1st vs 3rd World Expectations

After a bumpy start in Reproductive Health (ehehe), Ive been spending Wednesdays in the Surgical Department – a concrete block towards the back of the Clinic, to the left of the sea-blue plastic water tank.

Surgical Department

Thongs (flip-flops) of all sizes are heaped up outside the doorways in accordance with Buddhist shoe-removal etiquette. There is a 40-bed ward, two procedure bays, an outpatient clinic, a small, air-conditioned operating theatre and a staffroom (like all public hospital staffrooms) filled with stray chairs, unstable piles of notes, watermarked textbooks, empty bottles of Coke and Red Bull and a PC that looks like a grey rock stuck to a desk. This one also has a litter of indifferent kittens huddled in the base of the bookshelf with an entourage of fleas – less familiar, although no more disturbing than some of the things I’ve stumbled across on top of NHS staff lockers.

Entering a surgical inpatient ward barefoot is a disorienting sensation. After two or three times you start to get used to it, and to the curry bowls and green banana bunches everywhere, the cats (graduated from the bookshelf) and the patients lying in rows on wooden beds, all in the one room, with relatives mingling in the aisles. It’s a large, airy space, like how I imagine makeshift war hospitals might look like, with missing ceiling tiles and noise from a lone TV buzzing in the background.

Most of the admissions are for treatment of conditions like infected ulcers and burns and chronic cellulitis, or for post-operative care following on-site hernia and hydrocele repair. There are also occasional swathes of young men presenting with severe penile infections caused by unsterile injections of coconut oil into the shaft. How word hasn’t got out yet that this is a bad idea, I don’t know.

In the outpatient clinic I’m paired up with one of the medics, a Karen man who’s been studying or working at the Mae Tao Clinic for the past thirteen years. Together we assess patients with an array of wounds, work injuries, dog bites, abscesses, sprains, lacerations and lumps, mostly in the neck, breast and groin. They tend to stream through the door, one by one, in either a light trickle or a patient tsunami.

One young man walked in the morning after accidentally mangling his index finger with a machete while cutting down stems in a field (or something). He was joking around with his friend and seemed to have no trouble accepting the fact that there was a bloody stump where half a finger used to be – not something stitches could fix.

I thought back to the last severed finger I had come across, in a London A+E a few months before. A middle-aged woman had stuck her hand through her neighbour’s letterbox and had one of the tips bitten off by an overly zealous housedog. What happened next was difficult to follow. She called for help and somehow 3 friends appeared and managed to sidestep the dog, retrieve the fingertip and put it into the neighbour’s freezer, directly on ice (this is the wrong thing to do btw – readers take note!). Then when they arrived at the triage desk, bewildered and flushed, they realized the finger was still in the freezer and the ambulance had to turn around and go back for it, sirens blazing.

More drama ensued. To cut a long story short, my whole day was taken up with this finger, not least because while I was on the phone arranging an urgent referral to the plastic surgeons at a specialist hospital in the unlikely event they could somehow reattach it, the wide-eyed patient and her not-so-helpful but well-meaning posse jumped the gun, presumably in a fit of collective anxiety, and raced out the door without telling anyone, without clear instructions or a trackable mobile phone. And they forgot to take the finger. Again.

I remember wrapping the poor, frostbitten thing in a shroud of sterile gauze and noticing it looked very dainty and well tended-to. A perfect nail painted an inviting shade of coral, with a glitter sheen.

It would make sense that First World fingertips get more attention than the ones on the Thai-Burma border (except when they’re in the freezer or on a hospital desk). The loose phenomenon is one of Adaptation  – of priorities, expectations and distress levels falling in line with the resources at hand (ba-doom).

This is something that’s been on my mind a lot since moving to the edge of one of the least developed parts of Asia, where I happen to find myself spending a lot of spare time reading articles and blog posts related to current debates on the connection between happiness, expectations, and reality. Like this one: Why Generation Y Yuppies are Unhappy. And this one: Fuck You. I’m Gen Y, and I Don’t Feel Special or Entitled, Just Poor.

Some incipient thoughts on the psychology of 3rd world expectations:

There is a undoubtedly a positive side. Deprivation can bring out remarkable levels of human resilience (from experience, the converse is also true). And even observing it can instill a sense of perspective that is difficult to maintain in conditions of saturated affluence. Almost every morning at the clinic, often while fumbling with a cold thermos filled with mixed fruit frappe, I walk past another young man with both arms missing, likely an old landmine injury. Things like that make you remember – or realise – what matters. Fingertips and spilt fruit frappe don’t make the list.

There is also a disturbing side – the apparent resignation, or passive acceptance of a miserable status quo. Unlike a distal phalynx, the penis is a near-universally revered and undeniably useful appendage. Yet some of the young men who wander over to the procedure bay for their daily dressing changes seem almost resigned to the fact that theirs looks like it’s about to drop off. Maybe it’s just because I can’t read their anxiety, or maybe they don’t understand the potential long-term consequences. Maybe on discharge they’re planning to go out and start an awareness-raising/prevention campaign, with flyers and street theater, to alert other men in the community to the dangers involved.

It’s hard to tell.

Day 1 at the Mae Tao Clinic

Aung San Suu Kyi

In the midst of all the leaving-London mess, I hadn’t really thought about what I would be doing for my once-a-week placement at the Mae Tao Clinic.[1] And so my first day there was a daunting one.

The clinic is a sprawling, plant-filled complex of one-story buildings located just off the Asia highway, outside the center of Mae Sot. I was dropped at the entrance by a tuk tuk and jumped off the back in my grey hospital skirt outside a row of dark, shed-like food stalls with roofs made out of corrugated iron and dried leaves.

I instantly felt inappropriately dressed – although the skirt was knee-length (as per advice from the ‘Volunteer Orientation Manual’) almost everyone else was wearing a longyi. Tugging self-consciously at my waistline, I wandered in and around and tried to figure out how to find the ‘RH OPD’ (Reproductive Health Outpatient Department). This was only piece of information on ‘where to go’ I had discovered on trawling through my inbox the night before.

I followed some dusty signs with uterus drawings on them, passed an open-air delivery ward where a baby’s slick black head was crowning, tentatively stepped into a large room filled with pregnant-looking women, and introduced myself to someone sitting in a small office who seemed to vaguely register who I was. She sent me into another room where I was adopted by one of the health workers and sat down with a jolt for row after row of consults in the antenatal clinic.

Having no real O+G experience aside from medical school, I had to concentrate hard to remember/pretend to remember how to take an antenatal history, measure a fundal height, feel a cervical os, and determine estimated date of delivery (EDD) with that cardboard wheel-calendar thing. The health worker – a very patient, slender, seemingly sweat-proof woman in a clean, light-coloured shirt – seemed to figure out quickly that I was essentially useless, and relieved the awkwardness of the situation by both acting as a translator and telling me what to write in the notes. She was very good-natured about it, smiling and twittering quietly in clear but broken English in response to my frequent questions. The patients seemed bemused whenever I spoke directly to them – this was a bit disconcerting. 

MTC fanThe room was sticky with heat and I tried to position my plastic chair directly under the fan. Embarrassing moments included not being to find the fetal heartbeat 3 times in a row, then being asked to interpret a bedside ultrasound (I could barely make out the gestational sac in that swamp of inscrutable grey lines). And as the day went on I felt more and more uncomfortable, partly because I was dehydrated from all the sweating, and partly because of the pressing question: what is the point of me being here when I don’t speak Karen or Burmese, don’t know anything about O+G, and am only going to float in, ill-equipped, saddled with a mild but ridiculous white-saviour complex, for one random day per week?

I was relieved to be sent out for a break. I bought a longyi – a sarong-like tube of material that goes down to the ankles – from a makeshift hospital store that was dark, dank and covered in dust. For lunch I had a fluorescent orange chunk of fried chicken thigh, a small plastic bag full of noodles and some water from a flimsy bottle that tasted like chemicals. I swallowed it all in front of two expectant dogs, then stood under the shade of a large tree in the middle of the main passageway holding a green apple, feeling faint and staring blankly into the heavy air. Lost in a blur of human activity.

The Mae Tao Clinic was started by Dr Cynthia Maung when she was a young doctor fleeing the brutal repression by the Burmese military in the wake of the 1988 student uprising. From its beginnings in a small, run-down shack, it now provides an extensive range of free health and social services to an estimated 150,000 refugees, migrant workers and other displaced groups living on the border. Around half travel to the clinic from the Burmese side, where healthcare is essentially non-existent. Many belong to ethnic minorities (mostly Karen).

As I stood there eating the apple, I thought about how it was less sterile here compared to other hospitals I’ve been in – both literally and metaphorically.

MTC sinkThe toilets have splintered wooden doors with rusted locks and a plastic bucket floating in a dark pool of water for a flush. There are dregs of rice blocking the sinks, and cracked eggshells in the gutters. The soap is diluted. Gloves are scarce. But people seem more connected – less alienated and scared – with healthcare being this intertwined with everyday life. As per the website, the MTC is “not just a workplace…it is also a home” – there is an on-site orphanage, and 95% of the staff have themselves been displaced from Burma.

I went back to the RH OPD after lunch less naïve and more reluctant. The afternoon session was much the same, except the health worker wasn’t there anymore and none of the others paid me much attention. I spent some time taking blood pressure and walking in and out of different rooms, and attempted to communicate with staff and patients but didn’t get very far without intensive help. And when my longyi fell down while listening in vain for another fetal heartbeat, I decided to give up.

I left early, back on a tuk tuk through the searing afternoon heat. At the guesthouse I collapsed under my anti-mosquito tent and fell asleep in the dark with the air-con on.

I’m strongly attracted to the MTC, the buzzing humanity of the place – but one day a week won’t be enough to get the hang of things, let alone contribute anything. And I should probably ask to be moved somewhere other than the RH OPD (or anywhere else RH-related).

I remember now reading something about the problem with short-term overseas volunteering, but I didn’t pay much attention at the time. It suddenly seems very clear: I am here asking the MTC for help, rather than the other way round.


[1] The rest of the week will be spent working at a community-based women’s organization