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Learning lessons from working overseas: Thailand

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I recently worked as a nurse for a month in a small healthcare project in Thailand, close to the border with Myanmar (Burma).

I recently worked as a nurse for a month in a small healthcare project in Thailand, close to the border with Myanmar (Burma).

This wasn't my first experience of volunteering, as I regularly work for Project: London, a healthcare initiative in the east of the city.

These two projects are completely independent of each other, occurring 6,000 miles apart and supported by different organisations.

But the problems I saw at the Sangkhlaburi Healthcare Project (SHP) reflected many of those at Project: London - specifically access to healthcare.

The two projects

Project: London, run by the NGO Medecins du Monde UK, was set up in 2006 to provide access to healthcare for marginalised groups such as migrants, homeless people and sex workers on the streets.

It also undertakes advocacy work at an individual and group level in an attempt to promote and bring about change, as the target group have a significantly lower life expectancy than the general populace.

Similarly, the SHP in Thailand was created to meet the needs of vulnerable groups without access to healthcare, namely Mon and Karen ethnic tribal groups from Myanmar.

Most of these migrants do not hold the identification card needed to access healthcare in Thailand or the money to pay for treatment.

Access to healthcare is also restricted during the annual rainy season when roads become impassable and many remote villages are cut off for months.

The project is led by a Burmese doctor who provides assessment, diagnosis and treatment in a small clinic in the town.

If further diagnostic investigations are indicated, or inpatient hospital treatment required, this is paid for by the project.

My role was predominantly outreach to see patients in the villages, provide health education, perform physical assessment, dispense basic medicines (paracetamol, oral rehydration salts or laxatives) and to triage patients that needed further medical management at the clinic.

Health problems

Along the Thai/Burmese border Plasmodium falciparummalaria is endemic and is one of the major health problems among patients attending the SHP.

Without access to official healthcare services, some people have to buy their own drugs and self-medicate. Here, even quinine can be bought from the market.

However, unsupervised self?medication can cause further problems, as was observed in a case of cerebral malaria with black water fever. The latter may have been caused by the reintroduction of quinine, which resulted in an acute medical emergency.

A further concern is for maternal and child health. Most pregnant women do not have access to antenatal care and child mortality and morbidity is high.

We have identified similar needs at Project: London. Many migrant or homeless women have no access to secondary care, and therefore are excluded from the vital antenatal checks they require during pregnancy.

They are routinely denied access to a hospital birth on the premise that they are not entitled. However, antenatal care constitutes 'immediately necessary treatment? and therefore should be provided regardless of a woman?s ability to pay.

Many pregnant women are very apprehensive about the health of their unborn child and need reassurance. Without access to secondary care they are unable to monitor their pregnancy, plan the birth and make necessary preparations.

Language

In Thailand, many of the Mon and Karen people we saw spoke neither Thai nor Burmese but only their ethnic language.

A lay translator is available but translation is not simply a question of language - cultural sensitivity is equally important.

When describing symptoms, patients use a framework of traditional beliefs and the way the symptoms have been interpreted and understood within their culture.

Cultural awareness is vital to prevent misinterpretation, and is essential in gaining an accurate patient history and understanding of symptoms.

At Project: London, interpreting services are also necessary and are used at almost every session via language line, trained volunteer interpreters or multilingual staff.

Many people speak little or no English so the interpreting service, despite its limitations, is a crucial part of the care offered.

Conclusions

Migrant populations are extremely vulnerable due to poor economic and social conditions, and this is exacerbated by the inaccessibility of healthcare.

Lower life expectancy is seen among both groups of people in Thailand and the UK.

The lack of maternal and antenatal care is equally tragic in both countries.

Access is a complex issue and is also dependent on health-seeking behaviour - that is, people?s attitudes to and previous experience of medical care and their fear of being deported when dealing with statutory services.

Such issues may delay or even prevent access to healthcare. By limiting access for certain populations we are impinging on their basic human rights by jeopardising their health, welfare and life expectancy.

With regard to infectious diseases, it also puts the health of others at risk.

We have a responsibility as nurses to recognise these problems and work towards change and access to healthcare for all.

Helen Catton is a staff nurse at St. Bartholomew?s Hospital, London. Email: melonlama@hotmail.com

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