I spent my elective at a rural clinic in Thailand, established to support the healthcare needs of the refugees from Myanmar. It was set up in 1989 from a small house it is now a large complex of inpatient and outpatient wards. There has been political unrest in Myanmar from 2nd April 1948, this clinic has been set up to meet the demands of refugees. There has been ongoing political unrest in Myanmar. The clinic is separate from the Thailand Government Hospitals, it run solely on donations, patients can contribute to their health needs what they can afford but are treated regardless of their financial contribution. I arrived at the Mae Tao Clinic just before 9am on my first day, I was introduced to the staff members responsible for different departments. Then by 9:10 I was allocated to my first rotation. It was a very immersive experience.
This experience forced me to work on my non-verbal communication skills. The main language of the clinic was Burmese which I found incredibly difficult to learn. I found pronunciation of the words tough as I had felt I couldn’t create some sounds with my mouth. It was hard to support patients through difficult moments when I lacked the linguistic ability. I however had to develop very good non-verbal communication. I soon realised that a smile is one of the most powerful tools to building rapport.
On my first day, I supported a pregnant woman during labour. There was a lady who had been in labour for a while. She had no family in the room, no partner. It was only the staff there to comfort her. I did not even know the language so felt disappointed with myself for not learning some key words to comfort her. I tried to stay by her side and hold her hand as she would allow. I wanted her to know she could use me for support even though we didn’t share the same language. They had to give her an episiotomy. I gave her my hand and didn’t let go till she had given birth. They taught me how to say “push” in Burmese, တွန်းရန် pronounced twann raan). Which I tried to say at appropriate times. By this time, you could see she was so tired and in so much pain. She continued to push and eventually the baby came, she was so relieved but still in so much pain due to the episiotomy. They sutured in the delivery suite and practiced breast feeding. She gave birth to a healthy baby boy 13:11. It was such a privilege to have experienced this birth. It was an honour to have been in the room. I spent some time after talking with the staff trying to learn Burmese and Karen and asking questions about the clinic. So much can be communicated without language.
The language barrier provided a significant obstacle even with a medic offering to translate for me. This lady came in with characteristic signs of PID, abdominal pain, foul smelling discoloured discharge etc. This conversation was particularly difficult as the lady started to tear as she spoke about her relationship and how she was mistreated. It was very difficult to see her in this state and not have the words to comfort her.
To aid diagnosis, I performed a speculum exam, and I can finally understand there comes a time where you just know what you're doing, therefore you are not as nervous and can calm the patient with your demeanour. I remember my first speculum and being so nervous, it’s amazing to see how much better you can get at something over a few months. Piecing the history and examination together the most likely diagnosis was pelvic inflammatory disease, which she received treatment for. Before she left, I asked if she could do a pregnancy test, my supervisor looked at me with shock as she said that she is not pregnant. Although agree she was most likely not, I asked if one could be done to be sure. In a pregnant woman of childbearing age, I would hate to miss that, I think Bristol has drilled that into me. Also, my own personal experiences as my sister were sent home without a pregnancy test told that she had reflux when in fact it was an ectopic pregnancy that she needed surgical management for. I hope it is something that I never miss. This experience taught me how to advocate for investigations that you want your patients to have, no one wants to miss anything, if you inform a senior, you are worried about a particular diagnosis, most times they will either reassure you or take you suggestion on board.
I have practiced medicine in a resource rich environment, I have been very accustomed to single use equipment and have learnt the importance of infection control measures. I had concerns initially about the sanitation of the clinic due to lack of resources. I had read online that when it started, they used a rice cooker to sterilise instruments. Things have obviously moved on from that time. I was shocked at the level of resourcefulness that was shown in the clinic. Short term catheters and oxygen tubes were sterilised and then used again on different patients. It challenged me to the contrast in the UK of single use equipment. It would be underheard of to have reused a catheter on another patient, it would be seen as unhygienic. To them this was the norm. The only equipment that was disposed of was gloves, they were only used were necessary. Washing of hands and hand sanitizers were promoted and staff responsible for infection control would frequent the wards. This experience made me question the idea of single use equipment. I think there should be major rethinking on what could be used again, which could have such a major impact on the plastic consumption of the NHS.
Being in a resource poor setting has meant that you have access to less diagnostic investigations. The paediatric consultant spends most of her lunch break, reading journal articles that discuss interesting cases. Looking for links or clues that could help point to a suitable diagnosis for her patients. A child presented with hemihypertrophy, which I had never heard of before, she quickly does some reading to ascertain if there were any links between that and congenital CMV that the child had. She then formulates a differential for Beckwith-Wiedemann Syndrome, which fits with the child's current presentation. However, there is no genetic testing available to confirm this diagnosis. There was another child presenting with dysmorphic facial features, microcephaly, and torticollis. The lack of investigations makes it very difficult to be certain about a diagnosis. Observing this type of practice made me understand, firstly the importance of a thorough clinical exam, you must have examined enough patients to be confident when something is not normal. Secondly the importance of continued study. I think being able to do these things well will help me go very far and be a very confident and capable clinician.
This whole experience has completely transformed my outlook on life. I don't think I had ever properly considered the struggle of refugees. It may be because I have been so far removed from it that I haven’t reflected on how hard it must be to have your life completely upturned due to war or political instability.
My parents were refugees, and they fled the civil war in Sierra Leone. This civil war destroyed their home, and they lost family members. I was born here in the UK, far away from the atrocity of war. I've grown up in comfortability away from the harsh reality of war. I've been able to plan. I have not experienced the loss of immediate family. I have not experienced the impact of war.
The difference between the healthcare received in the Thailand government hospital and the clinic are stark. You see so clearly how much money plays a big part in health care. They have plans to open and accident and emergency department soon. This experience has made me keen to get involved with international medical work.
People just like me, are experiencing the effects of war. It was inspiring to see how hopeful people were despite their current situation. During this experience I met two medical students from Myanmar, they fled the military leadership in Myanmar, so they were not able to complete the medical studies in Myanmar. They are unsure if they will ever finish their medical training, as they are not able to go back or they would be arrested. They are also not allowed to go anywhere in Thailand as they are classed as illegal immigrants. It was saddening to hear, the amount of uncertainty they have about their future. This is just one story, during my time I heard so many. I heard about people who had family who were imprisoned for life for protesting the military leadership. The clinic has their own church which I attended. It reminded me of this verse “After I looked, and there before me was a great multitude that no one could count, from every nation, tribe, people and language, standing before the throne and before the Lamb. They were wearing white robes and were holding palm branches in their hand”- Revelation 7:9. There was no translation available, and the service was in Burmese, so I couldn’t understand or partake in much. It was clear that these people were praising the same God that I worship. I was in awe. It was such an amazing experience, to see where language or geography may divide us, we are united by our faith.
I wondered how receptive people will be to Christianity as Buddhism is the main religion in Thailand and Myanmar. It was encouraging to see how open people are to faith conversations and there was freedom to practice your faith freely. I witnessed many people despite being Buddhist would often accept prayer from Christians during times of difficulties or at celebratory events. These experiences have ignited a passion in me to work with refugee populations, I am currently seeking opportunities in the UK to get involved in. This experience has been truly transforming, I am keen to go back and visit them to see how they are all getting on. During my time there, strangers became like family.