Vol. #14, No. 6
Welcome to the September edition of Tips and Topics… or what I did on my summer vacation.
David Mee-Lee M.D.
Last week, I returned from my first trip to Borneo and Malaysia. I was fortunate to be invited to participate in a keynote, workshop and panel discussion at the 4th Asia Pacific Behavioural and Addiction Medicine Conference (APBAM 2016) at the University of Malaysia Sabah in Kota Kinabalu.
If you are like me, Kota Kinabalu is not a travel destination at the top of one’s bucket list.
Yet it was the starting point for a fun and meaningful work/vacation experience I’ll share with you this month. And unless you are a student of international affairs, your first thought about Malaysia might be the fateful 2014 flight of Malaysia Airlines Flight 370 which mysteriously disappeared from radar and still has not been located.
As you might expect, there is much more to Malaysia than missing planes and the “Wild Man of Borneo.”
A brief primer on Borneo and Malaysia
- Borneo is the world’s third largest island and is home to three countries: Malaysian Borneo, Brunei, and Indonesia.
- Malaysia is located in Southeast Asia and is made up of 13 states and 3 federal territories. It is a country with two regions separated by the South China Sea: Peninsular Malaysia (West Malaysia) and Malaysian Borneo (East Malaysia).
- Peninsular Malaysia shares a land and maritime border with Thailand and maritime borders with Singapore, Vietnam and Indonesia.
- Malaysian Borneo is made up of two states: Sarawak and Sabah.
- The capital of Sabah is Kota Kinabalu, the international gateway to Sabah.
- Sabah and its main city, Sandakan, is where you can experience some of the richest wildlife areas found anywhere in Southeast Asia.
Sandakan is where the wildlife, tourist part of my trip began. It was hot and muggy, being just 6 degrees north of the Equator.
Nature nuggets from the Wild Animal Borneo tour
Here a few highlight anecdotes that stood out for me:
To watch the young babies and others up to age 4 or 5 years swing from rope to rope in the “nursery” of the Sepilok Orangutan Rehabilitation Centre was fascinating. As they feel more adventurous there is nothing stopping them from venturing over to where the grown-ups hang out.
Lunch time for the big guy
A family affair
- We had an unusual and spontaneous treat. A 5 year old orangutan curiously explored contact with tourists and come out to the Sepilok entrance to take a look at all of us who were looking at him! Then he scurried up a tree right near the entrance. We witnessed something that can’t be planned.
Our curious young guy came to watch us watch him
- The Centre’s keepers teach the young ones many of the skills they need to survive in the jungle on their own. But what we saw was something keepers can’t teach; he must have learned from watching an adult.
- Once he reached a comfortable height in the tree, he bent a branch into a semicircle arc. Then he started breaking off other branches, laying them in the leafy bent branches building himself a little temporary bed.
- My guide said he would relax there for a few hours until it got cooler. Then he would hunt for food. Sure enough when we returned he was gone, having had a nice afternoon snooze.
Finished making his relaxation bed and peered out to see what the tourists were doing
“Proboscis” means long nose and you can only see this monkey in the wild, in Borneo. So of course I was curious: Why the long nose? I was told that proboscis monkeys are like dogs; they don’t sweat, so have to dissipate heat through their long nose. I’m not sure that is correct, having checked in Google. I did see that idea mentioned, but mostly different explanations for the long nose. (Perhaps my guide’s explanation is an example of that joke which goes around in travel circles- that guides have a lot of information but only sometimes is it true!).
The daddy Proboscis monkey with his harem
- The long nose seems to be more of a sex symbol – males who have the longer nose are more attractive to females.
The male leader of the family with his big nose
- Males have longer noses than females; and adult males have longer noses than young guys.
Mother proboscis monkey with her shorter nose and baby
- In times of danger, blood rushes to the nose and alters the resonance of the monkey’s calls of danger, which makes the warning calls more effective and more attractive to female proboscis monkeys.
- Proboscis monkeys can swim and are pretty good at it. So a long nose helps breathing when jumping in the river to escape predators like the Clouded Leopard.
- On our jungle river rides searching for birds, monkeys and crocodiles in the evening, we saw scores of proboscis monkeys finding their ideal sleeping spot high up in the trees nearest to the river. This gives them an escape route should a leopard climb the tree in hot pursuit. The proboscis monkeys just jump into the river and swim away.
Night jungle walks – I was ready for almost anything: dressed head to toe in clothing infused with odorless and invisible insect protection to keep out mosquitoes; wearing knee-high rubber boots and even higher cotton socks you tie tight around your leg to discourage leeches jumping on your ankles; and topped off with generous sprays of insect repellent.
- The high rubber boots were a must in the muddy jungle floor of rain forests where it can rain at a minute’s notice. In fact we had to cut one walk short as our guides could hear the spray of rain increasingly and quickly moving in our direction.
- As the sound of rain grew stronger, they said: “That’s it. We have to go.” We had to run ahead of the sound to make it back just before being totally drenched.
- But when we weren’t slipping and sliding or dodging torrential downpours, we were seeing multicolored, beautiful birds sleeping on tree branches just a few inches from our eyes and camera. Keep quiet -and they’ll continue sleeping while you watch.
- Four-legged animals are easier to spot at night. Just swing a flashlight around and look for glistening eyes.
Turtle Islands Park
A 45 minute speedboat ride from Sandakan whisked us to one of three turtle islands, Selingan Turtle Island. There, mother green turtles come ashore at night to lay their eggs and we tourists observe them up close and personal.
- Upon arrival on the island, you see a field of little green circle mini-fences protecting each mother turtle’s 80-90 eggs which have been replanted here. This gives the hatchlings a chance to survive predators.
Little green mesh towers protect the transplanted eggs from predators as they await to hatch
- The reservation rangers are dedicated to protecting the turtles. At night, they check the beach for the first arrival onshore. This can be anything from 9 PM to midnight or later depending on how bright the moon is, and how high the tide is.
- We all waited with anticipation for the first call of “Turtle time!” We then rushed to see the first mother lying in a big sandy pit she had dug out; she was ready to start dropping ping pong ball- sized eggs in the deep hole she had prepared.
Ping pong size eggs – 90 eggs about to be transplanted
- Watching her lay her eggs is the first of three parts of the turtle island experience.
- We were lucky- the conditions were ideal to come ashore- a dim moon and a high tide. The female turtle came in early so we didn’t have to wait up until midnight.
- The second part of the experience was to see the 90 eggs we just saw laid transplanted into a new deep, man-made sand “nest”
Soon these eggs will be inside a green mesh hole ready to hatch
In the afternoon when it cools, you keep your eyes on the inside of those little green mesh towers. A stirring in the sand suddenly reveals a little baby turtle. More and more appear; the rangers collect these in a basket to prepare for the third phase of our turtle adventure.
Newly hatched baby turtles about to experience the big sea
- As we all scurry to the water’s edge, the ranger passes around the basket
of newly hatched baby turtles. We marvel as he gently tips the basket to release them to the sea.
- You’ve probably seen video of of hatchlings race as fast as they can to splash for the first time into the water.
- Sadly, only about I in 1,000 will survive to adulthood.
Despite several river excursions, scouring the riverbanks to see crocodiles, I glimpsed -for just a few seconds -the head of one as he slipped below the surface. (Or was it a she?) All those floating logs though gave plenty of fodder for my imagination: “I think that was a crocodile I just saw.”
I did see relatively fresh tracks of where elephants had crossed the river, but no actual elephants on the move. Oh well, back to the zoo.
Addiction and mental health in Southeast Asian countries
The working part of my trip to Borneo centered on Kota Kinabalu or KK as it is popularly known. (Much easier to say). It is the state capital of Sabah and home to the University of Malaysia Sabah. Attitudes about addiction as a treatable disease have years (and maybe a decade) to go before there is the will to expand treatment. Drug use and certainly trafficking are crimes taken very seriously. Here are just a few bullet points about complex problems in Southeast Asia.
- Several tourist brochures carried this Advisory in a bold red text box:
“In Malaysia, the Possession and Trafficking of Illegal Drugs carry the Death Penalty.”
- Psychiatric patients, I was told, suffer almost equal discrimination and in treatment settings are called “inmates” and are “released” from hospital – not “patients” to be “discharged” or “transferred”.
- Addiction “patients” do two years or longer in residential treatment – first offense, six months; second 6 – 24 months; third offense – years and maybe the key is thrown away.
- We in the USA may think we face a workforce problem, but these Southeast Asian countries have very few counselors or “allied health professionals” as they call them. The need is great, but helpers are few.
- We still struggle here with parity for addiction and mental health treatment, but addiction treatment is hardly on the healthcare menu screen of services in many places.
- I met many dedicated local and ex-pat professionals from the USA, UK, and Australia doing their best to influence attitudes, raise consciousness, educate about addiction and mental health and develop staff and services.
- My admiration goes to them acting as “missionaries” in the best sense of the word, not literally in the jungles, but certainly in the jungles of sparse healthcare resources and negative and cultural attitudes about addiction and mental health.
Perhaps you are happy to enjoy a “staycation” at home – no planes to catch (or pay for); no rental cars, hotel rooms or expensive restaurants to drain your bank account; no worries about who will look after your pets, plants and valuables. You’re at home taking it easy.
However if you are like me and find traveling to foreign countries fascinating and fun, then here are a few tips on foreign travel.
Travel tips for an overseas vacation
You’ll need cash immediately you exit Immigration and Customs formalities – for taxi, train fare or a quick snack. You can probably use a credit card for many things, however, if at all possible, I avoid using credit cards in foreign countries. It’s bad enough -at home- to discover your credit card information has been hacked, and has been charged a flow of expenses you don’t recognize at all. I feel even more vulnerable in a foreign country. You do not want to be waiting for a new credit card to be sent to you from all that distance.
- Find a bank or investment institution that allows you to draw out cash in local currency from most bank ATMs , ones using the current currency exchange rates with no commission or bank ATM fees. I have successfully used a Schwab High Yield Investor Checking Account. (This is not a paid endorsement; there probably are other competitors I haven’t researched.)
- Figure out ahead of time the money conversion math so you are prepared to do quick arithmetic and roughly know what something costs. I had it easy in Borneo; a quick division by 4 converted 100 Malaysian Ringgits into 25 US dollars equivalent. 1 Ringgit equaled about 25 US cents.
- You can avoid the mental math method by simply using a currency conversion app on your smartphone. But that leads to my next tip:
One of my first purchases is to switch out my iPhone SIM card for a local SIM card. This gives me gigabytes to check email on my phone, make phone calls and use apps or directions guides like Google Maps.
- Use a reputable digital network company so your phone will likely work even in more remote areas of the country.
- Having a local SIM card means you avoid the roaming feature of your home mobile phone network, which is much more expensive than a local SIM card and network.
- Do you have the Skype app on your phone? It is an inexpensive way to make international calls to family and work back home.
- Better still for calling home, check if your hotel has free Wi-Fi service (most do these days); then call home using Skype on your laptop computer. That makes communication (computer-to-computer) free, rather than incurring expensive roaming fees or long distance telephone charges.
Google the local customs about tipping. Do the math and research what tip percentage is customary.
- Don’t assume you should use the same percentage formulas you use in the USA. Many countries don’t even have tipping as a general custom; or expect tips only in certain situations.
- If you obtain foreign currency from a local bank ATM, they will be in large denomination bills. Change that into smaller coins or notes to be prepared with tip money, if needed.
- Keep some tip money loose in your pocket or outer pocket of your handbag. Avoid pulling out your wallet or purse displaying a wad of big denomination bills. Locals, especially unsavory characters looking to relieve you of your wallet, know what color notes are worth what amounts. At first you are oblivious just acquainting yourself with the coins and notes. You may not initially realize the wad of green or blue notes represents quite a lot of money.
Before you leave home, check the voltage and electrical outlet plug style used in your foreign destination country.
- You can buy an adapter plug at airport shops before you leave or when you get there. But I like to be prepared and buy ahead of time – and it’s less expensive on the internet.
- Remember that whatever adapter plug you insert into the electrical outlet in the foreign country is not an electrical transformer that can convert your 110 volt hairdryer into the 220 or 240 volt system in the new country. All you’ll end up with is a fried hairdryer if it doesn’t say that your hairdryer works for a range of voltage systems from 110-240 volts.
- If you are using a computer or other device that clearly indicates that it has a range from 110 to 240 volts, then you can safely just use the electrical outlet plug adaptor without concern of harming your laptop or another device.
From the USA to Southeast Asia – learning from our mistakes and experience
At the conference in KK, many of the countries represented are still quite early in developing addiction and mental health services. Simply because we, in the USA, have been providing services for decades, doesn’t necessarily mean that longer means better than another country earlier in the developmental process. I do happen to believe many things we do in the USA are indeed better. But they better be better, because we’ve had more resources and more years to learn from our mistakes and celebrate our successes.
An old Chinese proverb says something like: “The foolish man learns from his own mistakes. But the wise man learns from the mistakes of others.”
Recognizing the many needs for services, but still early in their process, they are eager to learn. I shared a few recommendations to help them learn from our mistakes:
1. In many countries there is a tendency to think the gold standard of addiction treatment is residential treatment. I recommended they put greater emphasis on developing a broad range of community-based outpatient and supportive living services, in addition to residential and inpatient levels of care.
- The USA also still thinks of residential levels first. As States react to the opioid crisis in the USA, the cry goes out for more beds, when we really need more community outreach, recovery supports, living environments, intensive care management and assertive community treatment for addiction just as is available more for severe mental illness.
- Still too often, residential treatment is considered primary care and outpatient services just aftercare or continuing maintenance care. As these countries design services from the ground up, I recommended they consider all levels of care important but if anything, put more emphasis on building community supports and services than large residential facilities.
2. In a punishment-oriented culture, there is already a focus on long lengths of stay in residential and controlled environments for those caught using and dealing drugs. While it is true that longer lengths of stay help achieve good outcomes, that length of stay doesn’t need to be all in the one level of care e.g., residential.
- Just as we have historically had long lengths of stay (LOS) in residential levels in the USA, these countries would do well to not repeat our mistakes.
- I encouraged them to focus on a broad, flexible continuum of outpatient and residential levels of care and to move clients through that disease management according to progress and outcomes.
- Unlike our USA history of treatment, I recommended they plan for no fixed lengths of stay in any one level of care; and manage people in a broad continuum of services with variable LOS.
3. The USA at the Federal agency level still seems to not embrace addiction as a diseasethat manifests for some as alcohol and for others with drugs such as methamphetamine, heroin, nicotine etc.; and for still others, as gambling disorder. There is still in the USA a distinction between alcohol and other drugs. Hence the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) exist as separate entities as if people come with just a drug problem or just an alcohol problem.
- I recommended they notice how they already are predisposed to keep alcohol and other drug problems separate. In China, for example, people with alcohol problems are treated under the Department of Health. But those with other drug problems are treated under the jurisdiction of the police and criminal justice.
- Decreasing stigma and discrimination about addiction has been hard enough in the USA. However in Malaysia, Singapore, Vietnam and other Southeast Asia countries, reducing stigma and discrimination has even a greater uphill battle when drug use alone has such severe legal and incarceration “treatment” consequences.
You don’t have to travel overseas to understand different cultures. But if you do have the opportunity to travel and see firsthand different people, customs, houses, joys and challenges, it sure comes alive. Walking myself through some of the villages of Malaysia allowed me to really grasp what conference presenters face as they described their outreach projects to the villages. What did I learn?
- In the villages, the main activity at the end of the day is a gathering of the families and friends to enjoy music on their guitars; and drink alcohol served from large jars on the ground circling the happy group.
- Just about everyone in the village learns early on how to distill their own alcohol (e.g., home-made rice wine) so they are not dependent on spending huge sums of money, or having to travel to the local liquor store, which is not local anyway.
- Alcohol is embedded in the social fabric of daily life. That can happen in our culture too, but when there aren’t a lot of options for activities in the village, music and alcohol rise to the top.
- Conference presenters explained that teaching and expecting abstinence in the village is futile and naïve. They had to think what would be first steps that would work to start to change the culture and practices of everyone.
- They started engaging the mothers and other women in an educational and change process. Women are the ones who traditionally draw from the large jars of alcohol and keep everyone’s cup full.
- Once the women were engaged to make some changes, the first strategy was to move the jars away from the circle of music, laughter and drinking. The alcohol was then placed on a table away from the socializing, which meant, no more refills right where you sat. Want a refill? Sorry, you have to get up and go get it.
- This small but significant change has started to shift the culture of drinking.
One more anecdote on culture:
Singapore is up there for sophisticated, cosmopolitan and expensive living – nothing like the Malaysian villages. Singapore, however, is not advanced in their attitudes and treatment of their people with addiction. (How many strokes of the cane do you think you should get for your second flare-up of addiction?) There is still a very punitive and incarceration approach, thanks (I was told) to some expert psychologists from the USA. Some years ago they came, by request, to consult to government officials about what to do about addiction. They declared that treatment for addiction doesn’t work; and this has been the “scientific” advice driving “treatment” ever since.
More enlightened addiction treatment specialists in Singapore recognized the importance of developing better community resources and mutual help groups for those trying to establish recovery in this cosmopolitan society. There are Alcoholics Anonymous and Narcotics Anonymous meetings. But local people in recovery don’t relate well to meetings attended mostly by white ex-pats from the USA, Canada, Australia and the United Kingdom. What to do?
- Harnessing the passion of the Chinese, Malay, Indian and other diverse ethnicities in the recovery community, they started mutual help groups much more inviting to local people.
- Building on that growing community, more outpatient resources have blossomed to balance the government’s predominantly punitive and “lock them up” approach in Singapore and in the other Southeast Asian countries.
It was humbling to meet dedicated people running Non-Government Organizations (NGOs) and faith-based treatment programs who were countering the widespread negative attitudes about addiction and mental health. Often on very limited resources and support, they respond courageously to the increasing need for services.
This is a time, in our current culture of fear, when some would respond by building walls, demonizing certain people and oversimplifying complex issues. I am in awe of the people and the work they do in NGOs, humanitarian aid agencies and other outreach projects not only in Southeast Asia, but the Middle East, Africa and all around the world where it is not so safe and comfy as California or your neck of the woods.