The biggest and busiest town on the western front of Thailand, Mae Sot is located in Tak province directly across the Moei River from the Burmese town of Myawadi. It is about 400 km northwest of Bangkok (8-9 hours by bus), and about 250 km southwest of Chiang Mai (5-6 hours by bus). Different ethnic groups have lived in this town for over 100 years: first was the Karens, later the Tais, the Chinese from Yunnan, the Burmans, the Muslims from Bangladesh and northern Thailand, and the Sikhs and Hindus from India. Before the construction of a highway from the city of Tak to Mae Sot over mountainous terrain, it was far easier for Mae Sot’s residents to trade with people of the Moulmein province of Burma. Just west of the Moei River in Burma rise the 8000’ Dawna mountain range and just west of it a historically famous seaport on the Andaman Sea. Under British rule, Moulmein was one of the most important seaports of British Burma.
This historical trading with Burma continues with vigorous vitality today in Mae Sot. It is a community of 100,000 people with estimates of less than half being Thai citizens. Mae Sot continues to be a manifestation of multi-cultural localities where both official and black market economic transactions simultaneously thrive. The Thai national culture has not been easily entrenched here due to the “cultural displacement” of fleeing Burmese from every ethnic group. The majority of shop workers in town - especially in the open markets - speak one of the Burmese languages (of which there are over 100 recognized) rather than Thai. The sheer number of diverse ethnic groups, the bounty of natural resources, and the highly-charged political climate in both Burma and Thailand give this area so many layers of stories and activities that it may take being in Mae Sot for some time before sorting any of them out. There is an undercurrent of animosity toward the Burmese from the Thai people, propagated in part by the nature of trading that has taken place through the years. There are now many Chinese and Thai-Chinese that own businesses in the area, and are involved in everything from gem trading to textile sweatshops to brothels. Adding to the mix of Asian cultures is over 50 international non-governmental organizations (NGOs) that bring in a rotating band of Westerners with varying degrees of sensitivity to local culture. Intentionally or unintentionally, these NGOs aid the organized opposition to the Burmese government, and therefore support the existence of the 2 million illegal Burmese on this western edge of Thailand.
The many benefits of this multi-cultural area are evident as soon as you enjoy your first meal. There is no shortage of incredible places to eat, whether it’s in an organized restaurant or the many tin shacks or stands along the streets and alleyways. The two little tin and cloth-covered shelters next to the Mae Tao Clinic are a perfect example: on opposite corners from each other just 50 meters from the clinic entrance, these Burmese and Thai ladies serve some of the most delicious food in Thailand. You can enjoy papaya salad, sticky rice, barbeque chicken, rice or noodle dishes, wonderful soups, and fruit shakes for about a dollar per lunch. These places are filled with both medics and Westerners working at the clinic – and in fact, serve as excellent places for education of the area, discussions of patients, and plans for social activities. The daily lunch conversations run from which patients the medical students were horrified to see that morning to details of the weekend activities. As an example, today’s lunch was with 2 medical students, 2 public health workers, and a physician from Norway. We discussed the patient that came in with a bite to the face from a black bear in Burma, it took him 2 days to get to the clinic and he arrived with no nose or mouth, and one of our medical students promptly passed out upon seeing him. Fortunately, it was lunch and the details didn’t get too graphic, and we quickly moved on to more mundane topics. These included the upcoming May referendum in Burma and the sham election scheduled for 2010. Also discussed was the corrupt nature of the Thai government financially supporting the building of 3 dams in the Salween River in Eastern Burma that will ultimately flood vast areas of Karen land and destroy dozens of villages. This morphed into the description of this morning’s routine shakedown of illegal Burmese migrants by Mae Sot police, this time in the form of 20 police stationed on a street corner in town stopping every Burmese-looking person and asking for their “papers.” It was suspected that perhaps the town needed some fundraising for the upcoming holiday season. While enjoying my banana shake, the conversation turned to the annual Songkran water festival in 2 weeks. This is the biggest holiday in Thailand – it is their New Year celebration – and almost all businesses are shut down from 2-4 days. Many locals travel out of the big cities to their families’ historic homes, and in Mae Sot virtually everyone gets into the act by throwing water at each other. It’s well known to not bike down the street during these days with anything valuable that you don’t want wet (i.e. laptop, camera), because invariably hoses and large buckets of water will appear. It’s almost impossible to avoid, as you will be stopped in the middle of the road, sprinkled with traditional powder and ceremoniously “washed” – yet all in good fun.
March, April, and May are considered summer here in Thailand (the kids are out of school), with April generally having the hottest temperatures, averaging 105-115F most days. The hot weather arrived early this year, as it was consistently over 105F virtually every day in March. Adding to the heat is the smoke in the air from the burning fields. Last week the airport in Mae Hong Song was closed due to zero visibility, and drought conditions exist virtually everywhere now. We did get a slight break this week though, as an extremely rare rainy day occurred 2 days ago and was followed by the first somewhat clear day seen in over 2 months. The mountains in Burma finally reappeared and a nice breeze made for a lovely day – 95F never felt so cool. One benefit of being here in the dry season is the ability to run or bike virtually anywhere without fear of being stuck in the mud. While being in a constant state of dehydration, I’ve managed to keep up at least short runs daily, and longer bike rides on the weekends. It’s a shame the mountains are not visible most days, because biking on the empty roads along the Moei River with the imposing Burma Range just to the west is some of the loveliest biking around. It’s been great to reunite with my Thai friends in the Moei River Runners Club, and they were equally excited to see me. My friend Aote, whose Buddhist wedding I attended last year, now has a very smiley baby boy and still running quite well. His friend, the best man in his wedding, has qualified for Thailand’s Olympic team in the marathon and comes to train periodically with Aote in Mae Sot. I can’t imagine these are running conditions enjoyed by the world’s elite marathoners – smokey, hot air and a really dilapidated dirt track - but these are really tough runners and inspiring to be around.
While in Thailand last year for over 6 months, I was fortunate to not have any illness, not even an upset stomach. This year the first week wouldn’t pass without receiving my due. It came during a period when almost every Westerner was coming down with something, from just GI distress to dengue fever in 4 instances. While my little episode was not serious in nature, it did enough to drain the energy out of me for most of my first month here. I’m still not quite sure what it was, as it started with GI symptoms, but then struck one afternoon at the clinic like a freight train hitting my cerebral cortex. It was a very wobbly bike ride home as the dizziness created the illusion of twice the number of motor bikes and animals on the road than are normally navigated around during these daily journeys. I spent the next week or so with no appetite and incredible weakness. It was bad timing from a running standpoint as Aote and others from the running club had asked me to join them for a weekend trip to the Khon Khan ½ marathon – the largest race in Thailand. I had registered for the race prior to getting sick and was looking forward to the weekend, but could barely bring myself to running 13 meters let alone 13 miles. In addition, the following weekend was the only road race of the year in Mae Sot (5km and 16km races), but decided that helping the running club by working at the race would be the best option. I had a great time at the race working the finish line area, and as the only non-Thai worker, had a bonding opportunity with fellow runners and workers decked out in our bright pink volunteer polo shirts. While the first few weeks were a bit draining, my health has been fine since then, and on the bright side was able to be at a weight not seen since age 15.
Last year’s solo apartment was replaced this year by a “homestay” accommodation. There are 3 homestay houses in Mae Sot, all are traditional Thai teakwood designs of 4 bedrooms, lovely living rooms, kitchen and 2 bathrooms. One of the best aspects of this lodging, however, is that half of the rent goes directly to the Mae Tao Clinic. Due to the transient nature of the ex-pat community here, housemates can come and go at irregular intervals. During the past 3 months, housemates have included med students from Denmark, Australia, England, Canada, and America, musicians from Taiwan, and a solar power engineer from Scotland. One housemate who has been constant throughout has been Gideon, a Dutch aid worker with Child’s Dream, a NGO that supports children transferred from the clinic to Chiang Mai hospitals for difficult and rare surgeries. His stories of parents and children are tragic, heartwarming, and often gut-wrenching. Much to my delight, also staying here was my friend Andy, who graciously volunteered his month of February to be at the clinic and help out in any way possible. Initially he focused his information technology skills on helping our pharmacy computer conversion for the new central pharmacy, but his greatest contribution ended up being his nightly English classes with the clinic medics. It was great to have a running buddy to commiserate on the heat during our sunset runs, but Andy loves the heat and probably regrets missing these brutally hot days of summer.
I’ve been able to enjoy the company of wonderfully intriguing people during my stay in Mae Sot. The range of social activities includes splendid dinners, art openings, theme parties, and Ultimate Frisbee games every Saturday afternoon. One very interesting man who was in Mae Sot from September to March was an Irish priest named Alo. He had been teaching philosophy in Burma for the past 3 years (after spending 20 years doing the same in Chile), but had recently been asked to leave the country just before the September demonstrations and came here to teach philosophy and English to Burmese students and our clinic medics. He had heard I was also interested in taking Thai language lessons and contacted me about a person he had heard about in the Muslim section of town. We ended up having 10 lessons from Laily, which turned out to be quite an experience. Laily is a lovely Thai Muslim woman who teaches English to primarily Thai kids, and if we had actually received our classes from Laily, both of us would know much more Thai right now. Within the first 10 minutes of our first class, Laily introduced us to her brother Arif, who obviously was not a teacher. He immediately proceeded to take over our little lesson for the day (as unorganized as it was), and we thought perhaps it was just an obligatory gesture on his sister’s behalf. It turned out that Arif taught every class while sister Laily watched intently 10 feet away. Alo suspected that because 2 men were in the class, a Muslim woman would have to defer to a Muslim man to be with them. This would have been fine if Arif had any clue on how to teach. He had such a lack of patience with us that a number of times he would just walk away complaining of a headache and leave us wondering if the class was over . . . indeed, it always was. Alo and I would joke that our ineptness learning Thai couldn’t even keep the teacher in the room, and we would end up going to a nearby Muslim tea shop for their superb Burmese tea. Our conversations ranged from the social/political climate of Burma and other areas of the world to deeper, sobering topics such as the meaning of life. He gave me an interesting book by John Cottingham titled “On the Meaning of Life” which I’ve already read once and find myself going back over numerous pages. Although the topic is deep, it’s presented in a very understandable manner and has helped me attempt to bring some clarity to this madness of humanity we are surrounded by here.
On a lighter note, Alo also had another keen interest – he plays the accordion! I discovered this when telling him how I spent one evening trying to blow off steam after a long day at the clinic. On a bike ride home from the night market to pick up my favorite pad thai from Toom (spelled “Tom”), I noticed a new music store. What really caught my attention was a small used red accordion on the front shelf begging me to pick it up. I asked the shop owner if it was available to play, and he graciously agreed and asked what I liked to play (in very broken “Thai-lish”). I mumbled a few things, and he hustled to the back room to bring out his guitar and play along. Not only the shop owner, he’s also the music teacher and plays every night at a club down the street. He was an excellent guitar player, knew a ton of Western songs and exquisitely finger-picked the blues. I played background to his blues and folk songs and before we knew it, had spent an hour jamming in the parking lot (amid an audience of a few old men and older dogs). With a birthday party at our house that weekend for one of our clinic colleagues, the accordion would either be bought or at least rented for the night. Given the outrageous price he wanted for an old accordion with holes in the bellows making it difficult to generate sound, we negotiated for the latter and left a deposit to ease his concern of losing such a “prized” instrument. The afternoon of our party, I picked up the accordion and went to the homestay house of Richard, a med student from Australia who had purchased a guitar at the border market to play while he was here, and then would give to the music-loving clinic medics. Richard’s house was down the street from Casa Mia, one of our favorite restaurants in town, and the workplace of Charley, a very pleasant Burmese migrant who moved in a speed slightly slower than a snail. The previous week, we noticed Charley’s guitar had a broken string, so we presented him with a new full set of strings the following day. Stopping at Casa Mia to bring lime shakes to Richard’s house, it was hard not to notice Charley in his usual position of hanging out in the corner twiddling on his guitar. I asked him if he would like to join us for a little afternoon jam session . . . never was he seen so animated, he was ecstatic. The party that night turned out to be quite fun, with entertainment provided by 2 piñatas, and the musical meanderings of 2 guitars, one harmonica, 2 bongos, and one scruffy accordion. While we enjoyed jamming along to blues tunes made up on the fly, more entertaining was watching the 64 year old Alo playing Irish ballads with ease. Who would have thought those accordion lessons at age seven would come in so handy in Southeast Asia – thanks Mom and Dad!
Having the ability to relax and step away a bit from the misery surrounding us is critically important to maintaining sanity. We won’t soon forget the contrasts of the week of that party. Within the span of that week, I had given a 3 hour antibiotic lecture to the medics of our inpatient department during which one patient died and one had to be urgently transferred to Mae Sot Hospital (the lecture couldn’t have been that bad), we endured an excruciatingly painful clinic audit where our funding was threatened, the Karen National Union leader Mahn Sha was assassinated across town, and one of our junior clinic medics committed suicide by ingesting 30 chloroquine tablets. Perhaps that’s why the Friday night party turned out to be such a big hit, everyone was ready for a break from reality. That weekend we physically broke from Mae Sot, as 6 medical students, Andy and I visited the 12th Century Thai capital of Sukkothai, which is located just 3 hours east of here. We had a wonderful visit biking through the national park and venturing out to the deaf monk’s hideaway temple visited twice last year. Unfortunately, Mamit was away this time, but we communicated with him by phone texts and he remembered me and was sad to have missed us. We left food for him and enjoyed the peace and relative coolness of his mountain retreat before biking through the noon heat to make our bus back to Mae Sot.
While in Southeast Asia, I eagerly accepted an invitation to visit Cambodia from the Director of Khmer Health Advocates in Connecticut. She would be in Cambodia during my time here and had also invited the Director of the CDC’s National Education Program of Diabetes Translation to join her in a tour of hospitals and newly opened diabetes clinics around the country. Khmer Health Advocates is the only Cambodian health organization in the United States and is located in West Hartford, Connecticut. KHA provides care for Cambodian immigrants in Connecticut and Western Massachusetts, and advocates for holocaust survivors across the nation. KHA is meeting the challenges of outreach to this population through innovative technology tools that could be useful in other settings with marginalized populations. In 2007, KHA was named a Center of Excellence for the Elimination of Health Disparities by the Centers for Disease Control. My volunteer work with KHA will continue upon returning to the States and will focus on developing a cultural competency curriculum for pharmacists in conjunction with the Connecticut Pharmacists Association and the University of Connecticut School of Pharmacy. Involvement will include KHA’s unique telemedicine program which allows community health workers and clinicians to offer clinical supervision of in-home disease management and provide face-to-face education. The opportunity to visit Cambodia and learn about their health care delivery systems and clinical challenges will hopefully add knowledge to the multi-faceted issues facing this population.
Greeted at the Phnom Penh airport by Theanvy Kuoch, the KHA Director, and Jane Kelly of the CDC, we immediately were whisked off to what would be a whirlwind tour of Cambodian health care facilities. Our first stop was lunch at the home of Theanvy’s niece and a meeting with Maurits van Pelt, the Executive Director of the MoPoTsyo Patient Information Center. He was the former country director for Medicin San Frontiere (Doctors Without Borders) in Cambodia during the late ‘80s and 90’s, but now is developing a unique conglomerate of diabetes teaching modules throughout the country. We had a fascinating discussion on the rise of chronic disease (i.e. diabetes, hypertension) in Cambodia and how developing countries have funding solely for a communicable disease model. This model does not work for chronic disease and Maurits has took it upon himself to create chronic disease models focused on diabetes. Non-medical community workers have been trained to provide culturally specific education on the disease, treatment, diet, and lifestyle changes. One of the reasons community health workers are used rather than medical professionals, such as nurses, is because their reimbursement (which is low) is based on the education they provide, not on a drug that is dispensed or disease diagnosed (the traditional Cambodian model). Diabetes is generally not a result of obesity as it is in Western countries, and it may have its origins from many factors that are currently being explored. Some of these areas may be researched in the Cambodian American population, such as potential links with depression and post-traumatic stress disorder, to help explain why the American Cambodian population has a diabetes prevalence rate of 25%, four times the rate of the American population. In Cambodia, diet is a major factor as greater than 80% of calories come from carbohydrates, primarily in the form of white rice. Maurits explained to us that while meat might be a bit expensive to obtain for many people, vegetables are not and they are plentiful. Access to them is not an issue, but knowing which ones to eat and how to prepare them certainly is creating barriers.
Not having a history of a chronic disease model in a developing country results in not have funding, which has led to the use of only two medications for diabetes (glibeclamide and metformin) and very little use of insulin. Other than the very rare person who can afford the $10 vial of insulin, its use is limited to inpatient settings, and we would soon find out that even in those places it is rare due to cost. We were now off to inspect those institutions, and our next journey would be a 5 hour drive northwest to Battambang. The first experience of realizing the depths of Cambodian’s poverty occurred the next morning during a run through Battambang’s neighborhoods. The “colonial” atmosphere of Battambang’s one paved central road quickly turned into dirt roads narrowly lined with decrepit shacks and barely clothed inhabitants washing on the road or searching for their next scrap of food. As a White man running with fancy shoes (any shoes for that matter) through this spectacle of destitution, the sense of entitlement and abandonment was overwhelming. As quickly as the area turned into decay, it snapped back into “Western normalcy” upon stepping on pavement, meandering through children walking to school dressed in white shirts and navy blue pants or skirts. A 45-minute jog produced a kaleidoscope of surreal images which would be further enhanced by that afternoon’s travel.
While Theanvy was enjoying a visit with her family farther north and would reunite with us in Siem Riep the following day, Jane and I were joined by Dr. Patpir, a diabetologist who will be medical director at the new diabetes clinic in Kratie opening the following week. This morning will be spent at Battambang Hospital on a tour led by their diabetes clinic director, who was extremely gracious and patient with us despite his heavy caseload and obvious lack of resources. His diabetes clinic was only in its 8th day of operation and at this point consisted of 2 physicians and 2 nurses, and hundreds of patients. He lamented about their lack of resources and their inability to obtain medication for their patients. While diabetes is treated with only 2 oral medications, for unknown reasons the Cambodian government will pay for one (glibeclamide) and leaves the other (metformin) at the patient’s expense. No outpatients receive insulin because of their inability to afford it, and very few medications are used for hypertension, again due to the physicians’ justified fear their patients won’t purchase it. The medical director explains to us they have no problem with adherence to medications (an unintended benefit of poor access), however their greatest medical barrier in their diabetes patients is changing their diet. As mentioned, the Cambodian diet relies heavily on white rice, not always for economic reasons, as much of their consumption is due to cultural beliefs in the benefits of white rice. As an example of how the grain is so entrenched in Southeast Asian culture, the usual greeting for Burmese is: “Have you had rice yet?”
This clinic is the first example we’ve seen of how the chronic disease model is being implemented in Cambodia. In the diabetes, HIV and TB clinics education is such a dominant theme of their medical management that separate rooms are designated just for medication education. I was particularly impressed with the focus on medication education in the TB and HIV clinics, where multi-drug treatments are a necessity and non-compliance can lead to fatal drug resistance. Strains of highly lethal resistant TB run rampant here, and virtually everyone (patients and staff) on the hospital grounds wear face masks to prevent respiratory transmission. In the TB, HIV and outpatient clinics, patients receive their medication in one room, then are escorted to a specific education room for a lengthy discussion of their treatment. If it’s a returning patient, the health care provider attempts to work through a meticulous process of determining their previous compliance with their treatment. I was so impressed by this service that I told the medical director we didn’t have this level of education in virtually any American hospitals, although it’s not due to a lack of awareness of its importance. With a different payment mechanism in the American system geared toward product and technology rather than education, it was refreshing and inspirational to see a system give so much importance to education. It was also heartening to observe a system that realizes its lack of resources and yet rather than succumb to it, rises above it to explore other ways to improve care. We left the hospital forlorn over the shabbiness of the facilities, and yet exhilarated by the dedication of the workers. It was on to Siem Riep to explore other medical facilities and our mode of transportation would provide yet another educational experience.
Patpir, Jane, and I proceeded to the river that dissected town to find our “speedboat” and smiling driver waiting to trek us up river to Siem Riep. We decided on this means of transport because it would be faster than the 9 hour drive and infinitely more enlightening. The 5 hour boat ride started slowly through a narrow river lined with “floating villages” – not the type romantically written about in so many tour books, this was the reality of rural Cambodia and the stark images of poverty and naked kids frolicking in brown, turbid water will not soon be forgotten. It was a brutally hot, still day, and the plastic tarp pulled over our heads before starting out prevented certain sun stroke. The river was filled with bamboo shanties floating next to the river bank, so no land would need to be claimed. The river bank alternated between thick, rust-colored mud to traces of corn fields or fish remains deposited from the many fish farms floating where shanties were not. Expressions on kids’ faces varied roughly by the age of the child. Although it’s virtually impossible to guess the age of a child here due to their nutritional and resultant growth status, their love of life and the river seem to drain from their faces when they were old enough to realize this was their fate in life. Smiles and waves morphed to blank expressions of wonderment and despair as a boat with two white people and two Cambodians more fortunate than themselves slowly disappeared leaving a thick, mocha-brown wake of water behind. The sights from this river were almost too much to process: clothes, bodies and food being washed in filthy water, pigs jammed into floating bamboo rafts so tightly that one had fallen into the river, houseboats moving slowly in both directions made of any material available, and some with makeshift TV antennae protruding skyward. As soon as kids were able, they were paddling small wooden boats, it was obvious their life was on the water watching them nimbly bounce from boat to boat; perhaps their feet would never touch dry soil in their lifetime. Huge floating fish farms crowded the river, with cranes made of bamboo reaching over 100 feet in the air holding massive nets and large rocks for weights ready to anchor the nets in for the day’s catch. As the river widened further north, the fish farms took the form of fencing and nets, forcing boats to weave around them like a motocross course. The widening of the river allowed the driver to increase speed, but the propeller was not ready to cooperate. Having stopped 7 times already to clean various river “matter” off the propeller, the driver seemed a bit more concerned with the latest cut of the engine. After reaching under my seat for a wrench to pull off the propeller, a quick inspection revealed a noticeably bent wing. He nonchalantly reached for a back-up propeller under Patpir’s seat which was promptly installed and we were back on our way as if this was an inevitable component of the journey.
The wide river soon opened up into a huge lake, in fact it’s recognized as the Great Lake of Cambodia, and a quick transformation of claustrophobic river life to the open expanses of a lake where no land could be seen took place. The boat raced at its top speed (maybe 20 knots) presumably in a northerly direction with very little markers in sight to aid in direction. Within 20 minutes we were at the famous floating villages, widely known as evidenced by the many tour boats in the area from Siem Riep. These were the “upscale” floating villages, a far cry from what we had witnessed for the previous 4 hours in the river leading into this massive lake. We sensed tourists don’t experience the river humanity we had just observed, and this had been made pretty with bright paint and all the amenities of a village on land. We passed floating school rooms, stores, churches, a post office, police station, clinic, and a population that generally seemed to function normally and somewhat prosperously despite their distance from land being at least two miles. While this was very interesting to see, the influence of outsiders was evident here, making the previous stark images of river life much more poignant and depressing. Passing a cascade of tour boats, after 5 hours on the water, we tied our boat to another, and hopped across 5 boats to reach shore. It was nice to be back on land, although a very bumpy 45 minute tuk-tuk ride was ahead to the city of Siem Riep. This is now the tourist capital of Cambodia due to the famous Angkor Wat temples just north of town, and the abundance of hotels, restaurants, and upscale boutiques made it obvious this was not the “real” Cambodia. Tourism has exploded in this town, and its lack of planning and resultant overcrowding has somewhat diminished the spectacle of Angkor Wat. After visiting the temples just one year earlier, this year’s visit would focus on their health care delivery systems.
Our first visit the next day was to Siem Riep General Hospital and the Medicin San Frontiere (MSF) chronic care clinic. This hospital was in the middle of downtown and had surprisingly similar downtrodden images to the very poor Battambang Hospital we had visited a day earlier. Building construction and reconstruction was everywhere, as it was obvious money had been infused from the government to improve infrastructure, but yet was still lacking to procure chronic medical treatment. The chronic care clinics (HIV, TB, and diabetes) were being run by MSF and we had an extensive tour of them by a MSF physician. Everything for the care of these patients is free, thanks to the support of MSF, including medications, transport to the clinic, and overnight lodging. For TB and HIV, all appropriate medications seemed to be available and widely used, and again extensive counseling was provided with each visit. The free-standing diabetes clinic was christened the previous week in an opening ceremony, but was not officially open for business because new staff still needed to be trained. The MSF physician explained to us that MSF would be leaving Cambodia completely by mid-2009, and it was uncertain how this facility, and for that matter all facilities in the country would operate once they departed. MSF’s decision to depart was based on their mission’s purpose to operate in crisis areas, and the apparent determination that Cambodia no longer fit their criteria. Everyone we spoke to was quite afraid of the consequences of MSF’s departure, as they fear the Cambodian government will not respond with anything near appropriate levels of funding to fill the massive void. A recurring theme of governments in Southeast Asia is their rampant corruption, and Cambodia ranks as one of the worst, with its most needy citizens paying the highest price.
Our next hospital visit couldn’t have been more different than how we spent the morning. We spent the afternoon at Angkor Hospital for Children, on the fringes of downtown but light-years away from the decaying facilities of Siem Riep General. It was founded by Friends Without a Border, a NGO founded by a Japanese-American photographer who came to Cambodia on a photo shoot and left so moved by what he witnessed, his mission became this hospital in 1999. It was obvious this hospital opened with huge amounts of funding in place and a public relations and marketing department that would ensure continued funding success. Huge funders were virtually lining up at the door ready to contribute, and so many western volunteers had applied that year (over 1000) to help they needed to refuse some of their services. A building under construction will be used just for hosting guests and sell souvenir items of the hospital. We had entered a new world of philanthropic medicine, one where anything seemed possible with an organized effort to maximize the goodwill of people throughout the world. I couldn’t help but think of the possibilities for the Mae Tao Clinic if they had the luxury of a start like this, or the sophisticated (and paid) manpower to harness the philanthropy that results from their well-deserved reputation. In fact, this hospital’s “Wish List” was so impressively written and designed that Dr. Cynthia has already been made aware of potential revisions to MTC’s similar document. We toured each unit of the hospital and observed pediatric care that would rival any in the western world. As witnessed in other facilities, special attention was given to education of all types. Of all the slick brochures and extravagant technology employed at this hospital, one of the least costly projects impressed us the most. Filling the entire center courtyard of this square-shaped hospital was a huge vegetable garden, with each row of vegetables meticulously groomed and sign-posted. Just off to the side were 12 complete cooking stations. After all we heard in the previous days about the challenges to change the Cambodian diet, here was a glorious new hospital doing exactly what was needed to address the problem, spending their precious space to teach parents about the importance of vegetables, how to grow them, and how to cook them. There may not have been a better way to complete our tour of Cambodian facilities than to view this wonderful example of public health and how it fits into the infancy of their chronic care model.
Invigorated by the hope seen the previous day, an early morning run from our guest house brought me to the imposing moat surrounding massive Angkor Wat before sunrise. A streaming cavalcade of tuk-tuks, tour buses, and bicycles passed by while running in the morning darkness, as any tourist reading their tour book knows a sunrise visit to Angkor Wat is a “must-see”. For me, it was simply an early morning run necessitated by an 8am bus departure back to Phnom Penh. However, the sight of sunrise’s orange glow bouncing off lions’ heads and reflecting across the moat onto the 11th Century temples made for an exhilarating run home, and created one of those feelings that even if a camera came along on this run, the pictures would never do it justice. It would have to be a memory etched in the mind that would carry me through the upcoming 7 hour bus ride to Phnom Penh, the 75 minute flight to Bangkok, and the 8 hour bus ride to Mae Sot. A whirlwind tour of Cambodian health facilities had come to an end, a return to Mae Tao Clinic was soon to come, and reflection on how political atrocities in Cambodia and Burma have so dramatically affected the health of their citizens for generations, and perhaps how the similarities in their health care crisis may allow the building of one system become the blueprint for the other . . .
Sunday, April 6, 2008
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Monday, March 31, 2008
Reflections from the Thai/Burma border – Part 2, the Mae Tao Clinic, work activities:
My introduction back to the Thai/Burma border began with my nonstop flight from New York to Bangkok. For the first time I was able to clearly see almost the entire landscape of Burma. We flew directly over the heart of the country in our approach to Bangkok, following the majestic Irawaddy River south as it pierces the country in two on its way to the sea. I could make out the ancient city of Mandalay in the north and the outskirts of the former capital Rangoon to the south as we banked to the east toward Thailand. The massive Irawaddy tributary system could be seen fanning out across the barren and brown landscape. Finally, the landmark I was waiting to see appeared in the distance, the sawtooth Dawna Range in Eastern Burma. These 8000’ mountains create the imposing barrier and lush, thick forests of Karen State – the only remaining ethnic group still actively opposing the Burmese military junta. This tumultuous area is the reason I am returning to the Mae Tao Clinic after leaving there less than 12 months earlier. The Karen compose the vast majority of medic staff and patients at the clinic, most of whom have survived horrifying travel through these dense forests now recognized as the most heavily landmined area of the world.
Just over the east side of the Dawna Range I could see the Moei River, which provides the north/south border between Burma and Thailand for most of the Karen State. During the current dry season the river can literally be walked across without too much difficulty. Islands appear that are referred to as “no-man’s land” because no country can lay claim to them. Consequently, everything and everyone can be sold at will. But this same serene river becomes a raging torrent during the rainy season (May-October), and claims many lives that attempt to escape into Thailand. Mae Sot is the biggest and most active town along this border, and therefore is home to many illegal migrants, and a major depot for the trafficking of narcotics, gems, teakwood, and people. Because it is also a central outpost for the 9 refugee camps along the border, Mae Sot is also home to at least 50 non-governmental organizations (NGOs) providing comprehensive relief services to refugees and migrant workers along the border. Officially, there are just over 140,000 registered refugees living in camps along the border, but over 2 million Burmese are thought to be living along the Thai side of the border as illegal migrants. Since 1989, Mae Sot has also been the home of the Mae Tao Clinic, founded by Dr. Cynthia Maung when she fled Rangoon during the 1988 student uprising and traveled by foot for 10 months to open a “temporary” clinic for those fleeing the military crackdown. While she intended to return in 6 months to her young physician practice in Rangoon, 19 years later the clinic now has a permanent staff of over 300 medics and other ancillary workers – and like her, all of them “illegal” Burmese migrants without passports. Over the years, in response to the growing caseload and changing type of patients, the clinic has grown from an emergency health care provider to a comprehensive health care clinic. For the past 2 years, over 100,000 patients have visited the clinic per year, and in that time period the percentage of patients coming directly from Burma has risen from about 30% of patients to now over 50%. The patients who make the dangerous journey from Burma tend to have much more severe illness than those from Thailand. An acute spike in patient visits has certainly occurred since the September 2007 monk-led demonstrations and resultant military crackdown. The clinic offers a wide range of health and social services: over 200 inpatient beds (divided between adult, children, and OB-GYN), over 300 outpatient visits per day, surgery, reproductive health, child health services, laboratory/blood bank, primary eye care and eye surgery, prosthetics and rehabilitation, HIV/AIDS prevention, malaria management, migration health outreach services, schools for migrant children, boarding houses for children separated from their parents, and supports two clinics in Karen State just across the border. One of the major functions of the clinic is to be a training center. People from diverse ethnicities in Burma come to the clinic to train as health workers, or to upgrade or specialize their existing health skills. They then return to the border regions of Burma to provide much needed health services in rural or war-affected areas. This is one very important way for the clinic to save lives – to strengthen the ability of local health care workers inside Burma to provide health care.
Although I had only been away from the clinic for just over 11 months, I could not believe how much it had grown. The staff had grown from 200 to 300, more buildings had been erected, and many long-term westerners had been sponsored by NGOs to work in varying capacities of public health services. It was obvious the clinic had reached that critical point where its reputation had become widespread, and now was in a position to greatly expand and utilize the many requests of volunteers and sponsors that were increasingly calling. Dr Cynthia continues to be the recipient of major awards around the world, which certainly enhances the reputation and recognition of the clinic world-wide. This past November she was the winner of the 2007 Asia Democracy and Human Rights Award, given by the Taiwan Foundation for Democracy. The purpose of the award is to support democratic development and promote human rights throughout the Asia-Pacific region. The award committee duly noted Dr Cynthia’s dedication to training and educating refugees in order to build a community based on respect for life and human rights. The uniqueness of the clinic is that it not only provides medical care to patients but it also provides job training, social services, health education, child-protection services and community-building activities. In the past decade the Mae Tao Clinic training has brought community clinics to over 125 villages in Eastern Burma. For the first time, these villages finally have had access to Vitamin A to prevent blindness, vaccines, de-worming medications, anti-malarials and crucial antibiotics. The clinic also trains medics for the renowned Backpack Health Workers Team. This heroic group has grown to 75 teams of 3-5 people that go undercover through the jungles of Eastern Burma carrying 100 kg (over 200 pounds) of medical supplies for 6 months at a time. Each team is responsible for the provision of primary and preventive care for approximately 2000 people. Many times they travel in great danger due to landmines and the Burmese army. Unfortunately in the 8 years of their existence, 7 medics have died during their duty of providing care, some from landmines and others at the hands of the military junta.
While my first impression back at the clinic was on how much it had grown, my personal effect was in the relief of having virtually no “learning curve” on the vagaries of the clinic and the area. This was made readily obvious to me on my first day back at the clinic when I was asked to attend a meeting, and found myself understanding and contributing information at a level that took me about 3 months to reach during my first tenure at the clinic. One benefit of things moving so slowly here is that you can be away for an entire year, and not feel you’ve missed anything. As I look back at my time at the clinic last year, I’m thankful that I took 2-3 months to understand a bit about the workings of the clinic and allow myself to hopefully mesh with the staff. I found I wasn’t really able to contribute anything of significance until my last 2-3 months of work at that time. I certainly won’t have that luxury this time around! I have a very specific role in this tenure at the clinic, and that is to develop and help open a new central pharmacy for the entire clinic. The clinic currently has only an outpatient pharmacy and a tiny storeroom where overflow stock is kept. Each department has their own little pharmacy and a person responsible for ordering medications for their department every 3 months. It’s a similar philosophy to the way the rest of the clinic operates, almost as if each department is their own little fiefdom. While this does allow for great independence on the part of the medics in charge of that department (part of Cynthia’s goal is to promote empowerment), it has created some inefficiencies and potential areas of concern for medications.
Because each department has their own budget and wide latitude on how to use it, medications can be ordered very differently from one department to the next. In addition, if an emergency medication is needed and not available at the clinic, each department has had the ability to go to a pharmacy in town or Mae Sot Hospital to purchase the drug they need. After spending many years working in hospital pharmacies, I can be fairly confident in saying this is one unique way to procure medicine! While I continue to remain very sensitive to the cultural issues at hand with every decision made here, it was obvious to me and thankfully to Dr. Cynthia that the system had to be changed. So, she specifically asked if I could come to the clinic during this time period when the old kitchen (over 1500 square feet) would be renovated for use as a new central pharmacy. She also asked one of the refugee camp supervisors if they would let Po Tha Hay return to the clinic for at least the next 6 months to help with the transition. Po Tha Hay is one of the best pharmacy medics we had and was wallowing away at a camp awaiting potential resettlement. One of the travesties of the resettlement process is the forced placement of people into a camp while they wait they turn for resettlement interviews and placement. During this period they cannot work and have no guarantee that resettlement will even occur for them. So, it has been good to see Po Tha Hay return and help the pharmacy manager Naw Klo prepare the staff and the rest of the departments with this major transition of medication delivery.
Soon after my arrival we began work on a new pharmacy database with the tremendous help of a Thai pharmacist-turned-computer programmer who has volunteered her time at the clinic on weekends to not only assist with the database development but also training of the staff. The goal is to now have all inventory in one central pharmacy location, and each department will order weekly from the pharmacy and have their order delivered the next day. The central pharmacy will then be solely in charge of placing the quarterly inventory order with our wholesalers in Bangkok, and be the only people involved in the procurement of emergency medication from other local sources. We’ve modeled the program to allow each department to still be able to use their Excel ordering system (ably developed by my Global Health Fellow predecessor Anne Joly) that they are familiar with each week, and it will be automatically networked into the central pharmacy where it will be imported into an Access database, seen by the pharmacy personnel and allow them to fill the order. We have designed the system to alert for minimum quantities of each drug for the entire clinic and to bump up to the maximum amount of drug automatically to ease the process of completing the quarterly order from the wholesalers. We’re hoping this system can not only provide more control over the inventory, hopefully saving the clinic money and monitoring expiration dates, but also put systems in place for the proper “paper tracking” of where the meds came from and where they were dispensed. Due to the varying quality of medications in Southeast Asia, and the huge issue of counterfeit medicine, the Thai Ministry of Health has put into place some fairly stringent requirements for the documentation of every lot number of every product received and a certificate from the wholesaler that the manufacturer has been approved by the Thai Ministry of Health. We’ve included these provisions into the database, so again we’ve tried to anticipate not only a potential audit from the Ministry of Health but also to assure the many clinic donors that medication procurement is safe and efficient. The thought of our primitive clinic having a central pharmacy electronically networked into every department still amazes me. However, I’m snapped back into reality every time I look at the scrawny little cable that weaves through the trees connecting each tin shack building . . . that’s our network! A small bird could easily knock out our “network”, but until that moment happens, we’re forging into the technological age.
So, now that all the technical stuff has been completed, you might ask how is the progress of the actual pharmacy construction? Well . . . next question please . . . Actually it’s moving along quite briskly right now – of course one needs to keep in mind the nature of the tools and materials used here to know what “brisk” really means. The pharmacy construction couldn’t get started until the new kitchen was completed because the old kitchen will be the new pharmacy. This process took a bit longer than I was anticipating, and apparently than what Dr. Cynthia was anticipating as well. After seeing no progress during my first six weeks here, I casually mentioned to Dr. Cynthia that I was getting a bit concerned I would have to leave before the pharmacy would be finished. That morning she contacted the clinic construction supervisor and asked him to come speak to myself and the pharmacy manager about the pharmacy floor plan. At 10:00 am of that same day, the construction supervisor met with the two of us and we walked around the site. By 2:00 pm that same day, sledgehammers were crashing down walls of the old kitchen and cement was being mixed by hand in huge washing vats. To say that Dr. Cynthia still wields a bit of influence at the clinic would be a massive understatement . . .
So, with just 2 weeks remaining before my visa runs out and I have to return home, construction still goes on intently in absolutely oppressive heat. While I might complain about being hot sitting in an office with a computer or in a patient department with no AC anywhere in the clinic, I can’t imagine mixing cement and banging down walls in this 108+ degree heat. But the workers do it with smiles on their faces and are always willing to show you how things are going. Meanwhile, the Westerners working at the clinic are virtually non-productive every afternoon these days. Even with a fan blowing directly on you, it’s very difficult to concentrate and get any work done with sweat dripping from every pore in your body. It’s nearing the end of the dry season here, which means it’s getting toward the hottest time of year, and the fields are in a constant state of burning. This combination gives the air an almost surreal quality, the sunsets are spectacular (when you can see them), and the moon is the reddest I’ve ever seen. But the respiratory issues are not only affecting Westerners, they also are now a large percentage of our patient complaints. Fortunately, malaria cases are down as usual this time of year, but the percentage of malaria falciparum (the most severe form of the 4 types of malaria) is on the rise. This form of malaria can most commonly cause cerebral malaria, which in many cases is fatal or can lead to extremely debilitating meningitis, dementias, etc. Eastern Burma has the largest percentage of malaria falciparum in Asia, and malaria overall accounts for 23% of all medical cases and 42% of all deaths. Greater than 20% of children die before the age of 5, and half of these cases are from malaria.
During the rainy season, malaria accounts for 5 times more cases than the second most common diagnosis at the clinic. During the current dry season, the caseload is more evenly spread out among respiratory disease, infectious diseases (including large amounts of HIV and TB), malnutrition (present in almost every patient), renal disease, and surgeries for landmine injuries, etc. One mosquito-borne disease that does have occasional pockets of activity is dengue fever. This is actually a bit scarier than malaria because there is no preventive medication that can be taken to protect against it. Although not as serious as malaria, the first time a person acquires dengue they feel like the worst flu they’ve ever had, and treatment is just symptomatic, i.e. acetaminophen for the fever, etc. However, subsequent bouts of dengue can lead to more complications, such as hemorrhaging, and can be quite serious. There have been reports of small outbreaks of dengue in parts of central Thailand (at least 6 hours from here) this year, and unfortunately 4 medical students at the clinic in the last 2 months have tested positive for dengue. Since it’s not life-threatening, many look at it almost like a badge of honor or a “battle scar” from their time in SE Asia, however I’m willing to live without that badge, thank you.
Having worked at the clinic previously, I’m not naïve enough to think that the opening of the central pharmacy would be my only role here. Having a combination of pharmacy and public health degrees expands my ability (and interest) to work in many different areas. My challenge is not to find work; it is to manage expectations on what might be possible. Besides the issue of developing a database for the central pharmacy, and designing the actual workspace, the unenviable task of producing a policy and procedure manual for the pharmacy, which previously didn’t exist, needed to be addressed. The thought of this job immediately sent chills down my spine, and for a brief moment I thought it would be a nice joke to re-create a bogus policy & procedure manual given to me by another hospital pharmacist after enduring an agonizing process, it simply read “All pharmacies are the same.” I dismissed that thought quickly and attributed it to the heat getting to me. The nice thing about opening a new pharmacy is that I could write the manual completely from scratch and base the logistical flow on the new pharmacy, and not try to explain what we did previously. This also gave me the liberty to organize a system that hopefully would foster good work habits from the beginning. I’m still hoping I’ll be here to witness the transition actually take place.
On the clinical side, I’m frequently asked by a medical student or medic to come to a department to discuss drug treatment for a specific patient. Last year I was fortunate enough to be on the committee that updated the Burma Border Guidelines, the last update was 2003, and I was thrilled to see the actual delivery of the books on my second day at the clinic – it is now a very stylish hardbound book published in both English and Burmese. This has allowed for multiple opportunities to discuss with medics and med students changes to the guidelines, and use specific patient examples as good teaching opportunities. Each week I join the program managers and 2-3 physicians who have fled Burma and are now working at the clinic to discuss specific disease states in the guidelines and where changes were made. I’ve followed this up with Saturday afternoon lectures to the medic staff in specific disease areas. This is the slowest patient period of the week, so we can get all the medics together, and it’s amazing how attentive they are and still asking questions after a long, hot week. I can’t imagine any of my colleagues at home sitting through these 2-3 hour sessions (including me). If anyone is interested in seeing the Burma Border Guidelines, they can be found on this website: www.burmalibrary.org Look under the Health section and an updated pdf version can be downloaded. In that same section, you’ll also find the Health Messenger magazine, a quarterly journal published by Aide Medicale Internationale for medics and the lay public on both sides of the Thai/Burma border. I was asked to be on the edit committee for a couple of these issues, and just wrote a small piece for the next issue on how to properly use an inhaler. Since this magazine is distributed to primitive villages on both sides of the border I included a section on how to make a spacer when an actual spacer is not available (which is always the case). For all you pharmacists out there that run out of Aerochambers, feel free to use our method - we’ve found that one or two liter Sprite bottles work very well.
There is no shortage of public health issues that need to be addressed in this border region. I was happy to see the universal precautions program that I started at the clinic last year was up and running, and being capably handled by 2 nurses from Japan and England that have volunteered here in the past year. Remarkably, the original framework of the program is still in place, and just small tweaks have been needed to address issues discovered in the first 2 quarterly audits. With all the physical and cultural issues we needed to address to get this program off the ground, I’m thrilled it’s still moving along well. With that project under control, I was free to move onto other things, one of which involved the skills of my wife Cindy. While she was here last year teaching some diabetes classes to the medics, she asked if a diabetes education book with pictures might be something of value to the patients. I brought those pictures and associated education tidbits with me this year and asked the Outpatient Department manager his opinion of its potential use. It took him about 30 seconds to enthusiastically answer yes they could definitely use it, and he promptly took them from me and is now in the process of translating it into Burmese and printing up picture booklets. So, I’m happy to report another Cynthia has made her mark on the clinic . . . and I can go on to other projects.
I’ve just recently been involved in a big long-term public health project that is just getting off the ground now. A few of us with public health backgrounds, both at the clinic and those working with internally displaced populations (IDPs) across the border, have discussed with medics that villagers understand the behaviors they need to change and may have the tools to do so, but lack the interest to make these changes. Health workers are expressing frustration in continuing to try to have villagers change these behaviors, and feel as though they do not know specific techniques and activities to continue trying to get villagers to change these behaviors. We’ve decided to conduct an overall assessment of the programs along the border, both in IDPs in Burma and migrant populations in Thailand to provide insight into which specific behaviors groups are trying to change and if similarities exist between programs. After this initial assessment, workshops would be given with specific information on behavior change theory and ideas for activities that health workers can use to continue to try and change these behaviors. Creating behavior change teams within each of the specific organizations along the border will be critical for the continued monitoring and modifying of health behaviors. We realize this may be a daunting task collecting such diverse barriers to health behavior change, and know that we need to be sensitive to cultural aspects that may affect behavior. It will be a long-term project that hopefully I can contribute to even while back in the States through internet correspondence. While I was involved with some health behavior change work in the States with providers, bringing the multi-ethnic Burmese cultures into the mix adds entirely new dimensions.
I’m excited to report a visit to the clinic by three folks from Pfizer in Bangkok, two from the Pfizer Foundation and one from Business Technology. The purpose of their visit was two-fold, it was the first time they had visited the clinic (and specifically wanted to visit while I would be here), and to deliver their gracious donation of 25 IBM laptop computers. Dr. Cynthia gave them a comprehensive tour of the clinic and provided background on the history of the clinic and the unique challenges that the clinic continues to face today. We had presentations from some of the organizations the clinic supports, including the Backpack Health Workers Team, the Burma Medical Association (who works with IDP populations inside Burma), the school health team, the health information systems team, and of course some of our work specific to pharmacy and public health services. I think they came away from their day at the clinic with a new appreciation for the crisis of border health care, and the recognition of Mae Tao Clinic’s depth into the culture of this region. The clinic and Dr. Cynthia now have such a widely known reputation that each day specific groups ask to tour the clinic (we’ve heard it’s even in some tour books), and each time I interact with a visitor I’m struck by their reaction to the situation here and the clinic’s broad scope. Their reactions reflect a feeling that perhaps the existence of the Mae Tao Clinic itself is not only to cure the wound, but also to allow the world to know about the wounds inside Burma.
For more information on the Mae Tao Clinic, their website is: www.maetaoclinic.org
Just over the east side of the Dawna Range I could see the Moei River, which provides the north/south border between Burma and Thailand for most of the Karen State. During the current dry season the river can literally be walked across without too much difficulty. Islands appear that are referred to as “no-man’s land” because no country can lay claim to them. Consequently, everything and everyone can be sold at will. But this same serene river becomes a raging torrent during the rainy season (May-October), and claims many lives that attempt to escape into Thailand. Mae Sot is the biggest and most active town along this border, and therefore is home to many illegal migrants, and a major depot for the trafficking of narcotics, gems, teakwood, and people. Because it is also a central outpost for the 9 refugee camps along the border, Mae Sot is also home to at least 50 non-governmental organizations (NGOs) providing comprehensive relief services to refugees and migrant workers along the border. Officially, there are just over 140,000 registered refugees living in camps along the border, but over 2 million Burmese are thought to be living along the Thai side of the border as illegal migrants. Since 1989, Mae Sot has also been the home of the Mae Tao Clinic, founded by Dr. Cynthia Maung when she fled Rangoon during the 1988 student uprising and traveled by foot for 10 months to open a “temporary” clinic for those fleeing the military crackdown. While she intended to return in 6 months to her young physician practice in Rangoon, 19 years later the clinic now has a permanent staff of over 300 medics and other ancillary workers – and like her, all of them “illegal” Burmese migrants without passports. Over the years, in response to the growing caseload and changing type of patients, the clinic has grown from an emergency health care provider to a comprehensive health care clinic. For the past 2 years, over 100,000 patients have visited the clinic per year, and in that time period the percentage of patients coming directly from Burma has risen from about 30% of patients to now over 50%. The patients who make the dangerous journey from Burma tend to have much more severe illness than those from Thailand. An acute spike in patient visits has certainly occurred since the September 2007 monk-led demonstrations and resultant military crackdown. The clinic offers a wide range of health and social services: over 200 inpatient beds (divided between adult, children, and OB-GYN), over 300 outpatient visits per day, surgery, reproductive health, child health services, laboratory/blood bank, primary eye care and eye surgery, prosthetics and rehabilitation, HIV/AIDS prevention, malaria management, migration health outreach services, schools for migrant children, boarding houses for children separated from their parents, and supports two clinics in Karen State just across the border. One of the major functions of the clinic is to be a training center. People from diverse ethnicities in Burma come to the clinic to train as health workers, or to upgrade or specialize their existing health skills. They then return to the border regions of Burma to provide much needed health services in rural or war-affected areas. This is one very important way for the clinic to save lives – to strengthen the ability of local health care workers inside Burma to provide health care.
Although I had only been away from the clinic for just over 11 months, I could not believe how much it had grown. The staff had grown from 200 to 300, more buildings had been erected, and many long-term westerners had been sponsored by NGOs to work in varying capacities of public health services. It was obvious the clinic had reached that critical point where its reputation had become widespread, and now was in a position to greatly expand and utilize the many requests of volunteers and sponsors that were increasingly calling. Dr Cynthia continues to be the recipient of major awards around the world, which certainly enhances the reputation and recognition of the clinic world-wide. This past November she was the winner of the 2007 Asia Democracy and Human Rights Award, given by the Taiwan Foundation for Democracy. The purpose of the award is to support democratic development and promote human rights throughout the Asia-Pacific region. The award committee duly noted Dr Cynthia’s dedication to training and educating refugees in order to build a community based on respect for life and human rights. The uniqueness of the clinic is that it not only provides medical care to patients but it also provides job training, social services, health education, child-protection services and community-building activities. In the past decade the Mae Tao Clinic training has brought community clinics to over 125 villages in Eastern Burma. For the first time, these villages finally have had access to Vitamin A to prevent blindness, vaccines, de-worming medications, anti-malarials and crucial antibiotics. The clinic also trains medics for the renowned Backpack Health Workers Team. This heroic group has grown to 75 teams of 3-5 people that go undercover through the jungles of Eastern Burma carrying 100 kg (over 200 pounds) of medical supplies for 6 months at a time. Each team is responsible for the provision of primary and preventive care for approximately 2000 people. Many times they travel in great danger due to landmines and the Burmese army. Unfortunately in the 8 years of their existence, 7 medics have died during their duty of providing care, some from landmines and others at the hands of the military junta.
While my first impression back at the clinic was on how much it had grown, my personal effect was in the relief of having virtually no “learning curve” on the vagaries of the clinic and the area. This was made readily obvious to me on my first day back at the clinic when I was asked to attend a meeting, and found myself understanding and contributing information at a level that took me about 3 months to reach during my first tenure at the clinic. One benefit of things moving so slowly here is that you can be away for an entire year, and not feel you’ve missed anything. As I look back at my time at the clinic last year, I’m thankful that I took 2-3 months to understand a bit about the workings of the clinic and allow myself to hopefully mesh with the staff. I found I wasn’t really able to contribute anything of significance until my last 2-3 months of work at that time. I certainly won’t have that luxury this time around! I have a very specific role in this tenure at the clinic, and that is to develop and help open a new central pharmacy for the entire clinic. The clinic currently has only an outpatient pharmacy and a tiny storeroom where overflow stock is kept. Each department has their own little pharmacy and a person responsible for ordering medications for their department every 3 months. It’s a similar philosophy to the way the rest of the clinic operates, almost as if each department is their own little fiefdom. While this does allow for great independence on the part of the medics in charge of that department (part of Cynthia’s goal is to promote empowerment), it has created some inefficiencies and potential areas of concern for medications.
Because each department has their own budget and wide latitude on how to use it, medications can be ordered very differently from one department to the next. In addition, if an emergency medication is needed and not available at the clinic, each department has had the ability to go to a pharmacy in town or Mae Sot Hospital to purchase the drug they need. After spending many years working in hospital pharmacies, I can be fairly confident in saying this is one unique way to procure medicine! While I continue to remain very sensitive to the cultural issues at hand with every decision made here, it was obvious to me and thankfully to Dr. Cynthia that the system had to be changed. So, she specifically asked if I could come to the clinic during this time period when the old kitchen (over 1500 square feet) would be renovated for use as a new central pharmacy. She also asked one of the refugee camp supervisors if they would let Po Tha Hay return to the clinic for at least the next 6 months to help with the transition. Po Tha Hay is one of the best pharmacy medics we had and was wallowing away at a camp awaiting potential resettlement. One of the travesties of the resettlement process is the forced placement of people into a camp while they wait they turn for resettlement interviews and placement. During this period they cannot work and have no guarantee that resettlement will even occur for them. So, it has been good to see Po Tha Hay return and help the pharmacy manager Naw Klo prepare the staff and the rest of the departments with this major transition of medication delivery.
Soon after my arrival we began work on a new pharmacy database with the tremendous help of a Thai pharmacist-turned-computer programmer who has volunteered her time at the clinic on weekends to not only assist with the database development but also training of the staff. The goal is to now have all inventory in one central pharmacy location, and each department will order weekly from the pharmacy and have their order delivered the next day. The central pharmacy will then be solely in charge of placing the quarterly inventory order with our wholesalers in Bangkok, and be the only people involved in the procurement of emergency medication from other local sources. We’ve modeled the program to allow each department to still be able to use their Excel ordering system (ably developed by my Global Health Fellow predecessor Anne Joly) that they are familiar with each week, and it will be automatically networked into the central pharmacy where it will be imported into an Access database, seen by the pharmacy personnel and allow them to fill the order. We have designed the system to alert for minimum quantities of each drug for the entire clinic and to bump up to the maximum amount of drug automatically to ease the process of completing the quarterly order from the wholesalers. We’re hoping this system can not only provide more control over the inventory, hopefully saving the clinic money and monitoring expiration dates, but also put systems in place for the proper “paper tracking” of where the meds came from and where they were dispensed. Due to the varying quality of medications in Southeast Asia, and the huge issue of counterfeit medicine, the Thai Ministry of Health has put into place some fairly stringent requirements for the documentation of every lot number of every product received and a certificate from the wholesaler that the manufacturer has been approved by the Thai Ministry of Health. We’ve included these provisions into the database, so again we’ve tried to anticipate not only a potential audit from the Ministry of Health but also to assure the many clinic donors that medication procurement is safe and efficient. The thought of our primitive clinic having a central pharmacy electronically networked into every department still amazes me. However, I’m snapped back into reality every time I look at the scrawny little cable that weaves through the trees connecting each tin shack building . . . that’s our network! A small bird could easily knock out our “network”, but until that moment happens, we’re forging into the technological age.
So, now that all the technical stuff has been completed, you might ask how is the progress of the actual pharmacy construction? Well . . . next question please . . . Actually it’s moving along quite briskly right now – of course one needs to keep in mind the nature of the tools and materials used here to know what “brisk” really means. The pharmacy construction couldn’t get started until the new kitchen was completed because the old kitchen will be the new pharmacy. This process took a bit longer than I was anticipating, and apparently than what Dr. Cynthia was anticipating as well. After seeing no progress during my first six weeks here, I casually mentioned to Dr. Cynthia that I was getting a bit concerned I would have to leave before the pharmacy would be finished. That morning she contacted the clinic construction supervisor and asked him to come speak to myself and the pharmacy manager about the pharmacy floor plan. At 10:00 am of that same day, the construction supervisor met with the two of us and we walked around the site. By 2:00 pm that same day, sledgehammers were crashing down walls of the old kitchen and cement was being mixed by hand in huge washing vats. To say that Dr. Cynthia still wields a bit of influence at the clinic would be a massive understatement . . .
So, with just 2 weeks remaining before my visa runs out and I have to return home, construction still goes on intently in absolutely oppressive heat. While I might complain about being hot sitting in an office with a computer or in a patient department with no AC anywhere in the clinic, I can’t imagine mixing cement and banging down walls in this 108+ degree heat. But the workers do it with smiles on their faces and are always willing to show you how things are going. Meanwhile, the Westerners working at the clinic are virtually non-productive every afternoon these days. Even with a fan blowing directly on you, it’s very difficult to concentrate and get any work done with sweat dripping from every pore in your body. It’s nearing the end of the dry season here, which means it’s getting toward the hottest time of year, and the fields are in a constant state of burning. This combination gives the air an almost surreal quality, the sunsets are spectacular (when you can see them), and the moon is the reddest I’ve ever seen. But the respiratory issues are not only affecting Westerners, they also are now a large percentage of our patient complaints. Fortunately, malaria cases are down as usual this time of year, but the percentage of malaria falciparum (the most severe form of the 4 types of malaria) is on the rise. This form of malaria can most commonly cause cerebral malaria, which in many cases is fatal or can lead to extremely debilitating meningitis, dementias, etc. Eastern Burma has the largest percentage of malaria falciparum in Asia, and malaria overall accounts for 23% of all medical cases and 42% of all deaths. Greater than 20% of children die before the age of 5, and half of these cases are from malaria.
During the rainy season, malaria accounts for 5 times more cases than the second most common diagnosis at the clinic. During the current dry season, the caseload is more evenly spread out among respiratory disease, infectious diseases (including large amounts of HIV and TB), malnutrition (present in almost every patient), renal disease, and surgeries for landmine injuries, etc. One mosquito-borne disease that does have occasional pockets of activity is dengue fever. This is actually a bit scarier than malaria because there is no preventive medication that can be taken to protect against it. Although not as serious as malaria, the first time a person acquires dengue they feel like the worst flu they’ve ever had, and treatment is just symptomatic, i.e. acetaminophen for the fever, etc. However, subsequent bouts of dengue can lead to more complications, such as hemorrhaging, and can be quite serious. There have been reports of small outbreaks of dengue in parts of central Thailand (at least 6 hours from here) this year, and unfortunately 4 medical students at the clinic in the last 2 months have tested positive for dengue. Since it’s not life-threatening, many look at it almost like a badge of honor or a “battle scar” from their time in SE Asia, however I’m willing to live without that badge, thank you.
Having worked at the clinic previously, I’m not naïve enough to think that the opening of the central pharmacy would be my only role here. Having a combination of pharmacy and public health degrees expands my ability (and interest) to work in many different areas. My challenge is not to find work; it is to manage expectations on what might be possible. Besides the issue of developing a database for the central pharmacy, and designing the actual workspace, the unenviable task of producing a policy and procedure manual for the pharmacy, which previously didn’t exist, needed to be addressed. The thought of this job immediately sent chills down my spine, and for a brief moment I thought it would be a nice joke to re-create a bogus policy & procedure manual given to me by another hospital pharmacist after enduring an agonizing process, it simply read “All pharmacies are the same.” I dismissed that thought quickly and attributed it to the heat getting to me. The nice thing about opening a new pharmacy is that I could write the manual completely from scratch and base the logistical flow on the new pharmacy, and not try to explain what we did previously. This also gave me the liberty to organize a system that hopefully would foster good work habits from the beginning. I’m still hoping I’ll be here to witness the transition actually take place.
On the clinical side, I’m frequently asked by a medical student or medic to come to a department to discuss drug treatment for a specific patient. Last year I was fortunate enough to be on the committee that updated the Burma Border Guidelines, the last update was 2003, and I was thrilled to see the actual delivery of the books on my second day at the clinic – it is now a very stylish hardbound book published in both English and Burmese. This has allowed for multiple opportunities to discuss with medics and med students changes to the guidelines, and use specific patient examples as good teaching opportunities. Each week I join the program managers and 2-3 physicians who have fled Burma and are now working at the clinic to discuss specific disease states in the guidelines and where changes were made. I’ve followed this up with Saturday afternoon lectures to the medic staff in specific disease areas. This is the slowest patient period of the week, so we can get all the medics together, and it’s amazing how attentive they are and still asking questions after a long, hot week. I can’t imagine any of my colleagues at home sitting through these 2-3 hour sessions (including me). If anyone is interested in seeing the Burma Border Guidelines, they can be found on this website: www.burmalibrary.org Look under the Health section and an updated pdf version can be downloaded. In that same section, you’ll also find the Health Messenger magazine, a quarterly journal published by Aide Medicale Internationale for medics and the lay public on both sides of the Thai/Burma border. I was asked to be on the edit committee for a couple of these issues, and just wrote a small piece for the next issue on how to properly use an inhaler. Since this magazine is distributed to primitive villages on both sides of the border I included a section on how to make a spacer when an actual spacer is not available (which is always the case). For all you pharmacists out there that run out of Aerochambers, feel free to use our method - we’ve found that one or two liter Sprite bottles work very well.
There is no shortage of public health issues that need to be addressed in this border region. I was happy to see the universal precautions program that I started at the clinic last year was up and running, and being capably handled by 2 nurses from Japan and England that have volunteered here in the past year. Remarkably, the original framework of the program is still in place, and just small tweaks have been needed to address issues discovered in the first 2 quarterly audits. With all the physical and cultural issues we needed to address to get this program off the ground, I’m thrilled it’s still moving along well. With that project under control, I was free to move onto other things, one of which involved the skills of my wife Cindy. While she was here last year teaching some diabetes classes to the medics, she asked if a diabetes education book with pictures might be something of value to the patients. I brought those pictures and associated education tidbits with me this year and asked the Outpatient Department manager his opinion of its potential use. It took him about 30 seconds to enthusiastically answer yes they could definitely use it, and he promptly took them from me and is now in the process of translating it into Burmese and printing up picture booklets. So, I’m happy to report another Cynthia has made her mark on the clinic . . . and I can go on to other projects.
I’ve just recently been involved in a big long-term public health project that is just getting off the ground now. A few of us with public health backgrounds, both at the clinic and those working with internally displaced populations (IDPs) across the border, have discussed with medics that villagers understand the behaviors they need to change and may have the tools to do so, but lack the interest to make these changes. Health workers are expressing frustration in continuing to try to have villagers change these behaviors, and feel as though they do not know specific techniques and activities to continue trying to get villagers to change these behaviors. We’ve decided to conduct an overall assessment of the programs along the border, both in IDPs in Burma and migrant populations in Thailand to provide insight into which specific behaviors groups are trying to change and if similarities exist between programs. After this initial assessment, workshops would be given with specific information on behavior change theory and ideas for activities that health workers can use to continue to try and change these behaviors. Creating behavior change teams within each of the specific organizations along the border will be critical for the continued monitoring and modifying of health behaviors. We realize this may be a daunting task collecting such diverse barriers to health behavior change, and know that we need to be sensitive to cultural aspects that may affect behavior. It will be a long-term project that hopefully I can contribute to even while back in the States through internet correspondence. While I was involved with some health behavior change work in the States with providers, bringing the multi-ethnic Burmese cultures into the mix adds entirely new dimensions.
I’m excited to report a visit to the clinic by three folks from Pfizer in Bangkok, two from the Pfizer Foundation and one from Business Technology. The purpose of their visit was two-fold, it was the first time they had visited the clinic (and specifically wanted to visit while I would be here), and to deliver their gracious donation of 25 IBM laptop computers. Dr. Cynthia gave them a comprehensive tour of the clinic and provided background on the history of the clinic and the unique challenges that the clinic continues to face today. We had presentations from some of the organizations the clinic supports, including the Backpack Health Workers Team, the Burma Medical Association (who works with IDP populations inside Burma), the school health team, the health information systems team, and of course some of our work specific to pharmacy and public health services. I think they came away from their day at the clinic with a new appreciation for the crisis of border health care, and the recognition of Mae Tao Clinic’s depth into the culture of this region. The clinic and Dr. Cynthia now have such a widely known reputation that each day specific groups ask to tour the clinic (we’ve heard it’s even in some tour books), and each time I interact with a visitor I’m struck by their reaction to the situation here and the clinic’s broad scope. Their reactions reflect a feeling that perhaps the existence of the Mae Tao Clinic itself is not only to cure the wound, but also to allow the world to know about the wounds inside Burma.
For more information on the Mae Tao Clinic, their website is: www.maetaoclinic.org
Reflections from the Thai/Burma border – Part 1, the social/political dynamic:
Today, March 27, is Army Day in Burma. Each year on this day the country’s military leaders show a unified front in a pompous ceremony in their new capital, Naypyidaw. The junta chief, Senior General Than Shwe, has imported another new Mercedes Benz to stand in as he leads the parade. He brought in a new one last year for the same occasion. However, rumblings are more frequent that all is not unified within Burma’s military leadership. There seems to be a split between the “traditional army” and Than Shwe, who has major business interests and is among the small few amassing huge wealth through corrupt dealings with select trading partners such as China, Russia, India, and (sadly) Thailand. Ironically, the army faction (who see themselves as the real protectors of Burma) are said to be open to dialogue with Aung San Suu Kyi, the Nobel Peace Prize winner who has been under house arrest for 15 years and is still leader of the National League of Democracy party. The leadership of Than Shwe and his State Peace and Development Council (SPDC) have maintained a hardline stance since 1962, and ordered the crackdown on monks during their September 2007 demonstration in the streets of Rangoon and throughout the country.
Adding fuel to the fire of this tension at the top of a ruthless corrupt government is the upcoming May referendum to decide on a new Constitution. This will create the rules for the widely publicized “free election” in 2010. Both the referendum and future election are considered total sham events by the Western world. The May referendum will put in place such stringent rules that it effectively eliminates any possibility for Aung San Suu Kyi, her sons, and virtually of all her party members to be able to be on the ballot for any office. It will stipulate that any person who has a family connection with a foreign country (Aung San Suu Kyi’s deceased husband is from England) and their decendents would be ineligible to participate. It also bars any person who has been part of an “opposition” voice to the current regime to be ineligible to participate. The SPDC is effectively labeling any person who has a dissident voice a terrorist, and is conveniently hiding behind the “War on Terrorism” argument as the defense for their insidious behavior. As an aside, I frequently find myself asking what is the “war on terror”? As Roger Cohen notes, it amounts to a war without end, because “terror” is a tactic, and tactics don’t surrender. Perhaps a lesser known consequence of this policy is that rogue governments can hide behind it in order to persecute dissident voices crying out for justice.
Another farce of the upcoming elections was revealed this past week when it was discovered that civilians have been forced by immigration officers to buy identification cards to vote in the May referendum. For the pleasure of having these ID cards, they are asked to “donate” at least 5000 kyat ($5.00) to the officers. This is obviously a huge sum for a country where the average income is far less than $1.00 per day. The officers give them propaganda material to support voting in favor of the constitution as proposed, and the material describes the consequences of not voting in support of the constitution . . . imprisonment for 30 years.
Amid this political circus of the SPDC ruling power lays the ruin of the Burmese people. The September 2007 demonstrations, while temporarily making the world aware of the junta’s atrocities, have caused the targeting of monks and other sympathizers by the SPDC. This has resulted in the fleeing and forced evacuations of thousands of monks and others (primarily from the Karen ethnic group) to areas along the border of Thailand. Many have settled in the border town I’m living in, Mae Sot. It’s estimated less than half of the 500,000 monks that were in Burma prior to September are now in the country, and in the former capital of Rangoon, where there was once 30,000 monks, now only 3000 remain. Many are concerned the famous temples of Rangoon, that number greater than 10,000 in that city alone, will fall into ruin with no monks to maintain them. While many involved in the demonstrations have fled, the number of political prisoners now gruesomely held in the infamous Burmese prisons has tripled since September totaling well over 2000. For the first time ever, monks have been targeted and many defrocked their robes and wore crucifixes to get across the border undetected.
Political activities are not limited to the Burmese side of the border. To the casual tourist or person passing through town, Mae Sot looks like a sleepy little border town. However, it only takes a bit of time here talking with locals and Westerners working in the area to realize there is a very seedy underbelly to Mae Sot. While some of this is related to the illegal transport of gems, teakwood, and drugs across the border, much of it is the undercover political activity of Burmese (specifically) Karen activists living here and just across the border in the Karen state of Burma. This fact was brought home in a very real way on February 14th when a Valentine’s Day surprise occurred in Mae Sot with the brutal assassination of Mahn Sha, the General Secretary of the Karen National Union, the democratic governing party of the Karen people. Two gunmen entered his unguarded house in a residential area of Mae Sot (less than ¼ mile from where I lived last year) at 4:30pm, greeted him as their “uncle” and shot him at point blank range. I heard about it at 6pm while sitting in Casa Mia restaurant with 10 others having a farewell dinner for some med students. The streets immediately filled with police, which made for a very interesting bike ride home. Everyone was stopped and questioned at police road blocks, because apparently the license plate of the pick-up truck used by the assassins was communicated by a neighbor witness. It was actually quite comical to bike back to my very quiet little side road and notice at least 30 motor bikes take a quick detour down my road to avoid the police road block. Obviously, they were illegal migrants and try to avoid the police at all times. That night our side street became a major thoroughfare of motorbikes.
Although rumors abound concerning the responsible party for the killing, the prevailing thought here seems to be involvement by a splinter Karen organization that split from the KNU a few years ago and recently sided with the ruling junta (SPDC). The group goes by the name of the Democratic Karen Buddhist Army (DKBA), an oxymoron of a name that perhaps I’ve ever heard. This organization has sided with a military regime that has destroyed over 3200 villages in Karen state over the past 10 years, forcing more than 1.5 million Karen and Burmese to be displaced. As a point of reference, this is twice as many villages as has been destroyed in Darfur – a much more well-known world crisis. Attacks on Karen and other ethnic minorities in Eastern Burma are one of the most under-reported stories in the world. The attacks by their own government are aimed at civilians, destroying food supplies, schools, clinics, and homes.
The assassination of Mahn Sha was a severe blow to the Karen people, and struck the normally stoic people hard here in Mae Sot and at the Mae Tao Clinic, who knew and admired him very much. Mahn Sha and the KNU were strong supporters of Aung San Suu Kyi and her National League of Democracy, and he was known for his strong compassion toward child soldiers and Burmese army deserters. The Burmese army has conscripted more child soldiers than any country in the world, totaling more than 70,000 under the age of 16. Deserters and child soldiers have frequently fled the army and sought refuge with the KNU, and Mahn Sha provided homes and protection for them.
The days surrounding Mahn Sha’s death were quite eventful around Mae Sot and the clinic. The morning after his death (February 15), a junior medic was found at the clinic after committing suicide that night by ingesting 30 chloroquine (antimalarial drug) tablets. It was unclear if it was a Valentine relationship issue or some surmised it was his grieving of Mahn Sha’s death. With the constant stress of illegal migrant life endured by these medics, it’s little wonder that an occasional suicide does occur, and the prevalence of depression and post-traumatic stress disorder is quite high. The funeral of Mahn Sha in Mae Sot was attended by hundreds of people, including many Karen who had immigrated to Australia in past years and were good friends of the KNU leader. Tension was high and security quite tight with so many Karen and Burmese leaders in one place, including our own Dr. Cynthia from the clinic.
Rumors have been flying that more covert actions are in the works, and I’m sure many things have been happening that we never hear. It’s the nature of this very unique border town . . .
Adding fuel to the fire of this tension at the top of a ruthless corrupt government is the upcoming May referendum to decide on a new Constitution. This will create the rules for the widely publicized “free election” in 2010. Both the referendum and future election are considered total sham events by the Western world. The May referendum will put in place such stringent rules that it effectively eliminates any possibility for Aung San Suu Kyi, her sons, and virtually of all her party members to be able to be on the ballot for any office. It will stipulate that any person who has a family connection with a foreign country (Aung San Suu Kyi’s deceased husband is from England) and their decendents would be ineligible to participate. It also bars any person who has been part of an “opposition” voice to the current regime to be ineligible to participate. The SPDC is effectively labeling any person who has a dissident voice a terrorist, and is conveniently hiding behind the “War on Terrorism” argument as the defense for their insidious behavior. As an aside, I frequently find myself asking what is the “war on terror”? As Roger Cohen notes, it amounts to a war without end, because “terror” is a tactic, and tactics don’t surrender. Perhaps a lesser known consequence of this policy is that rogue governments can hide behind it in order to persecute dissident voices crying out for justice.
Another farce of the upcoming elections was revealed this past week when it was discovered that civilians have been forced by immigration officers to buy identification cards to vote in the May referendum. For the pleasure of having these ID cards, they are asked to “donate” at least 5000 kyat ($5.00) to the officers. This is obviously a huge sum for a country where the average income is far less than $1.00 per day. The officers give them propaganda material to support voting in favor of the constitution as proposed, and the material describes the consequences of not voting in support of the constitution . . . imprisonment for 30 years.
Amid this political circus of the SPDC ruling power lays the ruin of the Burmese people. The September 2007 demonstrations, while temporarily making the world aware of the junta’s atrocities, have caused the targeting of monks and other sympathizers by the SPDC. This has resulted in the fleeing and forced evacuations of thousands of monks and others (primarily from the Karen ethnic group) to areas along the border of Thailand. Many have settled in the border town I’m living in, Mae Sot. It’s estimated less than half of the 500,000 monks that were in Burma prior to September are now in the country, and in the former capital of Rangoon, where there was once 30,000 monks, now only 3000 remain. Many are concerned the famous temples of Rangoon, that number greater than 10,000 in that city alone, will fall into ruin with no monks to maintain them. While many involved in the demonstrations have fled, the number of political prisoners now gruesomely held in the infamous Burmese prisons has tripled since September totaling well over 2000. For the first time ever, monks have been targeted and many defrocked their robes and wore crucifixes to get across the border undetected.
Political activities are not limited to the Burmese side of the border. To the casual tourist or person passing through town, Mae Sot looks like a sleepy little border town. However, it only takes a bit of time here talking with locals and Westerners working in the area to realize there is a very seedy underbelly to Mae Sot. While some of this is related to the illegal transport of gems, teakwood, and drugs across the border, much of it is the undercover political activity of Burmese (specifically) Karen activists living here and just across the border in the Karen state of Burma. This fact was brought home in a very real way on February 14th when a Valentine’s Day surprise occurred in Mae Sot with the brutal assassination of Mahn Sha, the General Secretary of the Karen National Union, the democratic governing party of the Karen people. Two gunmen entered his unguarded house in a residential area of Mae Sot (less than ¼ mile from where I lived last year) at 4:30pm, greeted him as their “uncle” and shot him at point blank range. I heard about it at 6pm while sitting in Casa Mia restaurant with 10 others having a farewell dinner for some med students. The streets immediately filled with police, which made for a very interesting bike ride home. Everyone was stopped and questioned at police road blocks, because apparently the license plate of the pick-up truck used by the assassins was communicated by a neighbor witness. It was actually quite comical to bike back to my very quiet little side road and notice at least 30 motor bikes take a quick detour down my road to avoid the police road block. Obviously, they were illegal migrants and try to avoid the police at all times. That night our side street became a major thoroughfare of motorbikes.
Although rumors abound concerning the responsible party for the killing, the prevailing thought here seems to be involvement by a splinter Karen organization that split from the KNU a few years ago and recently sided with the ruling junta (SPDC). The group goes by the name of the Democratic Karen Buddhist Army (DKBA), an oxymoron of a name that perhaps I’ve ever heard. This organization has sided with a military regime that has destroyed over 3200 villages in Karen state over the past 10 years, forcing more than 1.5 million Karen and Burmese to be displaced. As a point of reference, this is twice as many villages as has been destroyed in Darfur – a much more well-known world crisis. Attacks on Karen and other ethnic minorities in Eastern Burma are one of the most under-reported stories in the world. The attacks by their own government are aimed at civilians, destroying food supplies, schools, clinics, and homes.
The assassination of Mahn Sha was a severe blow to the Karen people, and struck the normally stoic people hard here in Mae Sot and at the Mae Tao Clinic, who knew and admired him very much. Mahn Sha and the KNU were strong supporters of Aung San Suu Kyi and her National League of Democracy, and he was known for his strong compassion toward child soldiers and Burmese army deserters. The Burmese army has conscripted more child soldiers than any country in the world, totaling more than 70,000 under the age of 16. Deserters and child soldiers have frequently fled the army and sought refuge with the KNU, and Mahn Sha provided homes and protection for them.
The days surrounding Mahn Sha’s death were quite eventful around Mae Sot and the clinic. The morning after his death (February 15), a junior medic was found at the clinic after committing suicide that night by ingesting 30 chloroquine (antimalarial drug) tablets. It was unclear if it was a Valentine relationship issue or some surmised it was his grieving of Mahn Sha’s death. With the constant stress of illegal migrant life endured by these medics, it’s little wonder that an occasional suicide does occur, and the prevalence of depression and post-traumatic stress disorder is quite high. The funeral of Mahn Sha in Mae Sot was attended by hundreds of people, including many Karen who had immigrated to Australia in past years and were good friends of the KNU leader. Tension was high and security quite tight with so many Karen and Burmese leaders in one place, including our own Dr. Cynthia from the clinic.
Rumors have been flying that more covert actions are in the works, and I’m sure many things have been happening that we never hear. It’s the nature of this very unique border town . . .
Sunday, March 23, 2008
Monday, February 25, 2008
Sunday, February 24, 2008
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