Myanmar Heart Institute

Myanmar Heart Institute

Published on Sunday, 18 August 2013 17:10

Written by Dr Than Naing Oo (Michigan, USA)

Recently there had been a flurry of journal articles, internet blogs, posts and comments regarding the future Myanmar Heart Institute (MHI).  As the saying goes"you may take a lad out of Myanmar but you can't take Myanmar out of a lad" and I had always been a keen reader of Myanmar related topics and this one was no exception.

I read most of the recent clatter and chatter from many discussants on this. It all started with Dr Htut Kyaw Win's (DHKW) memo that was translated into Burmese in the Voice Weekly Journal followed by some articles in the Myanmar newspaper in response and then many other subsequent comments.

First,some disclosures to clear the air. I am a physician of Myanmar originfrom abroad but not a cardiologist. And for some foreseeable future, given my personal reasons, I have no intention of going back to Myanmar to practice medicine. I am not a stake holder in this whole project and DHKW's father was once my mentor and my benefactor. Based on those conditions, it seemed I am the least qualified individual to providean unbiased opinion on this and such that I had been steering clear of it. ButI now have decided to chime in since I feel that most comments were missing the key points. And many well qualified individuals had elected to remain quiet for reasons unknown. I aim my opinions to be constructive and unbiased in nature. DHKW had repeatedly mentioned in his memo that he was hoping to stir a lively discussion with a view to build up the MHI under local and overseas healthcare providers' collaboration. So far it has not elicited such kind of a discussion but instead emotional rebuttals.

Let me also lay out some facts, though again I admit they are my own observation. I read both the English and the translated Myanmar version of DHKW's memo. Sadly I believe some were lost in translation. Myanmar translation didn't convey the nuances of the original statement in my opinion. In future, one should try to write in Myanmar if one wants to do business in Myanmar. DHKW had clearly laid out his vision of MHI. He didn't say a word that it is going to be a philanthropic or a charity or an NGO project. He disclosed that it is intended to provide a much needed service at a reasonable cost which will eliminate the need for cardiac tourism to Singapore and Bangkok by the Myanmar citizens who are already well off enough to take such trips.

Hence there is no need to raise the patriotism issue in this discussion.  It is clear that he wasn't doing it out of patriotism. Unfortunately, the main response by the Myanmar counterpartDr Kyaw Soe Win's(DKSW) article in the Kyay Mon newspaper and many others had resorted to this wornout path of shaming the expatriates with apatriotism banner. The expatriates are usually scolded for having left the country. In fact the term abscond is more widely used for that.  But the thing that nobody brings up is, 15-20 years ago when the expatriates left the country, there was no guarantee of their future success. Many were taking a big professional gamble. It was a sink or swim situation. It was full of uncertainty.  There are many Myanmar medical graduates who couldn't pass the overseas qualifying exams and subsequently never become a doctor in west. Or never got into a specialty training of their choices. To plagiarize American poet Robert Frost, those who left the country are the ones who took "the road not taken". But because of that should we likewise label those who stayed behind as those who prefer the path of least resistance? Those who don't like to venture out of a comfort zone?  Of course not.  My point is, we all are grownups who had chosen our own paths taking the reins of own destinies. This is especially true for those who graduated in 1987 and beyond since by the time they had finished internship, foreign travel had become much easier compared to the Burmese Socialist Program Party era.  No need to frame or shame one anotheror play this old record of "patriotic people stayed behind" song.  We all are from the same profession serving the humanity at different locations in the world.

We Myanmars like to posture a lot and put too much regard on the self-importance.  Forget about who you were and let's talk about what you can bring to the table in accomplishing a project. Let's get down to the business. There is no doubt about DHKW's capability. In fact, to bring world class cardiology services to Myanmar, if that is likely to happen, he might be the best person to do so given support from his institution, the renowned Methodist Debakey Heart Center of Texas. And likewise, the fact that the cardiology team led by DKSW at Mandalay General Hospital being able to establish Myanmar's first Primary Percutaneous Coronary Intervention capability ( especially ahead of the usually better funded Yangon General Hospital) is a very commendable one.  But that should be the end of discussion on personal accolades. Let's go back to the project MHI.

Let's discuss if MHI is indeed needed and later on whether it is viable.  The question as to whether it is needed is a"yes" to me. But is it essential enough that the public sector shares its funds in supporting it? The answer soundly is a "no".  It is meant for those who can pay, no qualm about it. Therefore we still need public hospitals to be upgraded to such a capacity (like what DKSW and team had done at MGH) in serving the general public who can't afford the MHI. And that is the government's responsibility, not the private sector's.  Hence, Myanmar colleagues need not worry about their job security as long as they are employed by the government to serve the public. If anything, Myanmar colleagues should try to collaborate with MHI in further improving their cardiac skills. But if they want to share the pie of the fee paying private patients, that's a whole another story which I won't delve into now.

Next let's talk about how to implement this project. Ideas are good but we still require the nuts and bolts kinds of details. I feel DHKW's MHI is lacking many of those. Or maybe he doesn't want to share the details at this early stage which is understandable. But since he had released his manifesto to the public, I think it is equally a fair game for me to raise those questions in open.  Who is going to finance the project? Are there any investors? Mind you, the cost is going to be in tens of millions of dollars if not in hundreds to build such a facility. As I have said before, Myanmar government should not be spending its scarce resources on this private project. Government's funding should rather go to improve facilities in the existing public hospitals. So where is the funding coming from? Myanmar investors? Overseas investors? Methodist Debakey Heart Hospital of Houston? I severely doubt that the last one will be the case. Also how about paying the overseas trained interventional cardiologists who will supposedly rotate at the beginning?  It is going to be much easier said than done.  Cardiology is very lucrative in west, at least in the USA. If the cardiologists come, I think it is because of their dedication than the compensation which I suspect will be lower than the western standards.  Continuing on the business aspect of the project, I read that DHKW aims to see MHI become a premier cardiac center of SE Asia with possible attraction of patients from the neighboring countries in future. Now that's a tall order. Not because I have doubts about the capability of DHKW and other cardiologists planning to work at MHI.  But to become a mecca of the cardiology tourism, you need many other infrastructure improvements to go along such as communication, electricity, transportation, uncorrupted workforce, staff who takes pride in what one does and having a commendable work ethic etc. Many of those are lacking in the present-day Myanmar and they are beyond MHI's scope to handle. The one example I want to give is the Pan Hlaing Hospital that was put into operation close to ten years ago. It was well funded and built according to JACHO accredited standards, the one and only in Myanmar I believe.  Many overseas physician, both Myanmar and non-Myanmar nationals, provided service there, just like what DHKW is envisioning for MHI. But the business never picked up compared to the other local hospitals such as Asia Royal Hospital, Shwegondine Specialist center (SSC), Bahosi or Vitoria.  That's because it couldn't attract the local clientele and no overseas patients from the neighboring country came either. Given all these requirements, as ambitious as it is, I have doubts about the sustainability of MHI in the present model.

DHKW had touched on the vetting process and issuing medial license to the overseas practioners who want to come and practice in Myanmar. MHI can set up its own bylaws in granting privileges to practice at MHI but it may not be appropriate to set policies for the Myanmar Medical Council. Myanmar Medical Council should have the insight and the capability to come up with its own rules both to encourage exchange of information while safeguarding the citizens from the unscrupulous overseas practitioners. It should not create road blocks but be a vigilant watchdog to ensure safety of its own citizens. But all of us who were trained in Myanmar know that in many parts of Myanmar, the paramedics and health assistants(HAs) practice medicine freely as if they are qualified doctors. No action is taken. Enforcement of the rules is very lax. And how about the traditional healers who are legally allowed to practice medicine though their methods and treatment were never put into test in a scientific manner.  They are also free to advertise in national newspapers that they can cure many types of cancer with no real data to back up their claims. Given such an atmosphere and the chaotic nature of the Myanmar medical practice, I have little hope of Myanmar Medical Council enforcing a fair system of checks and balances on the quality of the practitioners wishing to come back. It can't even safeguard its own backyard.  DHKW should just focus on MHI's internal quality control and credentialing.

To sum up, I feel that DHKW still needs to figure out many key elements in pulling off the MHI project. But everything has to start from somewhere and this is a good start. I wish him well in his endeavor. MHI should be welcomed in Myanmar.  I also suggest his delivery of the message in future be more diplomatic.  Let me quote the legal lingo in verbatim. Standard of care in medicine at least in the lawyers' eye is defined as , "the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances. An "average" standard would not apply because in that case at least half of any group of practitioners would not qualify. The medical malpractice plaintiff must establish the appropriate standard of care and demonstrate that the standard of care has been breached, with expert testimony". It means that from a legal stand point, standard of cardiology care expected at a 50 bedded rural hospital in USA is different and can be lower than what would be expected of at a premiere cardiac institute such as the Texas Heart Institute.  So we should take into account of Myanmar's inferior resources in comparing the capabilities and outcomes though it is not a reason not to strive for the best practice outcomes in Myanmar especially at the major teaching hospitals such as YGH and MGH. At the same time I also request our Myanmar colleagues to discuss the issues in a non-personal manner, bringingup the facts than being emotional and not trying to paint everything with a broad patriotic brush. MHI never advertised itself as a patriotic or charity project but instead as a service provider for the consumers. It's up to MHI to figure out if there are such consumers in Myanmar and secure the funding from private sector. Like in the Silicon Valley, not all start up blossom into successful companies.  The risk of failure is always there and MHI is taking the chance which is commendable. Lastly but not the least, for those who had been going back home to provide philanthropic and humanitarian medical care in the past, Myanmar still needs you no matter MHI comes into fruition or not. Please don't feel slighted by this all recent clatter. We all have our own varying strength and skills to fill the needed niche. Actions speak louder than talk in the long run. Hope we all can collaborate professionally with no conflict of interest where egos are left at door step while sharing the same vision.

Source: http://www.news.myanmaronlinecentre.com/2013/08/18/myanmar-heart-institute/