- © 2004 Canadian Medical Association or its licensors
The patient is a 27-year-old man. He is the last patient of a long day here on the Thai–Burmese border in a large medical clinic founded by Karen refugees of the Burmese civil war — one of the longest-running civil wars in the world. He is emaciated, quiet and somewhat nervous-looking; I can understand him only through my favourite medic. A good friend and a bright light, Wei Lai has worked in this clinic for many years and is practised in the art of history- taking and counselling. We talk with this young man, taking a basic history, and do a general physical exam, which reveals little except for his wasted state. We know only that he does not have the productive cough of the tubercular patient. Nor does he suffer from lack of food, but rather from a prolonged low-grade fever with intermittent diarrhea. For six months.
He is lying on his back on the wooden examining table as the medic begins her fact-finding. I sit by and watch as Wei Lai speaks to him in Karen. I watch the interaction between the two — her long and gentle discourse broken by reluctant nods and short answers of the patient. I watch his Adam's apple rise and fall as he swallows hard, staring at the ceiling as he listens. His eyes speak of the fear and knowledge that all is not well. Does he know that he has waited too long to come, I wonder? Does he know that it might have made little difference anyway? He turns his head to answer our questions, swallows, and goes back to examining the ceiling.
Now and again the world grows heavy on the Thai–Burmese border. This is a place of joy and of sorrow; a place of undeniable hardship. A place where some demonstrate the very best of human nature — a solidarity and caring that is seldom to be found, a joie de vivre in spite of want and separation from loved ones — but also a place where poverty, lack of education, insecurity, exploitation and loss are rampant. Burma's health care system was ranked 190th out of 191 by the WHO in the year 2000. The Burmese citizens, whether members of minority groups or ethnic Burmans, come across the border to escape political oppression and imprisonment, poverty and food shortages, violence between the military dictatorship and armed ethnic groups and the harsh treatment of the Tatmadaw, the militia who relocate people, burning their homes and their land and using them as forced labour. The inhabitants of this border area can be relatively well-to-do members of the political opposition, or illiterate farmers lacking the most basic education and knowledge about health. Their medical problems are diverse, ranging from the psychological impacts of deprivation, fear and loneliness to the common complaints of infectious diseases and malnutrition to more “Western” illnesses like heart failure and COPD. They come to this clinic because it offers free basic health care to a population that has no official status in their country of refuge. Thailand does not grant refugee status to most migrants, and therefore most of the people fleeing across the border to find work or safety are illegal and have little access to services of any kind. Thus this clinic, now a multi-department quasi-hospital grown out of a small outpatient clinic founded fifteen years ago, serves as a safe haven for many.
Our patient has been listening for many minutes now. As at home, some days are filled with joy and others with sorrow. Today we have seen a 16-year-old woman with malaria; married before menarche at age 12, she had her first illegal abortion at age 14 and now has one child. We have seen a mother with severe asthma who, physically incapable of farm work and having left the relative security of the refugee camp, cannot feed her six children. We have also seen a 71-year-old man with a frozen shoulder and a huge, inextinguishable smile.
Wei Lai has finished her history and turns to me. Our patient has had a fever on and off for six months. He has lost much weight. His wife had a similar disease a while ago; as she deteriorated, she left to live with her parents. He has not heard from her since. At that time he was not yet ill. He might never have heard of HIV and tuberculosis. At any rate, he cannot describe these diseases and has no knowledge of their symptomatology, mode of transmission or prognosis. He has no symptoms of tuberculosis anyway, and there is no treatment for HIV/AIDS on the Thai–Burmese border.
The young man climbs down from the examining table and takes his jacket. He gives me a weak smile. Wei Lai will take him to the inpatient department, where he will receive pretest counselling for HIV and will then be tested, should he so wish. If the test result is positive, he will have the option of going home to his family or of remaining at the clinic for support. As he leaves the room, I am floored. Here is a young man dying of ignorance, for how could he protect himself against this disease without knowing that it exists?
I walk out into the sun — the perpetual sun of the Thai–Burma border in mid November. The flowers are blooming and the medics are off to the soccer field as the work day winds to a close. They will enjoy their game and return to play their guitars and sing popular songs into the evening. Teaching goes on in some classrooms, and in another the clinic choir practises for Sunday's service. A new father emerges from from the clinic with a tightly swaddled baby in his arms.
Eva Purkey Department of Family Medicine Queen's University Kingston, Ont.
Footnotes
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The author spent several months in 2002– 2003 working at the Mae Tao clinic in Mae Sot, Thailand. Founded by Dr. Cynthia Maung in 1988, the clinic provides essential services to a severely disadvantaged target population of some 150 000 in the border area.