Chapter 6: Maungdaw

Suggested Soundtrack: Charles Trenet - Boum!


I thought saving my wallet from falling in the latrine the other week would be my greatest catch ever. I was wrong.


Suggested Soundtrack: Charles Trenet - Boum!


I thought saving my wallet from falling in the latrine the other week would be my greatest catch ever. I was wrong.


This week I’m working in one of the clinics in Maungdaw. It is mainly a primary health care (PHC) clinic, but also does HIV and antenatal/postnatal care. The clinic manager is a tiny, very funny and very talkative Burmese lady with a high pitched voice. She’s spent a short time in the UK, working in the picturesque towns of Croydon, Sheffield, and Plymouth. Surprisingly, she is desperate to return – I’m not sure what that says about this place.


This clinic is incredibly busy – processing on average 350 or more patients a day, with only three or four doctors, a couple of nurses and a midwife. When I arrive in the morning, there are people congregated everywhere solemnly waiting for help. Packed in the waiting area, sitting on the staircases, hiding in the cupboards – its quite intense and fairly overwhelming.


Its tempting when faced with this type of stressful situation to don a top hat and sing a jovial French wartime song.


The emergency day care room quickly became full of children with acute watery diarrhoea. Nothing too difficult to manage, but the smell seemed to waft quickly through the clinic in the morning heat and made me glad I’d skipped breakfast. The nerdy tropical doctor in me was excited about the prospect of managing a possible cholera epidemic, but stool test results left me disappointed. No matter, I got my fix later that day when I saw one of the kids vomit out a very large intestinal worm (male Ascaris for those interested). It was about 30cm long, and crawled out of her mouth into the bucket on the floor. She seemed delighted by this, looking up at me and smiling with a sense of achievement. Her mother, on the other hand, was terrified. I wish worms could talk – imagine all the wonderful things it must’ve seen.


Just before lunch (typical), a lady arrived in labour covered in a blanket. As two men lifted the woman off the stretcher onto the day care bed, a large pink ball fell from underneath the blanket towards the floor, as if bungee jumping out of her vagina with its umbilical cord. When I relive the event in my head, I imagine me diving to catch it, but actually as I was standing so close that I just held out my hands and it landed comfortably into them. It lay silently for a few seconds before unleashing a loud cry to signal that it was alive and well. Unfortunately, the lady was having twins, and the second baby was inside the uterus lying in a difficult position to deliver. I tried unsuccessfully to externally change its position, a method I’d only read about in a textbook a long time ago, but as we could still hear fetal heart sounds we rushed her to the hospital for a caesarean section. It was a good catch though – if my old school PE teacher saw it maybe he’d stop calling me by my sister’s name.


Many of the emergency cases are obstetric related, and most do not end so happily. As in many places, the tradition here is for women to give birth at home thus present to clinic when something’s gone wrong, such as a prolonged or obstructed labour. Usually by the time they’ve got to us, the baby has unfortunately died. With limited resources, our best option is usually to stabilise the mother and send her to the local hospital to complete the stillbirth there. Explaining the whole situation to the patient and their caretakers is a difficult task, and one I’ve noticed that is often forgotten in the mad rush, especially with the multiple language barriers. It wouldn’t surprise me if most of these women go to the hospital thinking that their baby is still alive. A significant majority of our hospital referrals are obstetric complications. Maternal and infant mortality rates are high, and we really need to do something about it.


The clinic manager was on leave for a few days, so I took on the role. Working with staff from different communities means that differences of opinion easily become political, and mediating these discussions was both time-consuming and stressful. Even simple tasks, such as dividing duties among the medical team to organising lunch breaks, every decision required some convuluted discussion. As an expat, it is understandable that many staff members use me as a neutral listening ear, something that has also become quite common in Buthidaung. Stress levels are high here, and most staff have incredibly difficult living conditions. Doubling up as a clinic manager meant I really had little time to see patients. It was an interesting role though, and I did enjoy the power of telling people when they could go for lunch.


On Saturday mornings, we have a medical meeting, where I’m supposed to lead a teaching session with the other expat doctor. Although its a highly important meeting, where we discuss cases and guidelines etc. I would much prefer a lie-in. I’m quite lazy on weekends, and understandably its quite hard to motivate the inpat doctors after a busy working week.


I thought I was in luck when I was called at the start of the meeting by the security guard at the office, giving me an excuse to leave. Unfortunately a tuk-tuk had pulled up outside with a young pregnant woman in labour, surrounded by her family. Getting a clear story proved difficult, but it seemed she had been in labour for about a day, and her contractions were very weak. Understandably, she wouldn’t let me examine her outside on the street in the back of a tuk-tuk, so we drove to our clinic. When I finally examined her, I could see the baby’s head was stuck, and was in a position that required instruments that I didn’t have. Unfortunately she had clearly been like this for a while as the baby had died and the mother had become septic. I gave her some antibiotics and got her to the hospital for a forceps delivery. The mother survived, but underwent a complicated caesarean section to remove the stillbirth for reasons I don’t quite understand. MSF work hard to maintain our relationship with the Ministry of Health in order to be permitted to continue our activities in this state, so interfering with management in the hospital is not really an option. Frustrating, but all for the greater good.


This week I got to explore Maungdaw town, which is distinctly different from Buthidaung. Packed full of people during the day, its deserted by sunset. The plethora of pagodas seems slightly out of place strange given that the population is less than 10% Buddhist here. Currently, mosques and other places of worship for the Muslim population are banned in the state, most of them either closed or torn down. The market is an awesome sight, but fairly pungent due to the large amount of freshly caught fish being gutted on the street. The lack of electricity adds a vintage character to the many barbershops, repair shops and tailors. If it wasn’t for the occasional car, you could be fooled into thinking you’d stepped back in time to 100 years ago. The tailor shops are particularly impressive, packed with men operaing mechanical sewing machines and ironing clothes with hot coals. Who needs a cinema when you can spend an hour drinking tea and watch these men create various trousers and shirts?


Staying in Maungdaw for the week also allowed me to spend time with the other expats on the project. Its a good mix of nationalities from four continents, and we all get on well. In total, there are two doctors, two nurses, a logistics co-ordinator (logco), a medical team leader (MTL), a mental health officer (MHO), a HR admin, and a project co-ordinator (PC). A fairly big team, but given that we have six clinics and lots of other activities, we’re very stretched, and often separated. But we cope well. There’s not much to do in Maungdaw after sunset, so its nice to chill on the rooftop with a cold beer after a busy day. Lunch and dinner is prepared by the house cook – usually a curry and rice, with lots of different kinds of vegetables and beans. The only bar/restaurant in town, The Floating Recreation Centre, sits by the river and offers a nice view of sunset, as well as an extensive menu of fried snacks. Overall a pretty simple life outside work.


I wonder how long it will take before I get bored…