Chloé Perdrix writes: Myanmar, an amazing experience

Discovery of Myanmar’s (Burma) primary care, an amazing experience !

After Vietnam and Laos, we decided to visit Myanmar to discover this country which is known for its wonderful and preserved landscapes, very welcoming population and rich and unique history and culture.

I contacted with Dr Tin Myo Han three weeks before our arrival. This permitted enough time to plan meetings with Myanmar GPs in Mandalay, which is in the north of the country, and Yangon, the main city in Myanmar. Dr Myo is a Myanmar family doctor who works in Malaysia, and whose family lives in Yangon. She is the secretary of international relations of the Myanmar GP Society and Myanmar representative on WONCA Asia-Pacific region council.

Thanks to Dr Myo, we were put in touch with Dr Mie Mie, who lives in Mandalay, however at the time of our visit she and Dr Myo planned to be at the Asia Pacific region conference in Chinese Taipei. Therefore, we had the great pleasure to be welcomed by Mandalay GPs led by Dr Mg Mg Than and Mr Mie Mie’s daughter and husband. Her daughter, Nho Nho, is a medical student in her 5th year of studies, and her husband is a family doctor.

In Yangon, I also met Dr Min Zaw and Dr Myint Oo,, and a lot of GPs involved in the Myanmar Medical Association (MMA). All these colleagues helped me discover primary care in Myanmar, as well as cultural and touristic places with such a positive energy and helpfulness!

Photo: Myanmar Medical Association's team in Yangon

Here is what I learned from them :

Myanmar Health system

There is no public health insurance in Myanmar, and the health system is hospital-centric. What I observed is that charity based primary care in Myanmar is unique and is mostly organised without any government support and exists thanks to donations, from Myanmar people or the Buddhism religion.

We visited:
- a women’s health center, in Mandalay, run by a NGO named MMCWA. There, pregnant women can be followed and can deliver for free, in good sanitary conditions. If during the pregnancy or the delivery, midwives or doctors diagnose a complication, they refer the woman to the Central Women’s Hospital, run by the government. The women’s health centre provides some 300 uncomplicated deliveries per year. Dr Mie Mie works here as a family doctor.

- A Buddhist health centre in Mandalay where patients have access to some medications, as well as to general practitioners, or ophthalmology consultations for free. Doctors can also practice minor surgery and ophthalmologists can operate their patients for cataracts. There are 16 nurses and more than 18 doctors.

A Buddhist temple also funds a school and a library in the same area. It also provides food and beds for children who go to this school.

- The “U Hla Tun (hospice) Cancer foundation (Mandalay)” provides health care and palliative care for patients with cancer who cannot afford to pay for their treatment. They can sleep and eat in this place, have painkillers, and nursing care. They only have to go to hospital for their cancer treatments such as chemotherapy or radiotherapy. They can stay free for as long as they need, or until they die. Funeral fees are also free of charge.

- An aged care home in Mandalay where older people are selected according to their poverty and isolation levels. Isolation is pretty rare in Myanmar, since families live together in the same place, thus, one can imagine how difficult the life stories of these older people are.
Women and men are separated.

Three nurses work there and three doctors come if needed as volunteers. The place is very peaceful with a lot of space and nature. They also have a place to pray with a statue of Buddha.

A special paragraph for Hanthawady U Win Tin Foundation : a health center for former political prisoners.

I visited, with Dr Win Zaw, a Health centre for former political prisoners named Hanthawady U Win Tin Foundation. It is funded by The National Health Network, the health part of the National League of Democracy, a political party led by Daw Aung San Su Kyi. Its mentor is U Win Tin who endured brutal torture during the Burma military dictatorship and devoted himself to the democracy of Burma and development of human rights. After 20 years of imprisonment, he then devoted himself to help and rehabilitate former political prisoners.

He founded this health centre in 2012, soon after his release from prison. Since then, this foundation has helped 1135 political prisoners. It has helped them to find jobs and has provided primary health care to their families. The founder, U Win Tin (photo at right) passed away in April 2014.

Patients suffer particularly from post traumatic stress and physical consequences like blindness or chronic pain.

What does the daily life of a Myanmar GP look like?

In the morning, the doctors I met often practice in associations or factories, or in their private clinic. From 1 to 5pm, they provide voluntary work in NGOs, or for Myanmar Medical Association. Then, they practice in their private clinic from 5 :30 to 8 :00 pm.

During their private clinic working time, they provide medical care for 2.000 to 4.000 Kyaths per consultation in average (1,65 to 3,30 euro = 1,82 to 3,64 USD). They spend about 5 to 10 minutes per patents in a consultation. I was surprised that patients asked often that doctors give them medication by intra muscular or intravenous injection - even for benign diseases. In France, we use this kind of formulation, but only for very specific cases.

I suppose Myanmar population has just emerged from a long dictatorship, so they must have lived hard moments. They consequently need a painful and invasive way of medicine administration to feel that it will work. But this is just a supposition of mine, and I don’t know if it is true.

In their office, general practitioners also dispense medication.

Even though the consultation fee is not expensive, for a lot of Myanmar citizens, this represents a big part of their daily budget. They must pay every cost from their own pocket because there is no public health insurance in Myanmar.

Therefore, Family doctors are currently faced with the problem of often being unpaid, as poverty in Myanmar is very common.

Medical Education in Myanmar

Dr Mie Mie’s daughter, Nho Nho was in final year of medical school. In Myanmar, one finishes high school at 16 years old. Medical school is five years long. Then, they have one year compulsory as an intern/ house officer in government hospitals. The newly graduated doctors who get an appointment in government health services have the opportunity to select their medical specialization from among the 66 different ones in Myanmar. The doctors in private health sectors can only specialise as GPs which lasts one year and it is non compulsory. Other specialisations last three compulsory years.

I spoke with Nho Nho and medical students who attempted extra courses in a private school to prepare and coach them for final exam in Yangon. The majority admitted that GP specialization was not their first choice.

Actually, this opinion, which seems to be shared by most of medical students in Myanmar, can be explained. Indeed, family medicine development in the health system is not the priority of the government. There are no independent family medicine departments in the three universities teaching family medicine - sometimes as part of community medicine.

And to top it off the first years of working as a family doctor are very hard because young doctors have to buy their own clinic and then pay it off for about 15 years. To manage to repay their debts, they have to work on average 10 hours a day without any government financial support and in precarious conditions (direct contact with poverty, free consultations when patients can’t pay…).

How can a young medical student can be attracted to the family medicine specialisation when family medicine is not attractive ?

Fortunately, things are changing. Some engaged GPs like Dr Myo Myo, Dr Mie Mie, Dr Nay Myo Oo, Dr Mg Mg Than or Dr Min Zaw are fighting to get family medicine to be more attractive for young doctors, and recognised by government. They recently created a GP society named MAFP (Medical Academy for Family Physicians).

When I was in Yangon, I attended a meeting of this committee. They were discussing about their future education to be family medicine teachers, which would be held by a Taiwanese teaching group. They agreed to train a total of 20 Myanmar GP trainers for one year for free.
International solidarity in family medicine doesn’t end here. Indeed, the RCGP (Royal College of General Practitioners), RACGP (Royal Australian College of General Practitioners), WONCA, Boston University and GUEST (also from Boston) have provided free teaching and funds to organise two family medicine conferences, in Myanmar. The most recent was from the 11th to 15th of February 2014 and the earlier one was the 4th and 5th of December 2014.

Public health problems in Myanmar

I observed in Laos, Vietnam and Myanmar that some people had red lips and teeth. Actually, I have finally understood that it is because of Betel nut chewing. Betel leaves have addictive properties, like tobacco. They mix them with lemon and betel seeds. This is a real public health problem because ingredients give strong addiction and are carcinogens. A lot of people chew it from youngest adults to old people. Futhermore, you can add opium leaves to it, which adds another addiction.

Tuberculosis is also a big public health problem in Myanmar. An association named STOP had had a campaign of prevention, screening, and treatment of tuberculosis to get rid of it in several countries. Myanmar is among them. GPs I met in Mandalay participated to this program, and provided drugs and consultations for free to patients with tuberculosis, every 10 days.

Myanmar culture

Myanmar has a very unique culture.

Politics takes a very important role in Myanmar people’s life. Indeed, the country and its people are still struggling to have the democratic constitution which will give a hope of prosperity and happiness to Myanmar citizens.

I can’t write this article without talking about one of the most popular political parties which is the main opposition party The National League for Democracy (NDL) presided over by the famous Aung San Suu Kyi, General Aung San’s daughter. General Aung San was a very important man in Myanmar history because he was the man who negotiated Myanmar independence from British colonialism, in 1947. Photo of posters of General Aung San and his daughter, Aung San Suu Kyi

Aung San Suu Kyi has been kept under house arrest (locked in her house) during the military dictatorship and was released in 2011, after 15 years of captivity. She is very popular in Myanmar.

Buddhism is also a very important part of the life of Myanmar people. Myanmar is the country of the thousands pagodas all covered by gold. (see picture of pagoda in Hpa Han)

Men’s clothes are composed of a white traditional shirt on the top and a Longyi to cover their legs, which is a piece of material that they wear as a skirt. Women also wear skirts with more tonic colours, and a top with the same motifs as their skirt. Women make up with "Tanaki" on their cheeks as in the photograph.

Myanmar has also a big historic aspect such as the Bagan temples, which were built during the 13th century, as was Angkor Wat in Cambodia, as well as the Royal Palace, in Mandalay, where kings lived until they were sent into exile by the British colonisers. There is also a lot of old English architecture in the buildings, in Yangon.

I hope this long article interested you.

Next time, I will talk about primary care in India.
See you in two months !
Chloé

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