Power, politics and privilege: public health at the Thai-Burma border

Before arriving in camp, we imagined inaccessible dirt roads running through precarious, mountainous terrain but the camp is actually located off a paved highway. A cursory glance at the houses may lead one to hastily conclude that people have just arrived in camp but, in reality, these 120,000 refugees from Burma have been in Thailand for decades. In front of the Thai military checkpoint is a sign at the entrance of the camp that reads ‘temporary shelter’ – although the camp has been there for 17 years.

One of our Karen colleagues is 27 years old and has lived in camp for years. He came here from his village in Burma in search of an education. The fighting has caused many from his region to flee across the border to Thailand, and left very few educational opportunities in Eastern Burma. His family remained behind in Karen State, and he has not seen them since coming to camp. He got married but, soon after, his wife also fled Burma and was resettled to another country where she has lived and worked since. She sends small remittances to him, and they speak on the phone frequently, but he does not believe that he will ever be able to join her.

The situation for refugees is a dire one. In the current geopolitical climate none of the three ‘durable solutions’ of voluntary repatriation, local integration or resettlement is a viable option. The Thai government, in agreement with Burmese officials, has stated their explicit wish to shut down the camps along the border. Rumours of camp closures circulate but camp residents overwhelmingly state they do not want to go back.

During our time in camp, we came across an article written a few weeks prior to our arrival.[1] The author’s observations led him to believe that the time was right to close the camps, stating that: “sustenance is provided and work prohibited. This has discouraged independence, enterprise, and entrepreneurship.” Yet he cites data that half of camp residents suffer from a mental health problem, a consequence of “loss of self-sufficiency and growth of short-term thinking.”

For us as budding public health professionals but also simply as observers, these claims do not hold merit and in fact may harm refugees. The students we worked with are independent thinkers, enterprising and entrepreneurial, despite the confines of camp. They are also resilient. Mental health concerns are significant and under-addressed in camp but common mental disorders like depression, anxiety and post-traumatic stress disorder are rather a result of the terrible history of trauma so many of these refugees have endured.

Mental health

One of our group projects was designed and developed to assess community attitudes in camp towards mental health care. Having experienced stressors of violence and displacement, refugees are particularly at elevated risk for chronic mental health disorders. Factors that are associated with poorer mental health include unstable living arrangements, lack of economic opportunities, the fear of forced return and ongoing conflict in the regions they originally fled.[2]

In a study to assess mental illness among Karenni refugees, 11% of respondents indicated that they had a previously diagnosed mental illness.[3] Culture-specific, physical symptoms were quite prevalent. These included ‘“numbness”, “thinking too much” and “feeling hot under the skin”. As one refugee stated succinctly, “... I am not allowed to go outside the camp. There is no job, no work. So much stress and depression. I feel that I am going to go crazy here.” [4]

There is a clear need for a better understanding of mental health in this setting. Unfortunately, our Karen students were instructed at short notice that they needed to return to their home camp to be accounted for in a verification exercise, effectively putting a stop to the group’s proposed mental health study. The irony is stark, as it is this volatility and lack of control in day-to-day life that contribute to psychological distress. There are enormous mental health implications of living a life that does not adequately allow one to exercise basic freedoms of movement, livelihood and political agency. These are human rights issues, and these human rights are directly linked to individual health and public health.

The lens through which we view a situation determines how we understand its causes and our obligations. We were fortunate to spend three weeks accompanying our colleagues in camp. In that time we became acutely aware of how unbalanced power dynamics, a lack of political autonomy and an inherent lack of privilege lead to disparities in health and human rights.

Travelling 12,000 miles provided a valuable perspective on how the issues of power, politics and privilege are pervasive in refugee camps but also gave us insight into our own inherent privilege. We are at liberty to move freely, express ourselves freely and take advantage of seemingly endless opportunities. What then is our role as transient observers in this context? We believe that when we bear witness to injustice, we have a responsibility to advocate for and amplify the voices and concerns of those who lack the privilege to have their voices heard. Dr Martin Luther King Jr’s words written in a Letter from a Birmingham Jail in 1963 still ring true today: “Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality tied in a single garment of destiny. Whatever affects one directly affects all indirectly.”

Nikhil A Patel sunny.patel@mail.harvard.edu @sunnyapatel_
Resident Physician, Cambridge Health Alliance and Clinical Fellow, Harvard Medical School www.challiance.org/

Amos B Licthman amoslichtman@mail.harvard.edu
Resident Physician, David Geffen School of Medicine, University of California, Los Angeles http://medschool.ucla.edu/

Mohit M Nair mmn452@mail.harvard.edu
Public Health Researcher, Harvard TH Chan School of Public Health www.hsph.harvard.edu/

Parveen K Parmar pparmar@usc.edu
Associate Professor, Keck School of Medicine of the University of Southern California http://keck.usc.edu/

We would like to thank Shoshanna Fine, Blake Johnson, Kayla Enriquez, Paul Gregg Greenough and Kelsey Gleason for thought-provoking conversations about our shared experience. Finally, we would like to express our heartfelt thanks to our Karen colleagues for their hospitality and generosity.