AFTER-ACTION REPORTS:

• Thailand-Burma - February 9-24, 2008
• Thailand-Burma - October 12, 2007
• Thailand-Burma March 20-April 5, 2007
• Tanzania July 4 – July 14, 2006
• Medical and Surgical Assistance: Karen Refugees
• Northwest Thailand, Karen Refugee Village Health Workers

Medical and Surgical Assistance: Karen Refugees
REFUGEE RELIEF INTERNATIONAL MISSION 06-1

In response to a request from the Committee for Internally Displaced People, Karen National Union, a four man team consisting of David Mohler, MD, John Padgett, PA-C, Jeffrey Gieseke, RN, and Matthew Bigge, traveled to the Thai-Burma border to render medical and surgical assistance. The team departed the United States on April 13th, and reached the area of operations on April 16th. Medical and surgical assistance and medical training were conducted at two sites along the Thai-Burma border: one border village north of the Thai town of Umpang, and a new refugee encampment in the jungle next to the Salween River.

Following cleft lip repair, the surgical team escorts a pediatric patient to a primitive surgical recovery ward.

Refugee Relief International’s team arrived on the Thai-Burma border to find a group of 900 refuges setting up a camp in the jungle along the Salween River. The shelters were being constructed out of jungle materials: bamboo walls and floors, and leaves for thatched roofs. Some temporary shelters were made from plastic tarp purchased in Thailand. There was already a long bamboo building with open sides, which was functioning as a medical clinic. There a young medic, a graduate of a Refugee Relief International, Inc. course in trauma and basic medicine, was doing his best to treat refugees for malaria, dysentery, dehydration, and exhaustion.

The Refugee Relief International, Inc. Team of Mission 06-1poses with Karen medical counterparts.

The RRII team identified three surgical candidates in the village near Umpang, and did one hernia repair two cleft lip repairs on children there. Medical problems such as malaria, malnutrition and dysentery were addressed. One patient had been experiencing back pains since escaping from a Burmese Army forced labor gang, where he was made to carry heavy loads on his back up and down mountainous trails.

In addition to medical and surgical cases, the RRII team distributed medical supplies to the village nurse at Freedom Clinic #5, and gave instruction in the use of medications supplied by RRII to the clinic. Karen National Liberation Army medics were at the village clinic, and were given combat aid kits, battle dressings, intravenous fluids and other lifesaving materials to enable them to stabilize the wounded in their operational areas inside Burma.

A Karen nurse looks from the open sides of the bamboo construction dispensary at Refugee Camp One, near the Salween River.

After two days near Umpang, the team moved north to Camp #1, the new camp for the 900 newly created refugees. Access to the camp was gained by an hour by 4WD from the nearest town, then 2 hours by boat, and then a 30 minute walk up a stream to the new camp, set in the jungled mountains. The team brought a great deal of medication, especially IV fluids and ant-dairrheals, as we had been told by our Karen counterparts that dysentery and diarrhea were rampant. Having experience with the Karen, we also knew that 100% of the Karen population in the jungle has malaria (usually P. falciparum), and brought anti-malarials and fever reducers. To address the dehydration and malnutrition certain to be present in refugees who had trekked through the mountains and jungle, rehydration salts and vitamins were included.

The Karen Committee for Internally Displaced People (CIDP) had been busy in helping their people set up the camp. Already there were huts hewn out of the jungle, with bamboo and thatch being the building materials. Some plastic tarp was brought in from the nearest Thai town for temporary shelter from the rain, until families could complete their dwellings. The CIDP’s medical representative, Saw Diamond, had already addressed sanitary needs in the camp by supervising the digging of latrines and shipping some Turkish toilets and concrete in to seal them.

A small jungle dispensary had already been set up to care for the sick and injured. This was staffed by a graduate of the training conducted by a Refugee Relief International, Inc. team during RRII mission 05-1 (see the report of mission 05-1 on the web site).

Medical problems encountered included diarrheal disease and dysentery, malaria, malnutrition and vitamin deficiency, dehydration, parasites, upper respiratory infections, pneumonia, problems associated with pregnancy, filariasis, heart failure, obstructive pulmonary disease, and asthma. The team worked with the Karen medic to address these problems, using the opportunity to do some teaching, and the medications were put to good use.

Surgical problems included previous injuries from land mines, burns, and bullets, and hernias of different types: inguinal and umbilical. Dr. Mohler, assisted by the team, performed field surgery on a child with a large umbilical hernia, with good results.

The RRII team identified several areas of need, as well as opportunities, and in which future projects and future funding, are essential. They are:

1. The need for vaccinations. The Karen refugees coming out of areas of ethnic cleansing in Burma have had no access to health care, and certainly not to vaccinations. Those who have made it across the border into Thailand, unless they are settled in a recognized (and restricted) border camp recognized by the Thai Interior Ministry, do not have any access to vaccinations. As they are stateless and not Thai, and do not speak Thai, they are not allowed health care services from the Thai Ministry of Health. There is no system in place to address the need for immunization for the tens of thousands of children and adults who are internally displaced inside of Burma, or who are undocumented victims of persecution who have escaped to Thailand. Hundreds of children who contract measles and mumps, tetanus and meningitis, could be prevented from suffering these illnesses by simple vaccinations that are not now available.
2. The RRII team conducted a non-scientific experiment to determine if a “cold chain” could be maintained to keep vaccine cold and viable in the field environment on the Thai-Burma border.  Using a commercially available cooler and ice, the team managed to maintain an acceptable cold chain for two days. It is felt that using dry ice and improved containers would lengthen the time the biologicals can be kept viable to a week or longer. A low tech system of dry ice, a sealed cooler and a thermometer would be al that is required to reach the majority of the population with vaccinations.
3. It was determined that the Karen village health care workers keep accurate health records on the patients they see. These medics and nurses can be counted on to document vaccinations in a central village register. Simple cards can be printed at low cost to provide the individual patient a record of vaccinations.
4. The CIDP is currently providing the refugee community at Camp 1 with rice and the occasional meat source to keep the refugees alive. The area around the camp will soon be depleted of game, and though the camp in proximity to the Salween, catching enough fish to provide the daily protein requirements of over 900 people will be difficult. Malnutrition and vitamin deficiency are expected to be even more severe as time goes by. Malnutrition and the lack of available food sources are already affecting pregnant mothers, who are showing signs of fatigue and anemia. The team was not in the operational area long enough to assess recent birth weights, but those pregnant women with little access to food other than rice are going to have babies with low birth weight and developmental problems.
5. The advent of the rainy season means that people will be spending more time in their huts in close proximity. The incidence of contagious disease is expected to rise, including insect-borne disease. More rain means more standing water, which means more mosquitoes and more malaria, filariasis, and dengue fever.
6. Due to the Burmese Army’s continuing ethnic cleansing campaign, the number of refugees is expected to increase.

Refuge Relief International, Inc. will work with other organizations and private individuals to attempt to secure funding for a vaccination program for the Karen, and will work with the CIDP medical representatives to implement same. The initial plan is to secure vaccine for common childhood and adult illnesses, as well as cold containers and dry ice, in Bangkok from a medical supply company with whom RRII has an established relationship. The CIDP would identify sites and patients. RRII team members and Karen medical will administer the vaccine and provide records.

RRII will contact other agencies to alert them of the need for urgent food relief at Camp One. It is vital that relief agencies in the area with the capability and motivation to help this refugee population come together at this time of urgent need.

Financial accounting for this mission will be accomplished by the Team Leader under separate cover.

Respectfully Submitted,

John E. Padgett, PA-C, Ph.D.
Operations Director

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