Malaria as a weapon of war

Life and death on the Thai/Burma border

By Robert Semeniuk

December 2007/January 2008

Behind the recent headlines, Burma’s military dictatorship has been waging a brutal war against the country’s ethnic minorities for decades—-and malaria is one of its most deadly weapons. Veteran photojournalist Robert Semeniuk reports from the Thai/Burma border on the Burmese struggle for survival.

Once a month, babies are brought to the clinic in Le Per Her, an Internally Displaced Person camp in Burma, where they are weighed and a blood sample is analyzed to detect any plasmodium parasites. Out of 26 children seen by the medics, 14 had malaria. Held close by her father, this young girl was one of the few showing any symptoms. Le Per Her is a small camp five hours drive north of Mae Sot, Thailand, just inside the Burmese border. The people here had to flee their village when the Burmese attacked and burned them out three years ago. Following the advice of clinic staff at the Mae Tao clinic, no names are used in any of the text accompanying the photographs.

In the rainy season, the incidence of malaria soars among the refugee and internally displaced populations. These girls go to school and are boarded in an orphanage dorm in the Mae La refugee camp, 60 kilometres north of Mae Sot, Thailand. The Mae La camp’s 50,000 residents are dependent on outside donors for all their needs. They are not allowed to travel or grow food. They are unable to work. “The Thais even restrict the bamboo we can cut for our houses,” my young guide, Hoo, tells me. Refugees here have three options: stay, be repatriated to Burma, or be chosen to emigrate to the West.

For five baht, about 15 cents, a boat ferries internally displaced people between Burma and Thailand. At the Mae Sot border crossing they come mostly for the malaria clinic, visible in the background.

At the clinic in Le Per Her IDP camp, parents bring their babies to get weighed and for a blood test for malaria.

Mothers and expectant mothers receive ultrasound and blood tests for on-the-spot malaria diagnosis at the Mawker Tai clinic.

The garbage dump near Mae Sot, Thailand, is home to over 300 migrant people who live off salvaging scraps from the border town’s garbage. Every morning these “illegals” jostle for position while waiting for the next truck to arrive with its foul-smelling cargo. The only other jobs available to them are in the hundreds of sweatshops conveniently located along the border, where most clear about 1000 baht ($30) per month.

This man was brought to the Mae Tao Clinic by his wife and brother-in-law. They had walked four days from inside Burma. This clinic was the closest place to access help. By the time they reached it, the father of three had falcipurum malaris so severe that he required a blood transfusion. He was unconscious for nearly three days. Last year, the Mae Tao Clinic employed 200 workers, maintained 120 inpatient beds, and treated over 100,000 patients.

“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 to where the Burmese soldiers are. After the chaos and paralyzing panic comes the eerie silence between artillery barrages and machine-gun fire. This morning five Karen soldiers were killed and nine injured.”

I wrote those words in 1988 after walking for days in the jungle, up and down steep hills, with a group of young Karen soldiers on their way 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 on their backs and whatever little else they could in little bundles on their heads. They were fleeing to the relative security of the border, away from their destroyed village, which we walked through days later. Nothing was standing in the village; everything was charred.

The Karen are one of Burma’s largest ethnic minorities. In 1949, they rose up in insurrection against Burma’s ruling junta; they have been at war ever since. In the late 1980s I was in Burma working with war-affected children and on assignment as a photojournalist for the Helsingin Sanomat (Finland), which was how I found myself on the front lines with that particular group of insurgents.

On another day, we met a group carrying a boy swaddled in a bloody sling hanging from two bamboo poles. He had stepped on a land mine while running from a village being 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 grueling. 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 it, for nearly six decades.

The young land-mine victim died of malaria. I never knew his name, but I’ve never forgotten the young doctor who treated us both. Cynthia Maung was fresh out of medical school and on the run from a government in Rangoon that was imprisoning and killing democracy activists—-more than 10,000 students, civilians and monks were killed following the popular uprising of August 8, 1988. Maung’s mission was to give emergency medical attention to fleeing students.

Today, Dr. Cynthia, as she is known, is considered 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. Last year, 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 to two million political and economic refugees uprooted by this, the world’s longest-running civil war.

Now, almost 20 years after Cynthia Maung and I first met, it is prenatal day at the Mae Tao Clinic, and scores of mothers and children quietly wait to have their blood tested for malaria parasites and to have their babies weighed. The sound of crying children 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 ideal habitat, and this battlefield is home to the planet’s most drug-resistant plasmodia parasites and the most lethal strain of malaria, Plasmodium falciparum. Despite widespread human violence, malaria remains Burma’s biggest killer.

It is the rainy season, mid July 2007, not yet 9 a.m., and two new malaria patients have been admitted to the clinic. One woman is unconscious. The plasmodia parasite population is exploding in her blood stream. The attending medics, all trained here at the clinic, 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 anemic. She is one of the 350 to 500 million people in over 100 countries ravaged by this sophisticated parasite that multiplies and mutates and hides from the immune system with terrifying effectiveness.

If malaria is diagnosed early, it can be treated in 24 hours. “If they make it to the hospital they almost always live,” says a medic when I ask about this woman’s chances of survival. Globally, at least one million people die from malaria every year—-some estimates go as high as two million—-with half the fatalities being children under five years old. The number is increasing because of lack of treatment, drug resistance, and mosquito persistence. Warmer temperatures and deforestation are expanding the mosquito habitat, while increased travel and indiscriminate anti-malarial use further aggravate the problem. The fear now is that the world’s most dangerous strain of 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 IV. Twenty-six years old, very thin, and 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 her red blood cells before returning to her liver to begin the cycle again.

Her father carried her here, a five-day journey, with the help of members of the Back Pack Health Worker Team. This multiethnic group of medics, trained at the Mae Tao Clinic, trek for months in the Karen and Shan states of Burma at great risk and with meagre resources to deliver emergency and primary health care to an estimated 170,000 internally displaced people. The total number of internally displaced people along the eastern border of Burma is estimated at between 500,000 and 600,000.

Many of Burma’s internally displaced are perpetually on the run. Their communities have been systematically destroyed by soldiers. They are denied land, education, health care, and freedom of movement. They live in the jungle, often without the basics of food, clothing or shelter. Malaria and malnutrition statistics among the internally displaced in eastern Burma rival the worst in the world.

Then there are the refugees on the Thai side. About 160,000 of them are registered and live in 10 camps run by the UN Refugee Agency. The rest, over a million people, are undocumented migrants with no legal status. For Thailand, these migrant workers are Burma’s most lucrative export. The Thai government is attempting to identify and register some of this huge, cheap labour pool. Until then, the lack of legal acknowledgment means migrants are vulnerable to extortion, arbitrary arrest and deportation, abuse from employers and police, torture, and health problems—-especially malaria.

The refugees 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. They work long hours for low wages and miserable living conditions.

I met Win, 23, and Sony, 26—-I asked her name, and she said, “just call me Sony”—-at a shelter run by the Burmese Women’s Union located about a half-hour motorcycle ride from Mae Sot. I found them 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 explains, before shifting into her role as translator for Win and Sony, who tell me about their experience 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, 12 to 18 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. “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 Sony how long she’s worked, eaten and lived in sweatshops. Nine years, she says—-nine years of 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 of the women 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 back in Burma, where poverty is widespread in rural areas. More and more migrants and refugees stream across the porous border, particularly in the wake of the recent crackdowns on pro-democracy protests.

At the bottom rung of the ladder in this border city are 200 migrants who live on the Mae Sot garbage dump, and the hundreds of “illegals” that end up in the holding tank behind the police station each week. The latter are routinely herded into a caged truck and hauled back to the border, only to return again another day. They have no legal status—-and therefore no 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 and powerless. 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. Organizations like the Red Cross and Medecins Sans Frontieres have been forced to scale back their operations, and have threatened to pull their missions out of Burma entirely—-the French section of MSF pulled out in 2006—-because of increased restrictions imposed by the dictatorship. For the same reason, the UN Global Fund for AIDS, Tuberculosis and Malaria decided to withdraw its five-year, $96 million dollar grant agreement with Burma in August 2005.

Without the Back Packers, Burma’s internally displaced people would have no medical care at all. Through the use of epidemiological tools, field observations and surveys, the Back Pack Health Worker Team estimates that malaria accounts for half the deaths among internally displaced people and that at least 12 per cent of the internally displaced population is infected at any given time. Infant mortality is twice as high among the internally displaced 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, diarrhea, night blindness, malaria, and land mine injuries.

In Mae Sot, I arrange to meet “Eh Kalu,” a leader of the Back Pack Health Worker Team, at their office near the highway, on the way to the Friendship Bridge—-the only official border crossing between Burma and Thailand. “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 explains 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 15 young people, mostly in their twenties, sit at computers working on tasks including the creation of training manuals and medical hand-out sheets, funding applications (the group has received funding from the Canadian International Development Agency and from George Soros’ Open Society Institute), and record keeping—-budgets, logistics, statistics, and maps. There are 300 “Backpackers” in 76 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 hardship. How can they not be overwhelmed? Their home is the jungle path. They have been beaten and shot by soldiers who confiscate their equipment. They distribute medicine, knowing that soldiers who find it will beat those they are trying to help—-or worse. Since 1998, when Dr. Cynthia and other local ethnic leaders helped establish the organization, eight Backpackers have stepped on land mines. 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 swept aside. Burma spends two to three per cent of its budget on health and 40 per cent on its armed forces. While the dictatorship consolidates its power in the wake of the latest failed uprising, millions of Burmese people suffer—-from diseases such as malaria, from crushing poverty, and from political repression and denial of their civil and human rights.

The accumulating wave of protests from below that began in August 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.

Veteran photojournalist Robert Semeniuk (www.robertsemeniuk.com) works on long-term projects that have included war-affected children, landmines, aboriginal cultural integrity, and ecological sustainability. He is currently engaged in a project entitled “Personalizing the World Health Crisis.” Donations to this project are welcome and tax deductible through www.ontheground.ca. Robert acknowledges the support of the Canadian International Development Agency.

To support the work of the Mae Tao clinic, visit www.maetaoclinic.org.