Kaci Hickox, a nurse from Texas, worked as the primary health care manager for Doctors Without Borders/Médecins Sans Frontières (MSF) programs in northern Rakhine state, Myanmar, from May 2007 to March 2009. The majority of MSF patients in this area, on the border of Bangladesh, are part of an ethnic and Muslim group called the Rohingya. They have great difficulty receiving any health care, as travel restrictions or fees for travel permission keep them confined to their own villages. Even if they can reach health care facilities, often members of this group cannot afford to pay and are subjected to discrimination at government- run hospitals or health centers. During the two years she worked in northern Rakhine state, Hickox’s primary responsibility was managing three rural clinics that serve approximately 110,000 Rohingya people.
I fell in love with the primary health program in Maungdaw, Myanmar, before my first week was completed. With such a diverse set of activities a health professional could never complain of boredom, and direct contact with the community drew me into the culture and concerns of the people. There, we used what I have come to call the “bridge or barefoot” approach to primary health care in a unique rural setting—you must be creative in your program and be prepared to walk barefoot through the rain and mud when the bridges are broken.
By Tractor or by Foot
ROHINGYA IN BANGLADESH AND THAILAND
Bangladesh 2006 © Greg Constantine
MSF began providing health services in Bangladesh for Rohingya refugees in 1998. MSF has assisted about 7,500 people who were struggling to survive, otherwise unaided, in atrocious conditions in Tal camp near the border.
“The overcrowded, unhygienic living conditions were a breeding ground for respiratory tract infections and skin diseases,” said MSF medical coordinator in Bangladesh, Gabi Popescu. Diarrhea and malnutrition were rife, and mental health problems added to the burden, Popescu said.
MSF also initiated a mental health program to support those struggling with the psychological impact of life in the camp. The Rohingya are not considered refugees by the Bangladeshi government, and they receive no support.
In June, MSF was alerted to the fact that about 20,000 Rohingya were living in foul conditions in a makeshift camp in the Kutupalong area, near an official camp operated by the office of the UN High Commissioner for Refugees. An MSF team assessed the area and discovered the would-be refugees have a dangerous lack of access to safe drinking water or sanitation, and have alarmingly high levels of malnutrition. MSF immediately began planning an emergency intervention.
Many Rohingya who make the dangerous journey across the Andaman Sea to reach Thailand perish while en route. “At sea, I saw another boat carrying around 80 people sink in front of my eyes. I think everyone died,” said a Rohingya man who arrived in Thailand in 2008.
MSF has been granted access to groups of Rohingya detained by the Thai authorities on a number of occasions in recent years. Medical staff treat them for dehydration and skin diseases, but many detainees have also shown signs of severe psychological trauma.
A typical day would begin with my waking to the sound of geckos singing from our bamboo shelter, having kauk hnin pauk (sticky rice with shaved coconut) for breakfast, and then off to work in surrounding villages. I would set off with my team, composed of two nutrition-support staff and one male and one female health educator for each of the three clinics, in a Chinese tractor— our main mode of transportation. The tractor could carry many staff patients, and food supplies to nutrition sites, where we would screen and monitor progress of children in our outpatient feeding centers and distribute nutrientrich, ready-to-use foods. Teams from each MSF primary health care clinic took turns visiting nine nutrition sites once a week for screening and treatment of patients.
During the rainy season, which would coincide with the hunger gap—the time just before the next harvest when food stocks dwindle—we would treat more than 1,200 severely and moderately malnourished children every week. Because of this great need, we refused to allow anything to interfere with our activities. When a bridge broke down near the MSF clinic in Inn Din, my team and I walked four miles in the mud, wind, and rain to reach the nutrition site. It was exhausting, but the smile of a malnourished child who had gained weight and seemed to come alive again made the damp and dirt well worthwhile.
Fascinating and Frustrating
As in other developing tropical countries, the most common ailments were pneumonia, diarrhea, and malaria. Some of the most fascinating, yet frustrating, times for me included seeing and treating diseases that most medical professionals working in the US only read about in books. There was the two-year-old girl with swollen legs, hands, and face due to kwashiorkor, the most deadly form of malnutrition; the six-year-old boy whose bones were deformed due to rickets caused by a vitamin D deficiency; and a four-year-old boy with the classic fever, runny nose, cough, red itchy eyes, and rash from measles, a vaccine preventable disease.
Many of the health-related difficulties we treated were directly linked to poverty, and we saw its effects daily on our patients. Infrastructure in the area is poor and most villages are without covered and lined wells for safe drinking water. There is also a lack of sanitation, leading to contamination of other water sources like ponds and enabling diarrheal disease. Aside from this, most people live in crowded bamboo and thatched huts, a likely contributor to the spread of respiratory infections and tuberculosis.
Medical Miracles through Mullahs
In Rakhine it was critical to gain the trust of the population, and a highly effective way of doing this was working through community leaders. I wish I could say it was my idea to train mullahs—Muslim men educated in Islamic theology who are religious leaders of the community—to help health education activities. In most villages where we worked, the population was 90 to 95 percent Muslim.
As in many religious communities around the world, family planning and condom use were met with great resistance in Rakhine, but these are two critical aspects of health promotion. HIV has continued to spread throughout Asia, especially in border regions, so condom use for prevention is vital. Also, there are many benefits to family planning, including reduced prenatal mortality and improved maternal and child nutrition. I once went with an MSFtrained mullah health educator to discuss these issues with a group of mullahs in a village called Myin Hlut. The local mullahs were very responsive and glad that MSF had come to discuss these ideas and issues with them. The mullah also proved to be necessary for other interventions, including responding to a diarrhea outbreak during Ramadan when he spoke with community leaders and explained that drinking oral rehydration salts—a lifesaving treatment for dehydration caused by diarrhea—was not against religious rules if villagers were sick with diarrhea and vomiting. He was also vital in speaking with HIV/AIDS patients about continuing to take their antiretroviral medicines on schedule during the fasting period to prevent drug resistance.
My time and experiences such as those with the mullah health educators in northern Rakhine state helped strengthen my belief that to be successful, we must have a community-centered approach and a high level of dedication. Only then can we meet the most vulnerable people where they are and gain their trust in order to meet their needs.
In Rakhine state, MSF supports six primary health care clinics, three HIV/AIDS/STI clinics, and over 20 malaria clinics. MSF also has HIV/AIDS programs in other parts of Myanmar, including the city of Yangon and in Kachin and Shan states, 16,000 HIV-positive patients whose health is monitored and more than 11,000 receiving antiretroviral treatment.