David Yost taught English to Burmese refugee groups in Thailand in 2004 and 2007. It was there that he encountered the medical problems of Karen children born in the midst of one of the world’s longest running conflicts, a conflict that has raged continuously between the Karen peoples and the Burmese government for over sixty years. Like other ethnic groups in Burma, the Karen peoples have sought liberation from the Burmese central government. They have been denied political representation and have endured forced re-settlement and labor as well as incarceration. Many have watched as their homes have been forcibly razed, and others have been the victims of ethnic cleansing. Many thousands have immigrated to Thailand as refugees. In January 2012, the Burmese government signed a ceasefire agreement with the Karen. The fragile agreement offers hope for a still uncertain future.
David’s essay tracks an extremely unfortunate situation. It deals less with the sticky question of Karen independence and more with the even stickier question of how much a life—particularly a child’s life—is valued during war.
WHEN I MET Hser Lay in the spring of 2007, she was five months old, and it was already too late for her. Her father turned her so that the medics and I could see. At the base of her spine trembled a lavender mass of nerves and spinal fluid, about the size of a plum. She suffered from a form of spina bifida known as a myelomeningocele, in which an improperly closed spinal cord causes fluid and nerve tissue to bulge and protrude from the skin.
Andy, the British medical student who had agreed to serve as my guide, conferred with his Karen counterpart.
“Can we send her to hospital?” he asked.
The medic smiled and looked away. “Maybe,” she said. In the polite culture of the Karen, this was a clear “no.”
Andy took a Mickey Mouse sticker and put it on Hser Lay’s wrist. Later, parents would come to realize that these stickers were Andy’s quiet apology to a child he could not help, and he would have to stop. For now, though, the young mother simply smiled.
Hser Lay needed a shunt to drain the fluid, Andy told me, and a pediatric neurosurgeon to close the opening in her spinal cord. Already her condition had likely disabled her for life, but without the money for surgery, the point was moot. Sooner or later, her young parents would lapse in their watchfulness, or the girl would roll over, and the bubble of her exposed spinal column would burst. In the impoverished conditions of a Karen village, a fatal infection would be almost inevitable.
After a lengthy discussion in Karen, the medic referred the parents to another clinic worker who would prepare an appeal through the Burma Children’s Medical Fund, an organization which raised money for high-cost individual cases that the clinic couldn’t cover. The parents seemed to understand that this was a long shot and were clearly reluctant to leave. The father worked part of the year hauling wood and the rest growing rice, they told us; Hser Lay was their only child. As the three of them spoke, the mother kept looking at Andy and me as if waiting for us to intervene. But we said nothing, and finally, they left.
HSER LAY HAD the misfortune to be born into one of the world’s longest-running armed conflicts, and while her condition was rare, her story was common. The Karen National Liberation Army (KNLA) has been fighting for independence from Burma’s central government without significant pause since 1949, shortly after Burma declared its own independence from Britain. Once a dominant force, the KNLA has in recent decades lost stronghold after stronghold to the Tatmadaw—the armed forces of the Burmese dictatorship—which is supplied by both China and Russia in exchange for cheap natural gas. Today, the KNLA has more or less given up on holding territory, preferring hit-and-run attacks from the hills of Karen State and from refugee camps across the border in Thailand. In response, the Tatmadaw introduced its notorious “Four Cuts” strategy, targeting Karen civilians in order to cut off the KNLA from food, funds, information and new recruits.
Human rights groups report that forced labor, rape and extrajudicial executions have become commonplace. In one village, Tatmadaw soldiers decapitated villagers suspected of supporting the KNLA and stuck their heads on stakes with cigars in their mouths. In another, soldiers crucified a man, a macabre taunt to the KNLA’s largely Christian leadership. Rumors of cannibalism abound on both sides. The fighting pauses for the monsoon season and then begins anew in the dry.
As a result, Karen State boasts the highest mortality rate of any region in Asia—it’s also the most heavily land mined. Only a part of this toll can be attributed to the traditional ravages of war; far more deaths are due to the area’s near total lack of health infrastructure. International aid to the region is strictly prohibited by the Burmese government, and health care workers who venture in regardless risk imprisonment and death. Forget neurosurgery; even simple antibiotics are illegal because the Tatmadaw worry that they could be used to supply Karen resistance forces. Lack of formal education compounds the problem; villagers attempt to treat malaria and dysentery through fasting and dehydration. The majority of the resulting deaths, of course, are children.
AFTER A BREAK for lunch, Andy gave me a tour of the child inpatient “department,” a large white-tiled room where parents and children lay on blankets and plastic mats. Since only the medic dozing at the corner desk spoke English, Andy gave a blunt assessment of each child we passed.
“Endocarditis. He’s fucked.”
“Nephrotic syndrome. She’s fucked.”
“Malnutrition and dysentery. She’ll be okay.”
We stopped before a boy who had a toddler’s body and a head the size of a regulation basketball. Hydrocephalus, Andy said. Even in photographs, he’d never seen a case allowed to get this bad; the boy’s head had grown so heavy with fluid that his neck could no longer support the weight. To survive, he’d need an operation to drain the excess before the pressure crushed his brain.
“He’s pretty much fucked,” Andy added.
WE WERE VOLUNTEERING at the time at Mae Tao Clinic where I was teaching English and Andy medicine. The clinic is based in Mae Sot, Thailand, a city my travel guide somewhat oversold as a hotbed of intrigue in which “the casual traveler must beware spies, smugglers, sex traffickers, and the occasional landmine and mortar shell.” I never saw any falling artillery, but I did see refugees by the thousands; the Thai government permits them to stay out of compassion for their situation and greed for their labor. The clinic is a particular draw, providing free health care to 150,000 Burmese patients a year. Roughly half these are illegal workers from Mae Sot factories; the rest make the dangerous journey from inside Karen State or other regions of Burma.
The clinic’s founder, Dr. Cynthia Maung, has become an international legend, the Mother Theresa of the Thai-Burma border. One of many young professionals to flee Burma following the suppression of the 1988 pro-democracy uprising, she then set up shop with a few colleagues to help the border’s refugee population, handling everything from diarrhea to gunshot wounds. At first they worked in a single building with dirt floors, sterilizing their surgical tools in a rice cooker. In the twenty years that followed, international donations helped expand their clinic into a fifteen-building complex with a staff of hundreds and an annual budget in the millions. Dr. Cynthia has now won awards from Jimmy Carter, the Dalai Lama and TIME Magazine; First Lady Laura Bush made an official visit to the clinic only a few months after I did.
But even a legend can only do so much with a fixed budget, and this is the reality to which Andy and the other Western volunteers had to adjust. The clinic’s 2009 budget came to roughly $2.9 million; treating 150,000 patients in that time meant that Mae Tao had an average of $19.33 to spend per case. Even with donated pharmaceuticals, volunteer labor like Andy’s, and low staff salaries for regular employees (the average Mae Tao medic makes only a few dollars a month, plus basic room and board), that cap makes it difficult to treat anything beyond the most basic conditions. Complicated surgeries are all but out of the question, and conditions requiring ongoing treatment—a ventilator, dialysis, insulin injections—are generally a death sentence. The medics thus work in a constant state of triage, sorting the patients they have the resources to treat from those they do not.
For purposes of comparison, in 2008, the U.S. Environmental Protection Agency valued an American “statistical life” at 6.9 million dollars. This figure is significant, as it represents the point at which regulation theoretically ceases to be cost effective; if a proposed rule costs $50 million per year to enforce, for example, but saves an estimated eight lives (a $55.2 million value), the rule stands. The announcement of the new figure–it was being lowered from $7.8 million the year before–set off a round of negative publicity, with environmental and consumer safety groups protesting that the EPA was “cooking the books” in regard to human life.
At the Mae Tao Clinic, on the other hand, a statistical life is about the cost of a good dinner for two.
TO SIT AND play with a child who’s going to die for a lack of a few hundred dollars is shattering, but it’s the sort of shattering every human being should experience. The problem isn’t so much the suffering itself—though this is bad enough in its own right—as coming face-to-face with the lie that makes life in a Western nation tolerable: the lie that your DVD player, iPhone and air conditioner do not translate into the exact dollar equivalent of the life of a child like Hser Lay. So we reacted as anyone would, I think. We sulked. We donated more time and money. We snapped at boyfriends and girlfriends over international phone calls. We drank, felt guilty for wasting money, and then drank some more.
“The reason I’m going to make a good doctor is that I test high for sociopathic traits,” Andy told me early on. “I can detach.” But though his wolfish features made this easy to believe, soon I could see that the clinic was getting to him too. One day a parent brought in a young boy in the advanced stages of rabies; the disease is still common in Karen State, while the vaccine, of course, is not. Once the patient becomes symptomatic, there is no cure. Andy spent most of the next day watching the boy die and then most of the night at the bar, drinking and cursing to anyone who would listen.
A week later, a ten-year-old girl was brought in with a dog bite. Andy, clearly upset, loudly berated his Karen counterpart for not moving quickly enough with the soap and water—a cultural offense so serious that the medic slipped out a moment later, leaving Andy without an interpreter. Fortunately, one of my English students was in a nearby room and offered to help us. The girl, it turned out, had been nipped while playing with the family dog, which showed no signs of illness. Andy washed out her scrapes and sent her on her way, sticker-free.
THERE’S A MOMENT in Les Misérables when Jean Valjean, following his forgiveness by the Bishop of Digne, stands in a field and reflects on his future. As the recipient of such kindness, he thinks, only two paths remain: he can strive to be worthy of it and become the best of men, or he can betray it by backsliding and become the worst. The middle road, however, is closed to him forever.
None of us went on to become Hugoesque living saints like Jean Valjean, of course. But meeting the children of Mae Tao still marked an important moral fork in our lives. One option was to spend as before, but now with the conscious knowledge that a concert ticket or designer sweater was more important to us than a child’s life. The second option was to deny ourselves the diversion and comforts we’d indulged all our lives, comforts which our friends and family still enjoyed. Neither path is attractive, and the balance between them is a daily struggle. In darker moments, it’s easy to wish that you had never met a child like Hser Lay at all, that she could have remained one of the million children that make statistics, rather than the individual girl who makes a tragedy.
A FEW WEEKS before the end of his stay at Mae Tao, Andy made a border run, briefly exiting and re-entering Thailand to renew his visa. Official travelers between Thailand and Burma cross the inaptly-named Friendship Bridge; refugees simply walk across the dry riverbed of the Moei below.
Near the center of the bridge, Andy saw a boy of about ten, dressed in a ragged T-shirt and shorts, slumped unmoving beside the guardrail.
He approached and took the boy’s pulse; the boy was dead. Andy proceeded across to the Burmese border and, after his passport was stamped, told the guards there about the body. They already knew, an officer explained in halting English. They had called the Thai station several hours ago to remove him.
Andy went back across, passing the boy’s body again. The Thai and Burmese people on the bridge smiled at Andy, but barely looked at the boy.
When he returned to the Thai immigration post, he repeated his story about the body. The woman working there only shook her head. “He is Burma,” she said, pointing across the bridge. “He is Burma problem.”
For all he knew, Andy told me later, the kid was still out there.