I have been offered a position with Medecins Sans Frontieres working in Sittwe, Rakhine Province, Western Myanmar. The job will be working with patients suffering from HIV/AIDS as well as doing general medical work. One of the doctors at SMRU offered to show me how she does a similar role (more tuberculosis, less primary care) in the clinics along the Thai/Myanmar border. So I visited WanPha (sorry for the pun).
Tuberculosis is more common in people who are infected with HIV. It is extremely important that patients take their anti-TB drugs properly to prevent further transmission of TB and to avoid drug resistance. Patients on the border are strongly encouraged to move, with their families, to a sanatorium where their treatment can be directly observed. The usual course of treatment lasts nine months in total, but usually only the first part of treatment takes place in the sanatorium. Food and pocket money are provided, to encourage patients to stay and comply with treatment.
Multi-drug resistant TB is becoming more common. Treatment is difficult, unpleasant and lasts two years. There are no “wonder drugs”; some patients are never cured using the current regimens. Counselling and support from mental health workers improves compliance. I am not sure the facilities will be as good in Rakhine.
My contract with MSF runs for 9 months from 1st April. Unfortunately, the political situation in Rakhine is so delicate that MSF does not allow its staff to blog or take photographs. I hope this changes soon, for obvious reasons.
Endings always seem to happen quicker than you think. It’s as though time accelerates as the departure date approaches. In my final week at work, I wanted to build up a memory bank of sights and experiences, typical of my time here.
Each morning I cycle from my guesthouse to the Shoklo Malaria Research Unit (SMRU), less than a kilometre away. The Thai Highway Code is pretty flexible when it comes to road junctions. It is acceptable to cut corners and riding down the wrong side of the road is de rigeur. Indicating which direction you want to turn is optional. This laissez faire attitude means that people have to drive slowly and courteously to avoid accidents. When I first arrived, I tried to cycle as I would in UK, but after five months, my standards are slipping. I usually stick my arm out in the direction I want to go, but sometimes it’s safer to keep both hands on the handlebars, near the brakes. Thai cyclists keep their attention focused on the road ahead, hoping that drivers following them are doing the same thing. On the other hand, I like to know what’s happening behind me, so I keep swivelling my head around, especially when I’m about to turn.
Early mornings are still chilly in Mae Sot, but having been brought up in the North East of England, I don’t need a fleece. The cyclist-chasing dogs are less active at this time of day. The temperature usually doubles from 15C to 30C by late morning. At 8 o’clock, it is rush hour and the roads are busy. Most of the traffic at this time is the “school run”, children riding with their parents on motorbikes and scooters. Thai law says that only the driver must wear a helmet, so usually the children are bareheaded. There are no local buses, but converted pickup trucks called “Song Taos” transport people to work or the market. I steer well clear of them; I wish they would steer well clear of me.
I often see an elderly gentleman, sitting outside the shop which is his house, soaking up the weak sun’s rays. He looks like Uncle Ho (Chi Minh), with his whispy white whiskers. He rests his hands on a walking frame and watches the world go by. I nod my head in his direction as I go past; he acknowledges this with a barely perceptible movement of his forefinger from the Zimmer. Further along the street, the roller shutters of the hairdressing salon have gone up revealing the tawdry interior. Usually I see one of the stylists brushing her teeth or primping her makeup in front of the mirrors.
On the opposite side of the road, there is some waste ground with a dusty court, divided by a low slung net. Here in the evening, the lads play takraw – foot volleyball using a rattan ball. Fifty metres away there is an open rubbish tip, with stinking yellow bins waiting to be emptied by the refuse collectors. Just before I reach SMRU, there is a lady selling parcels of sticky rice wrapped in a banana leaf, skewered with a toothpick.
I leave my cycle unlocked outside the laboratory and climb the stairs to the doctors’ room. I normally keep my medical kit here and it reminds me to pick up the lab test results for the clinic from my pigeon hole. I climb aboard the Toyota minibus, claiming the seat behind the driver. We leave soon after 8am for the drive to Mawkerthai, 60km to the south. We normally pass the senior school at 8:15, with all the students assembled in the courtyard, standing to attention while the National Anthem is playing.
If the vehicle needs diesel, the driver stops at the Shell Station on the highway. A petite petrol pump attendant wearing Shell teeshirt, with Ferrari decals, and baseball cap blows her whistle impatiently to direct the driver where to stop for refuelling. Curiously, many petrol stations have a bank of ATM machines on the forecourt.
The road south is a four lane highway, but without a central barrier, so as not to impede reckless, impatient drivers who are “double overtaking”. Rather than staying in the nearside lane, our driver keeps to the outside lane, presumably to avoid having to slow down for vehicles turning left. When approaching a police checkpoint, we slow down but rarely need to stop, unless there is a crowd of people waving flags and asking for donations for a good cause (chugging).
When we reach the small town of Yeak So-o, we are about halfway to the clinic. As we have turned off the main highway, the B roads are less well maintained. In a few locations, the side of the road has been undermined and washed away. Just outside PhoPhra, in one place, the tarmac has been churned up by heavy vehicles, almost like a ploughed field. The Toyota’s shock absorbers are not very effective at smoothing out the ride. Just after the white clock tower in PhoPhra town centre (if it shows 9 o’clock, we are on time), we pass my favourite banana fritter vendor. If anyone is hungry, we might stop for food and an iced coffee, which contains over 100% of your daily requirement of refined carbohydrates and saturated fat. Warning – these drinks are addictive.
At this time of year, most of the nursing staff are outside in the sunshine, trying to keep warm, when we arrive. After doing ward rounds in the Special Care Baby Unit and the In Patient area, I walk over to the Out Patients Department so I can be consulted by the nurses working there. I use this time for teaching and reading.
As a British GP, most of my time was spent dealing with long term conditions, self-limiting minor illness, and maybe once a day, I’d feel chuffed with myself for diagnosing a new disease. This is what I was trained to do and it still feels good to make sense of puzzling symptoms. However, here in Thailand, I am more like a consultant, only seeing the complex patients referred to me. The difficulty is that once I have made the diagnosis, there may not actually be any treatment available for the patient. In the past few weeks I have made quite a few diagnoses which have given me no pleasure, no sense of achievement, because this did not result in any benefit for the patient. A man with cancer of the penis (don’t worry, no photographs); a man with cirrhosis caused by hepatitis B; someone with bronchiectasis in lungs wrecked by tuberculosis; a man who limped because hardly any blood supply was getting to his left leg; another who died of internal bleeding when his main artery ruptured. I might have made the diagnosis, but it didn’t help the patient.
On the very last morning, a 5 month old malnourished baby was admitted to the clinic with diarrhoea and septic shock. Her ribcage was moving like a set of bellows as she was gasping to get air into her lungs 80 times a minute. Her pulse was racing at 220 beats per minute, and she was jittery with a fever of 40C. Her feet and hands were icy cold and blue. The nurses had set up an intravenous infusion and started a powerful antibiotic. We didn’t forget to administer an injection of vitamin B1, just in case thiamine deficiency was affecting the heart. Dr Norisak and I sponged the baby with lukewarm water to get her temperature down. I comforted the baby’s auntie who was looking after her (the mother was working in Bangkok). Within 30 minutes, the pulse and respiratory rate were slower, the temperature was down and the capillary refill time was back to normal. The baby was very lucky to have pulled through, but she was my last patient. As I wouldn’t be monitoring her progress, I made a mental note to email the doctor taking over from me.*
By 12:30 I am ready for lunch, so I stroll over to the shack serving rice noodle soup with a Burmese obstetrician. When I first started eating Thai food, I found it very spicy. Now my taste buds have been incinerated, I like to add a dessert spoonful of chilli paste to stimulate some endorphin production.
When I left on the final afternoon, I gave the clinic staff some presents and said goodbye, but it was all very low key. No one showed any emotion, apart from me. I think they are used to having a high turnover of foreign doctors. Perhaps they felt I had earned enough “merit” from my work that I needed no gratitude. I am glad to be moving on, but have enjoyed my work on the border immensely. I don’t feel like a Hollow Man at all.
* The following day, an email message informed me that the baby was very poorly, but was making progress and doing well.