James Harper shares his experience of working in a medical clinic in this politically charged area

After a two day journey from Kuala Lumpur by train and minibus I arrived in Mae Sot in the north west of the country, on the Thai-Burmese border. The town has one government and one private hospital, but I was here to work in what has become known as "Dr Cynthia's Clinic." Though anyone can turn up at the clinic, it was established to provide medical treatment to the local Karen-Burmese families and migrant workers who cross every day into Thailand.

The clinic

Currently it is divided into the departments of obstetrics and gynaecology, paediatric outpatients, trauma/surgery, a medical ward, and general medical outpatients, each situated in its own concrete and corrugated iron hut. These are staffed by "Medics," Burmese teenagers who have received approximately two years' paramedical training at the clinic and have chosen to remain here rather than return to their home as a "jungle medic." Supervising them while I was there were two doctors, one from Italy, the other from Australia. The founder, Dr Cynthia, herself Karen-Burmese, is present but occupied most of the time with administration, fundraising, and political activities.

The adult and paediatric outpatients' departments were always busy. Even so, the numbers of patients seen each day was a fraction of those trying to reach the clinic. This was because the Thai police were increasingly vigilant in arresting Burmese people as they crossed the border and deporting them. They received a "bounty" for each person arrested--the equivalent of a few days' wages. Hence I often saw the police escorting large cattle lorries packed with people heading for the border.

The medicine

The medics in the outpatients' department efficiently sorted the patients into the different diagnostic categories that they were able to treat. There was plenty of opportunity to conduct elaborate examinations of patients who presented with wonderful signs. The question often asked was not could you palpate the spleen, but how big was it.

Each consultation concluded with the patient being given a diagnosis, the medication they were to collect from the clinic pharmacy, and then two or three minutes of apparent shouting. This I was informed was part of the patient's health education--general advice about keeping hydrated, eating a balanced diet, and avoiding alcohol and tobacco (both chewing and smoking it).

A lack of resources was apparent. If you were fortunate enough to have a problem for which the clinic carried the correct medication this was often out of date or the wrong dose. Amoebic dysentery was very common.

The clinic's reputation is such that people will travel for three days through Burma to reach it in preference to using their local medical facilities. When I asked one family why they made this journey, they said that it was because they trusted the people here.

Politics outside the clinic

Burma is not a peaceful place, especially if you are from the "wrong" ethnic group. The Burmese army "encourages" these people to move out using any means possible. If you do leave the country or return for some reason, it was said that your life could be in danger. Of the approximately 250 "jungle medics," six have been caught and none heard of since. Each day, a few people presented to the trauma department with gunshot wounds, normally the result of "accidents" with their "friends."

Those who have been forced to leave their homes in Burma now live in huge refugee camps scattered along the border. The largest camp contains more than 30 000 people, all living in bamboo huts terraced up a hillside in a "no man's land." The inhabitants cannot return to their own country, but the Thai government policy prevents them from starting new lives here. They are given rations paid for by the Burmese government, plus extra aid provided by the United Nations. Médicins Sans Frontières and other non-governmental organisations provide medical care. I spent one night staying in one of the camp clinic/hospitals. There was one doctor two years postregistration and a few midwives and medics looking after the whole camp. I could feel that she felt under great stress, but still thoroughly enjoyed her work as every day she could see what a difference the clinic was able to make.

The women in the camps earn a little extra money by starting cottage industries, making traditional clothes and bags. For the men, however, work opportunities are limited to becoming a "medic" or a teacher. Occasionally, some are allowed to leave the camp on a day pass and seek work outside.

Many of the men were soldiers. The younger men had fought for the Karen liberation army. This organisation is still active, fighting a jungle war against the Burmese army and defending the remaining Karen settlements from attack.

Recruits are taken at 16 years, receiving six months' training before starting active service. Up until 1995, both sexes fought in a conflict that has been running since the end of the second world war. Their base is surrounded by home made land mines, powered by batteries. This allows them to predict (approximately) when an area becomes safe.

Final thoughts

The elective allowed me to experience some tropical medicine, but, more importantly, it gave exposure to the violence and political problems you see on the news, but never feel are real. While I was there international journalists arrived almost daily to take photographs and document what was happening in attempts to expose the problems to the rest of the world and apply pressure on the Burmese government to stop its violence. I look forward to returning and hope to find that things have changed.