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" I was very impressed by the way they maximised the use of
limited resources in a very cost- effective manner appropriate to their society."

"Trip To Yangon 20-24 January 1999 In Conjunction With The 45th Myanmar Medical Conference"

A 9-member team from the SMA visited Myanmar in conjunction with the 45th Myanmar Medical Association (MMA) Conference. This was the third visit by the SMA, the first being in October 1996 and the second in January 1997.

The team comprised Dr Cheong Pak Yean (President, SMA), Dr Tan Sze Wee (Treasurer, SMA), A/Prof Goh Lee Gan (1st Vice President, SMA), Dr Alfred Loh (President, College of Family Physicians), Dr Yap Chin Kong (Secretary, Gastroenterological Society of Singapore), A/Prof Ng Han Seong (Senior Consultant, and Head, Department of Medicine, Singapore General Hospital), Dr Chan Boon Kheng (Family Physician), Dr Kwek Seow Khee (Psychiatrist) and Ms Chua Gek Eng (Executive Secretary, SMA).

We arrived on Wednesday 20 January 1999 in the afternoon and had a familiarisation tour of Yangon city. A series of visits to hospitals and township clinics (equivalent to polyclinics) were conducted by the MMA over the following two days. This included the Pediatric Hospital in Yangon, a township clinic, psychiatric hospital and the New Yangon General Hospital.

The structure of healthcare delivery in the Government sector starts at the township clinic level with the family practitioner, complemented by private clinics in which all doctors are allowed to participate and the military hospitals. More complicated cases are referred to the hospitals. The Pediatric Hospital is a tertiary center for childhood diseases with surgical facilities except for neurosurgery and cardiac surgery. We were shown a range of clinical cases including whooping cough, spinal tuberculosis, nephrotic syndrome and dengue hemorrhagic shock syndrome. Mothers accompanied their children in the ward, slept beside the child and sometimes in the same cot. They attended to their feeding and the nurses attended to the more specific medical needs. Dengue fever is endemic and their shock cases occurred only in children under 5 years of age. Their policy for platelet transfusions in dengue is only for those with bleeding manifestations irrespective of the level of platelets.

The township clinic we visited supported a population base of 20,000. The doctors and nurses are active in health education and vaccination programs. Interestingly, hypertension cases are reviewed weekly because of restriction to a weekly prescription.

The Psychiatric Hospital origins date back to 1928 and was a lunatic asylum. A sprawling complex with one- or two-storey building formed the hospital which has 700+ beds. It was interesting to note that chronic cases formed the minority. We reasoned that mental illness is better accepted in the Burmese community. Also psychiatrists are available at most hospitals to deal with problems. We visited the electro-convulsive therapy room and the wards. Iron-wrought gates reminded us of the origins of the hospital as a lunatic asylum. We were shown a man with phenothiazine induced side effects and underlying cerebral malaria with delirium. He was treated with intravenous quinine by the psychiatrist and was recovering. Treatment for addictive diseases (heroin and derivatives) were also carried out in that hospital. One interesting rehabilitation facility was a gymnasium which included a boxing ring (donated by the Japanese) and punching bags.

At the New Yangon General Hospital, we visited the departments of gastroenterology, internal medicine, surgery and radiology. In the gastroenterological ward, we were shown cases of liver cancer, colon cancer, esophageal cancer and functional abdominal pain. There is a rather high prevalence of stomach and esophageal cancers in Myanmar which I thought could be related to their salty diets. Unfortunately, there were no patients with biliary ascariasis, an apparently common problem, on that day. The endoscopy room was equipped with 4 gastroscopes and 1 colonoscope with video-endoscopy capability. Up to 2,000 cases of upper endoscopy and several hundred colonoscopies were performed annually. There were facilities for ERCP (about a hundred cases a year) which they performed in the radiology department.

The internal medicine ward was reminiscent of the old Mistri Wing of the Outram Road General Hospital. There were relatives of patients who helped to look after them, thus relieving the nurses some of the nursing duties. We met a group of eager medical students in the internal medicine ward, crowded around a patient with their stethoscopes and books. I was impressed by the very high regard of patients for doctors in Myanmar and which leads to a good doctor-patient relationship. This, I felt, allowed the practice of good clinical medicine without the spectre of defensive medicine. In the event of a negative outcome, it is accepted as "bad karma".

Dr Cheong Pak Yean presented the department of internal medicine with a set of the latest Harrison’s Textbook of Internal Medicine. The practice of medicine is very much British-based and the consultants had familiar degrees from UK and Edinburgh. Many of them knew of Singaporean doctors who also had links with the Royal College of Physicians or Surgeons. The radiology department was well equipped and boasts of the only MRI machine in Myanmar. A wide range of equipment including CT scanner and angiography were available. There was also a room for radiotherapy.

On reflection, I was very impressed by the way they maximised the use of limited resources in a very cost-effective manner appropriate to their society. It contrasted with our high-tech, high-cost medical practice and patient-generated demands (stemming from high expectations, instant gratification and increased health education?) in Singapore. I wondered whether a patient in Myanmar with a similar disease (not too complicated) to one in Singapore could be treated with fewer investigations at a lower cost and has a similar outcome. It would be interesting to allow our trainees to do a posting in Myanmar and they could derive benefits from certain areas of medicine and also have insight into a different philosophy of medical practice.

We attended the opening ceremony of the 45th Myanmar Medical Association, opened by the Secretary-1, Lt-Gen Khin Nyunt. A large part of the meeting was conducted in Burmese. A/Prof Ng Han Seong delivered a lecture on viral hepatitis which was well attended. Dr Cheong Pak Yean and A/Prof Goh Lee Gan lectured at an afternoon symposium to family physicians. A lively interactive discussion ensued between the Burmese orthopedic surgeons, physicians and family physicians on the diagnosis and management of tuberculosis of the ankle.

At meetings with the MMA President, Prof Myo Myint, several activities between the SMA, College of Family Physicians, Singapore and MMA were discussed. These proposals included exchange visits and short attachments of students from both countries. The MMA is in the process of upgrading their premises to include conference facilities, library, offices and accommodation for guests. The Gastroenterological (GE) Society would discuss further with MMA on future visits and academic exchanges.

At a dinner hosted by SMA, we developed new friendships and presented gifts from the SMA and GE Society to the MMA. At two other dinners hosted by the MMA and Prof Myo Myint, we were treated to Burmese hospitality, food, music, dance and a magician show in addition to exchanging personal experiences. We were on the topic of wild animals when a Burmese Professor sitting at our table offered this tale _ which may come in useful one day. In his youth, he had attended to a tiger bite victim who survived. The unfortunate man was clearing a jungle path when he chanced on a tiger which pounced on him. He reflexively stuck his arm into the tiger’s throat and caught hold of its larynx. He sustained bites and fractures, but the surprised tiger asphyxiated and the man had sufficient strength left to bludgeon it to death. Afterwards, the kind Professor suggested a safari trip to the north to watch tigers, and I politely had to decline.

By Saturday, we felt exhausted by the heat and the rather packed program. So much was done and discussed in a short period of 4 days before returning home. We will certainly recall fondly the friendly people, hospitality, delicious food, shopping, sights, street markets reminiscent of Singapore 30 years ago, and the road side tea shops at night. Anyone for Myanmar on the next trip?