Letters to the Editor
CLINICAL ENCOUNTERS IN MYANMAR -
A VISIT TO 3 YANGON HOSPITALS AND 2 HEALTH CENTRES
Our first visit was to the Yangon General Hospital - the biggest hospital in Yangon with 1500 beds consisting of 3 surgical units and 3 medical units, in addition to the other specialities. We started off in Medical Unit 11 at the female ward organised in the old open format, reminiscent of SGH in the past. We were taken from bed to bed by our gracious Myanmese host (attired in longyi and sandals), who explained each case concisely, and the delegation were then invited to locate the clinical signs.
Several cases were presented during the morning. These included: a pleural effusion with a previous history of pulmonary TB; a young lady with chronic myeloid leukaemia who defaulted chemotherapy and had gross splenomegaly; a case of rheumatic valve disease (mitral stenosis) with a stroke; a thyrotoxic lady with a large goitre: and finally a man with TB meningitis and who was HIV positive.
The ward experience was followed by case presentations at their main lecture hall with the attendance of most of their senior staff. We started with a case of falciparum malaria in a fisherman from a malaria endemic area, presenting with shock and hepatorenal syndrome. Falciparum parasites were seen on the peripheral blood film and he recovered after treatment with artemether and mefloquine. A case of amoebic liver abscess was presented. This was followed by Professor Khin Maung Win who presented 4 cases of hepatocellular carcinoma from different age groups who received different treatment modalities. He also mentioned the problem with hepatitis B and their successful efforts to manufacture locally a hepatitis B vaccine that had been certified for human usage by New York Blood Center. He also mentioned problems with hepatitis C as there was no screening in blood donors for this disease. The possibility of liver transplantation was explored as a therapeutic option and he was willing to send appropriate cases to Singapore for living-related transplants instead of Paris as was his current practice. We then had 2 cases of rheumatic valve disease - one treated with a valvotomy and the other on medical treatment. These 2 cases presented another opportunity for clinical examination in the hall.
After this session, we were conducted on a tour of the rest of the hospital and in particular, visited the intensive care unit. There were several cases consisting of COPD, asthma, strokes, cervical vertebral fractures and tetanus. Equipment and the level of monitoring was adequate.
The next stop was the Mingalar Taung Nyunt Urban Health Centre for a township in Yangon. The director presented the role of such centres and the programmes that came under their purview. Various health indicators were provided and public health programmes were very much in evidence. In particular, immunisation was strongly emphasised with the second National Immunisation Day due in a few days time. A mother and baby clinic was in progress as they then took us on a tour of the premises.
Following lunch, we travelled north out of Yangon to the Bago township to the Inntakaw Rural Health Centre. This allowed a glimpse of country life and the state of their roads. We were met with what was becoming a familiar sight of smiling and charming Myanmese in their elegant longyis and sandals at the centre. Refreshments were provided and we proceeded to listen to a presentation of the rural problems and the various programmes in place. In particular, the problem of malaria was highlighted and mention was made about ongoing trials with WHO in the use of artemether. Manpower limitations on the ground was addressed by using voluntary workers who received short terms of training, as well as employing the midwives in a broader role as health workers.
Our second visit was on Friday morning to the Yangon Children's Hospital. We were hosted by Professor Thein Thein Myint, Professor and Head of the Department of Child Health. We started with case presentations which were again conducted in the standard format with the aid of transparencies and an overhead projector, plus the presence of the child and mother that we could examine clinically. We listened to cases of malaria, tuberculosis, dengue shock, rheumatic fever (chorea and valvular disease), Histiocytosis X, and tetanus. Again as previously at the Yangon General Hospital, the session was well attended by the senior and junior staff allowing a thorough discussion of the cases and mutual exchanges about the varying practices and patterns of illness between our two countries.
After the case presentations, we visited the wards and were shown both paediatric and neonatal wards. In addition, we visited their intensive care unit. The low dependency wards were arranged in separate areas with different groupings according to the disease.
Our last visit was to the New Yangon General Hospital. Here we engaged in the ward visits first (including the ICU), followed by the case presentations. Numerous cases were presented, some were pre-operative and many were post-operative patients. Cases presented included hepatocellular carcinomas, oesophageal varices, hernias, TB spine, gastric carcinoma, thyroid nodules, breast carcinomas, penile carcinoma and colon carcinoma. The subsequent case presentation focused on problems with biliary stones and their high incidence of biliary ascariasis (80% of all obstructive jaundice). We discussed the various issues of stenting, ERCP, and laparascopic cholecystectomy as well as the problems of rural facilities. The case of the TB spine with an associated cold abscess pointing above the left iliac crest was also discussed.
Our short trip to Myanmar had provided an invaluable look-in on medical practice in their country. It was also interesting to note that there was a close similarity between the case-sheets used in the Singapore General Hospitals and the government hospitals in Yangon. We discussed the reasons for this. After World War II, Sir Arthur Gordon Ransome, the Professor of Medicine in the University of Malaya in Singapore, had introduced the case-sheets used in hospitals in Rangoon at the time to the government hospitals in Singapore. During the war, Professor Ransome was working in Burma in the British Medical Corps. Rangoon was a more developed medical centre and many doctors who visited Singapore used to be stationed there.
We salute the Myanmese doctors for their obvious clinical skills and dedication and hope that such trips will continue to bridge our two countries in friendship and enjoin a common feeling amongst the medical fraternity.
Dr Lee Kang Hoe
Dr Elaine Tan Suan Leng
Dr Tan Ee-Ching
Dr Elsie Yong