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Medicine Where They
Need It Most

Clandestinely crossing the Thai border into Burma, a resolute band of "backpack medics" dodge minefields and army patrols to provide basic health care to the besieged Karen. Prepping the medics for this perilous work is the job of volunteers like Adam Richards.

By Dale Keiger

Last February, Adam Richards sat on the floor of a teak-paneled room in western Thailand. He was near the Mae Tao Clinic, near the frontier with Burma. Four small fans labored to cool 22 people engaged in an animated workshop. Members of the Karen (pronounced Kuh-REN), an ethnic minority besieged in Burma, they were talking about how to get more villagers in their embattled province to use latrines. Mundane stuff, as discussions of public health go, but Richards listened, fascinated. Five years ago, he would have led the discussion. Now he mostly was a spectator. It occurred to him that perhaps he had made substantial progress toward a goal: Perhaps he had nearly taught himself out of a job.

The 22 Karen men were part of a unique medical corps known formally as the Backpack Health Worker Teams. Everyone involved simply calls them backpack medics. After new training and resupply at Mae Tao, the medics strap all they need on their backs and slip back into Burma, where they tramp through the jungles from village to village, living off the land, dodging army patrols and minefields to provide medical care for thousands of Karen imperiled by fighting and Burmese government repression. Since 2000, whenever he could take time from his Hopkins studies, Richards, MPH '04, MD '05, has gone four times to Thailand to train them in everything from suturing techniques to conducting morbidity surveys.

In a month, back in Baltimore, Richards would learn where in the States he would serve his medical residency. He knew that his latest stint in Thailand would be his last for at least two years, and he felt pressure to accomplish as much as he could before he returned home. And as he watched the medics, he thought, I have never known medicine without them.

In the rugged area of Burma across the border from Mae Tao, the Karen have waged a sporadic war of resistance against the despotic Burmese government for more than 50 years. The fighting has displaced hundreds of thousands of people and destroyed what had been a functional Karen health care system. Now Karen villagers suffer from malaria, diarrheal diseases, tuberculosis, scrub typhus, worm infestations, malnutrition, high infant mortality, and the ghastly injuries inflicted by landmines. Plus, they never know when Burmese troops might sweep in, burn their villages and their crops, and force them to flee. Many thousands would have no medical care were it not for the backpack medics.

Map Courtesy
Jean Wisenbaugh
The medics are, typically, male and in their 20s, with the equivalent of a few years of medical training. They carry whatever they need strapped to their backs: medicines, basic surgical tools, IV fluids, other clinical supplies, a ream or two of data forms. Some have large donated backpacks like those carried by adventure trekkers, but many use a sort of woven plastic sack with a head strap. When they must ford a river, they lash bamboo into small rafts for their packs, then swim alongside them. When they come to a village, they examine patients, collect data, treat the ill as best they can, and provide preventive measures such as vitamin A and deworming medicine. They stage workshops on sanitation, nutrition, and disease prevention. If they find someone wounded by a landmine, they are trained to perform field amputations and stabilize the patient for transport to a clinic, often several days walk over roadless, mountainous terrain.

For decades the government has tried to force the Karen into compliance with its rule. If Burmese troops hear that the medics are in a village, they will send a patrol after them. Rarely can the medics spend more than three or four days in one place before word reaches the army and they have to melt back into the jungle. Richards says that villagers sometimes warn them, "Today we have to go and tell the military that you're here, but we'll walk really slow." Since 1998, six medics have been killed, and a number of others have been taken into custody and interrogated.

After about five months in the field, medics recross the border into Thailand and make their way back to Mae Tao, where they regroup, undergo more training, and turn in the health survey data they have collected—data that documents the effects of government repression in Burma and gives human rights advocates more powerful arguments as they exert pressure for reform on the Burmese government. After three or four weeks at the clinic, the medics shoulder fresh loads and clandestinely walk back into Burma. "These guys are constantly laughing, constantly singing and smiling," Richards says. "To see their dedication, and their humor, in the face of all this adversity is truly inspiring."

Richards' engagement with Burma began before he'd graduated from high school in Los Angeles. How that happened involves the unlikely figure of a beauty queen, screen actress, and revolutionary leader who became friends with his mother.

Richards was a teenager when his mother met Louisa Benson, who was born in Rangoon in 1941, to a Portuguese father and a Karen mother. In the 1950s, she twice won the Miss Burma beauty pageant and starred in several Burmese films. She also spent a year in Boston studying at Tufts University. In 1964, she startled the Burmese public by marrying Lin Tin, a considerably older former Karen revolutionary commander who had made his peace with the regime, or so he thought. After Burmese government agents murdered him in September 1965, Benson, the former beauty queen, went into the jungle, regrouped her late husband's old revolutionary brigade, and became, briefly, one of the world's more photogenic guerrilla fighters.

Her father and several siblings had fled Burma for the United States. When Benson contracted malaria, an American friend from her days at Tufts, Glenn Craig, persuaded her to come to the States for treatment. She eventually married him and moved to Los Angeles, where she met Carol Richards, a PhD candidate at UCLA. Richards, who describes herself as "an anthropologist and free spirit," was so moved by Benson's story that she helped her found Burma Forum Los Angeles, a source for uncensored news from and about the country and a center for social activism.

Carol Richards began attending rallies for Burma, and she sometimes took her son Adam with her. He concedes that his social conscience was, at best, nascent—he preferred baseball and the Grateful Dead to thinking about U.S. corporate social responsibility on the other side of the globe. But in his household it was hard to escape a sense of social obligation. His father, David, had prospered as an investment manager but did not materially indulge his children. For Adam's first three years of grade school, his parents had him bussed to an integrated public school; most of his boyhood friends were black or Chicano kids he met there. When he played Little League baseball in Santa Monica, his parents fudged his address to place him on a team drawn mostly from a poorer, more ethnically mixed neighborhood. His mother admits this wasn't purely a matter of social conscience. "There was better coaching in those neighborhoods," she says, laughing. "That was a factor." Nevertheless, as Adam recalls, "I was raised with a strong sense of civic responsibility. There was always discussion [in my house] of social issues or race issues."

Richards finds the medics at Mae Tao always "eager to soak up new ideas" and "adamantly argue their points."
Photo 2004 by Janet Wells

After high school, Adam Richards attended Harvard. At the end of his first year, he declared a major in environmental science and public policy. But that summer he began to have second thoughts. "My freshman-year roommate had literally broken the binding of his organic chemistry book in half, and I realized that people who were going to be studying that hard were not the people I wanted to be up against as an undergrad." He switched majors, to history and literature. And he began to attend meetings of the Boston Burma Roundtable, where he felt a connection to home, Mom, and Louisa Benson.

He gradually got more involved as an activist, teaming with a classmate to secure a student council resolution in support of human rights in Burma, and using the Internet to organize student activism at other universities. During his senior year, Harvard's dining services pondered switching a $1 million beverage contract from Coca-Cola to Pepsi. Pepsi had bottling plants in Burma, and Richards helped lead a successful effort to convince the university not to switch the contract.

Recalls his mother, "I was never intentional in trying to educate him or get him involved in the cause. It kind of happened without my being aware of it. He wasn't the kind of kid who called home to discuss things a lot."

He spent one summer living in San Francisco and working with a Bay-area environmental alliance. There, he witnessed the public health impact of environmental problems. Before this experience, he says, "public health, if I had thought about it at all, was just, like, fluoride in the water." Now, it looked to be a potential career. In 2000, encouraged by advisers to get clinical training, he enrolled at Hopkins for the MD/MPH program. He also journeyed to the Mae Tao Clinic for the first time.

The clinic is near the border town of Mae Sot, a hodgepodge of concrete structures, wooden houses raised on stilts, and tin-roofed factories that operate round the clock. The town's market purveys live eels, caged birds, frogs, snails, Chinese textiles, and cheap electronics. Conversation is a polyglot stew of Thai, Burmese, and the languages of indigenous ethnic groups like the Karen. Outside of town, raised roads traverse rice paddies. One of those roads leads to the clinic, which was founded by a Karen physician named Cynthia Maung. It serves about 150,000 people, so it's always crowded, with a busy outpatient ward and an inpatient facility in a building that's like a modest aircraft hangar. A number of orphaned children live there, cared for by the staff. Other children sleep under the beds of their parents who are undergoing treatment; women cook meals in the courtyard. "It feels chaotic," says Chris Beyrer, an associate research professor at the Bloomberg School of Public Health, who has worked there. "But gradually, as you spend time there, you begin to understand that it really is an amazing, organized sort of health system."

Where Torture
Is an Institution

Burma, or Myanmar, as its rulers want it to be known, could serve as Exhibit A of a nation wrecked by repressive government. The Burmese army overthrew a democratically elected prime minister and parliament in 1962 and has ruled autocratically ever since. In the summer of 1988, protests by students and workers became so threatening that in September of that year, the military reasserted authority by gunning down 2,000 protesters. The government permitted new elections in 1990, but when the primary opposition party, led by Aung San Suu Kyi, the daughter of Burma's first prime minister, won a substantial victory, the military refused to allow the new parliament to convene and placed Suu Kyi under house arrest. She won the Nobel Peace Prize in 1991, but has spent most of the subsequent years either under arrest or severe restrictions.

The present government, known without irony as the State Peace and Development Council, or SPDC, has despoiled the country's environment, strangled its economy, and permitted heroin production to flourish. The Central Intelligence Agency lists Burma as the world's second-largest producer of illicit opium. Numerous human rights organizations regard the SPDC as among the world's most repressive regimes. Amnesty International states "torture has become an institution." So has detention without trial, forced relocation of ethnic populations, arbitrary extra-judicial executions, and slave labor. Human Rights Watch accuses Burma of deploying more children as soldiers than any other country—75,000 of them, some as young as age 11. They are one-fourth of all the child soldiers in the world. The government represses all free expression. The Burma Project of the Open Society Institute notes that in 1996, the ruling junta decreed up to 20 years in prison for anyone publicly opposing government policy, and up to 15 years for unlicensed possession of a fax machine or computer modem.

Beyrer was Richards' MPH adviser. "Adam has that combination of being intellectually gifted and compassionate, motivated by concern for people who are in such a tough spot," he says. "He's the kind of guy who could succeed in any field of medicine, yet he's trying to provide health care in the middle of a civil war."

A lean, cheerful man, 30 years old, Richards is a self-described salsa-dancing addict who is known for his inexhaustible energy. June Fisher, a clinical professor of medicine at the University of California, San Francisco, has known him since he was three months old. She recalls visiting him when he was a senior at Harvard. "He had me out for the better part of a night, meeting all his friends. Then he brought me back to the hotel around 2 a.m. and said, 'I'll be by at 5 [a.m.], because it's May Day tomorrow and we're going dancing at the bridge.' That's apparently a tradition at Harvard. At that point, I had to act my age and say, 'No, you're going. I'll be at breakfast.'"

His trips to Thailand have been made as a member of the Global Health Access Program (GHAP), a consortium of roughly a dozen volunteer physicians and other health professionals who support the backpack medic program by providing training, technical backup, and medical supplies. Upon his most recent arrival at the clinic last February, Richards did what he always does: made a list with his GHAP colleagues of all that needed to be done. He says, "Each time, we swear that this time we'll never be able to complete the entire list, but we do." A typical day began around 7:30 with a coffee-and-muesli breakfast. Next might be morning sessions of a three-day malaria workshop for the medics. Language can be a problem; most of the Karen do not speak English, and Richards does not speak Karen. But through role-playing, and some translation, and computer-generated images projected on a whiteboard, he could help guide the medics through the material. They are always ready to learn. "They could have traveled a month in Burma to get to Mae Tao, and arrived at 3 in the morning," Richards says. "And here they are [the next day], eagerly soaking up new ideas and adamantly, vociferously, arguing their points." Many of the medics have become sufficiently expert to train each other, which is one of GHAP's goals. "We want to train ourselves right out of our jobs," Richards says.

That done, he might spend an afternoon improving the design of a field data-collection form. Or he might anesthetize a pig with ketamine and demonstrate for the medics new clinical skills he's just learned at Hopkins. Or check on data entry for a health-and-human-rights mortality survey. The medics now routinely survey villagers to record malaria morbidity, infant and maternal mortality following childbirth, and information on nutrition and sanitation. Plus they ask questions like, Have you ever been required to do forced labor? Have your crops or livestock been destroyed? Have you been forced to relocate? The backpack medics have been able to document one of the highest mortality rates from landmines in the world. They have found that the percentage of Karen households forced out of their villages ranges from 30 percent to 50 percent, with some people made to move three times in a year—all data very useful to human rights advocates.

Advocacy is new for the backpack medic program, and it exposes the medics and people who work with them to additional risk. Richards and his GHAP colleagues are alert for signs of retribution by the Burmese government or military, and for people they don't know who seem too curious. Sometimes stories make the rounds: A Western expat living in Mae Sot went out for his nightly motorcycle jaunt and disappeared . . . his girlfriend may have had connections to the SPDC. "Rumors have nine lives in Mae Sot," Richards says.

He is by nature upbeat, but Richards will concede occasional discouragement. The medics have a greater capacity and desire for new programs than the clinic's administrative apparatus can support. And substantive, self-sustaining change is a slow business. "On some level," Richards says, "I decided to pursue a career in health and medicine because I wanted to witness the difference [made by] my actions in real time. I had tasted 'victory' for Burma during college when we kicked Pepsi off campus, but I couldn't point to a single Burmese whose life is any better because of it. What I've come to appreciate is how long it takes to build a foundation for truly community-based primary health care."

As February wore on, with Match Day rapidly approaching back at Hopkins, Richards knew it could be years before he can get back to Mae Tao and the medics. "They have been with me for as long as I've been a medical student," he says. "They have taught me so much more about the value of health than I could hope to learn from any lecture or textbook." He regards them as heroes. "It is they who, by far, have taught me more than I ever shared with them."

Dale Keiger is a senior writer at Johns Hopkins Magazine.

Return to April 2005 Table of Contents

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