Power to the people: training the healthcare trainers in Myanmar

The story of one nurse’s mission to empower communities in conflict zones by teaching them first aid.

My name is Jean-Philippe Miller. I am an emergency and trauma nurse, currently based at the Alfred Hospital in Melbourne. During my time nursing I have worked overseas for the International Committee of the Red Cross (ICRC) on several missions. ICRC’s primary focus is in areas of conflict and other situations of violence.

I chose to work with the ICRC because it works to protect human life and health, to ensure respect for all human beings, and to prevent and alleviate human suffering around the world.

Off to Myanmar

My work with ICRC took me to the mountainous Kachin State in northern Myanmar, formerly known as Burma. Kachin State is a culturally diverse region, bordering China, India and Shan State. It is rich in natural resources, including gold and jade, with a mainly rural population of around 1.5 million.

In Kachin, I worked in two main areas: Myitkyina, the capital of a government controlled area; and in Laiza, the headquarters of a non-government controlled area.

Armed conflict in Kachin and other areas of Myanmar has resulted in many people being displaced from their homes, with a rise in humanitarian needs and little or no access to healthcare.

My mission in Myanmar

I had several objectives during my time in Myanmar. I aimed to empower the communities in Myanmar to respond to emergencies through the development of a first aid program. I was also charged with ensuring that communities receive timely, humane and effective first aid support where and when needed, by confident and skilled first responders.

One of the critical parts of my job was to strengthen and improve the chain of emergency care from scenes of emergencies to referral healthcare structures, particularly in locations where there is limited or no access to pre-hospital treatment and care.

In any program like this, we first reviewed the needs and capability of the communities in the areas I was working in Kachin State. We held meaningful discussions with community leaders and local authorities before proposing a program to train first aid trainers.

On the one hand, we would be empowering the community to feel confident and skilled to independently respond to emergencies. On the other hand, we would be giving the community ownership of a first aid program so that they could continue it as required.

One of the first questions to address was, 'who would become a trainer?'.

Trainers did not require any medical background or prior knowledge of first aid. They just needed to be motivated, enthusiastic, and eager to learn and teach others. Ideally, participants were respected community members who would facilitate further first aid education. We ended up working with local nurses, teachers, village health workers and staff from a local non-government organisation.

Down to the business of first aid

Our first aid courses included generic vertical emergency cases; unconsciousness, bleeding, burns, wounds and fractures and context-specific emergency cases. Of course, first aid goes beyond providing basic life-saving techniques and applying bandages.

In our course, we integrated all dimensions of emergency response. We found it essential to include some key elements that are often not found in typical first aid courses, including the use of local resources, especially traditional practices and remedies, preserving dignity and providing psychosocial support.

We also focused on risk and security management, stress control and communication, seeking help from bystanders and managing teams. It was also rewarding to emphasise the importance of the continuity of care, including transporting a sick or injured person and referring them on for further treatment.

This was not an ordinary first aid course. On the agenda was awareness and education on the risks of landmines, dealing with the ever-present threat of snake bites and learning about the laws of war in relation to providing first aid.

All the content in the course that I developed with colleagues was considered in relation to a simple first aid framework. The objective is to save lives and to alleviate suffering. The requirements are not to be hurt and to do no harm, physically or psychologically.

This first aid framework was considered alongside basic humanitarian principles and values, including humanity, impartiality, neutrality and respect for healthcare. We also needed to take into account the insecure context of the local communities, their levels of emotional distress, mass casualty incidents and severe emergency cases. In mountainous Kachin, other key factors were limited resources, the remote locations, legal boundaries and cultural and ethical dilemmas faced by participants.

Knowledge of first aid in the community was low. Many participants knew about traditional practices and remedies, for example using traditional leaves to stem bleeding and treating burns with tomatoes or potatoes. Practices were neither classified as ‘good’ or ‘bad’. Instead, participants were encouraged to consider whether traditional medicine practices were safe and effective. In a respectful manner, we encouraged the use of traditional practices when it fitted within the first aid framework.

We found that including and promoting traditional first aid practices encouraged community ownership and durability. It helped embed first aid in the community and prevented community members from thinking that expensive medical items were always needed.

This information was fascinating and often the basis for frequent discussions during first aid courses. Concepts of traditional medicine were explored and considered in relation to the first aid framework.

A unique approach

Our training was unique. We strongly encouraged active and practical teaching, avoiding PowerPoint presentations and lectures. We focused on demonstrating and simulating first aid incidents with lots of group learning activities. There were plenty of laughs and learning with first aid games and a focus on meaningful first aid life-saving skills.

We taught simple first aid principles, and once these were understood, we applied them to more complicated situations. We intentionally concentrated on the ‘why’, the philosophy being that if participants could understand why they were doing things, then the ‘what’ and the ‘how’ would follow. This teaching approach fed directly back to my initial objectives to empower the local community and build confident and skilled first aiders to respond to emergencies.

Our approach was non-medical. In Myanmar, first aid needs to be for everyone and not exclusive to well-resourced communities.

It proved fruitful to avoid medical jargon, diagnosis and the idea of ambulances and other Western systems. We promoted treating signs and symptoms, encouraged them to look at the casualty as a whole, and to use local resources as well as non-medical equipment and non-medical transportation. 

We supported the use of local resources and traditional first aid practices and removed the idea from our training that a medical or first aid kit is needed to provide first aid.

Central to our training was carefully considering what materials could be sourced and used locally. We investigated what materials locals had access to and what they could afford.

It turned out that most people did not have access to any type of first aid kit, so participants needed to be reassured or shown that they could provide first aid with local materials.

First aid instructors were provided with training kits stocked with local materials, including items from the local market and their households. Plastic bags could replace gloves. Cloth from local dress called longyi replaced bandages, while umbrellas and newspapers were used to splint limbs.

We actively promoted first responders to use their initiative and think laterally when providing first aid.

Why is first aid critical?

Discussions with Kachin communities highlighted that traffic accidents, particularly motorbike crashes, are one of the main causes of injury.

I have found that empowering communities with first aid is important because injury is a major cause of morbidity and mortality worldwide, and it is a rapidly growing public health concern. Injury has many costs, including treatment, lost or reduced productivity/wages, death or disability.

The World Health Organization estimates that, worldwide, 1.25 million people die from road traffic injuries every year, and that 90 per cent of these deaths occur in low and middle-income countries.

Most of these trauma deaths occur outside hospitals due to blocked airways or excessive bleeding. Both can be effectively managed with basic life-saving and stabilising first aid measures.

Many programs in low-income countries around the world have demonstrated that lay personnel can initiate basic first aid and provide effective pre-hospital care in resource-poor settings.

In Ghana, commercial truck drivers provide basic first aid for trauma and improve pre-hospital care. In Uganda, police officers, taxi drivers and local council members have been trained in first aid to strengthen pre-hospital care. In Iraq and Cambodia, village first responders have formed a pre-hospital rural rescue system, reducing pre-hospital response times and mortality.

First aid success

One year after the program started, it has been pleasing to see 17 first aid instructors now educating their communities. More than 750 community members are trained in basic first aid. Curriculums at two high schools and the local nursing college feature first aid training. It’s also taught at a camp for internally displaced people.

Many of those trained are feeling confident and providing first aid at work and at home.

Recently a young girl fell off the back of her motorbike and was left unconscious and bleeding. Quickly and without hesitation a trained first responder checked her airway and breathing. The first aider stopped the scalp from bleeding using the girl’s scarf, while directing a bystander to locate a local tuk-tuk vehicle, safely transferring her to a local hospital for more care.

I’m happy we have empowered Kachin communities to become confident and skilled first aid responders, in turn strengthening their chain of emergency care.

Jean-Philippe Miller is an emergency and trauma nurse currently based at the Alfred Hospital in Melbourne. Visit the IRC website.

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