NUMB3RS...

I was warned.

When I signed up for my mission with Doctors Without Borders friends advised me that the administrative and management responsibilities would consume me. Time with direct patient contact would be limited.

Then, the first ART (Anti-Retroviral Therapy) Report needed to be prepared for Bhamo. Each patient’s clinical course on ART, since the start of our program, needed to be documented and analyzed. I debated whether to pass the task onto the unsuspecting Expat coming to replace me in a month or so, or to bear the inevitable frustration of trying to make sense of files from years ago.

As I dug deep into the patient charts, gaps in filing and record keeping were uncovered. Slowly, painstakingly, I corrected and updated our database. At the end of my mission, this unexpected and time-consuming report occupied most of my time and sidetracked my scheduled final activities here.

Week after week I poured over compliance, record keeping, clinic procedures and protocol, trying to put together a coherent report.

While in the clinic, between hunting and gathering ancient charts, a shopkeeper with AIDS was consulted. Polite and appreciative, he initially responded well to treatment and he took his medication regularly, though he did not follow his doctor’s advice to rest.

Our patient was frequently seen selling his wares at a local market festival into the early morning hours. The doctors insisted he slow his pace but mere words could not keep him from enjoying every minute of the festival, given his return to relative health.

His progress faltered.

We adjusted, then maximized his medication. Though he seemed to be getting by in his own way, we prepared him for skin scrapings, blood tests and a lumbar puncture.

Then his family requested a home visit.

Unexpectedly, his condition had deteriorated to the point that he was unrecognizable as the person I had seen days before. In a backroom behind his store, surrounded by relatives, we struggled to examine him in his delirium.

Following transfer to the MSF clinic, we had no more success and could not secure an intravenous line. He slipped into a coma. A careful discussion with his family followed, reviewing his limited options while respecting our patient’s privacy regarding his diagnosis.

A transfer to the relatively well-equipped Bhamo Hospital could offer this patient nothing more and would only drain the family of whatever financial resources they had. Focusing on comfort measures, the patient returned home to his family, with a promise we would support them with homecare as the days progressed.

The next day we received word that he passed away, at home, a few hours after leaving the clinic.

As I returned to the ART report, the tedium of sorting through old charts and tracking down missing information seemed more relevant. Between the lines of symptoms and diagnoses, the charts of patients I’d never seen developed personalities, families and tragic stories not to be forgotten.

Family Ties…

Communication with family is always a concern when leaving for an extended period of time but I felt comfortable that I could always be reached, if necessary, through MSF.

A few days after my arrival in Myanmar, as I recovered from an illness that made me wonder if I would be able to continue my mission, I received an e-mail from Canada. It reminded me to contact my family, as they hadn’t heard from me. It also explained MSF was to be called by my family in emergencies only and my parents would be informed if anything were to happen at any point. The e-mail also explained that parents often contact MSF about volunteers, especially parents “of Indian decent”. A general e-mail reminder had classified me as “of Indian decent” with all the unknown behaviours associated with this new label.

I could not access my email in Myanmar and by the time I saw the printout it had passed through the hands of most of my fellow Expats. The international volunteers here are dedicated to working with various populations regardless of classifications used to divide people. While I felt isolated from Canada and scrambled to arrange alternate methods for urgent communications, I found myself having to defend MSF-Canada and explain the e-mail comments to my new colleagues in Myanmar.

Recently a close relative was severely ill in Canada and I wondered if signing up for my mission precluded me from being present to support my family. Following my instincts, I made the decision that if any possibility existed for me return to Canada, I would go.

I spoke with my supervisor and within 24 hours I purchased a ticket and was on a plane headed for Toronto. No explanation was required, it was a matter of fact that I must go home, and the only question asked was how much time I needed, the other details could wait for my return.

In the field, people are placed together like pieces in a puzzle, forced to fit as a matter of function. Random connections which develop into a familial network. We all have families back home- sometimes we can be there for them, sometimes we can’t. We understand that, and that is a common bond we share.

The Bhamo Zoo…

When I go out, I carry about 10 000 Kyats (approximately 8 dollars) and a little piece of paper, in Burmese, listing what I can eat. In a place where rice is the staple and meat is a close second, finding vegetarian food can pose a problem. However, most people understand the concept of vegetarianism and are accommodating.

As far as towns go, Bhamo may as well be a farm- animals are everywhere, though a lot more chickens wandered around when I first arrived.

Initially, “bird flu” caused concern and people refused to eat chicken and restaurants refused to serve it. A chicken family living in front of the AZG clinic clucked greetings to people as they entered. Despite viral concerns, no one seemed to mind they couldn’t walk 20 feet before mingling with some birds. As worries subsided, the observable chicken population dwindled and the chicken family vanished.

I also realized roosters don’t wait until sunrise to crow, as the next-door neighbour’s rooster starts up at 3:30 a.m. and continues until dawn, daily. Like an alarm clock with a broken snooze button, if he manages to stop for more than 9 minutes, his counterpart down the road fills the gap.

Snorts and oinks from a neighbouring pigpen erupt into non-stop squealing at disturbingly loud levels. Lasting over 30 minutes, scattered into the mayhem would be a slap, a whip, a shuffle and a cry. As the noise continues, annoyance becomes irritation and then disturbance at what could possibly be happening on the other side of that fence.

Oxen pull carts, right behind air-conditioned buses, while cows walk single file along the side of the road, without a farmer in site. Seeing animals wander here and there, causing their little bit of chaos, is part of Bhamo’s charm and closes the gap between animals and the dinner plate; nothing here is hidden away in factory farms.

I looked forward to going to Goa for vacation, for a dose of animal rights, environmental well-being and healthy diets at the International Vegetarian Union meeting.

The conference, however, took an unexpected turn on its second day. In addition to animal welfare, a look inward challenged me to adopt a “vegetarian-attitude”.

Non-violent in thought and behaviour, a “vegetarian-attitude” encompasses the environmental and humane impact of our actions. Only examining the food we eat seemed passé, a “vegetarian-attitude” involved every aspect of our lives and our interactions with others.

One of many interesting concepts emerging from the conference, I carefully packed my budding “vegetarian-attitude” as I headed back to my Bhamo Zoo.

No, But I Saw the Movie…

As I biked to work one morning, a semi-retired hospital physician pulled up beside me on his motorcycle and “requested” a meeting with me. I wasn’t sure what the meeting was about, but I was sure I couldn’t decline.

I made myself available.

His pretext of being interested in foreigners and my life story was revealed when he willing accepted a 30-second summary of my life and directed the conversation towards medicine. Putting patient care first, he wanted to ensure continued co-operation and understanding between the local physicians and AZG.

I knew there was another purpose to the meeting, but this was an unexpected development.

The doctor, who spent his early years practicing medicine from the back of his motorcycle, described the personal war he took up against HIV. He passionately spoke of his years of commitment and dedication towards solving the HIV crisis and somehow equated that to my 9-month mission here.

He pressed a book into my hand.

"You will understand this," he said.

It was “City of Joy” by Dominique LaPierre, a story about humanity and hope in the slums of Calcutta.

“Have you read it before?”

“No, but I saw the movie,” I said, unintentionally revealing he may have over-estimated me.

“Oh, yes, there was a movie. I can not remember that actor.”

“I can’t either,” I said. “Patrick Swayze,” I thought.

“You must read the book, anything is possible,” he continued. “You can return it in 1 week?”

Explaining I was going on vacation, I gained an extension.

The book was interesting, slightly melodramatic at times, but fascinating in its perception of Calcutta's slums. The lifetime of dedication the lead character put into his work was remarkable, and certainly the book revealed an entirely different tale from what I can recall of the movie.

What really struck me, however, was the hospital physician chose to share this particular book with me as a bridge to mutual understanding.

As I progressed through the novel, the story developed an additional layer- the inspired determination of a Burmese doctor in Northern Myanmar, taking on a problem so much bigger than himself.

Right Behind the Rain…

Late May to early October is “Rainy Season” in Myanmar. Until recently, the rain was largely limited to sun-showers and early morning downpours, hardly interrupting my daily routine.

Then the rains came.

At 3 a.m. I awoke to a violent pounding on the roof. Louder than sirens or jackhammers, the heavy rain penetrated my dreams and pulled me into reality. There was no sleep. Each flash of light lit up the night sky, followed by a thunderous explosion that rattled my body, my bed and the entire house. This is the power that flattens homes and topples trees.

Hour after hour, the rain poured down. Awake and exhausted in the morning, I waited for a break in the storm to make my way to work, but the rain continued without hesitation. Finally, I decided to make my way, Burmese-style, to AZG. I rode my bicycle in the pouring rain, balancing an umbrella against the wind with my left hand while my right hand clutched the brake, not really certain the brake would work if needed.

For AZG, this can also be called “Malaria Season”, as the mosquitoes are not far behind the rain. Our malaria clinics are overwhelmed with feverish patients coming in for diagnostic blood slides and free treatment. For many, a short, simple course (of Artesunate and Mefloquine) is effective in reducing the high rate of illness and the many deaths from malaria. The rewards of curing a case of malaria in a matter of days compliments the rewards of the intensive, long-term management for people living with HIV and AIDS.

When the rain comes, within minutes temperatures drop by 10 degrees. Without air conditioning (or sometimes, electricity), the hot, humid weather often exceeds 40 degrees Celsius. The rain brings relief, though short-lived, as within an hour after the rain the sun returns in full force, evaporating any evidence that the rain was here.

As the sun and the rain take turns with each other, Myanmar comes alive. A hundred shades of green colour the landscape, brilliant and beautiful, and the crops shoot up, ensuring a bountiful harvest to reward the farmers.

With the destruction and illness that follows the rain, the only thing more devastating would be if the rains did not come.

A comforting thought, as I put on my damp and moldy clothes, for another day in Myanmar.

Lost in Translation...

One day, a telephone stand appeared in front of the staff house. Once established, it could serve as an observation point for one of the town’s sources of curiosity- the AZG staff. Though the attendant mostly sat in the shade, reading a book, a potential problem existed and, as the “Expat”, I looked into it.

The telephone stand was connected to the staff house's phone line. Previously, a storm damaged our phone line and the house owner refused to pay for repairs. The AZG staff managed without a house phone, only to have the owner reconnect the line, for public hire.

Initially, the owner agreed to move the telephone stand away from our house, but 2 months later the attendant sat below a tree reading yet another novel. Local rumour described the owner, a well-known engineer, as indulging his daughter’s efforts to start a business with this telephone stand.

In our search for the owner, we arrived at his house and met his daughter who stated she was authorized to discuss this matter, on her father’s behalf. About 22 years old, petite and soft-spoken, she found chairs for all of us while she remained standing.

Through the translator, I explained my need to consider the safety of AZG staff, the security of our supplies and respect for the lease, which does not mention a business at our doorstep.

Head slightly bent forward and hands folded in front of her, she explained the telephone booth will be moved in one month, and some of our rent money will be returned. A quick and pleasant end to the negotiations, I thought, and an offer to return some rent to compensate AZG for our troubles!

I did not understand that our unused rent money was to be returned in one month, when we are thrown out of the house!

In my mind the issues were settled, but a sudden rainstorm trapped us in her house, making small talk. I asked her if she was managing our house, as well as the telephone stand. Her voice rose slightly, tone a little firmer. The interpreter conveyed that her father had given her the house to manage, as she feels fit. I congratulated her, stating it is pleasant speaking with her and I looked forward to our future dealings. As my words were translated, the confusion on her face puzzled me; perhaps it was inappropriate for her to accept the complements.

My Burmese housemates accompanying me looked equally confused, but later applauded my strategy; as her attitude became more “rude” and her veiled threats became more obvious, I became more polite and complementing. Her words intended to anger were deflected by courtesy, causing frustration and confusion. A brilliant tactic on my part, if only I had known what was going on!

Still unaware we were to be homeless in one month, I praised her father’s sculptures and constructions around the town and encouraged her own business endeavors as a young female entrepreneur. Through the interpreter, she explained she is opening a home décor store, the telephone would move into that shop.

A lofty idea, Bhamo’s small middle-to-upper class community could hardly support such an endeavor, but it was not my place to discuss demographics. Her dream and her father’s money have little to do with me.

As the rain continued its heavy downpour, I asked her when she planned on opening her store. The translation, “in one month”, seemed a little unrealistic. Continuing the conversation, I asked her where the store would be located.

The interpreter flatly replied, “In our house.”

I looked at the interpreter, confused. There really wasn’t enough room in the house with five of us living there.

Then it dawned on me.

Suddenly, the small talk became nonexistent, and the pounding rain consumed the silence.

With my final words, I confirmed the telephone booth would be moved at the end of the month and we graciously accepted some umbrellas and left, all of us looking a little baffled by what had just occurred.

This Child…

Orphaned, when HIV claimed both her parents, a small child of 5 years is raised by her grandmother. Battling HIV herself, this child survives with life-saving ART (anti-retroviral therapy) to treat AIDS. The impact of MSF on this little girl’s life is not lost on her, as she is determined to become an AZG doctor when she grows up, just like the role-model she found in the female physician managing her treatment.

Our patient finds joy among her difficulties. Privileged to attend school for the first time in her life, she studies hard, takes extra tuition classes and reviews her books at bedtime, charting a path to achieve her medical aspirations.

In her grandmother’s struggle to care for her grandchildren, she attempts to make enough money to keep them clothed and fed while grieving the loss of her daughter. In her retirement, she did not expect to be caring for small children alone, particularly not a child with chronic illness. Tearful and distant, the grandmother quietly recounted the unexpected turns in their lives.

As the grandmother relayed their situation, the child sat still on a little stool beside the doctor. No cries or tantrums, I felt my heart break as I noticed her silently weeping, making efforts to hide the tears she could not stop, before her doctor would notice.

Love and duty, expectation and burden. This child understands too much of these things for her age.

Realizing the world is not fair, she makes the most of the limited opportunities in her life, rising above the labels she is given. Perhaps naïve, her dreams keep her motivated. What lies beyond her grasp will be obtained through determination, and her determination gives her strength.

20 years from now, it would be truly remarkable if this child beats the odds and begins working as an AZG doctor. Keeping dreams alive.