In face of malaria, malnutrition and repression, a remarkable health project is saving the lives of Burmese on both sides of the border with Thailand. The photojournalist Robert Semeniuk reports on a crisis where disease and denial of human rights interlock.
10 - 10 - 2007
SMRU Mawker Tai clinic on the bank of the Moi River, and the border between Burma and Thailand. Today mothers and expectant mothers receive ultra sound and blood tests for "on the spot" malaria diagnosis.
* * *
"Sweat runs off the faces of the two boys, 17 and 20 years old, who crouch in the front trench with us. After each shell hits they strain their eyes to see through the dust, and over the logs piled in front of the trench to prevent grenades from rolling inside of it, and shoot blindly down the hill, where the Burmese soldiers are. After the chaos and paralysing panic comes the eerie silence between artillery barrages and machine-gun fire. This morning five Karen soldiers were killed and nine injured."
I wrote this in 1988, after walking for days in the jungle, up and down steep hills, with a group of young Karen soldiers heading to fight the Burmese military. We slept on the ground and ate only rice and fish-paste. The nights were freezing and the days humid and hot. We passed groups of people carrying small children and whatever little else they could, wrapped in little bundles on their heads. They were heading to the relative security of the border, away from their destroyed village which we walked through days later. Nothing was standing, everything was charred. Another day we met a group carrying a boy swaddled in a bloody sling hanging from two bamboo poles. He had stepped on a landmine while running from a village shelled by the Burmese military.
I saw the boy a few weeks later in a clinic near the border where a Karen doctor had successfully amputated his leg. Now he was being treated for malaria. So was I. I had contracted it from sleeping too many nights in the jungle with no net, and not enough smoky fires. It was gruelling. I was exhausted and sick, and I had only been on the move in the jungle for a few weeks. The Karen have been here either resisting the dictatorship, or running from them since 1948. The young landmine victim died of malaria. I never knew his name, but I've never forgotten the young doctor who treated us. Cynthia Maung was freshly out of medical school and on the run from a government in Rangoon that was imprisoning and killing democracy activists. Her mission was to give emergency medical attention to fleeing students.
Today Dr Cynthia is called the "Mother Teresa" of Burma. She is internationally acclaimed for her enduring dedication to human rights and helping the displaced people on the border. She is the director of the multi-department, 120-bed, Mae Tao Clinic that sits on the outskirts of Mae Sot, Thailand, five kilometres from the Burmese border. In 2006, with a staff of 300, the clinic treated 8,000 malaria cases and over 100,000 patients. This is only a small portion of the estimated 1.5-2 million political and economic refugees uprooted by the world's longest civil war, its darkest dictatorship, and an unbearable economic disparity.
A killing cycle
Today is pre-natal day and scores of mothers and children quietly wait to have their blood tested for malaria parasites and to have their babies weighed. If malaria is diagnosed early it can be treated in twenty-four hours. The sound of children crying is barely audible over the chirping and whistling tropical birds that populate the courtyard trees. I can't hear the mosquitoes, but they are here. The jungle is their perfect habitat and this battlefield is home to the planet's most drug resistant plasmodia parasites and the most lethal strain of malaria, "falciparum plasmodium". Despite widespread human violence, malaria, transmitted by the female anopheles mosquito, is Burma's biggest killer.
It is the rainy season, mid-July, not yet 9am and two new malaria patients have been admitted to the clinic. One woman is unconscious. The plasmodia parasite population is exploding in her bloodstream. The attending medics, all trained here, explain that she needs an immediate blood transfusion, or she will die. They gather around her needles ready. They cannot find a vein because she is too dehydrated and anaemic. She is one of the 350-500 million people in over 100 countries ravaged by this sophisticated parasite that multiplies and mutates and hides from the immune system.
"If they make it to the hospital they almost always live", says a medic when I ask about her chances of survival. At least a million people die from malaria every year - some estimates go as high as 2 million - with half the fatalities being children under 5 years old. The number is increasing because of lack of treatment, drug resistance, and mosquito persistence. Warmer temperatures, deforestation, increased travel and indiscriminate anti-malarial use are expanding the mosquito habitat. The fear is the world's fastest killing malaria will find its way to Africa and the temperate zones.
The other new patient is barely conscious. There are no vacant beds, so they lay her on the floor. She is already connected to an intravenous drip. 26 years old, very thin, delicate features, beyond pain she looks innocent and bewildered. Then her head sways back and forth like it is too heavy for her neck. The whites of her eyes roll and her arms flail over her head uncontrollably, like a possessed rag doll. Fever and delirium come in waves. It means the parasites are reproducing, bursting the red blood-cells before they return to the liver and the cycle begins over again. Her father carried her here, a five- day journey, with the help of members of the Back Packers Medical Health Team. This group of medics, trained at the Mae Tao Clinic, trek for months in the Karen and Shan states, at great risk and with meagre resources, to deliver emergency and primary health care to an estimated 140,000 internally- displaced people (IDPs). The total number of IDP along the eastern border of Burma is estimated to be between 500,000-600,000.
Many of these people are permanently on the run. Their communities have been systematically destroyed by soldiers. They are denied land, education, healthcare, and freedom of movement. They live in the jungle, often without the basics of food, clothing and shelter. Malaria and malnutrition statistics among the IDP in eastern Burma rival the worst in the world.
How the displaced survive
Then there are the refugees on the Thai side. 160,000 of them are registered and live in ten UNHCR camps. The rest, over a million of them, are undocumented migrants, with no legal status. Other than drugs, these migrant workers are likely Burma's biggest export. The Thai government is attempting to identify and register some of this huge cheap labour-pool. Until then, no legal acknowledgment means migrants are vulnerable to extortion, arbitrary arrest and deportation, abuse from employers and police, torture, and poor health, especially malaria.
They are smuggled around Thailand to wherever there is work. They find it in the sex industry, construction sites, restaurants, farms or in one of the hundreds of sweatshops hungry for cheap obedient labour. The migrants work long hours for miserable wages and living conditions. I met Win, 23, and Sony, 26, (I asked her name, she said "just call me Sony") at a shelter run by the Burmese Women's Union located about a half-hour motorcycle ride outside Mae Sot. I got there through an introduction from a medic at the Mae Tao Clinic. I was given a phone number and a name, Rebecca. Not her real name. I'm not surprised, because many people don't want their names used. Administrators at Dr Cynthia's clinic suggested I not publish patients' names. "It is illegal for anyone to leave Burma without proper documentation, the human rights work I do here is seen as anti-state activities to the junta. For most of us, it is better to remain anonymous", Rebecca says, while translating as Win and Sony tell me about working in sweatshops.
They currently work in a garment factory, but they have also worked in a sweatshop that made electronic components. They often work seven days a week, for a minimum of twelve hours a day, and sometimes up to eighteen hours a day. They pay their employer "security fees" (for payoffs and work permits that often never arrive) and an allowance for food (they eat rice), and "accommodation" (they live in the factory). Their take-home pay is $30 per month. Or it would be it they had a home and they took it. "We send it all back to our families in Burma", they say.
They look tired beyond their years. Their faces are resigned to the utter lack of control they have over their lives. I ask the older one how long she's worked, eaten and lived in sweatshops. She says "nine years" - washing her clothes and dishes in the same water and sleeping on crowded shelves stacked four high. "If you are too sick to work, they fire you", she says. Neither one smiles. They have experienced too much. Or too little. "It is modern slavery", a doctor at a clinic remarked.
The low pay is no deterrent for people struggling to feed their families in Burma, where unemployment is 80%. More and more migrants and refugees stream across the porous border. At the bottom of the ladder are 200 migrants that live on the Mae Sot garbage dump, and the hundreds of "illegals" that end up, every week, in the holding tank behind the police station. The latter are herded into a caged truck and hauled back to the border, only to return again another day. They have no legal rights on either side of the border.
The increasing number of dislocated people reflects the elevated suppression, and isolation of the dictatorship. Elite cadres get rich on booming trade with China, Thailand, and India, but the masses remain dirt poor, disenfranchised by decisions that affect their lives. Persecution is rife in Burma where secrecy, fear, and systemic corruption rule the day.
The Burmese government does not want foreign eyes witnessing its brutality or the plight of its people. Organisations like the the International Committee of the Red Cross (ICRC) and Medecins sans Frontieres (MSF-France) have pulled their missions out of Burma because of increased restrictions imposed by the dictatorship. The United Nations Global Fund for Aids, Tuberculosis and Malaria was forced to withdraw its five-year, $96 million dollar grant agreement with Burma.
Without the Back Packers the IDP would have no medical care and there would be no documentation of the link between poor health and human-rights abuses. Through use of epidemiological tools, field observations and surveys, the Back Pack Medical Health Team estimates that malaria accounts for half the deaths among internally-displaced people and that at least 12% of the IDP population is infected at any given time. Infant mortality is twice as high among the internally-displaced population as it is in stable households. Households that suffer theft or confiscation of food, physical abuse, or forced labour at the hands of soldiers are many times more likely to suffer from malnourishment, diarrhoea, night blindness, malaria, and landmine injuries.
The convoy of life
In Mae Sot I arrange to meet "Eh Kalu", a leader of the Back Pack Health Worker Team, at their office off the highway on the way to the "Friendship Bridge" which is the only official border-crossing. "We don't call it an office, it is a house. Because of our illegal status in Thailand, we are not allowed to have offices, only houses", Eh Kalu tells me, as he shows me around their two crowded rooms. In one corner are bales of mosquito net material. A huge map detailing their operations covers one wall. "Most of the time a curtain is rolled down over it", he says.
Ten or fifteen young people, mostly in their 20s, sit at computers working on tasks including the creation of training manuals and medical handout sheets, funding applications, and record keeping - budgets, logistics, statistics, and maps. He tells me: "there are hundreds of unofficial places to cross the border, and they change depending on the security in the area". He means military clashes near the border and the periodic clampdowns by Thai border guards. I learn there are 300 "Backpackers" in seventy-six teams. They have 284 health workers inside Burma and they have trained over 7,000 village health volunteers, including more than 500 traditional birth attendants.
They do their work in the face of overwhelming difficulty. How can they not be overwhelmed? Their home is the jungle path. They have been beaten and shot by soldiers who confiscate their medicines. They distribute medicine knowing that soldiers who find it will beat those they are trying to help - or worse. Since 1998, when Dr Cynthia helped establish the organisation, eight Backpackers have stepped on landmines. But they are not overwhelmed. They walk on alongside a frightened father, helping him carry his delirious malaria-stricken daughter five days to a crowded clinic. And their research is chronicling how and why the Burmese government is making people sick, and contributing to the spread of infectious disease.
When freedom is denied, the vulnerable become invisible and human rights are held with little respect. Burma spends 2-3% of its budget on health and 40% on its 400,000-strong armed forces. The dictatorship has created a new capital, Naypyidaw, 460 kilometres north of Rangoon; a fortress with boulevards, new buildings, highways, and apartments, carved out of virgin jungle. This is a regime that seeks isolation, the better to sustain its power.
In the meantime millions of Burmese people suffer - from diseases such asmalaria, from crushing poverty, and from political repression and denial of their civil and human rights. The accumulating wave of protests from below in August-September 2007 fused their anger, desperation, and longing for a better life. The response from above has been pitiless and continuing persecution. The world looks on and sits by.
* * *
In the rainy season, the incidence of malaria soars among the difficult to count; refugees, migrants, undocumented, and internally displaced people.
Mae Tao Clinic. A malaria patient is admitted and the blood test indicated server cerebral malaria. The patient is being prepared for a blood transfusion and treatment.
Mae Tao Clinic. The Child Health Out Patient Department. Today it is crowded with women and children who have come for checkups, and malaria tests.
Le Per Her, a small IDP camp five hours drive north of Mae Sot. Held close by her father, this young girl is one of twenty-six children being tested for Malaria.
Robert Semeniuk is a photojournalist based in British Columbia. His website is here
For more on Robert Semeniuk and his work, see "Terrible truths", Seattle Times (12 August 2007)