The views and information presented here are my own and do not represent the Fulbright Program or the Department of State.

And now…on to diabetes.

The purpose of the orientation was to prepare all of the grantees for the experience of living abroad next year. We had information sessions on medical insurance, the administration of the program, and the histories and cultures of our respective host countries. I was excited to be able to meet the other grantees going to Estonia next year. Two alumni who had just returned from their year in Estonia were also there, and gave us dozens of tips about living in the country.

For most grantees, the preparation at the orientation was theoretical. In my case, the orientation inadvertently provided some hands-on practice for living abroad with diabetes. During the three days I spent in D.C., I had a small taste of the challenges I’ll have to deal with when I’m much farther away from home–as much of a taste as it’s possible to have in a nice hotel with a very helpful staff.

Of course, a major difficulty was maintaining good blood sugar levels. As every diabetic knows, it’s hard to count carbs when you’re away from home, eating unfamiliar food, and resorting to estimates rather than measurement. (At least I recognized the foods I was being served….this might not always be the case in Estonia!) Since my total movement consisted of walking from my room to the elevator, and from the elevator to a conference room, I was also getting much less exercise than I do normally. My blood sugar was high for most of the trip. Still, I was glad that I avoided having any serious lows, which would have been a greater cause for immediate fear.

An unexpected diabetes-related situation arose soon after I had arrived at the hotel. When I had signed up for the orientation, I had requested a refrigerator in my hotel room for my insulin. After I checked in at the hotel, I went up to my room and met my roommate, another grantee. We chatted for a while, then we unpacked and ironed our clothes. It wasn’t until we were finished that I decided to put my insulin into the refrigerator–and realized that the refrigerator was nowhere to be found.

In a way, I wasn’t too surprised. There were more than a hundred people in our group, and several more groups in the hotel. It understandable that the staff couldn’t keep track of each and every one of the guests’ requests. I also wasn’t too worried; I assumed it would be easy to have a refrigerator brought up to my room right then. When I went down to reception, however, a staff member told me that refrigerators couldn’t be brought up to certain rooms. Without elaborating as to the reason why this was the case, he added: “If we can’t move a fridge to your room, we’ll have to move both you and your roommate to a different room where there’s already a refrigerator.” I wouldn’t have minded switching rooms, but it seemed unfair to drag my roommate along with me.

The staff member promised to call me once he found out about the refrigerator one way or another. When I hadn’t heard from him by the time I was ready to go out to dinner, I decided to go back to reception and ask again. I felt hesitant about doing this. Having worked in retail, I know how irritating a pushy customer can be. Still, I was worried about my insulin, and I figured that if my roommate had to switch rooms, it would be best for her to know sooner rather than later. On the second trip to reception, I spoke to a different staff member who explained that there was a shortage of refrigerators because so many people had been asking for them. “But,” he added, “since you have special needs, I’m sure we’ll be able to work something out.” When I returned to my room after dinner, a refrigerator had been placed under the desk.

This incident was minor, but it reminded me that I’ll need to keep several things to keep in mind when traveling. First, prepare ahead–and never be complacent about those preparations. Instead of waiting until the last minute to ensure my room had a refrigerator, I should have called earlier that day to remind the staff that I would need one. Then I should have checked to see if it was in my room as soon as I arrived at the hotel. I also shouldn’t have assumed that a refrigerator would be readily available. Unforeseen complications happen all the time, and a diabetic can’t afford to take risks when trying to obtain necessary equipment. The importance of being vocal and assertive about diabetes was also underscored for me. If I hadn’t been persistent and asked for a refrigerator a second time, the hotel staff might have forgotten I’d ever requested one. If I hadn’t explained that I was diabetic and needed the refrigerator specifically to store my insulin, the second staff member wouldn’t have thought to prioritize my request.

I’ve already acted on the lessons I learned at orientation and made some concrete preparations for managing diabetes in Estonia. My program put me in touch with the nurse at the U.S. embassy in Estonia, who has give me specific information about insulin availability in Estonia, as well as the contact information for a endocrinologist in the city in which I’ll be living. I know that situations will arise in Estonia for which I haven’t prepared…but at least I’ll do my best to prepare for the ones I can foresee.

Soon there will also be an iPhone/iPad app (101 worst places)  that readers can use to send postcards to people from their own travels (both good and bad) and add their own entries to the list.

101 Places Not To See Before You Die is available on Amazon.

Twitter handle: 101worstplaces
Facebook Fan Page: http://www.facebook.com/pages/101-Places-Not-To-See-Before-You-Die/102647109497
Book website: 101worstplaces.com

]]> http://asweetlife.org/a-sweet-life-staff/tips/wisdom/101-places-not-to-see-before-you-die/8510/feed/ 1 http://asweetlife.org/beccak/blogs/personal-blogs/medical-clearance/7524/ http://asweetlife.org/beccak/blogs/personal-blogs/medical-clearance/7524/#comments Thu, 13 May 2010 04:06:17 +0000 Becca Kantor http://asweetlife.org/?p=7524 As I wrote in a previous post, I recently found out that I received a scholarship to study in Estonia for a year. Once my initial excitement at learning this abated, I realized that I hadn’t been given a confirmation postcard to send back or a telephone number to call. The only thing in the envelope besides the letter was a medical form to be filled out by my doctor.

Did the organization just assume that anyone lucky enough to get the grant would accept it? Well…maybe. But, as wonderful as the grant is, that seemed a little extreme. When I finally found the phone number of the organization online, the woman to whom I spoke told me that there hadn’t been any mistake. Before I could sign an agreement accepting the grant, the committee would need to review my completed medical forms to make sure that any problems I had could be dealt with in my host country.

Of course, the first thought that came to mind was: Will having diabetes prevent me from getting medical clearance?

When I think about it logically, I know it’s not likely that this will happen. Estonia is a fairly advanced country. There are hospitals and access to medical supplies in the university town where I’ll (hopefully!) be staying. Diabetes is also a common disease, so it’s safe to assume that doctors in most places will have experience dealing with it.

Nevertheless, the thought that diabetes could prevent me from taking advantage of an opportunity is jarring–even in the abstract. When I was first diagnosed, I was given the usual literature reassuring me that diabetes would never stop me from leading a normal lifestyle. And it’s true that in the two years since that time, I’ve hiked up mountains, swam, and travelled abroad for two weeks. Still, who knows what might happen in the future? It always makes me disturbed and slightly shocked to hear about other people encountering roadblocks because they’re diabetic–for example, Michael Aviad’s inability to get health insurance for the  Rotterdam Marathon. I think I have a good chance of getting medical clearance to go to Estonia, but do diabetics applying to less developed countries feel similarly confident?

Yesterday I had an appointment with my doctor to fill out the medical forms. She looked over the section that I had filled out, annotating some of my answers. (For instance, I had checked “yes” next to the box asking me if I ever have or have had swollen feet or ankles; since being diagnosed with diabetes, I’ve had some trouble with my left ankle swelling slightly. My doctor made a note next to this question saying that the swelling is minor and not at all incapacitating.) At the end of the form, my doctor wrote that my diabetes was well controlled on my current medication, and recommended me for the scholarship.

So for now, I’m keeping my fingers crossed for good news.

1. I had an appointment with my endocrinologist.

2. I found out that I received a grant to live in Estonia for a year starting in September (!)

They had more to do with each other than one might think.

Part of this was the timing: I was leaving my house for the appointment just as a postman was walking up to my door, so I took the letter right from his hands. The thrill of the good news overshadowed my anxiety about the doctor’s appointment, at least for the duration of the car ride there. (My blood sugar readings have been erratic recently, and I was afraid that my A1C results wouldn’t be so fantastic.) Still, the juxtaposition of the appointment and the letter prompted me start to thinking about the reality of living abroad with diabetes sooner than I might have otherwise.

And once I started thinking, I was overwhelmed my the amount of things I’d have to figure out before leaving the U.S. It’s true that I have some experience of managing diabetes in a foreign country–I travelled in Estonia and Latvia for two weeks this summer. But that trip was short enough for me to bring all my supplies with me, plus extra prescriptions from my doctor at home in case I ran out. Actually living in a foreign country will present a whole new set of challenges. What kinds of insulin and supplies will be available in Estonia? How will I find a good doctor? What will I do if there is an emergency?

At my doctor’s appointment, I also learned that I will have to deal with a new challenge from now on: eating gluten-free. In previous posts, I’ve mentioned that my brother is one of the many people who has both type 1 diabetes and another autoimmune disease, celiac disease. The only way to treat celiac disease is by eliminating all gluten–a protein found in wheat, barely, and rye–from your diet. Long before I was diagnosed with diabetes, I was tested for celiac disease. The doctors told me that the results were inconclusive.

I was more than happy to take advantage of this ambiguous diagnosis to continue eating gluten. On this visit to the endocrinologist, though, I had decided I would clear up matters once and for all: Should I go on the gluten-free diet or not?

My endocrinologist explained that the tests had shown that I had antibodies for celiac disease in my bloodstream, but they didn’t show the “gold standard” for diagnosis–damage to the intestines. Her suggestion was that I try to avoid eating wheat, barley, and rye as much as possible. Still, she said, it probably wouldn’t hurt for me to eat foods containing gluten every now and then.

For me, eating gluten-free at home is annoying, but feasible. After years of living with a brother who has celiac disease, I know where to buy gluten-free flour, and which brands of gluten-free crackers and bread taste the best. But trying to maintain a gluten-free diet in a foreign country will be more tricky. To begin with, I currently know a total of two words in Estonian (“hello” and “thanks”), so reading a list of ingredients on a package won’t be easy. To make matters worse, bread is an integral part of the Estonian cuisine–so much so that in previous times, “bread” was a synonym for “food.” There is even an Estonian saying: “have respect for bread; bread is older than we are” which conveys the reverence with which Estonian peasants regarded the food. Not exactly auspicious for someone on a gluten-free diet…or someone with diabetes.

The reason, in this particular case, is that my husband and I have decided to move back to the east coast, and are going to be leaving our lovely Oakland home in a matter of weeks. Before we settle in, we’re going to be going on a big trip — stay tuned to the blog for details — that’s going to include some pretty diabetically unfriendly places. Like Latvia, for example. Or Russia.

I had my last appointment with my San Francisco endocrinologist this morning, and instead of discussing basal rates or boluses, we focused mostly on a checklist of prescriptions for me to take with me while abroad, just in case my supplies get lost or stolen or I find myself in a foreign country with a bottle of Humalog that’s expired. It was actually a pretty funny interaction — I’m quite worried that a Chinese-speaking pharmacist is not going to know what to make of Symlin to begin with, let alone if it’s written in my doctor’s handwriting. So as he kindly created a ridiculously long list of prescriptions for me, I kept gently prodding him to, you know, write a little clearer. (“Thank you so much!” I said, as he scrawled out a prescription for test strips. “Can you just write that a little more neatly?”)

He tried, and I now have a stack of prescriptions for any sort of diabetic calamity I might face. He also gave me some valuable travel tips, including the fact that apparently most insurance companies allow you to do a “vacation override” where you can get more than three months’ worth of prescriptions at a time (I’ll believe it when Blue Shield sends them to me), and suggested that I get a Frio, a carrying case specifically designed to keep your insulin cool. The office even provided me with five copies of a doctor’s letter stating that I have Type 1 diabetes, and that any delay in treatment could result in “serious, even life-threatening, medical problems.” Take that, Mr. Customs agent! You will allow me to receive that shipment of test strips!

I’m now moving into the real planning stages of this trip, and am very frustrated at the fact that, in addition to dealing with normal concerns like finances, plane tickets, vaccinations and the like, I have an entire litany of diabetic concerns that most world travelers don’t even need to think of. Forget the fact that I’m likely going to be in some places where most dishes include noodles — I have to pack a separate bag with enough diabetes crap (and backup diabetes crap) to last till I come home.

I’ll be posting more about my travel planning and adventures as the trip draws close, but in the meantime, I’m interested in hearing from other diabetic travelers out there. What resources did you find useful? What packing tips do you have? Did you bring all your supplies with you, or was it possible to have them shipped from home? What do you know now that you wish you’d known before?

Do tell.

If you’d like to read the full text of some of his tweets, check out Access Hollywood – my 160-character limit doesn’t allow me to fully express his creative use of abbreviations. But what interested me is his perspective on the disaster as a Type 1 diabetic. “Imma Type 1 diabetic, and was sppsd 2 leave sunday,” he wrote, according to Access Hollywood. “I only packed enuf insulin pump supplies 2 last til then….airports r closed!”

You might be quick to point out that Elliott Yamin is just one visible example of a much larger population of Type 1 diabetics in Chile (or, for that matter, Haiti), for whom a natural disaster like an earthquake could have even more devastating effects — and who don’t have easy access to Access Hollywood. But that’s my point: the horror of both situations is difficult to wrap one’s mind around. Having a particular person in mind helps make the situation more real, even if the person writing is an American best known for his hit single “Wait for You.” It also highlights the special challenges all of us face when traveling with diabetes — we can usually navigate our normal lives without calling too much attention to our disease. But it just takes one event — a malfunctioning pump or, in this case, a natural disaster — to remind us of the additional challenges diabetes presents.

A practical resource: one good way to help other diabetics on the ground is to check out the International Diabetes Foundation, which we mentioned in the tip section after the disaster in Haiti.

In the meantime, Yamin is continuing to send updates of his situation that are more elaborate than his intial tweets. “This country isn’t very keen on insulin pumps,” he recently commented. “Supplies for my pump are running low. Hospitals here are very crowded, and as you can imagine, they are dealing with bigger things.”

The source of these quotes?  Fox News’s “Pop Tarts.” And to think I made fun of Twitter.

(In all seriousness, best of luck to Yamin and to all the diabetics —  Type 1 and Type 2 — currently stranded without supplies. I hope that help comes soon.)

I took a plane from Riga to Tallinn, Estonia’s capital. From Tallinn, I took a bus and a ferry to Saaremaa, an island off the western Estonian coast.

Saaremaa is Estonia’s largest island. The land is mostly flat, punctuated by meteorite craters; the largest crater, known as Kaali Lake, is almost circular and filled with water. The one town on Saaremaa is Kuressaare, which is made up of small limestone buildings constructed in a neoclassical style. At the center of the town is a medieval castle built by German crusaders. My great-great-grandparents owned a hotel in Kuressaare, and family legend has it that my great-grandfather worked as a scribe in the castle.

At the turn of the century, Saaremaa was already popular with summer visitors, many of whom came to take the mud bath “cure.” During Soviet Occupation, access to the island was restricted because of its proximity to the western border, but after Soviet Occupation ended, Estonians (as well as tourists from other countries) were thrilled to return to their favorite vacation spot.

Although spas have taken the place of the old mud baths, Saaremaa still inspires a culture of health-conscious visitors. People bike or walk the nature trails, and swim and play sports on the beach behind the castle. I even saw some kids canoeing in the castle moat.

View of the moat from the castle walls

I spend a lot of time walking in Kuressaare–hiking around the castle walls, going down to the beach, exploring the town and trying to form a mental picture of its layout. My new Lantus dose, which I had lowered during the first part of my trip in Riga, continued to work well.

A walk around the castle

Saaremaa’s castle now houses a museum with exhibits about the history and wildlife of the island. One of the small buildings outside the castle has been converted into an Archival Library, and it was here that I did most of my research. The people who worked in the Archival Library went out of their way to help me–translating documents from Estonian into English and taking me on a tour of the town to show me the places where my ancestors had lived and ran businesses.

The Archival Library, right next to the castle

One day as I was wandering in the museum, I happened to meet a Canadian family of Estonian descent. (They kindly offered to translate an Estonian placard for me.) I later had dinner with them at La Perla, a fantastic Italian restaurant in Kuressaare owned by an Italian-American. When she found out that I had diabetes, the college-age daughter in the family began telling me about a friend of hers who also had type 1 diabetes. This friend once got a massage and felt so relaxed while driving home afterwards that she didn’t realize she had low blood sugar and ended up getting into a terrible car accident (although she wasn’t badly hurt).

I wasn’t planning on getting a massage, but I was worried about going low in the middle of the night. What would happen if I became unconscious and no one noticed? The more I thought about it, the more irresponsible I felt for not having altered anyone about my diabetes. Finally, I decided to tell the husband and wife who owned the hotel where I was staying what to do if my blood sugar went too low for me to deal with it my myself. It was definitely the most awkward moment of the trip; I had felt guilty keeping my diabetes secret, but I also felt guilty burdening someone else (especially someone I hardly knew) with responsibility. Immediately after I’d finished my explanation, I tried to reassure them: “But of course that won’t happen, it’s never happened to me!” And luckily, it didn’t.

At the end of my trip, I got to spent one day in Tallinn with an Estonian architect and her family. Tallinn has a fairy-tale-like medieval old city constructed on a hill overlooking the Baltic Sea. The architect’s office is in one of Tallinn’s medieval buildings, and I was stuck by the casualness with with she and her colleagues inhabited the space.

Last year the Tel Aviv marathon took place on April 24^th, on a relatively nice day (a humid 72 °F). The race started at 7:00 am and the first 3 hours were comfortable, but the last hour was very hot. A mid-May marathon in Tel Aviv could prove to be a total disaster weather-wise, since the temperature can be as high as 85°F.  And furthermore, postponing the race by a month and a half also messes up my training program (I’m not sure I can keep the intensity up for that long).  Generally speaking marathon training is a four month project (16 weeks is the minimum), Unless you’re a pro or  are one of those 52 races in 52 weeks guys like Tristan Miller whom I met the night before the Tiberias marathon.

So, like many others in my situation, I decided to look for another race to run in April and found the Rotterdam Marathon.  There weren’t all that many options (cost, distance….) and the Rotterdam Marathon has a good reputation.  RunnersWorld (international edition) even voted it of the top ten marathons in the world.  It’s a very flat course and it’s very cool. I’ve met people who have  run the Rotterdam marathon in past years, and broken their personal records. In my case that shouldn’t be too hard.

I’m happy to say that I was able to make arrangements easily to get to the marathon, and – I’m not going alone. A good friend of mine, Yaron (the guy who got me into running marathons) is going too.

I am very excited. I’m also a bit nervous. Running a Marathon abroad means travelling, and that is always tricky. I’m already worrying about what I’ll eat the night before and the morning of the race (the race starts at 11:00 am). When eating at home (or at your usual cafe or restaurant) there are few surprises. But eating away from home with diabetes, especially in a foreign country, you never know where your BS will end up.

Check out last years highlight:

Click here to view the embedded video.

This summer, I went on a two-week trip to Estonia and Latvia to do research about my grandfather’s family. I had originally been given a grant to do this last summer, right after I had graduated from college, but then I was diagnosed with diabetes in early July. At that point, I couldn’t imagine traveling to a foreign country–I panicked even when trying to estimate the amount of carbohydrates in a Cosi sandwich. Luckily, the people at Penn who had provided the grant were understanding, and allowed me to wait a year before taking the trip.

I’m convinced that a major reason why Estonia and Latvia aren’t bigger tourist destinations is because they were behind the Iron Curtain, and so remain unknown to many Americans. They are both beautiful countries. I spent the first week of my trip in Riga, the capital of Latvia. Riga’s medieval old city is surrounded by rings of parks, constructed after the city’s medieval fortifications were razed in the late 19th century. Beyond these parks is Riga’s truly unique feature–a sprawling art nouveau district that UNESCO has declared a world heritage site. You can walk for blocks and blocks and only see incredibly rendered art nouveau facades.

One of Riga's many parks

Art nouveau architecture...

Before World War II, Riga was home to a large Jewish population that included my great-grandparents and their children. By coincidence, I found out that the hotel where I was staying was in the same neighborhood as the apartment buildings in which my great aunts and uncles lived. I walked to each one and took photos–the building in which my great-uncle Isak lived is now a Ramada Inn!

The Ramada Inn

I also got to see some of Latvia’s countryside. For two days I went to Sloka, a town about an hour away from Riga by train. Here, my great-grandfather’s family once owned a farm and raised horses. Architecturally, Sloka is now an incongruous mix of small wooden houses and looming Soviet-era structures. Although quite a few of the Soviet-era buildings are crumbling and dilapidated, many of the town’s inhabitants have no other option but to continue living in them. As I took the train back into the city, I looked out the window at the fields passing by and caught glimpses of people picking flowers to make into wreathes to wear on St. John’s Eve the next day.

Sloka

After all my worrying, my diabetes-related challenges in Riga were few. Since I was only going to be traveling for two weeks, I brought all my supplies with me, in addition to prescriptions from my doctor in case I misplaced the supplies I had and needed to buy more. (I’m happy to report I never did.) My parents, who were curious to see the places their ancestors had lived, came with me for the first week of my trip. It was reassuring to know that, in case of an emergency, I would have two people with me who knew what to do. In addition, many people in both Latvia and Estonia are at least reasonably fluent in English.

Unlike some of the other ASweetLife travelers, I didn’t do anything especially physically strenuous. But I was walking all the time. Our hotel was half an hour away from the Riga’s center, we’d inevitably make the trip back and forth more than once a day–retrieving maps, going out to dinner, etc. And once we reached the city center, we would have to walk somewhere else. It felt great to get so much exercise without even trying, but then my blood sugar started to go low more and more frequently. Finally, I decreased my dose of Lantus, and the problem was solved.