Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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412 Surgery and Healing in the Developing World
however, refused to transfer power and put Aung San Suu Kyi, the leader of the
party and winner of the Nobel Peace Prize under house arrest.
I was one of the many people who fled Burma in 1988. I was in my last year of
medical school in Burma, about 7 months away from graduation. I spent 2 years on
the Thailand-Burma border and in Thailand, working as a medic and helping set up
medical facilities for newcomers who were struck by malaria and other illnesses. I
left Thailand in 1990 to take refuge in England, and immigrated to the US in 1991.
I graduated from George Washington Medical School in 2000. I continued my
education at the Johns Hopkins School of public health and obtained a masters
degree in 2001. I am now working as a medical house officer at Johns Hopkins
Bayview Medical Center in Baltimore.
As I mentioned above, I went back to the Thailand-Burma border in the last year
of my medical school to work with the SMRU, my first trip back to the area in 10
years. The fundamental situation on the border had not changed much since I left.
The main difference is that there are more people in greater desperation and in more
need of help—and also many more outsiders providing help.
There are now some 100,000 refugees living in camps along the border with
Thailand, and there are estimated to be more than 1 million illegal immigrants from
Burma living inside Thailand. This has an impact not only on the social and economic
structure, but on the management of medical problems in the area.
The “border population” can be seen as a mosaic of various communities linked
by cultural and/or geographical similarities: Thai nationals (the majority are ethnic
Karen) who have settled in the area for years; refugees in established camps who
have fled political repression and conflict in Burma; and migrant workers from all
ethnic groups (Shan, Karenni, Karen, Mon and Burman) who travel back and forth
across the border in search of work.
In recent years, the challenge of medical management for all three groups, especially
malaria control, has grown. In the refugee camps, that challenge has largely
been met thus far. In collaboration with the medical NGOs working in the camps,
the SMRU has managed to develop a strategy of malaria control resulting in a dramatic
reduction of mortality and morbidity related to malaria, as well as the protection
of existing medicines against resistance developed by the parasite Plasmodium
falciparum. In well established refugee camps in this area such as Mae La, the health
situation has been improved, and the impact of malaria associated mortality and
morbidity has been significantly reduced since 1986, when the SMRU and MSF
began provision of medical services, which include weekly antenatal screening of
blood smear, prompt treatment, and health education. Before the introduction of
antenatal services to the camp population, severe malaria during pregnancy was a
major cause of maternal and fetal mortality. The annual maternal mortality directly
related to malaria was greater than 1%. There has not been a single death from
malaria in pregnant women living in the Mae La camp since the introduction of the
antenatal clinic (McGready and Nosten, 1995).
The health situation outside these refugee camps, however, is of a different
standard.
The migrant worker population in particular greatly complicates the task of the
Thai malaria control programme because of language barriers, cultural differences
and access difficulties. As a result, many individuals remain out of reach of the
otherwise highly efficient malaria control efforts. Unlike refugees, the migrant workers
are highly mobile, and the majority do not have access to basic health care.