The Awkward Pose

Cambodia Today – A Generation After the Killing Fields

Posted on 02/17/2014 by paulefallon

Thirty-five years ago, Vietnamese marched into Phnom Penh, liberating Cambodia from the Khmer Rouge, who’d ostensibly liberated the same people a mere four years before. The Khmer Rouge’s short but devastating regime capitalized on the Cambodian people’s reverence for nation and authority; the same attributes that ancient kings harnessed to erect the mammoth temples at Angkor. Thirty-five years is a useful timespan to consider how Cambodian society continues to subsume individual identity and whether it can prevent future killing fields.

I recently visited a rural home near Pursat where my daughter Abby lives with an extended family while serving in the Peace Corps. Two parents, two children, and seven boarders share five rooms, outdoor cooking and sanitation facilities. All are industrious, earnest, and quiet. They maneuver through well-established routines and eat mostly in silence, tolerating my visitor’s banter but dismissing personal or political questions with nervous laughter.

Abby’s Cambodian mother and father survived the Khmer Rouge and a Thai refugee camp. They returned to their home village in 1991. Now, they rarely leave. Nor do they speak of that time. Instead, they speak of order and authority. They do not bemoan Cambodia’s ongoing struggles or question why this beautiful, fertile land is still one of the poorest on earth. These survivors appreciate the peace of Hun Sen’s reign and seek nothing beyond their simple plot.

Abby’s Cambodian brother is a 25 year-old high school physics teacher who sleeps in the same room as his parents. He owns a moto but little else. He uttered no words during my visit. He never countered his parents. Yet he occasionally flashed eyes at me while his parents spoke, intimating that not all values of the father are automatically transferred to the son.

Cambodia’s history centers around two seminal periods. Ancient Angkor dominated Southeast Asia for over four centuries circa 900 to 1300 AD, while the Khmer Rouge’s bloodshed occurred within four years of enforced isolation during the 1970’s. Before and after, Cambodia’s enjoyed brief periods of independence, but foreign influence or occupation by France, Thailand, Vietnam, and others, has been the norm.

Twelfth century Angkor Wat supported over a million people; it was the largest city in the world. While Europeans built gothic cathedrals taller, wider, and more delicate, Cambodian serfs dug ever larger moats and sculpted endless stone relief. Over four hundred years, Angkor’s techniques of construction and sculpture never changed; they just got bigger. Cambodian craftsmen replicated what they knew rather than stretch their capabilities.

Over the next seven centuries Europe experienced enlightenment, revolution, colonization, massive war, and finally social democratic states while Cambodia continued to be a subsistence society whose abundant rice enriched extortionist rulers. The French hailed Cambodians as the most obedient people in Southeast Asia, and rewarded their exemplary behavior with the highest taxes in their colonial domain.

Little wonder that beleaguered citizens embraced the Khmer Rouge’s promise of a native Cambodian state. They couldn’t foresee Khmer Rouge’s radical transformations: abolishing private property, money, religion, and family. Still, they abandoned their cities and lives on nothing more than a revolutionary order to obey. The most baffling image at the Tuol Sleng Prison Museum is a photograph of fleeing émigrés. Remarkable for what’s missing. The Cambodians carry few belongings. No armed soldier pushes the crowd. They march into the unknown without resistance.

In less than four years, the Khmer Rouge killed more than a million Cambodians, as if by eliminating a population equal to Angkor’s glory, the regime could erase history itself.

Which in some ways it has. Khmer Rouge atrocities are so grotesque they cannot be discussed. For the older generation, the pain is too great. The younger generation is unaware because Khmer Rouge is barely taught in school. It doesn’t fit into any narrative of Cambodia’s Angkor glory or its fundamental values of family, ancestors, and Buddhism.

Left to its own devices Cambodia might choose to forget the Khmer Rouge, and thereby risk repeating it. But one unanticipated consequence of the killing fields is the international attention Cambodia’s attracted since the atrocities were revealed. Thirty-five years after the fall, there are simply too many NGO’s, Lexus, Camry’s, and foreigners like Abby, for the country to ever be corralled by such an insular vision again.

Today’s older generation deserves to live out life in quiet peace. But the new generation has lively eyes. They honor parents and tradition, but also Google and pizza. Their challenge is to preserve Cambodia’s gentle nature without succumbing to submission.

Abby’s Cambodian Father with the house of his ancestors

Abby and her Cambodian mother at the village market

A formal portrait outside the village Pagoda

Posted in Cambodia | Tagged Angkor Wat, Cambodia, Khmer Rouge, Killing Fields, Peace Corps, Pursat | 1 Comment

Personal Hygiene Tips from the Developing World

Posted on 02/13/2014 by paulefallon

One thing American’s dislike about traveling to developing countries is dealing with other, presumably lesser, standards of hygiene. After two weeks in Cambodia I not only got used to how this poor country deals with bodily functions, I came to believe that in many ways, their habits are superior to ours.

Toilets. There are two kinds of toilets in Cambodia: ones that look like ours, and ones that look like an upside down rabbit face, otherwise known as squat toilets. Toilets that resemble ours are easy, we sit on them just like we do back home, do our business, and hear a satisfying swoosh when our waste slides into the water.

Squat toilets are less obvious. A ceramic rectangle sits flush with the floor. It has a single round hole and a pair of ovals defined by a raised ceramic bump. We turn to face away from the wall and put our feet into the ovals that resemble the rabbit ears. Then we squat and deposit our stuff in the void. It’s a bit unnerving because you’re not sure how much flight your projectiles are going to enjoy. Sometimes you hear them land with a definite thud and try not to picture what they landed on. Other times they descend without a sound, in free fall forever. As I child in New Jersey I imagined things falling deep into the earth sprouting up in China, but in Cambodia, I envision myself fertilizing a Florida orange grove.

The biggest challenge with the squat toilets is what to do with the clothes that dropped from your waist. A conventional toilet bowl keeps them out of the way, but when you’re squatting, your clothes can drift back and catch, well, stuff that smells and stains. It’s ridiculous to take your pants and underwear off, there’s never anything so useful as a hook in a Cambodia toilet stall, if you’re lucky enough to even be in a stall. Instead I developed a new yoga pose. Drop to a full squat, then place you hands between your thighs, grab the back of your belt and pull your clothes forward. It’s actually a cool balance, but I don’t recommend showing it off in public.

So far nothing I’ve described seems superior to the way we go to the bathroom in the good old U.S. of A. The improved sanitation occurs after release, when our custom is to grab a wad of thin paper and smear telltale remains all over ourselves. Without the luxury of toilet paper, Cambodian toilets come equipped with a small spray hose that you aim and shoot. Instead of rubbing it in, you wash it out. Think about it; it’s a much better way to go. The first few times I did this I worried about wetting my clothes, since no one that can actually see where they’re spraying except maybe a contortionist from Cirque du Soleil. But the spray hoses are accurate and reliable and humans have a sixth sense for strategic body parts. After a few successful hosings, I realized how much cleaner I felt after a spray than after a wipe.

One word of caution. You can’t spray and go. You must linger in your squat for a few moments to let things dry out. Otherwise you might make a telltale squeak as you walk away.

Once finished, and dry, you stand up straight, rebuckle your pants, and realize another nice thing about taking a dump in Cambodia. Your hands remain relatively clean; they never get up inside of yourself. However, it’s still a good idea to wash them, and here again Cambodia has figured it out better than us.

Sinks. The American standard is to use the toilet, leave the stall, wash our hands in a sink that has either a reliable faucet or demonic sensor control, dry our hands, and then open the door to exit the public bathroom. What’s wrong with this picture, as anyone who’s ever witnessed the pile of paper towels right next to a public bathroom door can attest, is that we wash our hands and then immediately touch a door that thousands of others touch.

I never saw a public bathroom in Cambodia with a sink in it. The sinks are outside the rooms. You do your business, fix your pants, open the stall door and the main door, and there’s a sink, maybe even a vanity and a mirror, in an alcove. Once you’ve washed your hands, there is nothing more to touch.

There are so many things to love about Cambodia. The country is beautiful, the food delicious, the prices cheap, the people delightful. They love Americans. But I also applaud their sanitation habits. They may be unusual, but they’re hygienic.

Cambodia also has cool restroom signs

Posted in Personal | Tagged Cambodia, personal hygiene, squat toilets, toilets | 2 Comments

Same Same But Different

Posted on 02/10/2014 by paulefallon

I recently visited Cambodia and received foreign travel’s twin satisfactions: a deeper appreciation for others and a sharpened perspective on my own country’s strengths and flaws. I also snagged this souvenir T-shirt whose cryptic puzzle leaves me wondering how we are actually the same and how we are different.

Cambodia is littered with people wearing the same T-shirt. Locals wear it; ex-pats wear it; children and adults wear it. White block letters spell out SAME SAME on the front, BUT DIFFERENT on the back. My daughter Abby, a Peace Corps volunteer, says its based on a Khmer phrase. The SAME SAME part makes sense, Cambodia’s one of the most ethnically homogenous counties on earth. BUT DIFFERENT upends my perceptions of a place where people look so similar and are famously compliant.

The physical stuff – what people see – is easy to categorize. We’re all mammals, all humans, but we come in different heights and widths, ages and genders. Like snowflakes, people are easy to identify though no two look alike.

It’s our ethnic and cultural affiliations – how people see themselves – that are more challenging.

The Harvard Institute of Economic Research created a cool map that illustrates the homogenous / heterogeneous range of every country on earth. The researchers didn’t ask people to describe others; they asked people to describe themselves. The closer someone’s answer matched their neighbor, the more homogenous the community. Disparate responses within the same country indicated heterogeneity.

According to this map, Japan is the most homogenous nation on earth; the countries in Central Africa, where tribal identities still run strong, are the most heterogeneous. Cambodia is high on the homogenous scale, a poor nation with a long history of racial and cultural continuity but few immigrants. SAME SAME. The United States is dead center in the homogeneous / heterogeneous spectrum. That may seem odd, since we come from all over the world and look so different. Yet Americans are not as diverse as we look because ethnicity is a social construct based on perceptions rather than physical traits. Although U.S. residents look more different than people from many countries, the more we identify ourselves simply as American, the less our skin color, food preferences, or grandparents’ country of origin define our ethnicity. Our SAME SAME is that we’re American. (Although I wish we could find another term to describe us, since most people from the Americas do not live in the United States).

BUT DIFFERENT seems self-evident; the polyglot of cultures that intersect in the United States is unmatched. Yet, diversity doesn’t differentiate Americans so much as it defines us. The United States is not roast beef or empanadas or rice or chocolate, it’s roast beef and empanadas and rice and chocolate. One reason the rest of the world emulates us is that everyone can find something to like – and dislike – about the U.S. Our cornucopia of identities feeds our penchant to label everyone. We’re not only black or white, rich or poor, young or old, gay or straight; we’re Afro-American or Irish-American, 1 percent or 99 percent, Gen X or Greatest Generation, queer or metrosexual. We carve ourselves into unique identities. I find it exhausting.

Such fractional labels are less common in Cambodia. I’m sure the same range of traits exists, and provides gossip fodder among the garment-working majority. But fixating on labels that divide is a pastime for the affluent. Poor people must rely on each other, and are less inclined to fuel the friction of accentuating differences.

My T-shirt with its lettering on front and back, has taken on two different meanings for me. In the Eastern hemisphere SAME SAME proclaims Cambodia’s cultural glue; BUT DIFFERENT acknowledges human variation and accepts it with a shrug. In the West, SAME SAME acknowledges genetic similarities; BUT DIFFERENT proclaims each person’s self-definition.

Posted in Cambodia | 1 Comment

Yoga Cross-training

Posted on 02/06/2014 by paulefallon

I attended twelve yoga classes last week. Excessive? You bet. But I found benefit in every one.

Since I stopped doing Bikram last September I’ve expanded into doing a variety of yoga styles. My home base these days is CorePower Yoga. CorePower offers four different kinds of classes. C1 Fundamentals is a 60-minute class at 85 degrees with a set sequence of postures that cover yoga basics including flow, balances, inversions, and core strengthening. C2 Power follows the same guidelines at 95 degrees but includes a greater variety of poses since each teacher choreographs his own class. Sculpt is yoga-influenced aerobics; the class includes cardio, squats, bicep, and core work with light weights. Hot Fusion is modified Bikram; the 26 Bikram poses in a 104 degree room, held for shorter periods with some flow in between. Last week I went to 4 C2, 3 Sculpt, 2 Hot Fusion, and 1 C1 class.

I also attended two yoga sessions with Santosh Karmacharya, the Nepalese owner of Om Namo, an alternative medicine and bodywork center that offers therapeutic yoga. Santosh teaches a distinctly different approach to yoga. He doesn’t focus on building strength, as Sculpt does; or balance, as C2 does; or flexibility, as Hot Fusion does. Santosh’s approach emphasizes postures that use an array of muscles at equal intensity. He arranges students around the perimeter of the room with our mats perpendicular to the wall, and then uses the wall as a support for many positions. During 75 minutes I never stress any particular area, yet when class is over I feel every part of me massaged and enhanced.

It’s been six months since I moved from monolithic yoga (Bikram every day) to a cross-training approach. I don’t experience the same benefits I did from Bikram; I don’t feel as light, I’ve lost my body temperature sensitivity, I catch colds (never sick a day in four years of Bikram), and I rarely have those intense mind/body/consciousness moments that Bikram’s intensity fosters. However, I feel better rounded and I enjoy the process of yoga rather than simply it’s end product. After more than a thousand classes, Bikram was simply too hot, too repetitive, and too grueling. The mental stamina that got me into the hot room has evaporated. I used to feel great after yoga, now I feel great doing yoga.

I also love the variety, and having fewer expectations for each class. I woke stiff this morning, after shoveling out ten inches of snow yesterday. My C2 class was rich in plank/chaturanga/upward dog/downward dog flows that helped firm compress, and expand my spine. It was the perfect way to counter the hundreds of pounds of snow I hauled. Tomorrow perhaps I’ll want to work with weights or build a heavy sweat. When you do as much yoga as I do, it’s good to have options.

Santosh Karmacharya

Posted in Yoga | Tagged Bikram, Bikram yoga, CorePower, COrePowr Yoga, Om Namo, Santosh Karmacharya | Leave a comment

Columbia Maryland: Violence in Suburban Utopia

Posted on 02/03/2014 by paulefallon

Last weeks shooting in Columbia, MD struck a deeper chord in me than other recent public carnage. We will never know why Darius Marcus Aguilar chose to open fire at the Mall in Columbia over any of the other enclosed shopping mall in our country, but in defiling Columbia he trampled on a place that defined our nations aspirations nearly fifty years ago.

I was twelve in 1967 when real estate developer James Rouse unveiled his new planned community of Columbia, MD. Mr. Rouse developed shopping centers in the 1950’s and conceived the planned community of Columbia before becoming best known as the visionary who created Boston’s Faneuil Hall Marketplace as well as festival markets in other major cities in the 1970’s. Mr. Rouse’s goal for Columbia – 100,000 diverse people living, working, and playing in a coherent community – incorporated 1960s era notions of equality in a suburban ideal.

Columbia, MD covers over 22 square miles. The original plan includes ten walkable villages, a city center, and peripheral industrial. As a young architect-to-be, such grand gestures stirred my soul. However, Columbia’s innovative way of living extended beyond physical planning. Columbia espoused racial balance, religious diversity and economic integration. Social scientists rubbed shoulders with designers and financiers, promoting such novel concepts at the Columbia Medical Plan, an early HMO.

Mr. Rouse and his partners proved expert at creating profitable yet socially sensitive ventures. Dozens of articles were written about Columbia; a city that spoke to America’s noblest aspirations while bolstering the inherent consumerism of suburban living.

The United States has a long history of planned communities. Colonial visionaries created Philadelphia, Charlestown and Savannah. Nineteenth century surveyors’ gridded Manhattan and Boston’s Back Bay. In the twentieth century, planned communities became less dense. Garden cities of the 20s and 30s with housing, recreation, industry and commerce, like Radburn NJ and Greenbelt MD, gave over to more suburban models like Columbia and Reston VA. In almost every case, these communities evolved in a similar way. The housing was desirable, property values rose, the population skewed upper-middle class, and the proposed industry never materialized

Columbia adheres to this trend. Today, it has almost 100,000 residents. The median income is over $43,000 per person and the median house costs more than $350,000. More than 60% of Columbia’s residents over 25 have college degrees, and more than 90% of the workforce is white-collar professional. Columbia does not represent America’s economic reality. However, the city is a good reflection of our racial diversity. Columbia is 52% white, 25% black, with a remaining Hispanic, Asian, and mixed-race population that closely the mirrors the nation as a whole.

There is no industry to speak of, the GE appliance plant closed in 1990. Instead, Columbia has office parks and many people commute to Baltimore or Washington, DC. Columbia has benefited from forty years of growth in government jobs. Ultimately, Columbia’s just another upscale suburb. Still, the city offers a quality of life that many people value; Money Magazine frequently names Columbia as a top ten place to live.

Darius Marcus Aguilar killed two people, then himself, and traumatized hundreds more. He also opened fire on the aspirations that defined my youth. Although Columbia ultimately fell short of expectations, it espoused our dual objectives of equality and the 1/3-acre house lot. We believed that the path to racial and economic balance required a mix of private initiative and public support, and we were blessed with so much it seemed we could find a way to share it among all.

That time is past. Those aspirations were extinguished by fear and greed before Darius ever pulled his trigger. His tragic actions simply call to attention the chasm between where we are and what might have been.

The People Tree at Columbia, MD

Posted in United States | Tagged Columbia MD, Darius Marcus Aguilar, Greenblet MD, James Rouse, planned cities, Radburn NJ, Reston VA | 1 Comment

Since They Lost Sammy – New York Times 1/26/2014

Posted on 01/27/2014 by paulefallon

Yesterday’s New York Times has a long and moving article about a Brooklyn family whose twelve-year-old son Sammy was killed by a truck on the street in front of their house. Since They Lost Sammy The article touches on their grief, but focuses on how the tragedy galvanized Amy Cohen and Gary Eckstein to become activists for increased pedestrian safety.

The article resonated with me because I know something about families who turn tragedy into a greater good. I spent two years in Len Gengel’s shadow, watching him twist his grief into something remarkable, the Be Like Brit orphanage in Haiti. I also observed, with pain, how Len recriminated himself for his daughter dying in the Haiti earthquake. Britney’s death was an arbitrary accident, but affluent Americans, accustomed to controlling our lives, cannot accept arbitrary or accident with any grace.

My heart went out to the Cohen/Eckstein family and I applaud how they are directing their grief for public good. But I am disappointed by how the New York Times presents a grieving parent’s feelings as fact.

By all evidence Sammy was a great kid, bright and engaging. Since the family has become public advocates, they have exposed themselves to public scrutiny, as I am doing in this post. Mid-way through the article Ms. Cohen counters, “There was the suggestion that it was just some stupid kid who ran into the street for his ball.” New York Times writer N.B. Kleinfield follows with, They knew that was impossible.

This is where the New York Times slips in its reporting. Ms. Cohen and Mr. Eckstein certainly believe this was impossible; it may have been improbable, but it is wrong of the Times to report this impossibility as fact. None of us were there. A twelve year old, no matter how mature, is still a twelve year old, and accidents happen.

The disservice the New York Times brings to this family and everyone reading this article is to present a family’s belief, no matter how strongly felt or how much they need it to justify getting up every morning, as a fact. I have no doubt Ms. Cohen and Mr. Eckstein’s belief in their son is steadfast as a fact. My own mind has conjured and bent ambiguities to help me sleep through the night. But the article’s author should know better.

I hope that Ms. Cohen and Mr. Eckstein find solace in their advocacy work. I hope it helps reduce the number of pedestrian and bicycle fatalities in New York and elsewhere. I also hope that the New York Times will be more careful in their word choice; not every ‘fact’ we carry in our heads is objectively true or verifiable. Finally, I hope that the family realizes that whatever caused the horrible intersection between Sammy and that truck was a terrible accident, and accidents, by definition, cannot be fully explained. Why this happened to your son and not mine I do not know. Sometimes we just have to accept.

Posted in Personal | Tagged Amy Cohen, Be Like Brit, Gary Eckstein, Len Gengel, N.B.Kleinfield, New York Times, NY Times, pedestrian safety | 3 Comments

January: MIddlesex County vs. August: Osage County

Posted on 01/20/2014 by paulefallon

I send an email to my housemate: Got a lot done today, want to go to a movie?

We do that sometimes; send emails when we’re too lazy to walk the stairs. I hate yelling between rooms.

Sure, what do you want to see?

I do a search, gave him four preferences in descending order: 12 Years a Slave, Dallas Buyer’s Club, American Hustle, August: Osage County.

I really only have three preferences; I don’t want to see Osage County. I’m from Oklahoma; I’ve been to Osage County, and Meryl Streep is a bit too perfect for me. But Paul loves Meryl Streep and we’d just had a fight, so I offer her as a peace offering. Being housemates is not really an intimate relationship, but six years under the same roof generates enough friction that we’ve figured out how to hurt each other.

Paul replies in under a minute. My top choice is August: Osage County.

You need to get into big screen action movies, buddy, with slaves, gay addicts, and pimps instead of screaming women, but for you I will suffer screaming women.

I’m accommodating, if not solicitous. Paul would pay good money to sit in a theater and watch Meryl Streep gaze into a fish bowl.

As usual, Paul proves more solicitous than me and agrees to 12 Years a Slave. Now I am in his debt.

The traffic to Arlington is gruesome but we’re retired folk who left home with plenty of time. The Arlington Diner is closed; our preferred dive has become a breakfast and lunch only place. We check out eateries as we walk toward the theater.

This looks good. Paul nods towards Comella’s, a hyped up red sauce place with counter service and mom’s unzipping children in puff parkas. I hate Italian food, and restaurants teeming with kids, but I won on the movie, so I demur.

Comella’s is, I don’t know, confusing. You get food at the counter but they have to deliver your beer. They key the bathroom. The staff tells me its occupied when it’s actually empty. I spend eight minutes squirming outside a locked door. You want knives and folks? Make a separate trip to the counter. Paul is gentlemanly, as always. This place could use some process improvement. My empty bladder’s content that the food’s not half bad, though overpriced.

Dinner doesn’t take long. Fine dining is a challenge when three-foot high creatures with sniffles and pizza slices hang onto your chair. I’m relieved to exit, to walk over to the theater to watch a slave.

There’s only one ticket left for the 7:10 showing. I stare at the ticket boy in disbelief. Doesn’t he know that, by definition, when I finally get around to seeing a movie it’s long past sold out? I sigh, fall away from the line, look at Paul, check my iPhone clock, and admit defeat. We still have half an hour to drive to East Cambridge and visit Osage County.

Now we hustle. We pass the busses on Mass Ave. We veer through the shortcut at Porter Square. I drop Paul in front of the Kendall with five minutes to spare. He goes to buy tickets. I park the car. When I return he’s standing in the lobby with two stubs and a bottle of water. Water! How about popcorn, or Milk Duds, something satisfying on this loser evening.

But there’s no more time for concessions. We find our seats. I visit the bathroom, which thankfully, isn’t locked. By the time I return, Sam Shepard is already hiring the Indian maid who will provide the emotional baseline from which to gauge the utter insanity of the white folks of Osage County.

I settle in. The panoramas of the plains are magnificent. Some of the dialogue makes me wince; some makes me tear. Who allowed Tracy Letts to eavesdrop on my family? He quotes my mother, god rest her soul, verbatim. She at least deserves a screenwriting credit.

As the film escalates, and people start yelling between rooms, I give myself over to the shock of the familiar. I hate them all, and love them too. My heart aches for Chris Cooper. I wish I understood Ewen MacGregor better. Julia Roberts is awesome; its good to see that huge mouth being put to such trashy use. I love the movie, maybe more than I would have been preserving twelve years of slavery.

The movie ends. Paul and I sit beside each other in silence. The credits roll. We measure our own chequered lives against the tortured souls of Osage County, just as people do everywhere after films that present a sharp mirror.

Of course, Meryl Streep is perfect. You don’t need to see the movie to know that.

Posted in Personal | Tagged Arlington DIner, August: Osage County, Chris Cooper, Comella's, Ewen MacGregor, Julia Roberts, Kendall Square Theater, Meryl Streep, Oklahoma, Tracy Letts | Leave a comment

Why its so hard to go back to sleep at 4 a.m.

Posted on 01/18/2014 by paulefallon

Once, when we were dating, you walked across your bedroom floor and I realized I’d love you forever.

You said our baggage didn’t match. You’d been singed. You had your dog. You would stay put.

Then you met someone who stirred your ashes, moved to New York and discovered you like heights.

I remain here, cherishing your stride.

Posted in Personal | Tagged dating, New York, poem, poetry, sleeplessness | Leave a comment

Remember Haiti

Posted on 01/12/2014 by paulefallon

Today is the fourth anniversary of the Haiti earthquake. 250,000 people died. Aid flooded in, some seeped out. The disaster has been eclipsed by Oklahoma tornadoes and Philippine typhoons and New York City hurricanes. Most Haitians have reestablished a daily pattern to their life, although that pattern was forever changed by the quake. Reconstruction continues, too little, too slow, but there is progress.

Yesterday’s New York Times editorial sums up the (lack of) progress Haiti-Unfinished and Forsaken. As usual, the article may be true, but it is only a partial truth. Haiti is a mess. But continuing to apply first world bandages to this developing countries problems will never address Haiti’s challenges or provide first world bean counters the data they crave to proclaim success. I am not surprised that a proposed industrial park to create 60,000 jobs has created only a few thousand. Anyone who ever thought 60,000 Haitians would march into factories and punch time clocks to produce goods for export doesn’t understand what motivates these proud, insular people.

I do not have the solution for how to best help Haiti, how to balance giving its citizens fish when they are starving while simultaneously teaching them to fish. I don’t know how to end the cycle of aid dependency that has ballooned since the post-earthquake foreign aid boom. But I do know the successful answer is not going to look anything like an industrial plant with 60,000 jobs. It is going to be local, decentralized, and respect that, although Haitians want a better life, they will not accept one dictated by first world interests. Haiti doesn’t want to be the United States, or Brazil, or even Rwanda. It wants better health and education and nutrition and housing. But even more importantly, it wants to be Haiti, accepted as an independent nation, warts and all, and not some poor stepchild of larger powers.

Please remember Haiti today, and tomorrow, and the next day. But please consider that the most effective way to remember Haiti, whether through donating money, time, or (even better) buying local products, is not to change Haiti. Our objective should be to enable Haiti to come more fully into its own.

My buddies in Grand Goave

Posted in Haiti | Tagged earthquake, Haiti, New York Times | 1 Comment

The End of the Annual Physical

Posted on 01/12/2014 by paulefallon

I am honored to be a contributor to WBUR Congnoscenti, WBUR’s online magazine of commentary. My first article, The End of the Annual Physical as We Know It was published 12/27/2013. Here’s the text:

Every day, newspapers, television, and social media dissect the potential and shortcomings of the Affordable Care Act (ACA). Will we lose our existing insurance? Will we gain greater access to care? Will the websites ever unsnarl? Gnashing over the mechanics of reform masks a deeper fear: that our idealized view of individual healthcare, rooted in trusted relationships, will be forever lost to a maze of impersonal transactions. We pine for Marcus Welby, M.D., that caring soul who knows us well and champions our interests, every time we’re forced to reveal personal intimacies to nameless providers prompted by their computer screen.

Last week I had my annual physical. My doctor of over 20 years thumped my chest, probed my prostate and listened to my heartbeat. More importantly he listened to my questions, asked about my work, my mental health, and my children. I described pinpoint headaches I’d noticed at my right temple. He ordered a blood test to check for a pressure block.

Despite the ACA’s stated aim to provide greater access to primary care, my annual physician check-up will probably not survive healthcare reform.

First, there are not enough primary care doctors to go around. Although the ACA promises to provide regular medical care to 15 million more Americans, we lack primary care physicians to treat them. The American Academy of Family Physicians predicts we will need over 50,000 more primary care physicians by 2025 to address the trifecta of population growth, aging population, and the newly insured. Yet, medical schools continue to emphasize specialty care. There are nearly 30,000 first year residency positions in the United States, but less than 3,000 in family practice and of those, the Student Doctor Network reports that only 40 percent will ultimately practice primary care.

This shortage of doctors leads to relying on nurse practitioners and physician assistants to fill out healthcare teams. Unfortunately, calling them ‘mid-level providers’ conveys to patients their second tier status and dilutes primary relationships. If I can’t see my doctor until I’ve climbed through the caregiver ranks, I won’t see him until I’m already sick.

Second, The Agency for Healthcare Research and Quality (AHRQ) has decided my annual physical is a waste of medical resources. The $7 billion America spends on 64 million annual physicals is not cost-effective. The study is probably correct: my annual physicals never turn up much of anything. But the study also ignores the most important aspect of the annual ritual: reinforcing my relationship with my doctor.

The true value of our 20 minutes together is greater than what my doctor diagnoses and treats. Our visits inform whatever issues lay ahead. Because our face-to-face connection is strong, I’m more comfortable relying on our web portal when I’m ill. Twenty years of mutual trust means that I accept his specialty recommendations at face value and don’t seek second opinions. Since my doctor knows me in health, he can serve me better in disease.

To be sure, electronic communications are more efficient than office visits. But as anyone who’s ever spiraled down a series of email miscommunications can attest, the potential for mistakes through remote media is great.

We do not expect the nameless clerk at Wal-Mart or Home Depot to know us; we’ve forfeited the familiarity of neighborhood storekeepers in favor of the huge selection and low-costs that superstores offer. Yet we still yearn for personal attention in healthcare. When even the simplest procedure requires us to interact with five, maybe 10 different faces, we’re frustrated when each repeats the same annoying questions. We fantasize that if the system were simpler, if these people actually knew us, we could avoid these dehumanizing protocols.

The ACA is neither the villain nor savior of our healthcare system. I hope that its kinks will smooth and more people will receive better access to healthcare. But ACA will do nothing to align our fantasy that healthcare is a vocational calling to serve mankind with the reality that it’s just another big business.

So far my doctor’s office has not adopted the AHRQ recommendations against annual physicals; my doctor and I will meet again next year. But I foresee a time when our annual chats, relics of relationship-based medicine, become memory. I won’t be able to defer a pinpoint headache by putting it on my list of annual discussion topics. I’ll have to evaluate the pain and decide myself whether it needs immediate action. This could lead me to seek more frequent care and turn me into just another transaction for that harried provider who knows nothing about me except what the screens displays. My anxiety will certainly rise, even if my blood test comes back negative.

Posted in United States | Tagged ACA, Affordable Healthcare Act, AHRQ, annual physical, Cognoscenti, WBUR | Leave a comment