A quiet voice of comfort

Originally published in C2 Focus - The Nation; Bangkok, Thailand

Manas Intarasak, an elderly monk, shuffles quietly along the corridor of the 10th floor leading to the Ear Nose and Throat (ENT) cancer wards at Suandok Hospital, Chiang Mai University.

He crosses the broad entrance leading to the first communal room with some ten cancer patients resting in their beds. He begins his rounds, as he does every Saturday morning, step-ping up to the bed of the first patient.

The patient is an elderly woman who recently had her voice box removed in a cancer operation (a "Iaryngectomy"). Laryngectomy patients can be easily recognized ... they have a hole in the middle of their throats about the size of a small one-baht coin in order to help them breathe. And, as their voice boxes have been re-moved, they are no longer able to speak.

Upon seeing the monk, the elderly woman wais him. Manas leans over the bed and talks gently to her. Other patients nearby turn to catch what he is saying. Several of them struggle over. Even the children shift their attention from the television to the monk. Laryngectomy patients especially, turn and move towards him. It is for them that Manas comes most of all.

At first glance Manas seems neither singularly outstanding nor in any way remarkable. His attire, manner and bearing are all indistinguishable from other members of the Buddhist clergy. What separates Manas from other monks, however, becomes obvious on closer inspection of his neck. There, clearly visible, like a polished silver piece, is a cavity or "hole" in the lower part of his throat. This small opening offers the most telling detail of Manas' recent life.

Nine years ago Manas came to the ENT department at Chiang Mai University complaining of hoarseness. Diagnosis revealed that he had cancer in his voice box (larynx) that had grown to such a size that it prevented his vocal cords from moving or vibrating normally.

Like a crab, the cancer had plunged its pincer claws into the delicate folds of his larynx and the effect was to lower the pitch of his voice. When he swallowed, the crab again made its presence felt; the pincers edged in a little more, impaling yet deeper layers of the fragile muscles of his larynx and causing pain that would pierce him like a dozen tiny daggers.

That had gone on long enough for the monk. The sacred mantras, meditation and blessings had soothed his own mind but had failed to impede the relentless march of his cancer. Manas quickly moved into the hospital. Any further delay would only mean the fearful disease tightening its claws on his larynx, before. advancing into heretofore untampered domains: the adjoining throat or possibly the lymph nodes of the neck.

A day after his admission to the hospital, Manas had surgery to remove his cancer-doomed voice box. But his recovery was swift. Within two weeks he returned to his temple. A monk without a voice, unable to offer the timeless alms of Buddhist wisdom to the laity who came seeking spiritual advice. His legacy of guidance was now banished to the stony silence of his meditation.

Despite his adherence to the eight-fold path, a shadow had decidedly muted this transient existence. A nidus of frustration had cloistered itself in the spacious centre of Manas' heart.

But implanted though it was in the fertile substrata of Manas' soul, and rather than corrode the sturdy foundation of his Buddhist worldview, the frustration would metamorphose into something else: a promise; a crystal of resolve. in the chemical transition of that inner change, a lotus flower would blossom instead.

A small crowd of patients, including all the laryngectomy patients able to get out of bed, gathers around the monk. An impromptu dhamma (Buddhist teachings) session, led by Manas, forms in the corridors of the ENT wards. There are no Buddha images, incense or candles in this hospital floor turned temple but it makes no difference. A seat is brought for the elderly monk to sit on.

The patients perform a triple wai upon approaching the monk and then sit before him. The younger patients too participate, usually sitting in the laps of, or alongside, one of their "aunts" or "uncles." After everyone has settled, Manas grasps a small metallic tube-like structure and switches it on.

It creates a faint vibrating hum, barely perceptible. He places one end of this device against the skin of his neck just slightly below his jaw. He then begins his sermon.

The words sound something like a cross between a frog in heat and an android. The words, though, are intelligible. Even the subtle tonal shifts of the Thai language, which can alter totally the meaning of a word, can be appreciated by the listeners. But the words have a disembodied, robotic quality. It is not an inspiring or soothing sound, but it is speech. Ideas can be expressed.

For someone without a larynx and otherwise silent and isolated, it is a godsend; a chance to resurrect this essential aspect of their lives. However metallic, artificial or disconsonant it may seem to others, for both speaker and laryngectomy patients listening, it is opera. The speaker is no longer internally exiled in his own world, unable to verbalize.

The device Manas is using is known as an "electrolarynx." It is a vibrating instrument that when held to the skin of the neck picks up resonances created in the throat and oral cavity as the speaker "mouths" the words he wants to say. This instrument, because of its expense is not available to most of the laryngectomy patients in Thailand. However, there is still another option for them.

Manas is discussing Buddha's teaching. Despite the otherworldly quality of his voice his audience remains rapt. Their eyes do not shift restlessly around and no one is yawning. After a while, he removes the electrolarynx from his neck. He then begins to swallow air and "belch" it out while articulating the sounds he wants to make, again resulting in recognizable speech.

This technique, referred to as "aesophagal speech" is equally or more effective in speech production because it creates a more human sound. It is far from being completely natural but it is an improvement. And it doesn't cost a single baht. However, it involves greater effort to master. Both techniques in fact require much forbearance and many patients give up in frustration, unable to create effective speech.

Manas alternates fluidly now between the two methods. He is a virtuoso. He even manages a joke or two bringing laughter from his captivated audience.

Manas' sermon is not unlike sermons taught by other monks. What makes it a particularly patent jewel of encouragement however, especially for laryngectomy patients, is that it is being delivered by someone who has survived the ravages of larnygeal cancer (for nine years now) and gone on to master speech production.

While expounding on the teachings of Buddha is inspirational enough, coming from someone who has had his voice box removed endows his sermon with even greater force. . Each word he speaks is imbued with not just the theme of his - sermon but with the seductive suggestion that cancer of the larynx can be survived and that it is possible to recreate speech. A full life is still possible.

He offers the Buddha's teaching with all its seminal sparks of insight and transcendence; but beyond this he bestows to the patients, by his own personal example, the belief that they too can resume their productive lives again.

In Thailand, cancer of the larynx is one of the most common cancers. Early problems with the larynx can often be treated with radiation so that the voice is preserved. But as most of the patients in Thailand visit the doctor at a very late stage in the course of' the disease, extensive surgery including removal of the voice box is usually required if the patient is to be cured.

Removal of the larynx and subsequent loss of voice is probably one of the most feared consequences of cancer surgery. The reason is obvious: it is our principal form of communication. The ability to express ourselves verbally is what makes us distinctly human.

Take this one step further and realize that many of the older Thai patients from rural areas cannot read or write. They are therefore totally dependent on speech for communication. Perhaps for their livelihoods. Many patients refuse potentially life saving surgery because of their reluctance to part with this essential organ.

Consider further the psycho-logical aspects of loss of voice. The voice is not just speech, it is also sound. Not only does the voice transmit bits of information, it also communicates a background texture within which that information is conveyed. Our voice, its quality and rhythm, its musicality and modulation is an integral part of our message and, more broadly, our total being. Its loss then separates us from an essential component of our identity.

Manas soon finishes his rounds. He has stopped, if for only a moment, at the bed of almost every cancer patient in the wards. He then walks down the corridor to the elevator, feet bare, with a walking stick in his hand. He has tended to his flock in a manner befitting a spiritual leader with a common problem to share.