Where do you work?

Shoklo Malaria Research Unit (SMRU) on the Thailand Myanmar border, which is part of the University of Oxford-Mahidol University and Wellcome Trust Overseas Tropical Network programme.

How did you get into your line of work?

I’m not of the genre that knew from a young age this is what I always wanted to do, and I didn’t always dream of being a doctor. The world of health care is a buzzing kaleidoscope of different individuals in different roles, in part because humans mature (usually!) at their own pace. We come to our line of work and discover our talents and strengths in different ways and times. Working where I do I now realize the absolute privilege it was to be able to attend university. Even at that stage I was sure that I did not want to work in a laboratory or an office – I liked the outdoors.

Seemingly overnight, a six month volunteer job turned into more than 20 years and I still love it.

After working in remote parts of Australia intentionally mustering a broad exposure to work with indigenous Australians, and in obstetrics, pediatrics, anesthetics and emergency medicine, I headed off to study tropical medicine at the Liverpool School of Tropical Medicine in the UK.

I assumed this would be followed by a stint in Africa, but a job became available in Asia on the Thailand-Myanmar border. Seemingly overnight, a six month volunteer job turned into more than 20 years and I still love it. I went not expecting a salary but when it came along, the dream of working ‘relatively’ outdoors became a reality.

What do you do in your normal working day, and who do you work with?

A wonderful mélange of researching, clinical work, learning, and teaching. And a not so wonderful increasing mound of computer work (we can’t call it paper work anymore – life has changed).

In a typical day the interactions include:

• greeting the driver who carries us to the field sites and waiting to see if it will be in Thai, Karen, Burmese or broken English (and a mouthful of betel nut);
• gesturing to the cleaner who is wearing her gloves today (yay!);
• clinical rounds with a blossoming skilled birth attendant who has completed her training at SMRU;
• arranging a blood transfusion from a relative (no blood bank) for a pregnant woman with malaria-related anemia;
• participating in the profound silence of a mountain Karen woman giving birth, then the glorious burst of crying from her newborn (SMRU assists approximately 2,500 women in childbirth every year);
• arranging patients for x-rays at the local Thai hospital with the logistic manager, who, every time you look at him, you wonder how he survived his time as a ‘porter’ for the Myanmar military;
• working closely with the local medic or senior midwife who you know if life’s chances had been different, they could very well be standing in your shoes;
• appreciating the wide open eyes of medical students on their placement;
• learning from the locally trained sonographer who now has the experience to teach you what you are looking at;
• consulting with a beautiful, pregnant, diabetic Burmese Muslim patient wearing a colorful headscarf in the heat;
• skyping with one of our very supportive network of specialists in far-away countries who promptly respond to help with clinical and research queries;
• hearing the hearty laughter of steadfast and loyal staff at the water dispenser discussing who likes drinking it at ambient temperature (33°C) water and who likes it from the cooler;
• reviewing the case recording forms of data from malaria studies and discussing how we can understand gametocyte data in falciparum and vivax cases;
• opening my ears to the accent, and my mind to the background of any of our international group of doctors when being consulted about diagnostic possibilities of a complicated patient who has travelled, with difficulty, from deep in Karen state on the Myanmar side of the border to our unit;
• and cracking my head against a bamboo wall when receiving divergent responses from ethics committees on either side of the globe.

Well, maybe all these things don’t happen every day but at least you can appreciate the mix.

What are the challenges and opportunities you and your team face?

A fusion of nationalities and interests and daily surprises contribute to the beauty of working in an international setting. Resource limited settings, those in conflict and vulnerable populations are not attractive to everyone’s work ethic. If a country has not been operating properly for more than half a century, the education and health of the people suffer.

Medical work becomes difficult on two fronts: neglected and preventable diseases of poverty are inherent in the case load. Service provision by local health workers is limited to the best of their abilities. It is, at times, heart wrenching to see what this situation has done to the people’s health.

It is, at times, heart wrenching to see what this situation has done to the people’s health.

Moreover, on another level, the same can be felt when you realize the enormous lost potential, simply because people have not been able to access a basic standard of education, let alone higher education. The divide in our globalized world is stark.

However, at the same time, and contrary to these negative emotions, there is the humbling experience of appreciating the phenomenal resilience that emerges from human beings that have lived with disadvantage or suppression, and also the utter joy when you see a health worker without a university degree conduct a complicated medical procedure with ease and confidence.

A challenge is an opportunity for us to get one step closer to solving our problems. I hope our team keeps climbing the walls that pop up every day, from physical events, like the clinic flooding over our heads, to personal events like explaining a false positive result to an illiterate patient.

What is the best aspect of your job?

I shall never forget the day I received a pumpkin for helping a twin baby stay alive…best present ever.

I shall never forget the day I received a pumpkin for helping a twin baby stay alive…best present ever.

What’s the most important thing non-specialists should know about malaria?

Fit young men, mums and dads, and kids, dying from malaria, a preventable death, is harsh to witness and a profound loss. Treating malaria early is easy – like treating a sore throat…non-threatening and low risk; yet in a pregnant woman even uncomplicated malaria has a significant negative effect on the fetus, mostly through fetal growth restriction, that can never be reversed.

Cerebral and complicated malaria is something you need to consider in the unconscious patient (don’t forget the history of travel question) and if you do diagnose it, rapidly gather and implement the resources available to save life. Intravenous artesunate is more effective and easier to use than intravenous quinine.

Immunity requires exposure and it is not maintained when a native of sub-Saharan Africa living in Europe or USA travels home: prevention is needed. The malaria parasite is complex and despite the advances, the parasite has continued to evolve and evade the blocks placed in its way.

Breaking the cycle of malaria needs all of us, including governments, to fight for equality.