Hepatitis B in rural Myanmar – Putao project site assessment

May 20-22, 2019

Written by Dr Alice Lee on behalf of trip team Drs Alice Lee, David Hilmers & Thao Lam.

The HOPE C project in Yangon has just about reached completion. 193 patients have started hepatitis C treatment, with 18 left at Myanmar Liver Foundation (MLF) yet to start. There are enough medicines left to treat 40 people. With this first cohort of patients about to finish, we have been asking, what next for the program? This is where Putao comes in.

Putao, Myanmar had been proposed by the MAM (Medical Action Myanmar) as a potential site to expand our work in hepatitis C treatment. Putao is a city in the northernmost part of Myanmar, only accessible by flight. It is home to 60 000 people, who are mostly farmers, miners and mountain herb gatherers. It is cold in winter and surrounded by mountains. MAM have worked in Putao since 2012, where they provide care for a community of people who inject drugs (PWID). This region is has one of the highest rates of PWID in Myanmar. There is no hepatitis treatment here, with the closest treatment centre more than 14 hours bus ride away and not accessible for most.

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Thao, David and I arrived in Yangon on Saturday 18th May. We stayed in a small apartment in a typical local suburb, with multilevel buildings crammed close to each other, narrow staircases locked at each apartment entrance. There were unpredictable but scheduled power outages for at least 4 hours a day. Hype of activity and noise surrounded us from the crack of dawn as the market set up at the front door and closed well into the night. We wove our way through local streets in search for food, mangos, hot cakes and soup and noodles.

At 5:30 am the next day, we got ready to fly to Putao with Thet Myat, the hepatitis program officer at MAM, for whom this was also her first trip to Putao. It was a four hour flight with two twenty minute steps along the food. We worked on the talks for the day and tidied up the lap top. I tried to sort my head and mentally prepare for what needed to be done. I needed to get a good handle on this, have realistic expectations and develop some relationships.

Putao represents many challenges. First we needed to assess whether it was feasible to work here. But at the same time, is this not why we set up in the first place? To work in areas where it seems too hard, whatever the reason may be; to help those who are least likely to get help.

Putao felt immediately different from Yangon. China to our east, and India to the west, a 7 day walk over land and 6 hours or so by car on the other side. I was told that there are no real check points but the soldiers on the Indian border will shoot to kill. We were met by customs officers who scrutinised our passports. We need special government permission to be anywhere but the town.

We were picked up by the program medical coordinator in Putao. (This is his fifth day on the job). We checked into a local hotel and made our way to the MAM office where we were greeted enthusiastically by Medical director and Organisational director. They have come to Putao ahead of us with the Global Fund audit team. We get to know each other and plan the one and a half precious days we have here so as to make the most out of our working time.

We arrive at the MAM clinic and are met by a very young but enthusiastic group of doctors. The success of a new hepatitis program will rely on them. These doctors come from all over Myanmar, the most junior having graduated only 2 months prior and the most senior 4 years ago. We spend the afternoon chatting and getting to know each other. They are excited to have us here. David runs a hands-on ultrasound training session, with local doctors as models. There is a palpable excitement in their desire to learn, quickly replacing my reservations about the youth of the group.

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Ultrasound training session for MAM Clinic doctors led by Dr David Hilmers

The clinic lies at the end of a long driveway of dirt and gravel. Chickens roam freely. There is a needle exchange box at the entrance of the driveway, gates closed for security, the staff house on the left with laundry hanging over the fence and wherever there is hanging space. It seems fitting for a house for young men.

The clinic has two medical and two counselling/consulting rooms, a dispensing area, a waiting room, reception, a data room, a lab, and a kitchen. Apart from the ultrasound, there is a small nebulizer, one sphygmomanometer and a small pulse oximeter. The doctors would like a little more. This is the better equipped of the two MAM clinics.

We had dinner with Ye Aung, Thet Myat and Yan Lin Aung at the dining pavilion at the hotel. We sit in a hexagonal room with a bar at one end, one of just two tables of people in the restaurant. Deer heads feature in the centre, looming over the drinks. The menu includes dried dear meat, and lots of garlic, onions, chillies and salt on top of piles of white rice. Discussions bounce between sharing stories of our journeys to date, what we would like to do here and the challenges that lie ahead. I don’t imagine for a moment that any of us sitting together are naïve as to the task ahead. I am reminded of the goal of Hepatitis B Free – to help and provide services where it seems impossible. Putao seems like the perfect fit.

The next day we start with a local breakfast of noodle soup, sticky rice, toast, “two in one” (tea, coffee and powdered sugar/milk), and walnuts. At the opposite end of the dining hall are a team here to train local pastors. Christianity is the most common religion in this area – many cross the border to India to study, then return to set up a church. Some villages have more than 2 churches.

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Our first stop is the methadone clinic at the Putao hospital. It is nothing more than a small stand-alone building with 3 small spaces, including a waiting room, consult room and a dispensary. Two ladies in uniform sit behind a barred window, and dispense cups of methadone. More than 200 people come each day. In just 30 minutes, at least 10 people come by, mostly on bike to collect their daily dose. No fuss.

Next door is the back entrance to the hospital, a square building surrounding a central courtyard. We glimpse into the wards and see the windows without glass frames, metal beds with minimal bedding, and no flow of air. Patients lying on their beds, some have a person sitting nearby, presumably a carer. In one corner of the hospital, the doctor rounds with the nurses. Otherwise it is a quiet area with very little activity. We make a short visit to the lab. The power is unreliable and there is little here, rapid tests remain the basis of most laboratory assessments. Machines including fridges are plugged in, but none are on and most are empty. One patient waits in the corner, the kindly lab technician looks on as we walk around. The ART clinic is one room with a curtained space for consults with the doctor and a table with the meds for dispensing. Discrimination and privacy are not major concerns here.

We head to the MCB clinic, about a 30 minute ride from the hospital. Two ride ahead of us on their motorbikes – the deputy project medical officer and the preventative doctor – and three ride in the back of the car with the back wagon flipped down. David offers to ride in the back but we know it is useless. It is unusually hot and humid today. There are mountains every direction we look, green pastures and lots of cows. There is little traffic, just the occasional truck, army trucks, car and motor bikes.

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Waiting for us at the MCB clinic is the team leader doctor, who has just graduated two months ago from medical school. He now leads a clinic that cares for over 1000 patients and also covers the nearby hospital when the local town medical officer is away. Sleeping in a room on the second floor of the clinic, his job is his life. He must look forward to the weekends when he can head back in to main clinic to socialize (drink and smoke) with his fellow medics from clinic 1. Despite his seemingly extreme youth and inexperience, he had identified a young 24 year old woman who came to his clinic soon after given birth to her second baby with abdominal pain, low grade fever and a mass. Local physicians had diagnosed a liver cancer based on ultrasound findings and he wanted us to review her. Her husband was a PWID and she was found to have a positive hepatitis C antibody test, but otherwise she was well. She was back to her usual routine, attending to the farm and caring for her two young children, one now aged 2 months.

Hearing her story, examining her and completing an ultrasound, we wanted her diagnosis to be anything but a liver cancer, but an alternative diagnosis seemed less and less likely. With no blood tests, no pathology, no other imaging, we needed to come up with a reasonable action plan. As best as we could, we tried to explain what we thought. Her response was unexpectedly calm, without hysteria or tears, simply, “I would prefer it out of me if possible.” We all hoped this would be possible. However, the reality was that we needed to do further tests and at best, if she could have an operation, it would cost over $1000 USD. This was well beyond anything that was within reach. A 24 year old lady with a possible life-saving intervention at that price. MAM would have a policy and we needed to ensure that we were not crossing boundaries.

In the afternoon we travelled down the main road and off a short dirt track to a village. MAM signs and a needle sharing box identified our destination, a simple structure with a palm roof, bamboo floors and windows framed with a colorful cotton curtains. It was both home and clinic to the community health workers (CHW) who had been providing first-line care to her village for nearly two years, and she lived here with her three children and husband. PWID come to the clinic for needle exchange and general health needs. Her main concerns are that the needles are not returned and they steal her chickens. We promised to look into that. Outside we saw just one chicken roaming around with her chicks.

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Three patients were invited to come and share their story. The first was a 34 year old opium turned heroin addict who has now been abstinent for 5 months. He tested positive for HIV and HCV. He was unaware of his status, but happy that he can support his family. He would do whatever the doctors recommended to be well.

The next two were women, both hepatitis B positive. The first lady had three children, all under the age of six, and her husband is a PWID. She gave birth in hospital, and her baby was vaccinated. The second women was found to be hepatitis B positive before the delivery of her youngest baby – one of five children. Although she delivered in the village, her baby received the birth dose hepatitis B vaccine. Having been advised of its value, her husband took the baby to the hospital within 24 hours of delivery to have their first dose. However, none of her children nor her husband have been tested.

There is much to do in Putao, and a lot of it is very simple. Sitting on the floor of the clinic room, in a circle with the local doctors, my head spun in a million and one directions, trying to process it all and form a strategy. I felt a sense of familiarity in this space, so similar to PNG in its physicality, but different in people and culture.

The team was waiting back at the main clinic at the promise of a training session. The heat was finally subsiding, replaced by wind and a sudden welcome downpour. We narrowly escaped getting soaked. The projector was set up in the waiting area, wooden benches lined in row, an open-air teaching space against the backdrop of tall bamboo trees. Over the next two hours, eyes were glued to the projector, and despite my computer screen blacking out with power cuts, the doctors interrupted with questions along the way and not a single head nodded off in a nap. I am pleased to share what I can and wished we had more time together. As we closed the session, we wanted to encourage and say that we will do whatever we can. I wanted them to know that they are not alone in this. We promised to train and be back, no matter what, and this promise we know we can keep. I just hope that some of these doctors will still be here.

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Photos by Alice Lee.

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