Myanmar and what I did there

So I find myself back in Yangon.  This being my second time here, I am already acquainted with the topography of the city. I choose to stay in the thick of it, in Chinatown, walking distance to the hospital.  And like Chinatowns everywhere, it is noisy, dirty, and congested. There are too many cars and too many people.  The smells are pungent, committing olfactory assault on my overly sensitive nose.  Imagine, if you will, a potpourri of fried foods, fishy fish, overripe fruit (durian anyone?), and urine.  I walk carefully, so as not to twist my ankles on the uneven sidewalks, not to step in filth, and not to collide with other pedestrians.  Everything becomes an exercise in mindfulness.

I have come in October, the tail end of rainy season. The weather is hot and humid, making outdoor activity uncomfortable.  In choosing a hotel I had three criteria: air conditioning, Wi-Fi, and free breakfast. Welcome to the Hotel Grand United 21^st Street, my home away from home. What makes it “Grand” is the rooftop restaurant from where I survey the city, from the Yangon river to Shwedagon Pagoda.  Shwedagon is the oldest and most sacred of Burma’s pagodas.  Its 110-meter gold and jewel encrusted stupa is the “crown of Burma.”  In contrast, my room is small, austere, and tidy.  The bed is hard and the pillows soft. The staff is helpful and pleasant.

Whenever I move to a different city, I recalibrate my daily activities.  How do I get drinking water, do laundry, buy groceries?  Where do I get a SIM card and top-off my cellphone?  Everything takes longer simply because it is unfamiliar.  And when I find good Indian food, fresh laundry, a nearby park, it is a small victory.  I establish a routine, perform meaningful work, and become part of a community. The shift from being a tourist to being a resident is subtle yet sublime. 

I was last here in 2013.  As both a volunteer and the director of the Orthopedic Overseas program, I have spent six weeks in the last three years in Yangon.  What draws me to Myanmar? What draws anyone anywhere?  I am here to check on the program—to ensure its viability and value for the local doctors and volunteers.  But there is also something deeper, something alive in my blood memory. There are the stories of my great-grandfather, an oil man in Yenangyaung.  Burma was one of the first countries to have a petroleum industry, a fact exploited by both the Indians and British.  My grandmother and eldest aunt escaped through the jungle during the World War II Japanese invasion. There is also my literary memory—Rudyard Kipling poems and stories and George Orwell’s Burmese Days.  In my Chinatown, however, there are no gloved servants, lush gardens, and gin and tonics.  Only the heat and humidity are the same.

Yangon General Hospital, where I spend most of my days, is the national trauma center.  The building is a proud red brick structure, built during the days of the British Empire. Patients are housed in long wards, segregated by gender and medical specialty.  The schedule is well established.  Audit starts at 7:30 am, when the post-call residents present cases from the previous 24 hours. There is review of radiographs, treatment options, and clinical decision making.  My role is to encourage the residents to think beyond classifications systems and to consider the patient’s circumstances.  An American surgeon must undergo a paradigm shift in providing orthopedic care in the developing world.  It is not enough to treat the X-rays.  The patient’s age, nutritional status, pre-existing medical conditions, and living conditions will impact their recovery. Road traffic accidents provide the vast majority of the trauma.  Men and women, children and the elderly, monks and laypeople, all are affected.  There are work-related accidents, such as falls off scaffolding or hands caught in machinery.  And the rare and usually fatal elephant attack. 

I split my time between the General Orthopedic team and the Hand Surgery Team. During my last visit I had focused on general orthopedic trauma.  This involved primarily treating long bone fractures, especially those of the femur and tibia. The preferred treatment here is a SIGN nail, an American implant that can be inserted without use of fluoroscopy (a portable X-ray machine).  This implant, the brainchild of orthopedic surgeon Lewis Zirkle, has revolutionized fracture care in the developing world.  It is an implant rarely utilized in the US, so as an American surgeon I did not have much to teach about its use.  I was more helpful in dealing with complex elbow trauma, an area of overlap between hand and orthopedic surgeons.

With the exception of two weeks in Malawi, I had not operated much in the last six months.  Back in the OR, I supervised the fellows and residents.  I was reminded how much I enjoy surgery.  I delight in the familiarity of anatomy, the challenge of a complex fracture, the satisfaction of restoring the former from the latter. The six month hiatus reinforces that I’m still a decent surgeon.  I have acquired a hard fought set of skills in my 20 years of practicing surgery. If only I could find a (paying) job that allows me to utilize these skills, a job that doesn’t deplete my joy like a Harry Potter dementor.

As my career has become more focused on hand surgery since my last visit, I spent more time on the Hand team.  I was warmly welcomed by the team, led by Prof. Khin Mg Myint.  He is a gregarious, jovial, and insightful professor.  He also never sleeps, often doing multiple digital replantations after hours as part of his own private clinic.  He is rightly revered among the staff and students.  The Burmese hold their professors in high esteem, using the honorific title Sayar (“teacher”) to express this.  There was a ceremony held during my visit in which professors were honored with gifts and food. 

The sharing of food remained a common theme throughout my visit.  I couldn’t walk into the operating room or morning conference without being offered tea, breakfast, and snacks.  It was certainly not because I looked emaciated.  My petite frame was carrying around a Buddha belly from lack of exercise and excess of kindness.  Along with teachers, guests are also honored in this society, and I happened to be both.  As with my own Indian culture, food is a way to express affection.  I was the beneficiary of many lunches and dinners. 

I worked in various settings with different residents and fellows, taking them through challenging cases in the OR, and discussing management dilemmas during rounds.  They in turn drove me between hospitals and clinics. One day the Professor had a couple of the junior residents take me on a field trip to Bago, a historic city about 50 miles away.  We spent the day driving through the countryside, visiting monuments (including a large reclining Buddha), drinking tea, and eating Chinese food.  I felt a little guilty pulling the residents out of their clinical duties, but they didn’t seem to mind the excursion.  

It’s great fun interacting with this team of enthusiastic and energetic residents. They have a well-established hierarchy.  The junior resident is the first one to evaluate and stabilize the terrible injuries that come through the emergency department (ED).  He manages the injuries in the ED, often staying up all night, and then presents the cases to the entire team the following morning.  When I was in residency training, you could always spot the post-call resident.  He was the unshaven, bleary eyed, disheveled one in wrinkled scrubs.  In America, as in Burma, most orthopedic residents are male.  In Yangon, every resident shows up freshly shaven, in an ironed white shirt, with perfectly combed hair.  The Professor does not tolerate alcohol, coffee, or tobacco use in his team.  The residents serve as a testament to healthy living.

After the junior and senior orthopedic residents, you have the hand surgery fellows.  They are more advanced in training, skills, and decision making.  While I try to be impartial, I do have a soft spot for one fellow in particular.  Than Kyaw was a senior orthopedic resident when I first met him three years.  He is a big man with a warm demeanor and is universally adored. His mannerisms and appearance remind me of one of my favorite uncles.  Despite his limited English and my non-existent Burmese, we developed an instant and easy rapport.  In our first case together, we were managing a patient with a wound of the lower leg.  In the US we harvest skin grafts for wound coverage using a specialized instrument called a dermatome. Than Kyaw laughed when I asked for the dermatome, holding up a simple razor blade. “This is our dermatome.”  Whether big cases or small, I was impressed by his skill and confidence.  Three years later, he is now a hand fellow, and greeted me enthusiastically when we met.  He is as friendly as ever, and has taken on the maturity of a more experienced surgeon. I marvel at the invisible bonds which connect us to each other—how relationships can flourish despite differences of language, culture, and background. 

I took two weekend excursions during my time in Myanmar.  For the first, I spent a few days in Mandalay district, visiting the surrounding ancient cities of Ava (Inwa) and Sagaing, and then Mandalay itself.  Nora was my local guide throughout the weekend, and she was a wealth of knowledge about history and culture. Myanmar has had many capitals, including Bagan and Moulmein.  And every capital has an abundance of pagodas. Yangon was the seat of government during British and modern times, until it was moved to Naypyidaw in 2005.  One of the residents succinctly described Naypidaw as a “city with buildings but no people.”  I’ll check it out during my next visit in 2018.  Perhaps it will have a more enticing personality by then.

My second weekend I retreated to the resort town of Ngapali Beach.  I needed a respite from the urban chaos of Chinatown.  I spent most of the weekend walking along the pristine and tranquil beach, watching the sunset, and eating pizza.  I hired a private boat to take me to a few snorkeling sites around the adjacent Pearl Island.  All was going swimmingly until about three hours in, when both my calves inconveniently seized up.  Turns out it is difficult to swim if your legs don’t work.  I signaled to the boatmen who were fishing nearby, and they waved back.   Eventually they recognized my distress (even if they didn’t understand “help me, please!”), throwing me an inner tube, and reeling me in.  Once again I had escaped death by water.

My three weeks in Yangon passed quickly.  I had started growing restless, ready to leave Chinatown for China. 

To be continued…

See pictures at Myanmar 2016

Lessons from the road

Be generous with your gratitude, stingy with your expectations.  Travel is a gift that life offers you, so accept it with both hands and don’t be greedy.  Failed expectations, in travel as in life, lead to anger and grief.

Don’t be an a**hole.  Remain courteous, calm, and kind at all times.  Especially when encountering challenges at checkpoints, check-ins, delays.  Respect queues, even when others don’t, because you are not an animal.  Have your paperwork ready.

Tiananmen Square, Beijing

Learn how to say “hello,” “please,” and “thank you” in whatever place you visit.  And if you can’t express yourself in words, do your best with a smile and hand gestures.  If there is some important information you may need to share, (e.g. health issues, dietary restrictions, smoking preference) have a resident write the local translation on a card to carry with you.  Make sure you include the English translation so you know what you are pointing to.

Yangon Traffic

Walk the world like a VVIP (very, very important person).   I coined this term based on an experience I had at the Livingstone Zambia airport.  As the flight schedule would have it, my four seater plane was the only one on the runway.  I was the lone passenger in the newly constructed terminal.  My guide met me on the tarmac, expedited me through immigration, escorted me to the waiting driver, who took me to the lodge, where I was greeted by the enthusiastic staff with a cool towel and fruity drink.  I felt like a rock star.  Confidence is power, deters shenanigans, and makes people want to help you.  The corollary is treat everyone else like a VVIP, even if they don’t see themselves as one.  We are all rock stars.

Never travel with more than you can carry.  Don’t expect others to lift your load.  A porter is a gift, not a right.  A heavy bag creates a heavy mood.  That being said, there are some things you need to pack: 

a)    Headlight or flashlight.  Electricity is an unpredictable thing.  The light can function as a streetlight and a reading light. Indispensable in a tent. And illuminates caves.

b)   Toilet paper and hand sanitizer. Always. Water is precious and rare.

c)    Water bottle.  Because the world is drowning in plastic and you can drink boiled tap water.  Stay hydrated.

d)   Silk sleeping sac. A touch of luxury that packs small but makes you feel big.  Because you never know how clean those sheets are.  A barrier against bedbugs, mosquitoes, and low thread counts.

e)    Flip flops. For the beach. For going to dinner. For a break from hiking boots. For they are easy to remove at temples. For the floor is sticky and the shower is funky.

f)     Wear clothes you can wash in the sink and dry overnight.

g)    Carry a wrap of some sort than can function as a shawl, skirt, head covering, or scarf.  Useful on airplanes, in places of worship, in a desert storm.  A bandana is also helpful, although covers less.

h)    Sunscreen, lip balm, sunglasses, wide brimmed hat. Your older self will thank you.

i)      Instant coffee and/or tea bags.  Just add boiling water and you have instant comfort and hydration.

j)     Swiss Army knife, but only if you are checking your bag. Can serve as a bottle opener, corkscrew, knife, nail clipper, screwdriver, scissor, etc.

k)    Garbage bag. Acts as bag liner in the rain, keeper of dirty laundry and shoes, emergency poncho.

l)      Journal. So you can document and recollect all the wonders.

m)  Kindle. So you never run out of reading material.

n)    Cell phone.  Acts as address book, alarm clock, camera, stereo. With Wi-Fi can serve as map, newspaper, email carrier, weatherman, compass.  And if it is SIM card enabled, it can even be a phone.

o)    Cords and adapters, so you can recharge your Kindle and cellphone.

p)   Cash. In crisp, new (post 2009) American bills.  ATMs don’t exist everywhere.  And your bank or credit card will invariably be declined during an emergency.

Ask many questions. Listen to everyone’s story.  Appreciate that while we live in different places and circumstances, we are all the same.  We want the same things—freedom from want and suffering, health and happiness for our friends and family, the chance to be useful in this world, the opportunity to improve our lives. 

Barkhor Square, Lhasa

Give yourself time for silence.  Gaze out the window, walk the city streets, sit at a restaurant and observe the passersby.  Rest at a monastery, listen to the monks chanting.  Stand on a bridge and contemplate the traffic, the lake, the smoggy sky.  Smile to yourself that you have been given such a gift, to be here, at this time, at this place.