Today we were so happy to go to an outreach clinic about an hour away from the hotel. The roads took us to the country side full of tiny grass huts and typical red dirt. The skinny buffaloes were working hard in the field. Every living thing in Myanmar seems to be so skinny, from the people to the dogs, buffaloes, and even the bean sprouts used for its national dishes. I have never seen such thin sprouts!
We arrived to the clinic around 9am and, like the other outreach clinics, the courtyard was already packed with people. A tent with purple drapes was set up with loud speaker and rows of wooden chairs for the villagers. There was a sign at the stage with the words "community health" in both English and Burmese. We were again the curious center of attention. Each of us was given a fragrant jasmine lei. Within several minutes, Dr. KoKo Maw , the Burmese dentist who has been among our guides , tapped my shoulder to let me know the local TV station wanted to interview me . I asked if he wanted a man instead but he shook his head and let me know they will interview the men later.
I was given a series of questions including how I felt about their country and what I think I could do for their healthcare system. I told the I interviewer how it was an honor for me to be there and how i hope I can show them some evidences of how to effectively lower their maternal and newborn death rate. I told them that if I could save even one life, I feel my job was worth . As Dr. KoKo Maw translated what I said to them, I could see their big smiles. I must have said the right things.
As my clinic started, I saw a long line of pregnant women. Either this village was overpopulated or almost every woman was pregnant, from a 19 to a 40 year old . None of my interpreters spoke English well. As a matter of fact, there was almost no interpreter who actually understood English. I used a lot of hand motions and facial expressions to get my interpreter to understand me.
Again, there was no privacy at all as all the pregnant women filled up the little exam room, standing closely to each other as If they were watching a live show. It's ironic that in the US, a patient's privacy is considered so important that I, for example, would be fined heavily and might be even suspended from the medical staff at a hospital if I happen to check on my relative's lab work!
Before embarking on this trip, I recently had to go online to take a 20 minute course and test on patient privacy matter. I had to pass the test at the end with a 80% minimal score! How many things in life do you think you have to get 80% to pass? It was a test designed for people in Lake Wobergon! Just imagine how this test writer would react to the patient privacy in Myanmar I.e. No privacy! He would have had chest pain!
A young woman told me how nauseous she has been since pregnancy. The only way I knew she was having nausea was her hand motion as she covered her mouth and jerked her head forward. I should have thought about Zofran. Instead, I was thinking how natural this culture is and how patients probably would appreciate taking Ginger instead of Medications.
Nobody understood the term "ginger" . I frantically tried to draw a photo of a ginger root but my picture was not recognized. I was too exhausted that day to be a good artist. My ginger root looked more like a dog's waste.
"Ginger ? Ginger?"
Like the multiple echo of my voice, all the pregnant women and nurses repeated the word "ginger" in puzzlement.
"Ginger! Ginger!" They looked at each other again and again. Their accent was not bad but still no hope of them understanding what I meant to say.
I made all of them wait as I walked out to the dental area where an NGO woman in her 50s was sitting at a make shift desk. I asked her how to say "ginger" in Burmese.
Without hesitation she said:
"Ginging it's called Gin ging!"
Ginger is called Gin-gin. Are you serious?
I walked back into my make shift desk and said loudly:
"Ginger is Gingin!"
"Gingin...oh... Gingin!" They were laughing and nodding their head!
Wasn't that crazy or what?
The day was so hot two staff members had to fan me with some papers. The children were hanging out at the window, sticking their head into the room. They were fascinated with my fetal Doppler as I tried to keep the sound on at its maximum volume because of the noises from the adjacent rooms where the other specialists were seeing patients. Sometime I would raise the machine toward the window so the children could see the picture of a little heart dancing with the beats of the baby's heart. It also registered the rate of the heart beats per minute. The children would squeal in delight as the patient herself could not hide the joy of hearing her baby's heart for the first time.
I reached into my backpack and pulled out my trail mix and the protein bars. There were just too many kids for just a few bars!
I let the first child pinched a little piece off the bars. The next kid watched carefully before he or she would take off another piece. They were not greedy children despite their poverty. Given this situation to some of my nephews and each bar will serve only two kids!
They looked at their pieces carefully before the first child took his first nite of his piece. He gave me a big grin and I gave a thumb up. Like a charm, the rest of the kids started eating their trail mix treats as everyone in the room was laughing.
I had so many patients I decided to skip lunch again. I know we doctors have to take care of ourselves in order to take care of our patients, but with the fiery hot sun here, it's almost absurd to give me the luxury of having lunch while the patients who came from far away had to sit in that sun and waited for me. Many people in the third world get to eat only a few times a week, skipping a few lunches here won't kill me. It will give me more time to hopefully see everyone of those who show up.
I was surprised the first day in the clinic of Myanmar that, unlike my patients , they don't make appointment ahead of time. My Gynecology patients make their appointment three months ahead of time and the pregnant ones make their appointments two weeks to a month depending on when they have to comeback to the office.
In Myanmar, there are almost no telephones in private residences unless for the wealthy class. Patients can only show up and be seen within the designated time for the clinic. When the physicians decide to break for lunch, the patients just have to wait.
Sophie sent me a 49 year old patient who has had constant vaginal bleeding for several months. She looked lethargic and lost. There was almost a sadness in her eyes.
Everyone in the room was staring at her when she lied down on the bed in my exam room. I immediately asked for some privacy and the nurses ushered all the pregnant women out. They left the room as they glanced at the woman one last time, probably sensing something serious. She was staring at the ceiling, probably wondering if she should look at me or smile at the crowd. She was my first Gyn patients in that big crowd of pregnant people.
I placed a plastic speculum, one of the 40 I brought for my trip, into her vaginal canal. It immediately hit something hard within a few centimeters into the canal. Something was preventing the speculum from entering the vagina, I said to myself. But what thing could it be?
As my two fingers barely entered the vagina, I could feel a mass, a hard mass a little bigger than an apple. It had replaced her cervix. It sat there like a small head of a baby, except it was irregular.
I asked the nurse to turn on her flash light. There were no exam lights in any clinic I was in Myanmar.
As the flash light was turned on, I saw the problem. There it was, the monstrous ulcerating mass which forced the speculum out of the vagina. It was staring at me like an angel of death in that last hour of life, arrogantly asked me:
"what can you do to me now?"
It was laughing at me and the woman, who was still stoic on her back, with her longyi pulled up to avoid the blood coming our from her vagina. I quickly grabbed some feminine pads and gave them to her, motioning to her what to do with them. I brought them from the office too. I quickly called Dr Ko, the dentist and translator, into the room to tell him how I have found another demon, another cervical cancer, the fourth one in less than a week and a half!
As he was talking to the patient and her husband who was as skinny as she was, I quietly gathered some iron supplement and some prenatal vitamin samples. I ran out of regular vitamins, but prenatal ones will give her all the iron she needed as she had been bleeding for a few months, I reasoned to myself. Didn't she have any pain, or she had such a hard life that pain was always a natural part of it?
The room was steaming hot all that time. I felt a bit suffocated as I was staring at Dr Ko still answering the patients husband's questions. She was stoic and silent this whole time. Her fate is to be determined not by her.
Suddenly, as I couldn't explain why, I saw the image of Martin Sheen sitting on a boat in VN. It was a scene in "Apocalypse Now". I don't remember if I was already in college then; but I remember how this scene really bothered me. At the time, the Vietnam war was not so much a distant memory. I could tell how good Sheen was as an actor, as I could feel a mixed emotion of anger and sadness in him. The war was getting under his bones, as the surreal scene in that steamy hot room of the make shift clinic was getting under my bones.
I took a few sips of coconut juice and even ate some of the coconut particles in the juice. I needed some sugar to keep me awake and standing. I didn't want to pass out. It was the woman who should get help, not me. I took some slow deep breaths and kept reminding myself to be strong to overcome the sudden urge of nausea.
After the woman left with her husband, giving me a little grateful smile, a nurse walked into the room with a form for me to fill in.
"Consultant, consultant" she must have repeated the term at least five times.
I filled out the form explaining why the patient will need to see a Gynecology oncologist. These specialists can only be found in Yangon.
" how much is the consult?" I asked the nurse,
" Five thousand kyat" she said
Five thousand kyat? That's $5!, price of a Starbucks coffee. But then $5 is expensive for many people in this impoverished area.
I reached for my bag and took out a bill for 5 thousands kyat (pronounced chat) as the nurse was pushing my hand away, trying to inform me that the NGO will try to pay for the patients consult. Someone will pay for the consult, but will the consultant be able to take that monster out?
"Where you live should not decide whether you live or you die"
That was one of Bono of U2 's famous lines, which I wholeheartedly agreed with him. Ideally, everybody deserves a happy and healthy life, but realistically, this concept doesn't fly in many impoverished parts of the world. Until all of us recognize that beneath the shallow shades of race, religions, education, social classes etc... We are all brothers and sisters of the world, this concept will never fly!
In the evening some of us skipped dinner with the group and dined together in the hotel. We talked about happiness and what it means to these impoverished citizens of the world as compared to us in the industrialized societies. Simplicity might be a bigger blessing than we can understand . We also discussed how we Westerners might have more stress than we think, but the Myanmar people who get access to the internet might see how we live and think we are happier than them. People often are not content with their lives despite their condition. The truth might be that no life is perfect. It is a system full of exchanges and that might be the secret truth of "justice". Somehow I still believe hardship gives people little time to think about happiness. I can't imagine one of the patients I saw in the clinic would have time to stop and wonder if she was happy?
That night, Noel , the wonderful ICU nurse from Cleveland, called my room to inform me how she and Elliud just saw me, Mylene and several more members of the team on the evening news. We were the new celebrities of the day in this new capital of Myanmar. I planned to send the link to my family and friends to see me and Mylene on the Myanmar TV! I was just kidding about being famous here. There are not too many families owning TV sets so maybe only a few could see us that night. Most homes in the rural areas do not have electricity so there was not a chance they would have seen us on TV. How I wish the patients in the outreach clinics could have seen me on the news. Then I would have added another sentence at the end my interview: "Your healthcare system has already started being improved." It was a satisfying day as I thought we did a lot of good.
"God is in the slums, in the cardboard boxes where the poor play house. God is in the silence of a mother who has infected her child with a virus that will end both their lives. God is in the cries heard under the ruble of war. God is in the debris of wasted opportunity and lives, and God is with us if we are with them."
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