Hearts Beating in Shadow
We are sharing a series of journal entries that the author, JH, contributed following an invitation from Insight Myanmar for publication on our website. She includes the following message: The following entries from my journal along the Burma-Thai border were first shared more than 18 years ago. On the advice of a respected teacher, they were distributed only on paper, so as to protect involved parties while raising awareness. Later, when the Internet became available, many of us still hoped in our hearts that these descriptions would soon become obsolete. Finally, I offer these words here in realizing that certain details remain far too accurate. May they bring benefit. Please forgive my youthful ignorance and arrogance. Errors are my own.
“I once jokingly compared the eradication of various ethnic groups in Burma to that suffered by the Jewish people under Hitler’s World War II reign, when a colleague reminded me that at least Hitler was elected.”
Burma Border Journals #6
Thank goodness for Min and Moo. As opposed to the previous armchair descriptions, the patient who presented at 21:35 last night initiated me into the subjective experience of medical decision- making dynamics in the refugee clinic setting. I met her in the morning. An exquisitely polite fifty-five-year-old Burman woman, she presented with “no breathe, no breathe,” and oliguria for four days. Her past medical history included ascites of unknown etiology treated successfully with diuretics approximately three months prior to this presentation. She reported an inability to lie flat and experienced obvious dyspnea in even a slightly recumbent position. A grown daughter massaged the patient’s swollen feet. No fever, no sweats or chills, nausea but without vomiting, no changes in bowel habit. This information actually represented a pretty thorough history compared to some, owing to the patient’s minimal English skills, and I proceeded to the exam. Afebrile, 110/80, 98 beats per minute, 26 respirations shallow. No pulse oximetry. She looked sick and generally puffy with jugular venous distension to the jaw, visible from halfway across the room. Heart rate and rhythm regular but distant, point of maximum impulse non- displaced, question of a third heart sound. Lungs with fine crackles at the bases bilaterally. Abdomen distended about seven liters with positive fluid wave, non-tympanitic. Digits slightly cyanotic, with 2-3+ pitting edema from both lower extremities up to and including the sacrum.
The staff fluid-restricted the patient and had begun her on two oral diuretics the night before, realizing correctly that this woman was experiencing both heart and kidney failure. By morning still a urine specimen could not be obtained to test for red blood cells, renal casts, proteinuria. A serum sample was sent to the Thai hospital in town for blood urea nitrogen (BUN), creatinine (Cre), and electrolytes, including Potassium (K+). We didn’t want any peaked T-waves indicating cardiac abnormalities due to excess K+. Electrocardiograms and chest x-rays are not so readily available; so, we held off.
The two treatment practicalities about which I felt strongly were: one, to give the Furosemide intravenously (IV) for improved absorption, and two, the need for an indwelling urinary catheter to measure kidney output and at least obtain a specimen. The staff present had some training in clinical reasoning, but without as much theoretical background as those trained in medical school. The younger assistants adhered rigidly to the protocol they had memorized from the Burma Border Guidelines, which is to always offer oral (PO) medicines unless the patient is unconscious or unable to swallow. They seemed to feel sorry for me that I could not understand such a simple rule and tried repeatedly to educate me in broken English as I gently but with tenacity advocated for IV drugs. A similar rule seemed to apply when employing urinary catheters; the patient was neither paralyzed nor incontinent. Why would she need such a thing? They considered the thought of a catheter in this case nothing but cause for a good chuckle. I couldn’t find the chief medic at the time and really had to defer to him. I let go and saw other patients.
Later that afternoon around three o’clock, I brought my colleague to show him this patient’s impressive neck veins. By this point the edema had transformed into full-blown anasarca and the abdomen was further distended. When the revered foreign attending came over from the Surgical department to visit, he noted the additional and proximal belly swelling to be tympanitic, meaning filled with air and worrisome for gastric distension. He also pointed out the absence of uremic fetor as suggesting primarily cardiac disease process. He urged me to request IV Furosemide, since at this stage obviously PO medications would be poorly absorbed, and to demand the insertion of a Foley catheter. He also recommended a nasogastric (NG) tube to relieve the apparent ballooning of her gastrointestinal tract. Two out of three of the above I had already attempted to obtain. My patient was clearly dying. So grateful was I for the input, and so embarrassed. It looked like I had done nothing and was killing her off by way of negligence.
And the NG tube, well, an hour later when prompted, the guy from the evening shift said, “We wait, tomorrow.” He did not know how to do it. Smiling, I said “Oh, ha ha, tomorrow patient dead,” and asked that I might insert the thing myself. This suggestion received full support as I had been focusing on relationship-building up to that point, that is until I actually put the thing in. Their watching eyes, unfamiliar with the procedure, seemed to accuse me as the perpetrator of some inhumane crime. The patient found sixteen gauge tubing down her nostrils and throat disagreeable, and so after aspirating some mucous and curdled milk, it was removed. The truth is she is dying. The sort of chronic medical regime needed to treat heart failure is not going to be available to her here, however much I like her.
I met a narcotics contact who offered his own personal stash for patients in great pain or air hunger, but because the clinic is not exactly legal, I don’t feel comfortable risking the clinic’s existence on Thai soil and future patient encounters just to assuage the physical suffering of one woman.
What I mean by gratitude for Min and Moo is that the mind was spinning while the body was walking home. These parts considered to be me had commenced to separate, until twelve-year- old Moo, who studies English in school, called out to me in her uniform from her mother’s food stall from across the street. We hung out with her little sister Min, employing the universal language of big smiles, exaggerated facial expressions, hand gestures, and girlish giggles, interspersed with energized silence. The attention moved from conjured thoughts, interpretations of replayed memories, planning, then closer to the outside of the head, in front of the face, and down into the chest, and just as consciousness remembered the heart, two feet started stinging, as if to remind me of something. The fact that I was standing in the midst of a congregation of red ants drew my attention further from abstract to ground. As I occupied myself fully, I was simultaneously protected from the judgement of medics or attendings, from sickness, death, narcotics and legal quandaries, taking refuge in the breathing pulse of the world, dancing around and swiping at ants.
Although the preceding case is neither rare nor extraordinary to any of the world’s populations, it does illustrate some of the treatment considerations more heavily weighted in what another new friend calls a “resource poor” setting. That said, it can be useful to remember that like other cultures, here too there are cardiovascular diseases, colon cancers, congenital cleft palates, the occasional myelomeningoceles, “quick come see the baby with two heads,” and the one child with neurofibromatosis. The more prominent personal benefit of clinical service on another continent, of course, is the exponential increase in disease recognition skills for conditions not common in the home country; here that means malaria and intestinal worms. In fact, in terms of screening, the numbers needed to treat are so low that all inpatients are de-wormed and blood- tested for malaria, including standard serum hemoglobin, on arrival.
During the twenty-four hours it took to find out my friend the cardiac patient had acidemia, a normal K+, an elevated BUN and Cre, a young man had presented with rigors, chills, convulsions that morning, and dolls eyes; he had arrested, been resuscitated, and had become pulseless and apneic again, gradually stiffening. This is cerebral malaria, a most undesirable complication of one species of the Plasmodium parasite.
My first Monday here, an English physician working at the nearby malaria institute reported that he had one hundred eight slides to examine that day. Evidently demand for diagnosis builds up over the weekend. When asked for the species breakdown, he estimated about one third of cases represented infection with Plasmodium vivax, one third with P. falciparum, and one third were mixed forms. The other two species, P. malariae and P. ovale, are more frequently seen in association with the African continent. All but P. falciparum are commonly referred to as benign, because aside from the occasional splenic rupture or infection of pregnant women, they rarely cause death. When blood containing P. vivax is smeared onto a slide, stained appropriately, and examined under the microscope, one sees red blood cells containing a single navy blue ring. It resembles small fingers in the pincer grasp position and holding a red dot between their tips. Later in the life cycle of the organism, the cell becomes filled with clumps of blue, though one still sees a round red nucleus as well. With P. falciparum, the rings are thinner, more delicate- looking with red stippling; the clumping stage is rarely seen. Unlike mature forms of P. vivax, which almost takes up the whole shape of its host cell leaving only narrow band of circumferential cytoplasm, the later stage of P. falciparum looks more like a band through the center of its host’s cell, or a crescent hugging the edge thereof. The host cell actually appears deformed to the examiner and devoid of hemoglobin meaning paler than when occupied by other species. A truth equally applicable to the larger political picture here too. This histological information was happily conveyed to me by a twenty-year-old boyish Arakanese trainee from at the Laboratory department.
The increased incidence of malaria documented for patients residing on the Burmese side of the border is multifactorial but includes: increased prevalence due to lack of diagnosis, lack of treatment, absence of spraying for mosquito vectors, greater area of jungle habitat, and failure to make mosquito nets available to the general populace. Although many people survive the mild malaria cycle, the discomfort can have social as well as personal ramifications. Classically there are repeating episodes of cold stage rigors with chills, hot stage fever to one hundred five, plus or minus change in mental status, followed by the sweating stage as the fever breaks. Not too dissimilar from the weather here, but it concerns the Karen in that it keeps their children out of school.
The Karen are a proud, dignified people who walk as if held aloft from the breast bone. They wear colorful hand-woven fabrics and sing playfully with one another. The calculated extermination tactics of the Burmese generals have forced these villagers deep into mountainous jungles hiding for their lives. I once jokingly compared the eradication of various ethnic groups in Burma to that suffered by the Jewish people under Hitler’s World War II reign when a colleague reminded me that at least Hitler was elected. Sometimes the army comes in broad daylight when the parents are out gathering the last edible plants and the young are engaged in a school lesson. The teachers try to help the kids run and hide, but for those who are caught, according to the Karen Education Department (KED), girls as young as nine are raped mercilessly, glass objects inserted into vaginas, homes razed and burned. This can happen up to three times per month. It takes whole families, including the school-aged children, to relocate and rebuild a village. More school missed, no small issue for the Karen who have made a unified decision that education must be a priority for their people.
Despite malnutrition and genocide, each village has a teacher, and every attempt is made to bring children to a middle school level of education. During the two-month hot season hiatus from school, the teachers assemble for in-services and trainings. Facilitators trek for two weeks into the remote heart of the forested hills, across strategically logged roads laced with landmines and dotted with troops of various warring factions. They carry sacks of rice the size of baby cows on their heads and divvy up equally large parcels that assembled together once filled an entire living room, all containing school supplies and teaching tools. For though they will never give up hope or relinquish their fight, they aptly state that in education of the children lies the survival of their State. These indigenous people risk their lives to train elementary educators!
So this is the problem with fact of life malaria, missed school days, not to mention that P. falciparum malariae hang out in large numbers in the blood and can stick to cells lining the tiniest of veins. Here they clog up the outflow of blood from important organ systems in the body, leading to severe sequelae such as impaired liver function with jaundice, hypoglycemia, renal failure, hemoglobinuria called blackwater fever, permanent neurological compromise, shock, coma, death. Aside from fever, these secondary phenomena also manifest with symptoms that interfere with subsistence foraging, armed resistance, and education. The generals from the capital have mosquito nets treated with Permethrin and wear DEET, a strong repellant on their skin. It is a type of germ warfare we who reside so far north of the Equator do not often consider. So when we see videos of the suppression of masses, after the machine gunning enters the hospitals and in order to hide the evidence patients are sent to the crematorium alive, the remaining prisoners complain of being covered with mosquitoes in their cells, it’s not itching they refer to. They mean this parasite impeding the flow of oxygen and nutrients, the removal of cellular waste products, from vital tissues of the body. Such diseases, however common, undermine a person’s ability to withstand psychological and physical brutality and can intensify the punishment in slave labor camps.
May this writing heighten awareness about the plight and great beauty of the people from all parts once called Burma. May it bring benefit to all who are described herein and to all who read it. May you be truly happy.