Ed Wilkins in Myanmar: Week 16

I realise now that if you write a blog, you tend to gravitate to the same old topics which can be a tad tedious for readers but is comfortable home territory for the author who, if like me, starts and finishes penning these without any idea as to what he’s going to tap out on the keyboard. To assist me in this I need the stimulant of a few expressos at the local coffee shop in the Myanmar Plaza, which for avid readers you will remember is my go-to place for Western coffee and other delicacies. So, outside of doctoring, my comfort topics are undoubtedly accommodation, dress, and food, which, so as not to change the habit of 16 weeks, is where I start today. I am now happily ensconced in my third flat since first arriving nine months ago and, I have to say, this is the equivalent to a Mayfair penthouse by previous Myanmar standards. However, it is close to a small temple outside where the monk dutifully peals out the hour on his gong right through the night. In the morning, this is then accompanied by the two cockerels that the compound guards have adopted announcing the start of day and, of course, if there is torrential rain, the cacophony emanating from the corrugated iron roof. But these are minor deficiencies of otherwise a super-duper flat.

But with my family soon to be on my doorstep, I am bizarrely moving to a nearby hotel, so the prospect of a lie-in plays happily on my mind. But their imminent arrival has made me think of my own first visit three years ago and what I remember. If you’re weary eyes are up to it after 5000 miles with minimal sleep (and if you’re more observant than me), you’ll immediately notice that the Burmese are never drab and grey (like their UK counterparts can be) but bursting with colour. The ochre cheeks painted with thanaka, the multi-coloured fashionable longyi, the burgundy red betel-leaf stained teeth and gums, and the abundance of colour-patterned umbrellas (ever-present to fend off fierce sun or tropical storm), makes the Yangon arrivals lounge an amazing technicolour experience.

Thanaka (right), as I’ve written about before, allegedly serves many purposes: sunblock, cosmetic, skin-lightener, cleanser for acne, coolant like calamine for itch, and insect repellent. Maybe there is some science behind it (after all they have been using it for nigh on half a millennium) in that anti-inflammatory, anti-oxidant, antibacterial, and anti-tyrosinase activity have all been shown (published in the Journal of Ethnopharmacology – a new one on me). My evidence-based approach tells me it’s all hocus-pocus, but the flawless skin and ageless beauty is a characteristic of the Burmese women so maybe there is something in it. But see it you will, everywhere: on children, young men, and women of all ages: yet to give it a go myself, but it is on my to-do list!

Next on the Myanmar colour chart is the red mouths from betel-nut staining (left). Your first experience is likely to be the taxi-driver transporting you from the airport to your hotel. The active ingredient is a psychoactive stimulant which it is said helps the taxi drivers stay awake for the long hours necessary for a decent return. Given the erratic driving as you’ll witness on that first ride, it’s both a concern and a probable explanation. During this trip if you do indeed have a betel-nut-chewing taxi driver, the noticeable aspect of the ride aside of the red staining of his gums, teeth and lips, is his high velocity spitting often at traffic lights when stationary that stains pavements, lampposts, and if you’re unlucky, you if you’re a cyclist or pedestrian (below, right). Indeed, vendors come to the car window and restock his supply if necessary and every street corner has stalls: it costs around 10 pence and is usually sold in packs. Kun-ya, as it is known in Myanmar, is a concoction of the areca nut layered onto a slake lime-coated betel leaf, then sprinkled with tobacco, chilli, or the acacia tree extract called ‘catechu’, and then pressed between cheek and gum and sucked. Chewing the package is a mistake and like biting into a bitter astringent in my experience resulting in an immediate desire to extricate the Kun-ya from your mouth. From a hygiene perspective, it’s obviously something that infection control would pick up on in NHS Trusts and betel-nut chewers would be sectioned off with the smokers somewhere remote in the grounds. Akin to smoking it is carcinogenic and has been linked to the high incidence of oral cancer here. Because of this the government are trying to curb its use. No longer can you chew around the most sacred and precious pagoda in Yangon, the Shwedagon, nor can street stalls set up shop within 50 metres of a school. Given how engrained in Burmese culture it is, banning it completely which is on the government’s agenda would be the equivalent of banning MacDonald’s, KFC and Starbucks in the USA together in one fail swoop.

But moving to clinic matters and I mentioned in my last blog about a patient who I thought had straight forward renal failure following four days of rip-roaring diarrhoea; nothing that lots of intravenous and oral fluid wouldn’t correct. But her impaired kidney function didn’t budge, so I then considered the possibility of renal tubular acidosis from an HIV drug (tenofovir) and expounded proudly to the junior staff about the logical reasoning that I was basing this diagnosis on. But, it transpired that a question asked by the junior doctor revealed the answer and I’d never heard of it: she had a serious penchant for the bean Jengkol (or Dogfruit) which is also believed by locals to have beneficial medicinal properties including paradoxically curing dysentery – a double whammy to your kidneys if you’re already dehydrated. Moral if there is one – you never stop learning in medicine and always listen to your juniors, especially in a foreign clime.

With that in mind, because of a recently arranged working platform with a centre called the Thabyay Educational Foundation (left), I find myself being volunteered out of my comfort zone to talk about sex to young Burmese students. But first you need to know about the organisation. The Foundation has worked for over twenty years in Myanmar to support students from all over the country to access an education currently unavailable to them and send them back into their communities with the higher qualifications and confidence needed to be a key part in the development of a socially just, democratic and prosperous-for-all society. The breadth of their training is impressive, from Peace and Conflict to Sustainable Development: Public Health and Gender Issues rightly take their place and that’s where I come in. Interestingly, there is also a module on Public Speaking which I might need to attend if my talks aren’t sufficiently informative and entertaining: even at 64, I hate feedback forms!

Back to lighter topics. Interestingly Yangon can be literally translated into ‘end of strife’ which, considering current events is slightly ironic. It has recently held the annual Miss Universe Myanmar for 2017 with the successful winner (who also holds titles for Miss Healthy Skin, Miss Beautiful Hair, and Miss Famous) presumably going off to the global Miss Universe competition later this year. Next on my list, is the news that a private initiative water service – the Yangon Waterbus – has been introduced at the beginning of October and will hopefully expand. The concern is it that it will suffer the same fate as the ‘Strand Tram’ service which stopped running after only six months because nobody bought a ticket despite massive investment. And yet it takes 90 minutes on the bus I catch to get to the clinics because of the traffic congestion, let alone the pollution that occurs, so let’s hope the Waterbus takes off. 

Finally, it’s taken me some time, but I have started learning about citizenship in Myanmar, which is the most complicated system but so important – and again the British can never be free of blame. Full citizens are only the descendants of residents who lived in Burma prior to 1823 (i.e., the start of British rule) or were born to parents who were citizens at the time of birth. Can you believe there are 135 legally recognised ethnic groups of Myanmar? Obtaining citizenship sometimes (as it differs between states) means producing citizenship cards going back to your great grandparents; not something the UK Passport office demand thank heavens. Otherwise you are an ‘Associate’ or a ‘Naturalised’ citizen. The Rohingya people are not one the 135 groups that qualify for full citizenship as one might predict, even though for some their ancestors go back well before the British invasion. A term used in the stipulations to achieve Naturalised citizenship is to have a parent who lived in the country before 1948 (the end of British rule), and to be of good character and stable mind – not certain how you judge that. Still, the restrictions seem limited including not being able to hold public office, but that’s true of other countries where you must be the real McCoy, born and bred as the genuine national article. This includes becoming the President of the United States. So, unfortunately as I’m British I’ll have to cross that one off my bucket list.

So little from the clinic but I promise more in the next blog.

 

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