My First Step in the Thousand Miles Journey

In the medical profession that emphasizes on evidence-based studies, I know that the only way forward inside this field is through journalistic articles. They say that a thousand miles journey starts with a single step. The article above is to remind me that this is my first step: my first article published in a non-medical student journal, or to look it in another way, my first article in an international doctor's journal: the International Journal of Public Health Research (http://www.ijphr.ukm.my/Manuscript/vol 3 no 1 2013_30.pdf).

I Have a Cricket Living in My Ears

Tinnitus/tin·ni·tus /ˈtinitəs/ : Ringing/buzzing in the ears; may cause depression and insomnia

The night I got it will never be erased from my mind. The thud, the pain, the sound in my ears as if someone opened a window as a plane was flying. Like all the air around me are sucked into my ears. Maybe that is why I find it hard to breath. Then the vertigo came, the world went spinning. I fell to the ground. But I felt as if I never landed. I was free falling. I was lying flat on the ground but the world kept spinning and I kept falling. At that time, I wish all of this is a dream. I waited for the moment to wake up. Please wake up, please wake, please wake me up. But I didn’t. Instead, I have to pull myself up and walked to the nearest checkpoint. Everybody else was still too busy playing the stupid war game. The ‘enemy’ must be happy that they shot me a plastic bag full of flour water right to my head during their ambush. What they didn’t know is that it changed the trajectory of my life for good.

To think of it, it is amazing how this small organ, the ear with all its parts, outer, middle and inner, can perform such a vital function that when it is damaged, a person could not hear, walk or feel the ground. The person who threw the bag of flour water must have done it with a very full force. Not only my ear drums are busted, the high speed energy must have driven the bones in the middle ear right into the inner ear through the oval window, so hard that the brain fluids began leaking out through the cochlear. I called my parents. I might be very lucky that my dad happens to be an ENT surgeon. At that time I didn’t know the extent of my injury. All I knew is that it is freaking painful. The eardrums being the most sensitive organ in the human body to pain, I might scale the pain 11/10. I could not sit still in the clinic until they gave me that jab of painkiller. My dad told me that eardrum perforation is common and it will heal in time. It got me relieved, and I went back to the hostel. Meanwhile, fluids are still coming out of my ear, dismissing it as flour water from the plastic bag.

I went to bed. I couldn’t sleep well with the eerie sound in my ears. It woke me up every hour. It was then that I noticed it. On my pillow, the fluid that soaks my pillow made the wet area look peculiar. Then I remember it: the ‘halo sign’ of CSF. I still remember my Professor’s words: In a head injury, always ask if you feel a dripping sensation on the back of the throat, and if the fluid drips out of the nose, test it in a white cloth for ‘halo sign’, which indicates the fluid is from the brain. “This is exactly how it looks!” I thought. I freaked out and called my dad again. I told him that I can feel the fluid pulsating out of my ears. Being a surgeon, he said this calmly but with a sense of urgency: “get back to UKM Hospital as soon as possible”.

It was in the middle of the night. I woke up one of the facilitators, telling him how severe the condition is. He straight away drove me back to Kuala Lumpur from Janda Baik. If my dad was not an ENT surgeon, if I hadn’t remember the lesson about the ‘halo sign’, I might just dismiss the fluids coming out from my ears as a normal physiological response of my ear to clear up flour water in my ears. Like how I sneeze and my nose become watery when there is too much dust.

I was hospitalized for 2 weeks. It was a harrowing experience. I can only stay still. If I walk, I fall. I couldn’t walk straight. My balance organ is damaged. I could only pray to Allah that this damage is not permanent. At that time, I don’t care about the hearing lost in my left ear and the newfound sound that won’t leave me alone 24 hours a day. I only start to care when I turn on my iPod and listened to it using my left ear. It sounded exactly like a broken radio. I can only hear some frequencies of sound but not another. Losing my ability to hear clearly left me devastated. I couldn’t walk, I couldn’t hear properly, and there is this weird sound that has always been with me since that night. In the wards, they gave me antibiotic cover every day to prevent my brain from getting infected through the leak in my ears. There was a very high possibility, with the flour water in the plastic bag kept for days. There is no questioning what type of bacteria is in it.

After nearly two weeks, I was discharged home, but I still have to take antibiotics. I still could not walk straight, but it is improving day by day, which was a good sign. I read that when the balance organ in one side of the ear is damaged, the other ear will adapt and tilt the balance to normal again. How powerful is Allah’s creation! But the effect does not remain physical. Emotionally, I was torn to pieces. If there was a point in my life where I someone to take care of me most, that was the point. I am glad that my families and friends gave me a visit. My parents were always there, but everyone has to go to work in the end. I have no one who I can talk to any time that I needed to.

I became depressed. A few weeks later after my balance has returned, I decided to return to class. Some lecturers suggested me to skip the whole posting and repeat the posting after exam along with the students who had fail. But I am not the kind of person who gives up easily. I skipped 2 weeks of Opthalmology and came back into Anaesthesiology posting. Because I skipped the 2 weeks, I still have to complete the tasks in my log book, do case write ups and sit for mini-CEX. So from morning until 3 or 4 pm, I was in the operating theatre for anaesthesiology. 4 to 6 pm, I went to the Opthalmology clinic to finish my log book with the patients that are left (clinic ends at 5). I was basically doing 2 postings in one. I survived. I completed my log book, passed my mini-CEX and did my case write ups.

It didn’t came without repercussions. The full day I had distracted me from the trauma, the tinnitus and the remnant sense on imbalance. But at night, when it is silent and I am alone. The world became a dark place to live in. I am usually a reserved person when it comes to my emotional thoughts. When I am depressed, all I need is to remain silent and withdraw into my cave of silence. Have a good night sleep. This time around, silence only exaggerates the ringing in my ears. I couldn’t sleep. How can I handle this suffering? This went on for weeks. I withdrew from society; I deleted all my existence on the internet, deactivated my Facebook, and live in seclusion. I pushed everyone away, even people who were close to me. I became over-sensitive and would lash out at the slightest thing. My friends told me that I am not myself anymore.

I am very good at hiding my feelings. When I go to the clinics, I put on fake smile and lived life as usual. I survived the first few months, until I came into psychiatry posting. We were at the clinic, and I was putting on my best face, knowing it worked well. But in the psychiatry clinic, it didn’t. Psychiatrists are trained to read people’s thought through their demeanour and body language. When the clinic ended, the Psychiatrist Professor asked me to stay back. It was amazing how she sensed something was wrong with me. When I told her about everything that happened, she was not surprised. She knew I went through something traumatic. She could see it in my eyes. She even offered me for short course of medications but I refused. Then we started talking about behaviour therapy. I told her I shut out everybody and lived like an anti-social. I told her I was off the internet, and never made an effort to reply every concerned friends on Facebook. She told me it was a wrong thing to do, and at times like these, I was in need of social support from my friends the most.

I received the news after a few follow-ups at the ENT clinic that my partial hearing loss is permanent, and so is the tinnitus in my ears. Most people would be devastated to learn about this permanent damage, but the only thing that got me through is that my balance has returned. I can walk straight. I can run! The months that follow was life-changing. When I sleep, I have to turn on tinnitus masking sounds on my laptop. It helped with the tinnitus. I kept myself busy to distract me from the noise.

Tinnitus has stayed with me from that night right until this moment. It has nearly been 2 years. I now take it as an indicator. Tinnitus gets louder when I am stressed, fatigued or at times of heightened emotion. I used it to remind myself to lay back when stressed, rest when fatigue, and be patient when I am about to get angry. Tinnitus serves as a reminder for me that I survived the worst, that I can walk and run without feeling that my feet are not on the ground. Tinnitus sounds like a cricket in my ears. So when I am in the middle of a hectic day, when I feel too worn out, I take time to listen to that cricket and remind myself that it is better to be busy doing something useful rather than lying around helpless, like how I was when I was admitted.

What happened has changed me, and changed the trajectory of my life. It was as if I was given a second chance at life. I appreciate every moment, and have become much more patient with people. I take time to listen. I thought that my life is too short to be miserable. There was a possibility that I die if I keep on dismissing the fluids as a normal ear response and catch infection to my brain. I swore to do good on earth realizing that life is too short. I might not have started my charity NGO in my final year if not of what happened. Without a traumatic event, there is no motivation for me to start building a hospital for the poor as a medical student. I will still be caught up in the idea that I have to fulfil all my degrees, be a specialist and stable before embarking on a journey to save others. My tinnitus taught me to say ‘Screw that, life is short. I’m doing it now!’. My tinnitus is like a magical cricket in Disney. What’s his name again? Jimney? He’s always there to remind me things get bad. It serves me some kind of comfort knowing that he’ll be there until I lie on my deathbed.

A Journey of Self Discovery

It has almost been 2 weeks since this journey began. From Phnom Penh going 150 miles north to Siem Reap and back again, this travel has opened my eyes to the harsh reality of living in a country still haunted by a recent tragic past that drives the country into extreme poverty. It has made me realize how absurd I was presenting about health care in resource stricken countries in air-conditioned conference rooms, when actually being here among the poor, going through the sweltering heat, thinking “how can these people live like this?” is an absolutely different thing. If my years spent living in Indonesia shapes my worldview of developing countries, Cambodia confirms this viewpoint. Yesterday we visited one of the best hospitals in Phnom Penh and I was still surprised to see a patient fresh off brain surgery put into a hot, dark room crammed with other patients. Being perfectly healthy, I could not maintain being there more than 5 minutes without being drenched in sweat. I can only imagine lying helplessly in pain or gasping for air when the air is already hard to breathe in. It reminded me of a patient back in Malaysia who demanded to change bed because the air conditioning is too strong. How we are blessed with choices when here, there is no such option.

My time in Phnom Penh was purposely devoid of living in hotels in order to immerse myself into the local culture. Living with the locals has allowed me to learn a bit of their language, eat their local dishes and live their daily activities. Each day is fully taken advantage of. Cooler mornings were spent writing or reading the numerous books written about Cambodia’s tragic history under the Khmer Rouge regime. Work starts near mid-day, where we would visit our proposed hospital site, visit the school which our collaborating NGO runs, go to our meetings, or scouting for a suitable site for our health screening project scheduled in a few months time. As young doctors, there seems so much for us to do, but so little resource we have. Sometimes we feel helpless compared to the gargantuan task of building a hospital in this resource stricken area and improving the health care of the community and their economy as a whole. However I kept holding on to a humorous quote I found: “Dream big, start small, but most important of all, start!”

The late Steve Jobs once said “The only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you will know when you find it”. I believe that I have found it through this journey. I set out to discover this so called ‘Kingdom of Wonder’, but it ended up as a journey of self-discovery. My days have never been happier doing all this work that I am doing now. It is very tiring, but when you love doing something, it is as if you did not go to work at all. All I wish is that this passion and excitement would not simmer down once I have started my housemanship training. Time and again I saw my friends lose their passion in the things they love to do, the things that really creates meaning, after beaten down by the harsh life of a young doctor. Things will not always be easy, but when everything seems to fall apart, I hope I will always remind myself of the worse hardship I see during this journey. When I do, everything else will pale in comparison.

Phnom Penh, 16 May 2013 

Malaysia, Why No University City?

This article was published in The New Straits Times, April 1st 2013

A friend of mine asked me to write a chapter in a book which revolved around the topic of medical education in Malaysia and it forced me to compare the education system between Malaysia and other countries. Suddenly it dawned to me: ‘Why Malaysia does not have a University city?’ University cities are cities that are built around a University, and its environment is purely academic that the economical activities of the city depends on the existence of the University, with the students being the driving force that lights up the city into a bright garden city of knowledge. We have a few in the world, like Oxford, Cambridge, Boston, or perhaps an example much closer to us, Bandung.

I have lived in two University cities throughout my life, namely Boston and Bandung, and have been to Oxford once, and what I can say is that we have nothing like those cities in Malaysia. Take Oxford, the whole city exudes an academic atmosphere. Just stepping into the city makes you feel smarter by 10 IQ points. Unlike the Universities we have, there are no walled boundaries to the University, and nobody is going to stop you at the entrance of the city to check on your student I.D. Oxford is the city, and the city is a University. The academic environment is evident through the people walking around the city carrying books, coffee shop with tables stacked with large mind maps and a group of students discussing around it. Bookshops selling all academic textbooks you can find in the world, and your casual walk by the sidewalk won’t be complete without a student stopping you to ask things like: ‘We’re running a survey for our research, would you mind participating? There will be a surprise gift’ and gives you a wink, which makes it hard for you to reject.

Then there’s Harvard in Boston. Unlike Oxford, the use of the word Harvard and Boston are not interchangeable, but when people say Boston, Harvard is the first thing that comes to mind. The whole Harvard compound is filled with shops that are built by Harvard students, for Harvard students. The Harvard Coop is essentially a student cooperative, like the student Co-Op we have here that sell stationeries, exercise books and food, except that instead of selling stationeries, exercise books and food, they sell everything and operate like a shopping mall. I had to spend half a day at the books section marveling at the wide range of books from academic textbooks to biographies to fiction that they have. The Universities also acts as a catalyst for NGOs, social and even political movements. For example, 'Partners in Health' which now operates in more than 20 developing countries across the world to cure infectious diseases was founded by Dr Paul Farmer when he was a Harvard medical student. The NGO is based in Boston and is largely fueled by Harvard student volunteers. Boston is also the birth place of ‘Health Leads’ which was founded by Harvard student Rebecca Onie, which now operates in 5 cities around United States to provide healthcare beyond the hospital walls. The organization is also largely student-driven, with volunteers from Harvard and Boston University. When the population of a city are largely made up of intellectuals, the people are open to new ideas and foreign culture. I still remember my years in Boston where we went from house to house in a large group for Marhaban during Eid and the people on the streets would greet us with ‘Happy Eid!’ and smiled and waved at us as we were crossing the road. In exchange, when their children went from house to house for trick or treats during Halloween, we gave them candies. There is acceptance of religion and culture because among intellectuals, the level of understanding is very high. We never get shallow debates about why my religion or culture is better than yours. What we get is volunteer services organized together by mosques, churches and synagogues that serves the same purpose of providing for the poor living in the city.

In University cities, learning happens all the time, inside or outside the classroom. I remembered one of the students in Harvard telling me that he’s having dinner with his study group and his Professor at a nearby restaurant before having their extra class at night. Then at one time I realize that many waiters and people behind the cashiers are part time workers and are actually university students. The girl behind the cashier reading the Constitution of the United States of America’? She’s actually a Harvard law student making ends meet by working as a part time cashier. Because the shops in University cities are catered for students, their working hours are very flexible and tailored towards their class schedules. It seems that the whole city is a communion between the university and the community.

University cities are not only achievable in developed nations. Even Bandung in Indonesia developed because of the existence of Padjajaran University, which is virtually embedded into the city. Ask anyone who has been to Bandung and they would say ‘Padjajaran University’ sounds familiar, or at least the black-yellow crest which became the logo and identity of Padjajaran University looks familiar. The university and the city depends on each other. We have faculty buildings scattered around the city, in between shopping malls and housing areas. When I was studying in Bandung, I was hanging out in a shopping mall and I met my Indonesian friend, asking her if she is out shopping, watching a movie or anything. She answered, oh no, she just went to the ‘free speech’ corner near the mall where crowds gather to hear some political science students talk about democracy. Do you ever get that in Malaysia? When the whole city is driven by the force of knowledge, smart things happen and we do not get too many stupid things happening. It also encourages students from different faculties to gather and communicate with each other. When there is more interaction between students of different fields, the spirit of interprofessional learning is very much alive. The openness of one faculty towards another allows me as a medical student to join an event organized by the Political Science faculty which finally ends up by finding myself one day inside the United Nations building in New York. Amazing things happen when we venture into other fields that seems foreign to us.

In Malaysia, we have UKM in Bangi. But Bangi is not a University city. Outside the UKM compound, Bangi is just another city. No bookshops founded by students. No study groups taking place at cafés in shopping malls. No ‘free speech’ corner set up where crowds of people gather such as shopping malls. If UKM is wiped off Bangi, Bangi would still be Bangi. The students do not play a large role in the survival of the city. Same goes to Gombak which houses UIA. Gombak has always been Gombak even before UIA came, and people would relate Gombak more to the indigenous people living in Batu 12 than UIA. How about Tronoh which has UTP? Outside the UTP compound, Tronoh is basically a dead town. I do not like to write ideal things without coming up with a solution idea. So recently, almost all the major universities in Malaysia are given autonomy by the government, which essentially means they can do whatever they want to that is best for the university. Perhaps prior to being given autonomy, Universities are not given the independence to expand and assimilate university entities into the city, like turning the Co-op into a shopping mall, starting a business for students, allowing businesses to operate inside university compounds. This might sound like a foreign idea, but imagine a pharmaceutical company building its facilities inside the university compound, with open collaboration with the university. They would have all the financial resources as a business, and all the intellectual knowledge from the university. Students from the business faculty can learn about business there, and students of medicine, biomedical science and pharmacy can learn the latest advancements in medical drugs and research, thanks to the financial strength of a private company.

All this while we thought that universities are able to generate income through researches and patents. However, this proves to take a lot of time, a lot of trial and error, and the risks are too high. Many researches in the end do not generate income for the University. I know that money making should not be a priority for a University, but nowadays, for a research centre to flourish, they need to have a lot of financial support. Universities can no longer depend on the government for financial support. My suggestion is, other than developing cities for investors like the one we are going to have in Nusa Jaya, Johor, how about investing in University cities?. Develop Bangi, develop Gombak, develop Tronoh into a University city. The results wouldn’t be seen immediately, but it will in the long run. Do you know what Facebook, Microsoft and Apple have in common? They are all founded in university cities, by university dropouts. Because in a university city, dropping out of a university does not mean being expelled from the city. That is where their learning continues, and they continue to have the support of fellow intellectual friends that together spark off a digital revolution. University cities are a catalyst for greater things to happen. It is like a place where great mind gathers to make the world a better place. We should look at Universities not as a mechanical structure where lessons are taught but a ground for sparking change and revolutions driven by knowledge. Perhaps someday Malaysia will have its own University city. I am not a person in the position to make things as big as this happen, but if it happens someday, I am glad that someone up there in the social hierarchy finally echo my thoughts.  

Dreaming Big but Starting Small

So last month fellow HBBers were in Publika, Solaris Dutamas for inaugural Hope Awards. The event is actually a closing ceremony for the Youth Business Social Summit 2012, where awards are given to the best youth-led NGOs in Malaysia. The summit was officiated by someone who earns my upmost respect for receiving a Nobel Prize in Economics: Muhammad Yunus, the founder of Grameen Bank in Bangladesh. I had just read his book ‘A World Without Poverty’ and it gave me a lot of insights and ideas that could be applied to HBB. Anyway, several categories were contested that night and we were very lucky to be nominated for best NGO advocating civic actions and human rights, especially realizing ourselves as a very new NGO.

So the results came out, and turns out that we did not win. Being such a new organization, it was quite expected. However, we were disappointed nonetheless for missing the chance to win the award and RM8000 in cold hard cash that could really jump-start our organization. Disappointed, so we went looking for a nearby café where we can let off some steam. It was around 11 PM and most of the cafés are closed. We walked a bit far from the venue until we saw a café still lit open, even with Christmas lights on a Christmas tree still blinking (it was near Christmas at that time). As we got closer, we realized that some of the chairs had already been stacked together, signalling that it is almost time to close. We were about to pass by when a waiter said hello and invited us in. ‘Are you still open?’ I asked.

I had to do a 3 minutes 'elevator pitch' to promote the cause of our HBB. 3 minutes only!

The program booklet for the event

The café was called Coffee Societé, and it was only after we sat in that I realized I have read about this café before in Foursquare community. It has some good reviews and was rated quite well. Being a coffee connoisseur, I am excited to taste their well talked about coffee. It was said that even the Sultan of Kelantan came here for coffee and the Airasia CEO Tony Fernandes regularly come for his caffeine kicks. Then as we were about to order, bad news came in. Since it was already late, the espresso machine has been cleaned up with chemicals, so coffee is not available at that time. ‘What?!’ I thought. Already felt down by the results of the awards, I could not bare any more frustrations and went on to order hot chocolate, the closest I have to coffee.

The coffee bar decorated for Christmas that was coming

Then came in a young man from the back asking us ‘How was the drink?’. We told him that we actually wanted to taste their coffee. Then we went on to tell him that we’re from HBB and why we were there in Publika that night. We also told him about our project in Cambodia and our future plans. He was so excited to hear about us that he offered to reopen the coffee bar and serve us coffee! Although the espresso machine has been cleaned up with chemicals, he was willing to spoil it and clean it all over again just to serve us coffee. We were so happy, ordered the coffee purportedly to be the best in town, and went on to tell him about our exciting projects.

Coffee Societé's nice interiors

At last we had our coffee served with beautiful latté art!

Turns out the young man was actually the owner of the coffee shop. He tells us about his experience of having heart failure when he was young (we guessed it was a rheumatic heart disease) and had to stay in the hospital for weeks and there were moments where the doctor thought he might not survive. It reminds me of my own experience of being warded for 2 weeks and almost having to suffer vertigo for the rest of my life. Interesting is, we both made a promise to God that we would do something significant towards humanity if we went out of this hospital healthy. Different faith (he’s a Buddhist), but same promise. After a few doses of caffeine, our spirits were uplifted sky high. We thought about what will be of HBB in 10 years? So I put out a tissue paper, and wrote our ultimate target for HBB in 10 years. Here’s how it goes:

Our ultimate vision

The great thing about starting young is that there’s no telling where we’ll go in 10-20 years. We may not win an award that night, and although it was never our intention to win awards when starting this NGO, but who knows what award we’ll win in a few decades. A Nobel wouldn’t be too far-fetched when time is on your side, isn’t it? I think it is absolutely fine to have manic flight of ideas (especially after a few shots of caffeine), as long as we keep it within logical means and break it down into small, manageable steps. The rule is simple. If you want to go fast, you can go alone. But if you want to go far, go together. HBB is not about going somewhere fast. It is about going far to help those in need and connect with people who has the same purpose as ours. We think big, but we start small. In the end, all we want to do is answer life’s most persistent and urgent question: ‘What are we doing for others?’