The Insulin Express

by Oren Liebermann

  We find a pharmacy in Lakeside that lets us use their scale for a second. I step onto the scale, but the number staring back at me doesn’t make any sense.

  “Are you sure this scale is right?” I ask the woman behind the counter.

  “Yes,” she says, smiling back at me.

  I start converting kilograms to pounds in my head. Multiply by two. Figure out ten percent, then add that twice. That means I weigh … wait, double check the number … 180 pounds? If that’s right, I have lost forty-five pounds. I thought I had lost twenty pounds at most, but forty-five means I have lost nearly a quarter of my body weight from my usual 225. How is that even possible?

  Lacking anything that would qualify as helpful medical knowledge, we email some of my doctor friends back home and describe my symptoms. Weight loss. Thirst. A constant need to pee. Weakness. We even Skype with one of them so that she can see me, or at least a pixelated version of me, which is the best we can manage over Nepali Wi-Fi. Their verdict is unanimous: malnutrition. Since entering Nepal, I have been on a vegetarian diet, eating far fewer calories than I normally eat since there isn’t too much junk food here. The massive infusion of rice into my diet explains the thirst, since rice can draw fluids out of the system. And the weakness and weight loss come from a lack of protein. All I have to do is eat more. One of my friends says I have the classic symptoms of diabetes, but we both agree that’s incredibly unlikely, since there is no history of diabetes in my family.

  Back at Krishna and Bimala’s house, we email the medical update to my family. We didn’t want to consult them first because we suspected they would immediately and irreversibly freak out. We were right. They start sending panicked emails, begging me to go to the doctor. On a Skype call with my parents at night, I make a simple deal with them. I’ll go to the doctor if they track their diet and go to a personal trainer. My parents are overweight and putting on more pounds. In Israel, a friend of the family had told me to force them to get help. Now, I use their concerns about my health as leverage for my worries about theirs.

  “Not even the Jews in Auschwitz lost weight as fast as you,” my dad says. “You have to go to a doctor.”

  “I’ll go to a doctor when you see a personal trainer.”

  “What does our weight have to do with your health?”

  “You can’t worry about my health until you take care of your own. Write down what you eat for three straight days and see a personal trainer.”

  “You’re not going to survive that long, and I’m not coming to Nepal to bury you.”

  “Okay then. I’ll try to die in Laos so you can at least visit somewhere you’ve never been for my funeral.”

  The conversation goes around in circles, each of us trying to get the other to seek help. But each circle becomes more frustrating, and our voices rise in unison until we’re yelling at one another. My mom starts crying, which makes me feel worse than I already do. I refuse to find a doctor because they refuse to see a personal trainer. And we have too much on our agenda coming up. We have one more week of volunteering before we return to Thailand for scuba lessons and the continuation of our Southeast Asia explorations. I promise to find a doctor when we have some free time in Thailand. By the time we hang up, I am furious at my parents, and I suspect they feel much the same way toward me.

  When we arrive at the monastery for our final week of teaching, one of the workers kindly informs us that the monastery has announced a holy day, called a pooja, and canceled morning classes. There will be one class in the afternoon. We can sit around the monastery for five hours and wait for class or we can simply come back tomorrow. Cassie and I decide to take advantage of the unexpected free day to visit a doctor.

  We hail a cab to Quality Healthcare, one of the few medical providers in Pokhara and one of even fewer that has any positive reviews online. We walk in and take a seat in the waiting room. The doctor’s assistant invites us into the examination room a moment later.

  A doctor, whom I’ll call Dr. Griffiths, introduces himself. “What seems to be the problem?” I describe my symptoms to Dr. Griffiths. He doesn’t look right at me, instead tilting his head ever so slightly to his left in a way that comes across as mildly disconcerting, as if he’s not quite listening to me. I suspect this is how he focuses, picturing my symptoms in his mind, but it would be a bit more reassuring if he occasionally turned to glance in my direction.

  The doctor has his assistant take my temperature and blood pressure. He says I have a low-grade fever, and he comes to the same conclusion every other doctor has, that I’ve been suffering from malnutrition since coming to Nepal. What I need, he says, is some protein and vitamins. He recommends juices and chicken, and sends me on my way.

  “Don’t you want to take a blood test?” I ask.

  “I can if you want me to.”

  “I want you to.”

  The blood test reveals that I am healthy, although with a minor infection. Dr. Griffiths gives me a multivitamin, electrolyte powder packets, and an antibiotic for the infection.

  I can’t wait to get home and email my family. I was right all along, as backed up by the opinions of five different doctors now. Cassie and I stop at the store to pick up some extra nutrition—pomegranate juice, soy milk, and a few other snacks. Up in our room, I compose an email that I hope will silence the insanity, liberally adding my own sarcastic annoyance to the mix.

  Mon, Feb 10, 2014 at 7:01 a.m.

  Oren Liebermann

  To: Yaffa Liebermann, Eli Liebermann, Tamar Brooks, Hadas Liebermann

  Subject: You should all convert to Buddhism

  I had promised all of you that I would go get a blood test when we had a free day in Thailand in a week. This morning, we went to volunteer at our monastery, only to find out that Buddhists had decided to schedule an unannounced day of prayer and canceled class.

  Given the free day, we went to a medical clinic, got a blood test, and saw a doctor. As we expected, the blood test showed no infection, no illness, and nothing unhealthy. Dad’s doomsday prognostications of my imminent death were absolute bullshit, which we all should’ve have recognized immediately. (Don’t worry, apology accepted.)

  The doctor gave me electrolyte powder, because he agreed my diet lacks nutrients. He recommended eggs, fresh fruits, and lots of fluids. He also gave me a pill for worms. He said worms can have no symptoms, but can suck nutrients away from the body. That’s a one-time pill that I take in a few hours. He said there’s no way to know if it’s worms, but it’s fairly common here and the pill has no side effects.

  In 3 days, we’ll find out if there’s any bacteria or a parasite in my blood, but he said there’s no way that’s the case since I have no stomach pain, nausea, or diarrhea.

  I will go to him again on Friday to check my weight and see if anything has changed.

  Let me be clear about one thing. The mass paranoia and hysteria on that side of the Atlantic was absolutely unacceptable. Tamar and Erez started with reasonable emails, then went into freak-out mode when Mom chimed in. Our health is our number one concern, and we take care of ourselves and each other. Your sharing bullet points and sending childish, guilt-trip emails (most of which got snide responses or automatic deletions) were patently ridiculous. You’re thousands of miles away, and when I tell you that I’ve described my symptoms to doctors with valid medical opinions, I expect you to respect those opinions instead of voicing your own wild guesses about what’s going on. (Mom calling my in-laws was particularly outrageous.)

  We learned that what was wrong was exactly what our doctors told us (and what we told you in the first email, in case you forgot)—a lack of nutrients and a low-calorie diet for too long. We’ve made the adjustments to my diet and I will be fine (again, as I told you in the first email, in case you forgot).

  Now that you’re done worrying about my health, you can make sure the parents fill out their 3-day food log and meet with my nutritionist/personal trainer.

  You’re welcome,

 
Oren

  Improvement does not come quickly. The next morning, I’m feeling as bad, if not worse. On a one-hour walk to the monastery, I drag my feet along the sidewalk. My mouth is half open as my breathing drags. I stare down at the street a few feet in front of me, barely able to muster enough energy to focus my eyes on one particular spot. At the bottom of the three hundred stairs to the monastery, I stop. For a long time, I stand still, trying to find the courage to attempt the first step. Once I start, I know I will have no choice but to keep climbing every single one of those steps, and that seems like a monumental task right now. I begin working my way up, trying to keep up some forward momentum with a slow rhythm. One step every two seconds.

  Once at the top, I collapse onto a bench and polish off half my water bottle in one swig. I need to stop drinking for a moment only so I can swallow a few breaths before I continue. Then I start walking to the bathroom, knowing I will have to pee in a few minutes.

  I tell Cassie I need to rest. I spend the entire first period sleeping in the library, trying to find the strength to help my wife teach.

  I get through the next class but only manage to eat a few bites at lunch. I push my food around my plate, wondering if it will look any more tempting in a few minutes. My appetite is nearly gone, and my enthusiasm for the final group of the day goes with it. At one point, they’re not responding to Cassie’s request for silence. Without energy, my patience is nonexistent. I walk over to the nearest table and slam my fist down on the desk. I know I’m weak, but the noise is loud enough to shock the class into silence. As a teacher, I am a failure. But as a disciplinarian, I’m showing some real promise.

  At night, I notice a strange taste at the back of my mouth. Almost a fruity taste that won’t go away. I’m sure it’s the aftertaste of the electrolyte powder, which has an orange flavor much akin to an awful spin-off of orange Gatorade. But when I sip the electrolyte water, it’s obvious that it’s an entirely different flavor. Whatever is creating the taste at the back of my mouth is something different, and it won’t go away, no matter how many times I rinse out my mouth.

  The next day is the same. I have to rest through the first class, I barely eat anything at lunch, and I struggle through the rest of the day. Even the students take notice.

  “Are you okay?”

  “No.” I don’t even bother feigning health.

  “Oren is very sick,” Cassie says from the front of class. She has no idea how right she is.

  Chapter 11

  February 13, 2014

  28°14’13.4”N 83°58’44.8”E

  Lakeside, Pokhara, Nepal

  I wake up feeling sapped of all my energy, completely exhausted to my very core. All week I had felt tired, and the creeping lethargy has only gotten worse in the last forty-eight hours. On Tuesday and Wednesday, I had made it to Matepani Gumba only to pass out in the library during the first class I was supposed to teach with Cassie. The hour walk to and from the monastery feels like running a marathon, and the three hundred stairs to the top might as well have been the Hawaii Ironman.

  During meals, I force myself to eat as much as I can per the doctor’s orders. But I can scarcely down a few bites. For the first time in our relationship, Cassie eats more than I do. Far more. It’s not a function of her appetite dramatically increasing but of mine effectively disappearing. Food doesn’t look appealing to me anymore, and I want to retch with each new serving of dal bhat placed in front of me. The lentils, beans, and rice that are the staple of every Nepali meal look absolutely abhorrent to me, even though as recently as last week I was having second helpings.

  I try to get my nutrition through juices and soy milk, drinking mouthfuls each morning and evening to sate my unquenchable thirst. After waking up, I double-fist pomegranate juice and soy milk, alternating between the two cardboard containers. I also manage to swallow a few small bananas and oranges throughout the day. But each spoonful of rice and each forkload of curry require a cup of water to swallow. In the morning, Bimala’s oatmeal only goes down with equal parts water and nausea.

  At dinner the night before, I ate only a few bites. Krishna and Bimala both said I didn’t look very good, so Cassie and I agreed it was time to go back to the doctor. She would teach, and I would try to figure out what was wrong with me.

  But first I have to summon the energy to get out of bed. For ten minutes, I sit on the narrow wooden frame, hunched over on the thin pad that hardly qualifies as a mattress, unmoving with my elbows on my knees, resting my head in my hands. All I have to do is straighten my legs, tilt my back, lean forward, and stand up. And that seems impossible. I am somehow more tired now than I was before I went to bed.

  Eventually, I realize that sitting on my bed on the third floor of a house in Pokhara, Nepal, isn’t getting me any closer to the doctor, and it’s certainly not making me any better. Bimala brings up some coffee, and a short time later, I walk the quarter mile to the main road where I can grab a taxi to the doctor’s office.

  Once again, Dr. Griffiths sees me moments after I walk in. This time, we sit and talk in what would qualify as the waiting room in any doctor’s office that I’ve ever visited, except here, without anyone else in the building except Dr. Griffiths’s assistant, it becomes a makeshift examination room.

  “What seems to be the problem?” he says in his thick Indian accent, restarting the diagnostic conversation from the very beginning as if he hadn’t just seen me earlier in the week. He is seated to my right, and we are halfway between looking at each other and looking at the wall in front of us.

  “I’m just not feeling better. I’m feeling a lot worse.” I tell him about the last couple of days, eating more food, drinking more juice, finding fresh fruit—following his instructions exactly. “And it doesn’t seem to be working.”

  I tell him I have all the same symptoms: parched mouth, never-ending thirst, a constant need to urinate, and an awful taste at the back of my throat. Oh, and one more.

  “I haven’t …” I pause, seeking the right words. “I haven’t gone to the bathroom in five days.” I hope it comes out eloquently, but in my state of exhaustion, the higher rules of general etiquette no longer qualify as important or even relevant.

  Dr. Griffiths nods to his assistant, who knows exactly what to get and where to find it. I have the distinct impression that Dr. Griffiths talked about my possible return to his assistant, and they both knew what to do in the event that I found myself in the Quality Healthcare office once again.

  The doctor opens a small black case, about half the size of my old lunch box, and pulls out a navy blue medical device shaped like a deformed oval. I recognize it immediately as a blood sugar monitor, having seen some of my friends test their blood sugar when I was a kid.

  Dr. Griffiths’s assistant, who has been nothing but helpful since we first met him on Monday, pricks my finger and draws a tiny bead of blood that sits ever so gently on the tip of my extended digit. He scoops up the droplet with the tip of what looks like a small plastic strip and inserts it into the monitor. I watch the numbers blink on the monochrome display.

  5 … 4 … 3 … 2 … 1 … 406.

  The doctor takes a deep breath. Whatever he’s gleaned from the number does not bode well for me, though I have no idea what it means. There is a moment’s hesitation that I will never forget, a well-defined temporal demarcation that denotes the end of one era of my life and the beginning of another. This brief second is the present, and it sharply separates the past and the future.

  “I’m sorry to tell you, my friend,” Dr. Griffiths says, pausing mid-sentence, “but you are a diabetic.”

  He allows the weight of the news to sink in. In the brief span of one compound sentence, my life, my health, and my well-being have been twisted, warped, deformed into something completely different. If I’m breathing, I’m unaware of it. If I’m thinking, it’s not in coherent thoughts. Mere spasms of syllables and phrases echo off of the suddenly empty walls of my mind.

  Holy shit.


  I’ll say that again.

  Holy shit.

  A few of the doctors I had spoken with back in the States earlier in the week mentioned there was an outside chance that I have diabetes, but they didn’t believe it, and neither did I. One does not “catch” diabetes in the same way that one catches a cold or a flu. My whole body goes numb, and so does my mind. I cannot think. I cannot feel. I cannot reason. I can barely talk. Oxygen, which, until this very moment, constituted about 20 percent of the air around me, suddenly seems overtly and conspicuously lacking.

  There is an awkward silence that I’m sure everyone who has gone through a life-changing diagnosis would recognize immediately.

  “I am diabetic too, and you will be okay,” the doctor reassures me.

  Somewhere in the deepest parts of my subconscious, I know what he says is right. It must be right. I have friends who have diabetes, and they’re doing great. But in this first minute, it’s impossible to believe.

  I feel like I got kicked in the nuts. Swiftly, solidly, and squarely in the jewels of my masculine plumbing. Except that’s more of a physical sensation, and this is almost entirely emotional. I think the physical pain of getting crushed in the testicles would actually soften the emotional shock of such an unlikely diagnosis. I firmly believe that doctors should keep a small but well-trained staff of short people around to kick patients in the nuts before major diagnoses to soften the second blow by focusing on the first.

  “Okay,” I say with as much mirth as I can muster, which amounts to a whopping sum of barely none. My plans to keep traveling—to get on board a plane to Thailand, to ride a train to Koh Tao, to earn my scuba certificate—have vanished. Instead, I have one simple mission that is now the focus of every bit of my energy. I need to go home.

  Doctor Griffiths explains to me that I have late-diagnosis type 1 diabetes. In short, I am thirty-one years old with juvenile diabetes. Of course, this doesn’t really mean anything to me, but, from what I can understand from his explanations, my diagnosis at this stage of life is astronomically rare.