Wednesday, March 23, 2016

Traveling Around the World with Diabetes

Some of you who have read my blog for a while may remember that my current ruptured quad tendon wasn't my first medical issue.  After a fairly healthy life, it seems that in my 50s, things began to catch up.  In early 2011, just three months before beginning a sabbatical trip, I was diagnosed with type 1 or childhood diabetes.  I thought I was a little old for that, but something had gone haywired in my pancreas and it wasn't producing nearly enough insulin.  This is the story about my disease and my travels as I headed off around the world (I flew to Indonesia and rode trains around Java), then flew on to Sinapore and stayed on the ground (trains, boats and buses) to Europe and came back to the United States on a ship.  The picture to the left was taken of me on board a train in Indonesia.   Since I didn't blog at Sagecoveredhills while traveling, this might provide a good introduction to my A-Z challenge that starts in April.  I'll be writing about places still on my bucket list.

Mt. Meripa, Indonesia

 I hike through the ruins of Kinah Rejo at mid-morning, making my way toward the smoky summit of Mount Meripa.  What used to be the main street is now a steep trail.  Lava and ash cover the town, leaving only a few rock walls standing.  Where the town had been six months early, there are a few enterprising merchants selling drinks and snacks to tourists like me, but I’m the only Western to be seen.  Most sightseers are Indonesian, although there was a group Japanese who spoke a little English.  Leaving the town site, I continue on the trail as it climbs even steeper.  The sun is bright and hot and the air, so close to the ocean, humid.  Although sweating profusely, it feels great to stretch my legs in this strange landscape.  I’m shocked to see banana trees and shrubs already growing out of the black soil.  By mid-day, still a long ways from the mountain, I realized I needed to take a break.  I’m breathing heavy.  There are no longer tourists in sight.  I drop my daypack on the ground and sit on a rock, when I suddenly feel lightheaded.  I drink some water and check my blood sugar.  I’m at 70 and feel as if I’m dropping fast.  I eat a candy bar and drank more some water as I rest.  In fifteen or twenty minutes, I feel okay again, but I decide to turn back. 
I’m in my first week of a four month sabbatical with plans to travel overland, from Southeast Asia to Europe. 
In early 2010, I was presented with the opportunity to take a sabbatical.  Excited with possibilities, I began making plans.  But then, in February 2011, four months before setting out, I find myself fatigued and rapidly losing weight.   My physician orders a battery of blood test.  Although I’d never had problems with blood sugar before, my fasting blood sugar came back at 315.  Within an hour of receiving this report, his nurse has me back at the lab for more test.  The second test indicated that my A1C was 15.4.  Something has happened.  Two days after that first blood test, I’m on insulin and seeing an endocrinologist.  I’m worried I might have to forgo my plans, but both my primary care physician and my endocrinologist encourage me to continue planning but also to learn everything I could about my disease.
Over the next few months I took advantage of every available educational opportunity as well as read books about diabetes.  My endocrinologist has me met with several diabetes educators, one who has extensive mission experiences, most recently in Haiti, after the earthquake.  She explains how, in just days, people unable to get insulin were dying of ketoacidosis.   This is frightening, especially since I was unsure of my ability to obtain insulin.  She assures me insulin will be available, but it might be different from what I am using.  She reviews charts of different types of insulin and their usage.  She shares experiences of diabetic patients in Africa who are dependent on mission shipments of insulin.  These shipments are what’s available. The patients often find themselves changing types of insulin. I had begun my insulin intake using dial-up pens, but she teaches me how to draw and inject insulin with a syringe.  I leave the office with a sample vial of insulin and a bag of syringes so that I can become comfortable injecting myself.
In addition to dealing with my diabetic needs, my primary care physician suggests I make an appointment with the county health department travel nurse.  During my visit, we go through my proposed itinerary and she gives me needed vaccines and completes an international health card that I carry with my passport which contains my immunization record and medication needs.  My primary care physician provides prescriptions for a number of antibiotics for various infections with instructions for use, just in case.  I packed two kits, one with insulin and another with general medical supplies.  Because I’m going to be traveling around the equator and in hot areas, I purchased an extra-large water activated cooling pouch to store my insulin.  This pouch needs to be soaked in water every few days, but does wonders in keeping medicine cool.  Wanting to try it out before hand, I soak it in water and place it on the dash of my truck on a sunny day.  Late in the day, after sitting in a parking lot where the temperature inside the truck had soars to 140 degrees Fahrenheit, the temperature inside the pouch was only 80 degrees Fahrenheit!   I also wear a diabetic “UBS” necklace.  The UBS port could be plugged into any computer and my medical information would pop up.  Knowing I would often be traveling alone, wearing this provides comfort that someone might be able to help
            My trip was wonderful.  With the exception of a head cold that I had early on in the trip, I had no medical problems and returned home with all my antibiotics.  I did have a few swings in blood sugar levels, but nothing out of the ordinary.  However, it required planning.  I began my trip with a four-legged flight to Jakarta, Indonesia.  As I had been on an evening shot of long-acting insulin (insulin glargine), I just changed to taking the shot in the morning (as I was on the other side of the world).  When I left home, I carried a small six-pack sized cooler in which I had extra pens of insulin and gel cooling packs.  Due to refrigeration issues, it was impossible to carry enough insulin for the entire summer, but I had enough for two months.  When traveling on the longer flights, flight attendants were more than willing to keep my insulin in their refrigerators.  After three weeks in Indonesia and Singapore, where I boarded a train through Malaysia, I decide I can no longer keep the insulin refrigerated.  I give away my cooler and only use the water-activated cooling pouch to keep my supply cool.  Knowing that most insulin pens are designed to be kept at room temperate for a month, I knew I would have to resupply while traveling, which I did in Vietnam.  After seeing the types of insulin available, I emailed my endocrinologist and we decide to try a 70/30 premix vial of insulin, which would be taken twice a day, before breakfast and dinner.  This worked well until I obtained insulin in Europe. 
            Although worried about traveling with diabetes, I had no problems.  I was able to carry enough supplies to get me through (I did have extra test strips mailed to a hotel in Beijing along with a guide book for the Trans-Siberian railroad).  However, I found test strips were available almost everywhere.  Along the way, I often stopped and talked to pharmacist about the availability of insulin.  To my surprise, many of the smaller pharmacies didn’t stock insulin.  Some could obtain it (a few day wait), but most suggested I go to a hospital.  Larger pharmacies did carry insulin and in most places I would not have needed a prescription to purchase it.
The train from Hanoi to the Chinese border
            I always made sure that I kept insulin on me.  I knew the danger of not having it.  Even when I stepped off a train at a station stop, I had insulin and my test kit on my body (I often wore a vest with convenient pockets or cargo pants with large pockets on the thighs, both of which were ideal places to stash my test kit and extra insulin).   However, traveling with so much medication also had me worried.  As I walked down the corridor to customs in Indonesia, I couldn’t help but notice a large sign reading “Death to Drug Dealers.”  Knowing that I had several hundred needles for insulin pens in my bags, I was concerned that they’d question me.  But it wasn’t a problem.  Taking the train from Hanoi into China provided another scare.  Those of us changing trains at the border were told to go to our berths and leave our luggage out.  When the custom agent came into my compartment, he immediately pointed to the top pocket of my pack and asked that I open it.  I did and he reached in and pulled out a bag of syringes.  His eyes opened wide as did the Australian guy who was sharing the compartment with me.  I immediately said “diabetes” and he responded, “Insulin?”  Yes, I said and showed him the vial of insulin I’d purchased the day before in Hanoi.  He smiled and didn’t look any further into my pack, signed my form and moved on to the other passengers.  
Scenes from the Chinese side of the trip from Hanoi to Beijing

            Traveling with diabetes provided occasions to meet local people.  I was in the waiting room of the train station in Nanning, China, getting ready to eat breakfast that consisted of several pieces of fruit.  Quickly counting the carbs, I proceeded to give myself an injection.  A Chinese man sitting across from me smiled and pointed and then pulled out a little kit from his pocket with a test meter and filled syringes.  Although he didn’t speak English, we had connected, which is the best part of traveling. 

Monday, March 21, 2016

Back on the water and A-Z Challenge

Boats taking toward the windward mark\

 My brother was in town this weekend.  Although he does a lot of boating, he had never sailed and was interested in the experience.  I arranged for him to sail with the club.  Even though I am slowly gaining strength and mobility, I am still no where close to be jumping up on the deck of a sailboat or even jumping side-to-side when one tacks, so I went out on the committee boat.  It was my first time on the water since my accident on January 9th.  It felt good to be back out on the water.  It started out being fair day of sailing, but in the third race the wind died.  We ended up calling the final race and giving some of the boats a tow back to the marina.  Then, while having a beer and telling stories on the porch above the marina, the wind came back up...  But we were all done and my brother had a good time and hopefully learned a little and I got to try out my sea legs with a brace on my left leg. 
my brother (in  yellow shirt)
 It appears that today is the day those who are doing the A-Z challenge are to reveal their plans.  I had kind of already done that, but I'll do it again.  For my first A-Z challenge, I'll write about places I would like to experience that are on my bucket list.  Look for some interesting off-the-beaten-path ideas.  I'm sure I don't have enough years to do it all, but some of them, yeah!

Friday, March 18, 2016

Visiting St. Patrick's Cathedral

Yesterday at Bonaventure Cemetery

Yesterday was St. Patrick’s Day and it’s a big thing in Savannah.  While I stayed away from the parade as there was other things to do, a morning downpour thanks to a thunderstorm turned the streets of my island into rivers of green (or yellow-green from pollen).  In the afternoon, I was at an funeral service in Bonaventure Cemetery, which is beautiful this time of the year. Thinking about St. Patrick’s, I jotted down this memory last night about visiting the cathedral of his name in Dublin, Ireland.

Inside St. Patrick's
In the summer of 2011, after traveling overland from Singapore to Europe during a sabbatical, I returned to the United States on a Holland America ship that made a number of stops along the way.  One of the stops was Dublin, Ireland.  It was a Sunday morning and the ship docked during breakfast, allowing for a long layover (18 hours).  Being Sunday, as is my usual custom, I wanted to find a place to worship.  In Dublin, St. Patrick's Cathedral was the place.  After all, Jonathan Swift, author of Gulliver's Travels and A Modest Proposal (which has probably ruined the appetites of more high school and college students than any other tract) was Dean of the cathedral back in the early part of the 18th Century.  Although I'm not one who worries much about the canonization of saints, if I was, I would support Swift as the patron saint of satirists and all smart-asses.  And if you need a miracle to prove that he’s worthy to be "beautified," it could be him not being defrocked for inappropriate relationships with his friend Stella.  Of course, no one has ever proved the two had such relationships.  Some believed the two had been secretly married even though there was no proof of such a union.  They certainly spent a lot of time together, travelling together, and are buried together, side-by-side near the front of the sanctuary. 

St. Patrick's is a cathedral associated with the Church of Ireland which is within the Anglican Communion.  It is odd that there are two such cathedrals within Dublin, both with long histories.  St. Patrick's was built between 1220 and 1260, but on a site of an older church and supposedly the place where Patrick himself first baptized Irish converts around 450.    Christ Church Cathedral was built a century earlier than the "new St. Patrick" (but this wasn't the first "St Patrick's on that site and it had former site was already declared the site of the cathedral).  Ironically, both churches are a part of the Church of Ireland, which is the minority.  Most of the population being Roman Catholic.  I didn't know any of this when I visited except that St. Patrick's was an Anglican Church.

After breakfast on the ship, they ran shuttles into downtown Dublin, dropping us off at Trinity College.  From there, tour buses were lined up for our fare.  I took one that allowed me to get on and off, so I could see the city while stopping for church at St. Patrick’s.  The church was beautiful from the outside, but was not yet open, so I found a place for coffee and caught up on my journal and read some as I waited for the doors to open.  I was surprised to learn there was a fee for touring the church, but if you attended worship, you didn't have to buy a ticket and would then be allowed to look around afterwards.  So I put my contribution in the plate instead of investing in a ticket. 

Although the outside is beautiful, the inside of the church is magnificent.  I took a seat (there were plenty around as only a hundred or so attended the service in a sanctuary that seated 100s).  My eyes feasted on the tall stone columns, the artwork, the incredible stain glass windows.  Looking around, I realized that probably half the congregation were tourist (and many were there to pay homage to Mr. Swift, as afterwards we all congregated around his tomb).  The choir was incredible, their voices filling the cathedral and echoing off the tile floors, stone walls and rising up in the nave.  The pastor, an English chap named Rev. I. P. Poulton, preached on "What will a man profit if he gains the world and loses his soul."  He proceeded to tell us about his granddaddy's farm in Central England.  It was a good sermon that challenged our commercialist culture, but I wonder how the Irish felt being dragged back across the channel into England...

When the service was over, I walked around the nave and looked at where Swift was buried before heading out to tour around Dublin.  Lunch was in an Irish pub.  I was in need of a haircut (I hadn’t had one since Bangkok).  Afterwards, I toured some more, then headed back to the ship in time for dinner.  The ship didn't sail until 2 AM, but I decided I was not up for a night of partying and even if I was, would have worried about having a little too much to drink and missing the ship.  The next stop was the Faroe Islands, which would have been difficult and cost a small fortune to reach if I had to catch up with the ship. 

I was sound asleep when the mooring lines were tossed and the ship sailed.  I woke up the next morning and before going out to walk around the deck, checked our location.  We were still in sight of land, as we passed through the North Channel between Ireland and the Mull of Kintyre in Scotland.  The wind was blowing around 30 knots and from the northwest.  The waters were gray capped with white foam, under clouds that hid the sun.  I felt alive, but wished I had had more time to spend in Ireland.  

Friday, March 04, 2016

Good news and "Finding George Orwell in Burma"

On Tuesday, I had my six week post-op appointment and the doctor granted me thirty degrees of movement in my left knee.  It has been two months since my accident and it feels great to be able to tie my shoe and to get behind the steering wheel of a car (even though I still have to twist a bit to make it).  On Wednesday, I started physical therapy and have light exercises at home.  The horror of PT has yet to hit as they are being very careful not to do anything that would damage the tendon while it is still healing.  But I’m coming along and that feels good.

Emma Larkin, Finding George Orwell in Burma (New York: Penguin Books, 2004), 294 pages, one small map.

I have been interested in Myanmar or Burma for some time.  In 2011, I was just 10 kilometers or so for the border in Thailand.  It was a time people were discouraged from traveling to the country as a way to economically discourage the military leaders and their harsh reign.  The country government is a weird blend of totalitarianism, socialism and Buddhism.  Burma was a former British colony and George Orwell began his career there as a colonial police officer.  It was there he began to despise colonialism and his first book, the novel Burmese Days was set within colonial Burma.  In the early 1940s, the Japanese moved into Burma.  At first, they were welcomed by the Burmese.  Some of those fighting the colonial regime had even been trained by the Japanese and returned with the Japanese army, but the native Burmese realized that the Japanese treatment of their country was worse than the British and soon, the Burmese soldiers began to fight against the Japanese.  After the war, Britain granted Burma its independence.  The nation, which has eight ethnic groups and 130 sub-groups, has been hard to govern, leading to civil war and an oppressive military government that stifles dissent.  Yet, the population is fairly literate, which leads student groups and others trying to bring change, which is brutally crushed by the government.  The all-present “MI” or military intelligence watches everyone (including Larkin as she traveled around the country).

Larkin visited the country having immersed herself in Orwell’s writings.  Interesting, Orwell’s novel Burmese Days is the only one approved for publication and sale in Burma.  The anti-colonial stance of the book fits the ruling regime’s politics.  Others like Animal Farm and 1984 are suppressed.  Of course, Orwell was writing these books in light of the totalitarian dictators such as Stalin.  Larkin, however, found these books as fitting descriptions of modern day Burma, with the ever-present thought police and the danger to those who are bold enough (or foolish enough) to question the actions of the generals who run the government.   Throughout the book, Larkin keeps referring to Aung San Suu Kyi, the daughter of a former leader of the country who fled, then returned and has lived for years under house arrest.  She appears as a strand of hope for the country.

Larkin follows Orwell’s path around the country, while visiting with many of the country’s writers and publishers.  One author laughs and says that you can write anything, you just can’t have it published.  (134) Almost all the authors she met have had a book banned by government censurers.   As for the nation’s readers, Larkin discovers they’ve developed a skill of reading between the lines.  If a particular politician or general suddenly disappears from print, people quickly conclude that they have fallen out of favor with those in power.  This “reading between the lines,” along with a desperation for hope, has led to some unique interpretations of stories.  The movie “Lion King” was described by one as the story of Burma.  Simba, the young lion who flees his home, is Aung San Suu Kyi.  Simba’s father, like Kyi’s, was murdered.  The evil lion that turns a beautiful kingdom into a wasteland, Scar, is Ne Win (the leader of the generals who overthrew Kyi’s father’s government in 1962).   (132)  She also tells of a dream from an ancient king of Northern India that was interpreted by the Buddha to refer to a future time when the rulers were wicked and greedy.  Paintings of this dream begin to pop up on pagodas around the country following the 1962 military overthrow as if the Ne Win regime was its fulfillment.

In addition to dealing with the literary and the political issues of the nation, Larkin’s book is also a travelogue as she describes the landscape of this mystical kingdom.  Mandalay, which has such an exotic sounding name, is hot and can be dusty and dry or wet.  Rangoon, is hot and humid and the delta towns that Orwell lived, was even worse.   It wasn’t the favorite location for a British citizen to work, but for Orwell, whose family had ties there, it was his first choice.  Contrasting to Mandalay and Rangoon, the foothill towns seem pleasant.  The British, including Orwell, would often take holidays there.  In addition the ethnic groups, Larkin encounters many who are of mixed races (Burmese and English).  Many of the mixed race people fled and those that didn’t now feel trapped.
This book left me grieving for this rich country that has been destroyed and whose people are also hopeless.   The book epilogue tells of Aung San Suu Kyi’s disappearance (thankfully, she survived).  Things are supposedly better in Burma today, but I wonder. 

A decade or so ago, I read Pascal Khoo Thwe’s memoir, From the Land of the Green Ghost: A Burmese Odyssey.  It tells the story of a young Burmese Catholic student who fled Burma and went on to earn a PhD from Oxford.  He was from a tribe that lived in the mountains, where opposition to the government was greatest.  Larkin did not get that far into the mountains and I’m sure travel there would still be dangerous.  I would recommend both books, however I think some familiarity with Orwell’s writings would help one appreciate Larkin’s take on Burma.