EM in Myanmar Takes Strides

An international EM meeting in Yangon finds an engaged audience of savvy EM physicians ready to take on the toughest trauma challenges

Our brief tour of the ED of the general hospital in Mandalay, Myanmar was an eye-opener. The first patient we saw was a young woman with obvious nephrotic syndrome; the next, a woman with a viper envenomation (and the dead viper in a plastic sack). Another patient, a middle-aged man with a heart murmur audible from three feet away, had wide-open aortic regurgitation from rheumatic heart disease, complete with Quincke and de Musset signs. We were there to teach, but we quickly realized that these physicians see much more advanced pathology than we do.

Six months prior to this tour, Dr. Joseph Lex had received an email from Maung Ohn “Tony” Htoo, a Burmese expatriate physician practicing in California. He asked if Dr. Lex knew of people who would be interested in continuing the quest of bringing EM to the people of Myanmar. Dr. Htoo explained the current state of medicine in the republic, in which there are both public and private sectors. Dr. Htoo spoke of a group from Stanford University in California, under the guidance of Dr. Swaminatha Mahadevan, which had been teaching in the private medical sector. He also spoke of a dedicated group of Australian volunteers in Yangon, led by Drs. Georgina Phillips, Chris Curry, Rosanne Skalicky, and Nigel Klein, who had successfully trained and graduated eighteen junior specialists through a postgraduate EM diploma at the University of Medicine, Yangon. Before completing the diploma program, these physicians had been practicing doctors and eight elected to return to their previous practice. However, ten of the newly minted emergency physicians opted to practice in the ED one of three hospitals: Yangon General, Nay Pyi Taw and Mandalay General.

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Dr. Htoo’s vision was grand: hold a medical conference to attract practicing physicians and trainees and teach them why EM is different from other branches of medicine and convey why Myanmar needs acceptance of the specialty and specialty-specific training programs.

Drs. Lex and Htoo agreed to organize the conference for March of 2015 directly after the Vietnam Society’s annual conference. For more than ten years, a group of dedicated volunteers has been going to Vietnam and assisting Vietnamese physicians in their mission to bring EM to their population. This year more than thirty volunteers, not affiliated with any specific university or organization and each entirely self-funded, presented at a five day meeting in Ha Long Bay.

Dr. Lex sent a request for volunteers and quickly convinced a dozen experienced educators to make the hour flight from Ha Noi to Yangon. Many of the speakers had also seen the beginnings and rapid growth of EM in Poland, Argentina, and Vietnam. For those interesting in improving emergency care, it is hard to resist the mystique of Myanmar. This Southeast Asian country, roughly the size of Texas or France, is a former British colony that gained independence in 1948. After fourteen years of democratic rule, a coup established a military dictatorship that lasted for half a century [1,2]. Myanmar, isolated from the much of the rest of the world during this oppressive regime, has not kept pace with the health care improvements in other Southeast Asian countries. In fact, the World Health Organization ranked Myanmar second to last in health care performance out of 191 counties—only Sierra Leone received a lower ranking [3]. In 2013, Myanmar spent 1.8% of its GDP, less than any other country in the region, on the health sector. Because of the low expenditure on health care, Myanmar continues to struggle with communicable diseases like tuberculosis, malaria and diarrheal diseases. There is also a large burden of non-communicable diseases like stroke [4]. Those of us who have seen the specialty develop in other countries, know that EM is a critical component of a functional health care system.

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Our groups of international speakers were not sure what level of expertise to expect from the conference attendees. With this in mind, Dr. Lex asked the instructors to develop a mix of basic and advanced talks – everything from “Care of the Patient with Chest Trauma” to the most current updates in medical resuscitation. Topics covered a broad spectrum of traumatic and medical emergencies. In addition, there was an advanced EKG session, and a superb introduction to the use of Emergency Bedside Ultrasound in for resuscitation.

On Monday and Tuesday we presented in Yangon and quickly realized that the participants’ medical knowledge was at a very high level, at least equivalent to what would be obtained in the “developed” world. We adjusted our talks to meet their needs. We had expected to speak before polite audiences reticent to ask questions or challenge what we said; but over two days we were able to break through these cultural barriers as the speakers abandoned the podium and worked through the audience, making eye contact and asking direct questions of audience members. This intimacy allowed the audience, especially the younger members, to lose their hesitancy of questioning authority.

It is an exciting time to be involved in developing EM in Myanmar. Our group of non-academically affiliated volunteers want very much to do the right thing without impeding on progress made by the Australian and Stanford groups. In 2014, though the effort of these pioneers, the Myanmar Medical Association announced the formation of the Emergency Medicine Society and The Ministry of Health also recognized EM as a specialty in its own right. In addition, the government recently has begun to direct money from military spending (40% of the GDP) to the health sector.

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Furthermore, residency programs are being established. Eight candidates commenced the postgraduate Diploma of Emergency Medicine and are due to sit their final exams in August of this year. Professor Zaw Wai Soe, the Head of the first Department of Emergency Medicine at Yangon General Hosptial, is overseeing its inaugural EM residency program. The initial class of 25 began in January 2015 and a second group of twenty-five candidates is scheduled to start in January of 2016. Dr. Mahadevan’s group from Stanford University is helping Dr. Htoo establish an EM residency programs in the private health care sector. The first class starts in September.

One year ago, what we knew about Myanmar would have easily fit on a 3 x 5 index card. Now, after a week’s visit to Yangon and Mandalay we have gained a wealth of knowledge and a desire to see the specialty of EM become a reality in this Asian nation. While much has progressed from the humble beginnings of EM in 2012, there is still much more that needs to be done. Assisting both the government and private EM sector to develop, providing opportunities for EM education in areas that the government resources are not yet able to fully achieve, and advancing the reputation of EM within the medical community in Myanmar are critical to the development of a specialty new to this emerging country.

With these goals in mind we are returning to Myanmar in March of 2016 for a second conference. It is our hope that a cooperative effort among groups committed to improving EM in Myanmar will accelerate the development this specialty.

REFERENCES

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1. Central Intelligence Agency. The World Fact Book. 2015. https://www.cia.gov/library/publications/resources/the-world-factbook/geos/bm.html, assessed 27 August
2. World Bank. World Development Indicators Myanmar Country Statistics. 2014. http://data.worldbank.org/country/myanmar, accessed 15 August 2015.
3. Murray, Christopher JL, Jeremy A. Lauer, and David B. Evans. Measuring overall health system performance for 191 countries. World Health Organization, 2001.
4. World Health Organization. Myanmar: WHO Statistical Profile. 2015. http://www.who.int/countries/mmr/en/, accessed 15 August 2015.