COMMUNITY MEDICINE PROJECT OCTOBER 14-NOVEMBER 13,1988

MAURIE-LYNN KOZAK CLASS of 1989 UNIVERSITY of CALGARY COMMUNITY MEDICINE PROJECT IN mAILAND

I would like to extend my sincerest thanks and appreciation to the Department of .Community Health Sciences for providing me with the unique opportunity of studying medicine in Thailand. The experience has not only diversified my training · but has broadened my interest and goals in the. field of medic~ne tremendously. This elective was arranged through Dr. Arunee Sabchareon, Associate Professor of Tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University,. , Thailand. I was interested in doing a community health project because I plan to spend time overseas working as a physician at some point in my career. Having visited Thailand already I was most keen to return.

The Kingdom of Thailand, formerly Siam, has an area of approximately 542, 000 square miles. Occupying a strategic position in the centre of the South-East Adian penni.nsula,Thailand borders and to the east, Burma to the west, and Malaysia to the south. Bangkok. and its sister city, Thon Buri, are Thailand's government, business and commercial centers.

Thailand's population numbers forty-nine million. 80 percent are Thai, 10 percent are Chinese, 3 per cent Malaysian, and seven percent are other ethnic groups such as Laotians, Vietnamese and Cambodi'ans.

_The predominant in Thailand is . It is practised by 90 percent of · the population. A Muslim minority exists in the southern region. Although the national language is Thai, English is widely used in government and commercial circles.

The reigning monarch in the .kingdom of Thailand is King Bhumibod Adulyadej, crowned in 1950. Si.nee 1971. Thailand's government has experienced numerous changes. 1979 marked the beginning of the. rule by a popularly elected coalition government.

The are highly respected for their rich culture and customs. Thais

1 from all levels of society display a high degree of respect for religion and the monarchy. Respect for Buddha's teachings, the core of Buddhism. is evident by the presence of Buddha images on nearly every street corner: Mon.ks are the most venerated of all people, regardless of their social origins (a man must even pay reverence to his own son or servant once he is ordained). The acceptance of alms from lay people by monks is not viewed as begging, but as assisting common people in their religious and moral improvement. Females of all ages must avoid any physical contact with monks, even while passing by on a crowded street. The Thai people normally demonstrated respectful . behaviour towards elders and do not encourage easy familiarity between generations.

Thais view the head as the seat of the soul and, according to tradition. if it is offended against, sickne5s could result. It is thus appropriate to avoid touching the heads of others or placing objects near or over them. Even hats are stored in high places. Thai people always try to .keep their head at a lower level than the head of their social superiors.

The feet, on the other hand, are considered to be very base. They are made as inconspicuous as possible and are never pointed towards any person or image of Buddha. Shoes are similarly scorned and are always removed upon entering most homes and temples. When removed they are stored in low places.

Unfortunately the community medicine project that I was scheduled to participate in was not yet underway when I arrived in Bangkok. Be'cause the starting date was postponed for several consecutive weeks, an entirely new agenda was arranged to facilitate my study period. This report focuses on the experiences I had while studying tropical diseases in a developing nation.

·I departed Calgary on Friday, October 14, 1988 for Toronto - London - Bombay - Singapore - Bangkok, and arrived at 4:30 P.M. on Sunday, October 16. From my taxi I noticed that like many other developing countries, there is a great disparity between rich and poor, with an almost non-existent middle class as evidenced by the large number of expensive automobiles driving alongside beggars in the

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streets. Although October marked the end of the rainy season, the monsoons were still in full force, heavily flooding the streets and homes. Primitive plumbing and sewage systems contributed to the spread of disease and destruction of poverty­ stricken communities. My experiences revolved primarily around working with the less fortunate.

Upon arrival at the Faculty of Tropical Medicine, Mahidol University in Bangkok, I received a Thai welcome and was introduced to the various faculty members. The first week was spent at Mahidol University studying common tropical diseases in Thailand such as malaria, dengue fever, leprosy and parasitic infections. Teaching sessions were conducted by various faculty members on the these subjects. I also spent time in the laboratory under the guidance of a resident doctor and lab technician. There, using a microscope, I learned to recognize the common parasitic infections of man. Although limited, the time spent on the pediatric ward at Mahidol University examining children afflicted with dengue fever, malaria, T.B.­ meningitis and other diseases was most beneficial. Such conditions are rare in Canada, .therefore to see. such advanced cases of these conditions and the methods for dealihg with them was truly a learning experience. Finally, I was permitted to regularly attend "journal Club" at Mahidol University. journal Club was part of an M.Sc. training program for medical doctors, held weekly to discuss and critique the latest medical papers from around the world. I learned the importance of critically analyzing recent medical findings, drugs, etc. and to decide if they are acceptable. It also taught me how to approach a journal article in terms of content, findings, and recommendations.

Thailand is well known for its widespread problems of malaria which are compounded by the fact that most of the malaria in Thailand is resistant to the antimalarial drug, chloroquine. Furthermore, there also exist numerous strains· of Plasmodium falciparum resistant to the drug Fansidar (sulfadoxine).

Arrangements were made for me to spend time in a remote region where 100% of the malaria is chloroquine resistant. I visited Khong Takao Village in Cha Choeng Sao Province, a village of 20 000 people situated 200 km southeast of Bangkok. It

3 took "f.5 hours to reach the village riding in the back of a canopy topped truck over roads in very poor condition.

This particular clinic was built in· 1981 and is staffed by ten Thai workers, who live . on the second floor of the same building. The clinic is divided into two parts: one half of the clinic is committed to the management of minor health problems and is operated by a female midwife and a male paramedic. A physician visits the clinic one day each month and handles the multitude of medical problems too complicated for the permanent staff. Whenever a serious problem arises and an M.D. is unavailable, the paramedic radios to the nearest hospital 60 km away and receives instructions via short-wave radio.

The second part of the clinic is devoted solely to the coi:ttroi ·and treatment_ of malaria. People from within the region are encouraged to come to the clinic at any time during or after an episode of fever and chills to have a peripheral blood smear made. If their blood smear ,shows evidence of a malarial infection, the patient is given one course of an anti-malarial drug and asked to return in 28 days to once again have a blood smear made. Plasmodium vivax and ovale infections are treated with chloroquine and primaquine while P. falciparum malaria is treated with Fansidar and primaquine. Unfortunately, only 50% of patients return for follow­ up. Children who are severely infected with malaria are frequently driven to the Faculty of Tropical Medicine in Bangkok to participate in anti-malarial drug trial ) studies and later returned to their villages once they have recovered. Childre.n aged six months to two years receive mefloquine (a third generation quinine derivative) while children three to twelve years of age receive quinine, quinidine, or cichonine.

Another major task of the staff at the malaria clinic is mosquito control. In July

and again in November each year, a three man team attempt to sp~y every home in a twenty-seven kilometer radius with DDT and fernitol thion. The task takes about two months to complete and is generally succ~ssful.

Lifestyle at the clinic is simple and basic. Although the clinic does not have running water, air-conditioning or beds, it is equipped with electricity, mosquito nets, foam mattresses for the floor, and a light microscope. Meals consist of rice and four hot Thai dishes prepared each morning and served for the rest of the day.

After returning from Khong Takao Village, I had the opportunity to visit Phra-Pra­ Daeng Leprosy Hospital and leprosarium. The hospital is staffed by seventeen doctors, one dentist, one pharmacist. two physiotherapists and one hundred and sixteen nurses. It provides medical services primarily to leprosy patients from all over Thailand, facilitating care to approximately twelve to thirteen hundred people (of the l40 000 people afflicted with leprosy in Thailand). The hospital also provides general medical care to about one hundred and fifty out-patients and thirty in- ·patients.

Phra-Pra-Daeng Leprosy Hospital acts as a terminal referral system in caring for severely affected lepers. either as surgical or medical patients, that is, surgery to correct deformities, physiotherapy, prevention and correction of eye complicatiOns, and manufacturing proper footwear. It also prov.ides health education material to leprosy patients, paramedical personnel and to the general public in the hope of minimizing tlie social prejudice towards leprosy patients. Along. with an active leprosy research division the facility provides welfare services to the deformed elderly leprosy patients. Nearly one thousand leprosy patients live at the leprosarium (for approximately five to ten years) at a cost of 18 baht ($0.90 Can.) per day per patient, funded by the government. Often patients leave the leprosarium to beg on the street where more money can be had. The Thai · government has also set up twelve agriculturally based colonies throughout Thailand where leprosy patients abandoned by their family and friends, live independently and self-sufficiently. While I was at the hospital. various staff members graciously taught me how to diagnose and manage leprosy and its complications.

My final week was spent at a provincial hospital one and one-half hours from Bangkok in the city of Chomburi. There I had opportunity to work with a number of Thai doctors and residents throughout the hospital. I was permitted to attend seminars and make rounds. Although I unfortunately did not receive a great deal of .

5 "hands-on" experience I found that the bedside exposure to patients suffering f.rom diseases uncommon in No.rth America to be an invaluable experience. Fu.rthe.rmo.re I have found a new appreciation and .respect fo.r doctors of develOping n8.tions. The methods and means of diagnosing and treating patients is often primitive by No.rth American standards. The· public hospitals have ve.ry limited access to modern equipment such as CT scanners. Fo.r example, the entire city of Chombu.ri with a population of fou.r hundred and fifty thousand has only one CT scanner, and it is used by all the public hospitals in the city. Such ~ospitals a.re understocked, unde.rstaffed and ove.rc.rowded, with a.rmy style qua.rte.rs housing ·fifteen to thirty patients pe.r .room. The practice of medicine in countries such as Thailand is ve.ry challenging, yet also .rewarding.·

One should .remember that not all of the facilities in Thai hospitals a.re primitive. The.re a.re also new, modern private hospitals with high tech equipment. The disparity between .rich and poo.r is evident the.re also.

My experience in Thailand has been tremendous, both academically and personally. I have·discove.red that medicine in the developing wo.rld is a "whole new ball.game" with a.different spectrum of diseases and a new emphasis. The elective permitted me to lea.rn and see, as opposed to only .reading about certain diseases, thereby enabling me to become mo.re familiar and comfortable in .recognizing and properly treating many tropical diseases. · This is ve.ry important to me because it has provided a solid foundation upon which I can study fu.rthe.r. It will also help me to .readily .recognize a tropical disease in a t.ravelle.r o.r immigrant who has .returned f.rom overseas. I have not only experienced the customs and lifestyle of the Thai people, but I have also learned to understand and mo.re fully appreciate them.

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