Reflections from the Thai/Burma border – Part 2, the Mae Tao Clinic, work activities:

My introduction back to the Thai/Burma border began with my nonstop flight from New York to Bangkok. For the first time I was able to clearly see almost the entire landscape of Burma. We flew directly over the heart of the country in our approach to Bangkok, following the majestic Irawaddy River south as it pierces the country in two on its way to the sea. I could make out the ancient city of Mandalay in the north and the outskirts of the former capital Rangoon to the south as we banked to the east toward Thailand. The massive Irawaddy tributary system could be seen fanning out across the barren and brown landscape. Finally, the landmark I was waiting to see appeared in the distance, the sawtooth Dawna Range in Eastern Burma. These 8000’ mountains create the imposing barrier and lush, thick forests of Karen State – the only remaining ethnic group still actively opposing the Burmese military junta. This tumultuous area is the reason I am returning to the Mae Tao Clinic after leaving there less than 12 months earlier. The Karen compose the vast majority of medic staff and patients at the clinic, most of whom have survived horrifying travel through these dense forests now recognized as the most heavily landmined area of the world.

Just over the east side of the Dawna Range I could see the Moei River, which provides the north/south border between Burma and Thailand for most of the Karen State. During the current dry season the river can literally be walked across without too much difficulty. Islands appear that are referred to as “no-man’s land” because no country can lay claim to them. Consequently, everything and everyone can be sold at will. But this same serene river becomes a raging torrent during the rainy season (May-October), and claims many lives that attempt to escape into Thailand. Mae Sot is the biggest and most active town along this border, and therefore is home to many illegal migrants, and a major depot for the trafficking of narcotics, gems, teakwood, and people. Because it is also a central outpost for the 9 refugee camps along the border, Mae Sot is also home to at least 50 non-governmental organizations (NGOs) providing comprehensive relief services to refugees and migrant workers along the border. Officially, there are just over 140,000 registered refugees living in camps along the border, but over 2 million Burmese are thought to be living along the Thai side of the border as illegal migrants. Since 1989, Mae Sot has also been the home of the Mae Tao Clinic, founded by Dr. Cynthia Maung when she fled Rangoon during the 1988 student uprising and traveled by foot for 10 months to open a “temporary” clinic for those fleeing the military crackdown. While she intended to return in 6 months to her young physician practice in Rangoon, 19 years later the clinic now has a permanent staff of over 300 medics and other ancillary workers – and like her, all of them “illegal” Burmese migrants without passports. Over the years, in response to the growing caseload and changing type of patients, the clinic has grown from an emergency health care provider to a comprehensive health care clinic. For the past 2 years, over 100,000 patients have visited the clinic per year, and in that time period the percentage of patients coming directly from Burma has risen from about 30% of patients to now over 50%. The patients who make the dangerous journey from Burma tend to have much more severe illness than those from Thailand. An acute spike in patient visits has certainly occurred since the September 2007 monk-led demonstrations and resultant military crackdown. The clinic offers a wide range of health and social services: over 200 inpatient beds (divided between adult, children, and OB-GYN), over 300 outpatient visits per day, surgery, reproductive health, child health services, laboratory/blood bank, primary eye care and eye surgery, prosthetics and rehabilitation, HIV/AIDS prevention, malaria management, migration health outreach services, schools for migrant children, boarding houses for children separated from their parents, and supports two clinics in Karen State just across the border. One of the major functions of the clinic is to be a training center. People from diverse ethnicities in Burma come to the clinic to train as health workers, or to upgrade or specialize their existing health skills. They then return to the border regions of Burma to provide much needed health services in rural or war-affected areas. This is one very important way for the clinic to save lives – to strengthen the ability of local health care workers inside Burma to provide health care.

Although I had only been away from the clinic for just over 11 months, I could not believe how much it had grown. The staff had grown from 200 to 300, more buildings had been erected, and many long-term westerners had been sponsored by NGOs to work in varying capacities of public health services. It was obvious the clinic had reached that critical point where its reputation had become widespread, and now was in a position to greatly expand and utilize the many requests of volunteers and sponsors that were increasingly calling. Dr Cynthia continues to be the recipient of major awards around the world, which certainly enhances the reputation and recognition of the clinic world-wide. This past November she was the winner of the 2007 Asia Democracy and Human Rights Award, given by the Taiwan Foundation for Democracy. The purpose of the award is to support democratic development and promote human rights throughout the Asia-Pacific region. The award committee duly noted Dr Cynthia’s dedication to training and educating refugees in order to build a community based on respect for life and human rights. The uniqueness of the clinic is that it not only provides medical care to patients but it also provides job training, social services, health education, child-protection services and community-building activities. In the past decade the Mae Tao Clinic training has brought community clinics to over 125 villages in Eastern Burma. For the first time, these villages finally have had access to Vitamin A to prevent blindness, vaccines, de-worming medications, anti-malarials and crucial antibiotics. The clinic also trains medics for the renowned Backpack Health Workers Team. This heroic group has grown to 75 teams of 3-5 people that go undercover through the jungles of Eastern Burma carrying 100 kg (over 200 pounds) of medical supplies for 6 months at a time. Each team is responsible for the provision of primary and preventive care for approximately 2000 people. Many times they travel in great danger due to landmines and the Burmese army. Unfortunately in the 8 years of their existence, 7 medics have died during their duty of providing care, some from landmines and others at the hands of the military junta.

While my first impression back at the clinic was on how much it had grown, my personal effect was in the relief of having virtually no “learning curve” on the vagaries of the clinic and the area. This was made readily obvious to me on my first day back at the clinic when I was asked to attend a meeting, and found myself understanding and contributing information at a level that took me about 3 months to reach during my first tenure at the clinic. One benefit of things moving so slowly here is that you can be away for an entire year, and not feel you’ve missed anything. As I look back at my time at the clinic last year, I’m thankful that I took 2-3 months to understand a bit about the workings of the clinic and allow myself to hopefully mesh with the staff. I found I wasn’t really able to contribute anything of significance until my last 2-3 months of work at that time. I certainly won’t have that luxury this time around! I have a very specific role in this tenure at the clinic, and that is to develop and help open a new central pharmacy for the entire clinic. The clinic currently has only an outpatient pharmacy and a tiny storeroom where overflow stock is kept. Each department has their own little pharmacy and a person responsible for ordering medications for their department every 3 months. It’s a similar philosophy to the way the rest of the clinic operates, almost as if each department is their own little fiefdom. While this does allow for great independence on the part of the medics in charge of that department (part of Cynthia’s goal is to promote empowerment), it has created some inefficiencies and potential areas of concern for medications.

Because each department has their own budget and wide latitude on how to use it, medications can be ordered very differently from one department to the next. In addition, if an emergency medication is needed and not available at the clinic, each department has had the ability to go to a pharmacy in town or Mae Sot Hospital to purchase the drug they need. After spending many years working in hospital pharmacies, I can be fairly confident in saying this is one unique way to procure medicine! While I continue to remain very sensitive to the cultural issues at hand with every decision made here, it was obvious to me and thankfully to Dr. Cynthia that the system had to be changed. So, she specifically asked if I could come to the clinic during this time period when the old kitchen (over 1500 square feet) would be renovated for use as a new central pharmacy. She also asked one of the refugee camp supervisors if they would let Po Tha Hay return to the clinic for at least the next 6 months to help with the transition. Po Tha Hay is one of the best pharmacy medics we had and was wallowing away at a camp awaiting potential resettlement. One of the travesties of the resettlement process is the forced placement of people into a camp while they wait they turn for resettlement interviews and placement. During this period they cannot work and have no guarantee that resettlement will even occur for them. So, it has been good to see Po Tha Hay return and help the pharmacy manager Naw Klo prepare the staff and the rest of the departments with this major transition of medication delivery.

Soon after my arrival we began work on a new pharmacy database with the tremendous help of a Thai pharmacist-turned-computer programmer who has volunteered her time at the clinic on weekends to not only assist with the database development but also training of the staff. The goal is to now have all inventory in one central pharmacy location, and each department will order weekly from the pharmacy and have their order delivered the next day. The central pharmacy will then be solely in charge of placing the quarterly inventory order with our wholesalers in Bangkok, and be the only people involved in the procurement of emergency medication from other local sources. We’ve modeled the program to allow each department to still be able to use their Excel ordering system (ably developed by my Global Health Fellow predecessor Anne Joly) that they are familiar with each week, and it will be automatically networked into the central pharmacy where it will be imported into an Access database, seen by the pharmacy personnel and allow them to fill the order. We have designed the system to alert for minimum quantities of each drug for the entire clinic and to bump up to the maximum amount of drug automatically to ease the process of completing the quarterly order from the wholesalers. We’re hoping this system can not only provide more control over the inventory, hopefully saving the clinic money and monitoring expiration dates, but also put systems in place for the proper “paper tracking” of where the meds came from and where they were dispensed. Due to the varying quality of medications in Southeast Asia, and the huge issue of counterfeit medicine, the Thai Ministry of Health has put into place some fairly stringent requirements for the documentation of every lot number of every product received and a certificate from the wholesaler that the manufacturer has been approved by the Thai Ministry of Health. We’ve included these provisions into the database, so again we’ve tried to anticipate not only a potential audit from the Ministry of Health but also to assure the many clinic donors that medication procurement is safe and efficient. The thought of our primitive clinic having a central pharmacy electronically networked into every department still amazes me. However, I’m snapped back into reality every time I look at the scrawny little cable that weaves through the trees connecting each tin shack building . . . that’s our network! A small bird could easily knock out our “network”, but until that moment happens, we’re forging into the technological age.

So, now that all the technical stuff has been completed, you might ask how is the progress of the actual pharmacy construction? Well . . . next question please . . . Actually it’s moving along quite briskly right now – of course one needs to keep in mind the nature of the tools and materials used here to know what “brisk” really means. The pharmacy construction couldn’t get started until the new kitchen was completed because the old kitchen will be the new pharmacy. This process took a bit longer than I was anticipating, and apparently than what Dr. Cynthia was anticipating as well. After seeing no progress during my first six weeks here, I casually mentioned to Dr. Cynthia that I was getting a bit concerned I would have to leave before the pharmacy would be finished. That morning she contacted the clinic construction supervisor and asked him to come speak to myself and the pharmacy manager about the pharmacy floor plan. At 10:00 am of that same day, the construction supervisor met with the two of us and we walked around the site. By 2:00 pm that same day, sledgehammers were crashing down walls of the old kitchen and cement was being mixed by hand in huge washing vats. To say that Dr. Cynthia still wields a bit of influence at the clinic would be a massive understatement . . .

So, with just 2 weeks remaining before my visa runs out and I have to return home, construction still goes on intently in absolutely oppressive heat. While I might complain about being hot sitting in an office with a computer or in a patient department with no AC anywhere in the clinic, I can’t imagine mixing cement and banging down walls in this 108+ degree heat. But the workers do it with smiles on their faces and are always willing to show you how things are going. Meanwhile, the Westerners working at the clinic are virtually non-productive every afternoon these days. Even with a fan blowing directly on you, it’s very difficult to concentrate and get any work done with sweat dripping from every pore in your body. It’s nearing the end of the dry season here, which means it’s getting toward the hottest time of year, and the fields are in a constant state of burning. This combination gives the air an almost surreal quality, the sunsets are spectacular (when you can see them), and the moon is the reddest I’ve ever seen. But the respiratory issues are not only affecting Westerners, they also are now a large percentage of our patient complaints. Fortunately, malaria cases are down as usual this time of year, but the percentage of malaria falciparum (the most severe form of the 4 types of malaria) is on the rise. This form of malaria can most commonly cause cerebral malaria, which in many cases is fatal or can lead to extremely debilitating meningitis, dementias, etc. Eastern Burma has the largest percentage of malaria falciparum in Asia, and malaria overall accounts for 23% of all medical cases and 42% of all deaths. Greater than 20% of children die before the age of 5, and half of these cases are from malaria.

During the rainy season, malaria accounts for 5 times more cases than the second most common diagnosis at the clinic. During the current dry season, the caseload is more evenly spread out among respiratory disease, infectious diseases (including large amounts of HIV and TB), malnutrition (present in almost every patient), renal disease, and surgeries for landmine injuries, etc. One mosquito-borne disease that does have occasional pockets of activity is dengue fever. This is actually a bit scarier than malaria because there is no preventive medication that can be taken to protect against it. Although not as serious as malaria, the first time a person acquires dengue they feel like the worst flu they’ve ever had, and treatment is just symptomatic, i.e. acetaminophen for the fever, etc. However, subsequent bouts of dengue can lead to more complications, such as hemorrhaging, and can be quite serious. There have been reports of small outbreaks of dengue in parts of central Thailand (at least 6 hours from here) this year, and unfortunately 4 medical students at the clinic in the last 2 months have tested positive for dengue. Since it’s not life-threatening, many look at it almost like a badge of honor or a “battle scar” from their time in SE Asia, however I’m willing to live without that badge, thank you.

Having worked at the clinic previously, I’m not naïve enough to think that the opening of the central pharmacy would be my only role here. Having a combination of pharmacy and public health degrees expands my ability (and interest) to work in many different areas. My challenge is not to find work; it is to manage expectations on what might be possible. Besides the issue of developing a database for the central pharmacy, and designing the actual workspace, the unenviable task of producing a policy and procedure manual for the pharmacy, which previously didn’t exist, needed to be addressed. The thought of this job immediately sent chills down my spine, and for a brief moment I thought it would be a nice joke to re-create a bogus policy & procedure manual given to me by another hospital pharmacist after enduring an agonizing process, it simply read “All pharmacies are the same.” I dismissed that thought quickly and attributed it to the heat getting to me. The nice thing about opening a new pharmacy is that I could write the manual completely from scratch and base the logistical flow on the new pharmacy, and not try to explain what we did previously. This also gave me the liberty to organize a system that hopefully would foster good work habits from the beginning. I’m still hoping I’ll be here to witness the transition actually take place.

On the clinical side, I’m frequently asked by a medical student or medic to come to a department to discuss drug treatment for a specific patient. Last year I was fortunate enough to be on the committee that updated the Burma Border Guidelines, the last update was 2003, and I was thrilled to see the actual delivery of the books on my second day at the clinic – it is now a very stylish hardbound book published in both English and Burmese. This has allowed for multiple opportunities to discuss with medics and med students changes to the guidelines, and use specific patient examples as good teaching opportunities. Each week I join the program managers and 2-3 physicians who have fled Burma and are now working at the clinic to discuss specific disease states in the guidelines and where changes were made. I’ve followed this up with Saturday afternoon lectures to the medic staff in specific disease areas. This is the slowest patient period of the week, so we can get all the medics together, and it’s amazing how attentive they are and still asking questions after a long, hot week. I can’t imagine any of my colleagues at home sitting through these 2-3 hour sessions (including me). If anyone is interested in seeing the Burma Border Guidelines, they can be found on this website: www.burmalibrary.org Look under the Health section and an updated pdf version can be downloaded. In that same section, you’ll also find the Health Messenger magazine, a quarterly journal published by Aide Medicale Internationale for medics and the lay public on both sides of the Thai/Burma border. I was asked to be on the edit committee for a couple of these issues, and just wrote a small piece for the next issue on how to properly use an inhaler. Since this magazine is distributed to primitive villages on both sides of the border I included a section on how to make a spacer when an actual spacer is not available (which is always the case). For all you pharmacists out there that run out of Aerochambers, feel free to use our method - we’ve found that one or two liter Sprite bottles work very well.

There is no shortage of public health issues that need to be addressed in this border region. I was happy to see the universal precautions program that I started at the clinic last year was up and running, and being capably handled by 2 nurses from Japan and England that have volunteered here in the past year. Remarkably, the original framework of the program is still in place, and just small tweaks have been needed to address issues discovered in the first 2 quarterly audits. With all the physical and cultural issues we needed to address to get this program off the ground, I’m thrilled it’s still moving along well. With that project under control, I was free to move onto other things, one of which involved the skills of my wife Cindy. While she was here last year teaching some diabetes classes to the medics, she asked if a diabetes education book with pictures might be something of value to the patients. I brought those pictures and associated education tidbits with me this year and asked the Outpatient Department manager his opinion of its potential use. It took him about 30 seconds to enthusiastically answer yes they could definitely use it, and he promptly took them from me and is now in the process of translating it into Burmese and printing up picture booklets. So, I’m happy to report another Cynthia has made her mark on the clinic . . . and I can go on to other projects.

I’ve just recently been involved in a big long-term public health project that is just getting off the ground now. A few of us with public health backgrounds, both at the clinic and those working with internally displaced populations (IDPs) across the border, have discussed with medics that villagers understand the behaviors they need to change and may have the tools to do so, but lack the interest to make these changes. Health workers are expressing frustration in continuing to try to have villagers change these behaviors, and feel as though they do not know specific techniques and activities to continue trying to get villagers to change these behaviors. We’ve decided to conduct an overall assessment of the programs along the border, both in IDPs in Burma and migrant populations in Thailand to provide insight into which specific behaviors groups are trying to change and if similarities exist between programs. After this initial assessment, workshops would be given with specific information on behavior change theory and ideas for activities that health workers can use to continue to try and change these behaviors. Creating behavior change teams within each of the specific organizations along the border will be critical for the continued monitoring and modifying of health behaviors. We realize this may be a daunting task collecting such diverse barriers to health behavior change, and know that we need to be sensitive to cultural aspects that may affect behavior. It will be a long-term project that hopefully I can contribute to even while back in the States through internet correspondence. While I was involved with some health behavior change work in the States with providers, bringing the multi-ethnic Burmese cultures into the mix adds entirely new dimensions.

I’m excited to report a visit to the clinic by three folks from Pfizer in Bangkok, two from the Pfizer Foundation and one from Business Technology. The purpose of their visit was two-fold, it was the first time they had visited the clinic (and specifically wanted to visit while I would be here), and to deliver their gracious donation of 25 IBM laptop computers. Dr. Cynthia gave them a comprehensive tour of the clinic and provided background on the history of the clinic and the unique challenges that the clinic continues to face today. We had presentations from some of the organizations the clinic supports, including the Backpack Health Workers Team, the Burma Medical Association (who works with IDP populations inside Burma), the school health team, the health information systems team, and of course some of our work specific to pharmacy and public health services. I think they came away from their day at the clinic with a new appreciation for the crisis of border health care, and the recognition of Mae Tao Clinic’s depth into the culture of this region. The clinic and Dr. Cynthia now have such a widely known reputation that each day specific groups ask to tour the clinic (we’ve heard it’s even in some tour books), and each time I interact with a visitor I’m struck by their reaction to the situation here and the clinic’s broad scope. Their reactions reflect a feeling that perhaps the existence of the Mae Tao Clinic itself is not only to cure the wound, but also to allow the world to know about the wounds inside Burma.

For more information on the Mae Tao Clinic, their website is: www.maetaoclinic.org