely interested, but do NOT volunteer your friend’s contact details without his/her permission. That’s just plain unethical. Take down the salesperson’s contacts instead. Refrain from volunteering your own. (A mistake I made trying to get them off my back) “If I come across anyone who is interested, I’ll know who to send him/her to. Thanks for letting me know.”

(3) You might be fearful of losing a friend for refusing their sales pitch or saying no too often, but it was impolite of your friend to exploit your friendship for their profit in the first place. If the sales pressure continues, I don’t see why you don’t have any less right to be just as aggressive in your response. Repeated firm no’s and “Look, I love you mate, but I’m uncomfortable with this topic. Can we talk about something else now, please? That would be fantastic, thanks.”

(4) Make it about YOUR stand on this, not theirs. “I’m not accusing this of being a scam, or a cult, I’m just genuinely not interested.”

or “I really am not keen on this, please respect my feelings on this front. I hope you’ll understand, and I wish you all the best in this venture.”

or “I’m glad this is working out for you but I’m really not interested.”

(5) Inform them that “I’m already loving what I do full-time and I don’t want to take energy or time away from it.”

(6) Explaining that you’re not keen because your *insert relative/friend here* got in too deep and is now in deep waters and debts is just inviting trouble because they’ll launch into an elocution of why it isn’t so. You’re giving them something to argue with. Save yourself time, and do Steps 1-5.

(7) If said salesperson persists, repeat Steps 1-5 over and over punctuated by uncomfortable silence. People HATE uncomfortable silence.

These tips may sound easy, but it gets pretty difficult to remember how to deploy them when you’re ambushed by a whole guerrilla of these salespeople as I was, and they KNOW their strength lies in numbers and in brutally overwhelming the victim.

Last advice, if you are caught in the same rut as I was, don’t take it personally. It’s all part of their methods: start out friendly and engaging you actively and once you’ve thawed out enough, they’ll launch into how this vacuum cleaner somehow saved their grandma’s life. They do this to every other potential customer, so…nothing personal, really.

All the best!