Author(s): Amy Neiman, MSW; Eunice Soh, BSN, RN; Parisa Sutan, RN
Reviewer(s): Tao Kwan-Gett; Saw Steve
Contributor(s): Seattle Burma Roundtable and Karen community members in Seattle and Minnesota
Date Authored: July 01, 2008
Thai / Burma
The Karen, pronounced Kah- Ren (emphasis on the second syllable), are indigenous to the Thailand-Burma border region in Southeast Asia and are one of the many ethnic groups in Burma. There are Karen people throughout the country presently known as Burma or Myanmar. The Karen people live in the hilly eastern border region of Myanmar, primarily in Karen State, in Kayah State (Karenni State), southern Shan State (MoBye Region), Ayeyarwady Division (Irrawaddy Division), Southern Kawthoolei (Tenasserim Coastal Region) and in western Thailand. Karen State, “Kaw Thoo Lei”, is a heavily forested, mountainous strip of land that forms a divider between Thai and Burmese people, as well as between the people and the Irrawaddy delta within Burma/Myanmar.
Traditionally, most Karen people are farmers who cultivate “hill rice”. They live in villages that are small clearings in the forest. Houses are made entirely of bamboo and thatch. A nearby stream or river may provide a place for villagers to bathe, do washing, and collect drinking water. Life follows a seasonal pattern of planting and harvesting rice.
Each year in Karen state, usually during the dry season, the Burmese military attacks Karen villages. The military often burns down the entire village, destroying rice stocks and supplies that enable a community to survive. If the residents of these villages are able to escape, they go into hiding as Internally Displaced People (IDPs) in the surrounding forest. Life as an IDP is extremely difficult and many people become malnourished and infected with malaria. It is quite common for Karen people to have become IDPs several times in their lives. They often return to their villages when the Burmese army leaves the area.
Due to the conflict, thousands of Karen refugees have crossed the border to Thailand for safety and live in one of twelve refugee camps. The refugee camps appear as extremely large villages of bamboo and thatch buildings along the Thai-Burma border. Approximately 150, 000 people live in these camps as of April 2008 and many are being resettled to third countries at this time. (Thailand Burma Border Consortium, 2008) As of 2008, 10,000 ethnic Karen and Chin refugees have resettled in the United States. (International Rescue Committee, 2007)
Nearly half the population in Burma’s Delta that was hit by the cyclone in May 2008 was ethnic Karen. Many of the new arrivals in the U.S. have family in this area and it must be very difficult for them not to be able to help or contact their family members in the country.
History and Politics
“Rather than being known for its diverse ethnic history and rich natural resources, Burma is distinct as the setting of one of the longest-running civil wars in the world.”(Ward, 2002)
The Karen are one of the ethnic groups within the region known as Burma/ Myanmar. There are over 100 different ethnic groups and sub-ethnic groups within Burma. “While each ethnic group is different, they have one thing in common – they have all been oppressed by the military junta in Burma.” (Jinnah)
Little is known about the early history of the Karen. There are various theories regarding their migration from Tibet, China and through SE Asia most likely in stages. The Karen are an ethnic group historically and currently differentiated from neighboring populations including the Burmans, Thai, Mon and Shan. However, when the British colonized the area of contemporary Burma/Myanmar in 1886, the various ethnic nationalities were grouped within one country.
Throughout British rule and particularly around WWII, tension between the Karen and the Burmans was intensified. During WWII, the Karen aligned with the British and the Burmans with the Japanese. With the Japanese invasion of Burma, many atrocities were committed against the Karen by the Burmans as well as by the Japanese. When the British were negotiating independence after WWII, the Karen advocated for independence from Burma and for their own land. The Karen National Union (KNU) was established in early 1947. However, the British promise to consider the case of the Karen went unacknowledged upon Burma’s independence in 1948.
For a brief period after independence, the Karen attempted to live peacefully with the Burman majority, and some Karen even held government and army positions of leadership. However, in the fall of 1948, the Burmese government sponsored political militias known as Sitwundan, separate from the regular army. In January 1949, some Sitwundan attacked Karen villages and later that month, the Army Chief of Staff General Smith Dun, a Karen, was removed from his position and imprisoned. The Karen National Defense Organization (KNDO) fought to protect communities.
A stable government was never established within Burma/Myanmar. Any attempts at negotiations among the ethnic groups including the Karen were destroyed by assassination and military oppression. The Karen were joined by many other ethnic groups including the Shan, the Chin, the Kachin and the Mon in the development of ethnic resistance armies.
A military regime has been in power in Burma since the 1962 coup. It has increased the size of the military to 400,000 soldiers. In Karen State, the regime created a “Four Cuts Campaign” in which forced relocation and free-fire zones were employed to take away life-sustaining resources from the civilian Karen population. When the Burmese military takes over an area, the local people are forcibly removed to relocation sites, forced to labor for the military and used as human?land mine detectors. Women are often raped.
More well-known to the outside world, the military regime oppresses its internal Burman population. In 1988 there was a student uprising and many people were killed. Many students fled to the border regions and were taken in by the Karen. Daw Aung San Suu Kyi was democratically elected in 1990 and the military placed her under house arrest until this day. There are many political prisoners in Burma. The monks’ uprising of 2007 was in response to the regimes oppression. While these developments have occurred, the military regime continues to enact what some have termed “genocide” policies in the ethnic areas.
“Burma ranks among the poorest countries in the world; its schools and health system have collapsed; and it is home to a rapidly escalating HIV/AIDS epidemic- thanks in part to the fact that Burma has become one of the largest producers of heroin in the world. Ongoing internal skirmishes, military repression of ethnic minorities, forced relocations based on economic strategy, and pervasive poverty have resulted in a constant exodus of political and economic refugees.” (Ward, 2002)
There are three main Karen languages and many dialects. The Main types are S’ghaw (pronounced Skaw) Karen, Eastern Pwo Karen and Western Pwo Karen. Sometimes people also have different accents that make it difficult to understand each other. For interpretation purposes, one should ask if the patient speaks S’ghaw or Pwo Karen. The common language will generally be S’ghaw as a lot of the Pwo Karen will also speak S’ghaw, but the S’ghaw Karen don’t necessarily speak Pwo. It is very important to have interpreters available who speak S’ghaw. Some of the Pwo Karen from the city don’t speak S’ghaw at all, but will speak Burmese. Most of the people from the border do not speak Burmese. I t is the language of the Burmese military oppressor and should be used only as a last resort in interpretation with Karen refugees. If it is the only option for communication, then the patient should be consulted and given the choice of accepting the interpretation or not. A small percentage of Karen speak Thai. Around 1830, a written script for the Karen was created from the Burmese alphabet by an American Baptist missionary.
The Karen are addressed by given names. Traditionally, they do not have family names. This causes confusion with the system in the United States that identifies people by last names and may switch the order of the names on documents (you may find your patient by a search for their “first” name). Married couples do not share a same name. Usually Karen names mean something. For example, Bway Paw means Dew Flower. Sometimes if there is a significant event, a child will be named after the event (e.g. “uncle came”). People may have given names, and then nicknames. Sometimes people take on Western names as well. Karen are often addressed by their first names and a title that shows the relationship to the speaker. In S’ghaw Karen these titles are: Grandma (Pi) and Grandpa (Pu), Older brother (Jaw), older sister (Naw), auntie (Muah) or uncle (Di). Thra and Thramu are used for teachers and pastors. Saw is Mr. and Naw is Ms.
For those who are animists, if they have had children die, they may name a new child an unpleasant name so that the evil spirits will not want to take the child.
Status, Role Prestige
Elders are respected as well as teachers, pastors, priests and those with education. In the villages an elder may know traditional medicine.
Many Karen have a cultural value of not imposing on others or being quiet or less talkative. Doctors have high social status so patients may not be comfortable questioning them or expressing dissatisfaction with their treatment. Health care providers should ask open ended questions and allow opportunity for Karen patients to follow up with additional questions about their healthcare at a later time. Generally, patients consult with members of their own community about healthcare-related matters and then will have more information to follow-up with their doctor again.
Traditionally, Karen do not shake hands or bow. With experience with Western culture, people shake hands. Karen might shake with their right hand, supporting the right forearm with the left hand as it is a sign of respect to use both hands to shake.
In Sghaw Karen, people will say Good morning (Kaw Leh Ah Gay), Good Afternoon (Ni Leh Ah Gay), Good evening (Ha Leh Ah Gay) and Good Night (Na Leh Ah Gay).
“N’aw May Wele Ha” which means “Have you Eaten Rice” is small talk, akin to “How are you?”
Displays of Respect
When you are walking by someone, you duck and bow your head to be lower than others in the room especially if you are walking between two people having a conversation. One should avoid walking in front of those who are seated. One should walk behind them or ask for permission first.
Direct eye contact is sometimes not considered polite as it is a sign of equal status.
Normally Karen walk behind those who are elders or senior to them.
Folding one’s arms in front of oneself when talking to another is a sign of respect unlike in American culture
Pointing with the feet or showing the bottoms of one’s feet and touching the head is disrespectful.
One does not pick up something belonging to another person. When handing something to someone, it is respectful to use two hands rather than one.
One refuses invitations to eat with each other first as a manner of respect, and then accepts modestly.
Saying “no” is often a way of being modest.
Being direct is culturally considered rude. Many Karen find American directness, loud speech, and body language uncomfortable. Decisions are usually made by consensus. Confrontation is avoided, and problems may be addressed in a group or by an intermediary. Displays of anger are not respected and should be avoided. Politeness can sometimes lead to misunderstandings of Karen within American culture, as they may not directly inform you if their needs are not being met or if they disagree.
Men and women don’t traditionally touch in public. Women are very affectionate with each other, as are men with men. This might include holding hands or hugging, but not kissing. Such displays of affection do not indicate gender preference.
“The Karen are more conscious of people as opposed to time. Making and sticking to strict schedules is a difficult adjustment for many. We (Americans) might see rushing from one appointment to the next as efficient, while they (Karen) might see it as being rude to the person who is being left behind.
Related to the point above, making long range plans and setting goals is a rather new concept for most. As a rule, the Karen will take life as it happens to them.
Do not refer to the Karen as Burmese. Ethnically, they are a completely different group and many will not even speak Burmese. The Karen have come from the country of Burma, but not by choice and it is the Burmese that have driven them from their home. So many Karen will not identify with the Burmese in a very positive way. The political stance of the Karen will vary with their experience, but still, unless the person corrects you, it is much better to refer to people by their ethnic group (Karen, Chin, Kachin, Shan, Karenni, etc.) rather than call them Burmese.” (The Karen Konnection, 2007)
Marriage, Family, Kinship, Gender
Traditionally, some marriages are arranged. If a male is interested in a female, he will usually write a letter to her expressing his interest. Wedding ceremonies depend on the religion they practice: Christian, Buddhism, or Animism. Christian ceremonies are done in a church and Buddhist ceremonies are done in the temple. Animist wedding ceremonies usually last over several days and is often a long process for the bride to prepare. The average age for people to enter into marriage is in their 20’s. Not everyone has marriage certificates especially if the ceremonies were not done in the church.
After marriage, a husband will come to live with his wife and her parents. If one is married, traditionally, he or she will not be able to go to school. Although it is rare, divorce occurs and the children will stay with the mother. Males and females typically will not live together before marriage, but this value is changing with time.
The men will work in the fields. The women do the housework such as cleaning, cooking, collect the water, and gathering firewood as well as working in the fields. Men are honored in the home; however the women’s opinion is also well-respected. Primarily, Karen culture is a matriarchal society. The head of a spirit clan is always a woman and the husband becomes part of the wife’s clanat marriage. (Infomekong, 2008)
The basic and the traditional Karen dress for men are red cotton shirt with woven pattern and blue wide-leg trousers. Married women wear red skirts and red shirts more decorated than the men’s. An unmarried woman traditionally wears a white, long sack-like dress. (Infomekong, 2008)
Patients will generally feel more comfortable with same-gender interpreters due to the healthcare issues that may be discussed during their hospital visits.
Family and Kinship Structure
People in the past have had many children. It is common for many generations to live close to each other. Children are watched by everyone in the community. Due to the conflict in Karen state, family members have often been forced to live separately from loved ones. A patient should be asked about family involvement in their healthcare. If a patient is unconscious, families should be involved in making healthcare decisions.
Although it is more common for the daughter and her husband to stay and take care of her family, the son can also assume this responsibility. Adoption of a child is socially acceptable, especially if the birth parents are no longer able to take care of their child.
The infant mortality rate is high in Burma. As family planning is addressed in the refugee camps, people are familiar with it and some chose to use birth control such as the pill or Depo Provera. There is some opposition to birth control due to Christian beliefs. “Kids are given by God” and the use of birth control is not seen as following traditional culture. A Karen couple may want to have many babies.
In the past, when some women delivered babies as illegal migrants in Thai hospitals, they underwent forced sterilization. The doctors told them that they shouldn’t become pregnant because of their health and did sterilizations. Thus, some women were afraid of this happening when they went to the hospital.
Perinatal Hepatitis B has been common for the Karen who have resettled in the US previously. Education about stopping the transmission from mother to child via medication has been conducted in Minnesota. When mothers are pregnant, they should be checked for Hepatitis B.
Pregnancy and Child Birth
There is a lot of respect for pregnant women although pregnancy outside of marriage is frowned upon. When women get pregnant, there are certain things that they shouldn’t do- like eat some traditional spicy foods.
A study done on Karen women in a Karen refugee camp revealed that home births with the use of traditional midwives was preferred over delivering in the hospital. Of the 89 total mothers who participated in this study, 66 women reported that shame was the reason for avoiding hospital care and delivery. For example, vaginal examinations, leg exposure from not being completely covered by their sarongs, and male health staff being present were contributors to the shame of hospital visitations and stay. Furthermore, the comforts of family and friends where there is already an establishment of close relationships and understanding were key factors in preferring traditional delivery.
Traditionally, people do not recognize birthdays. Many refugees will put their birthdays on official documents as January 1 and a year estimated to be the year of their birth.
When women deliver babies, they are treated “like queens” and there are restrictions on how much work and movement a woman does in the post partum period. In order to maintain her health, traditionally women rest for one month. For the first three days the mother should not move so the father of her children has to serve her food and shower/bathe her twice a day. A fire is put by the mother’s beside to keep her warm.
Women can move around a little bit after a week but they are not allowed to go outside for about a month. This practice is meant to help a woman’s body return to normal and prevent her from getting sick. It is said that in the villages where there is “nothing to help your body return to normal,” women sometimes “get sick forever”. (Neiman, 2007) But the women who stay indoors for a month don’t get sick. During this time, they never touch cold water, and they drink and take a shower with hot or warm water. This tradition has changed some for the Karen community in the U.S.
For about one month after delivery, women often eat only rice and a soup that is a little bit hot and spicy. Turmeric, or tumeric, is a root found in the ginger family, and is dried and ground into a yellow spice commonly used in curries. Tumeric is often placed on the skin of babies, and may be mistaken for jaundice.
Infancy, Childhood and Socialization
Infant Feeding and Care
Babies are generally breastfed. Some are breast fed for about three years but the average is 1 ½ years. When birth control isn’t used, a woman might stop breast feeding when she becomes pregnant again.
Child Rearing Practices
The Karen are used to their children being able to run through villages and refugee camps safely (without the fear of traffic). Karen people watch each others’ children and it truly takes a village to raise a Karen child. Thus, it may be difficult for people to adjust to US child rearing practices and the restrictions on movement.
See also: Refugee Families from Burma, a cultural backgrounder focused on early childhood, produced by Bridging Refugee Youth and Children’s Services (BRYCS) and the Office of Head Start’s National Center on Cultural and Linguistic Responsiveness (NCCLR). This resource provides general cultural information, while recognizing that every family is unique and that cultural practices will vary by household and by generation.
Adolesence, Adulthood and Old Age
Education is highly respected in Karen culture. Children go to school from 5-20 years old, although some children do not start school until 10 years of age. Kindergarten is two to three years. During adolescence, some children must stay at home to take care of their younger siblings to allow their parents to work in the field. Sometimes the teenagers must work in the fields with their parents. School can get disrupted when armies invade villages and the people must flee for safety. There are no ceremonies to mark birthdays or rites of passage into adulthood. Adulthood is considered to begin around the age of 20 when people marry. All the children are responsible for their elderly parents in their old age.
Nutrition and Food
The Karen people are highly skilled farmers. Crops include rice, vegetables, corn, sesame and chilies. It is not uncommon for neighbors to help one another farm. Planting tobacco near rice fields keeps the insects away. Tobacco is used for this purpose as well as for smoking. A “living fence” is used between fields to separate and maximize the space for farming. A typical Karen dish consists of rice with a variety vegetables and meat on occasion.
Vegetables include cucumbers, squash, bamboo shoots, eggplants, mushrooms from the forest and edible wild vegetables. Often times, families will raise livestock such as chickens, pigs and cows. If fishing is an option, they will include in their diet a very famous dish among the Karen known as “nya u” or in Burmese “ngape”? a strong-tasting dish of fermented fish pounded into a fish paste that is usually served with rice and vegetables to add flavor. Karen often flavor their meals, such as curry dishes, with chilies and add spices such as turmeric, ginger, cardamom, garlic, tamarind, and lime juice.
Food Considerations and Taboos
There are many food taboos that exist in traditional Karen culture, especially in regards to illness. For example, people who have hepatitis are told to avoid yellow foods and papaya is thought to trigger malaria. It is important to address dietary concerns with patients when an illness is diagnosed.
The Thai Burma Border Consortium provides all refugees in camps along the border with a monthly food ration.
Food Ration (per month)
|Rice||15kg /adult. 7.5kg /child <5 years|
|Fortified Flour ( Asia MIX)||1 kg / person|
|Mung Beans||1 kg / adult. 750 gm / child < 5 years|
|Cooking Oil||1 lt / adult. 500 ml / child < 5 years|
|Fish Paste||750 gm / person|
|Iodised Salt||330 gm / person|
|Dried Chillies||125 gm / person|
|Sugar (pilot)||250 gm / person|
A diet composed mostly of rice, salt, chilies, and some vegetables contributes to a lack of protein and vitamin deficiencies. A clinical manifestation of vitamin deficiencies in children is the appearance of lighter colored hair. Thiamine deficiency is commonly seen in pregnant women, post-partum lactating women, and young children in the villages. Thiamine deficiency can cause congestive heart failure in infants and children. Vitamin A deficiency is an important factor contributing to blindness and respiratory infections.
Patients should be encouraged to consume more foods that contain vitamin B1. Such foods include green peas, spinach, liver, beef, pork, navy beans, nuts, pinto beans, bananas, soybeans, whole-grains, enriched cereals, breads, yeast, and legumes. Vitamin B1 aids in the body’s metabolism of carbohydrates and fat to produce energy.
Drinks, Drugs and Indulgences
The Karen may drink whiskey, chew tobacco, and smoke cigarettes and cheroots. Smoking is part of the culture, and some male children can begin as early as 10 years in age. Unlike some other ethnic groups from Burma, the Karen are not traditional opium producers. Some Karen villages produce marijuana, mainly harvested to sell for profit or to feed elephants and other animals. On the other hand, the prevalence of amphetamine (ya ba) use is increasing in the refugee camps.
A contributing factor is the exposure of amphetamines to villages – the military distributes drugs in order to corrupt ethnic hill tribe villages, as part of the ruling SPDC’s ethnic cleansing policy. The Karen also chew a seed called betel nut, which comes from the Betel Palm tree. Betel nut, containing relatively high levels of psychoactive alkaloids, is chewed for its mildly euphoric stimulant effects. However, the teeth and gums can become stained red as a result of regular betel nut chewing. Betel nut was once believed to prevent cavities, and even at one point was put into toothpastes. However, the increase in mouth ulcers and gum deterioration (leading to total loss of teeth) caused by betel chewing outweigh any positive effects. Betel nut is a carcinogen and causes oral cancer.
See also: Understanding Alcohol Use in the Karen Community(2012), a report prepared by Kaela Glass, University of Minnesota, in partnership with International Institute of Minnesota.
The Karen have five known religious beliefs: Animism, Buddhism, Christianity, the Lehkai, and Telahkon. Of these five, the majority of the Karen are Animist, Buddhist, or Christian. Christian Karen make up the leadership of the resistance to the Burmese. There has been some religious tension between the Christian and the Buddhist Karen. A Buddhist faction broke with the Christian leadership and aligned with the Burmese military.
Christianity was introduced to the Karen, and other ethnic groups located within Burma, during the early 18 th Century. Before that time, unsuccessful conversion attempts were made by protestant missionaries. Karen oral legends told of tales similar to Christian teachings, thus allowing the Karen to more easily identify with the teachings introduced by the Christian missionaries. Burman rulers regarded Christianity as yet another tool being used by the Bristish oppressors. As a result, Karen Christians were severely persecuted; many were imprisoned while some were even subjected to crucifixion. (Keenan, 2005)
A large number of Baptist schools were established to provide Christian converts with high levels of education and also study-abroad opportunities in America. Around 1830, a written script for the Karen was created from the Burmese alphabet by an American Baptist missionary. With this history, the minority population of Karen Christians continues to hold much higher social positions than the majority population of Buddhist or Animist Karen. (Keenan, 2005)
Buddhism remains the predominant religion within Burma, with 85% of the population being Buddhist. However, it is more likely that the Karen Buddhists merge Buddhism and Animism with a very fine distinction between the two religions. Although there is not much data available on the number of Karen Buddhists, surveys from refugee camps along the Burma border indicate that 65% of the Karen population in the camps is Christian while 28% are Buddhist. (Keenan, 2005)
The religious conflict between Christianity and Buddhism alongside ethnic inequality between the Pwo and S’ghaw races is the major factor in the split between the Karen National Union and the Democratic Karen Buddhist Organization (DKBA).
Before the introduction of Christian missionaries in the 1800s, many Karen worshipped a form of animism. They believed that every living thing had a K’la, or spirit, and that there was a Lord reigning over every place, rivers, forests, or mountains. Each of these Lords had a number of servants, or ghosts, created from the spirits of people who had died violent deaths, that would roam around the Karen homeland smoking pipes and armed with spears and swords. It was believed that touching them, even accidentally, would strike the victim with disease with the only cure being blood sacrifices.
Other similar legends tell of the animal spirit Na, who in ancient times had ordered the Karens to eat a mixture containing the flesh of every creature. If the Karen failed to eat each kind of flesh, then the spirit of that creature would in turn consume them. Since that time, sickness and death have come upon the Karen because they were unsuccessful in consuming the flesh of every creature.
However, the most dangerous of the spirits are a particular seven who kill the Karen. One spirit kills by the use of a tiger’s mouth, another by sickness, one by old age, another by man, one by falling, another by drowning, and finally one by any other way possible.
The main belief of the Karens is that there are two separate parts to the body, the tha (soul) and the K’la (shade). The tha forms the conscience, and so deals with moral nature. On the other hand, the K’la is the flesh, concerned mainly with maintaining life. The spirits mentioned above constantly attack the K’la , therefore making protective herbs and charms a necessity in guarding against these malevolent spirits. When the body dies, the K’la is believed to leave the body and come back as the K’la of a newborn child. Furthermore, when the body sleeps, the K’la departs from the body, and so care should be given not to awaken the body before the K’la returns or else death will follow soon after.
In Karen animism, there are also many spiritual beings. The more important spiritual beings have human attributes and have the power to control the destinies of mankind. A few in this group are spirits, some who have divine, god-like powers, who are responsible for the crops, or another that is considered the ruler of hell. Even though many Karen may consider themselves as Buddhist believers, a large proportion continues to follow and believe in the traditions of animism, and often times mix the two beliefs.
Formed in the early 1860s, the Lehkai mixes Buddhism with traditional legends from the Karen Golden book, and continues to integrate some animistic beliefs. There are over 1000 students in 17 schools that teach the Lehkai. One of the five stated aims of the Lehkai is to prohibit meat and flesh to be cooked for meals, as well as to prohibit alcoholic beverages. (Keenan, 2005)
Based on religion, practices differ concerning death. Christian Karen bury their dead, while Buddhists and Animists perform cremations. When a person dies, a feast is prepared and there is often chanting and drinking. Spirits are encouraged to leave the area rather than hang around the community. Ghost stories are related about deceased members of the community who have been offended and continue to haunt an area.
The idea of organ donation is very foreign. There is an idea that one’s body should be kept intact when one dies.
Traditional Medical Practices
The Karen traditional medicine borrows from both Indian Ayurvedic systems, including Alchemy, and Chinese medicine. The Karen from the remote jungles also exhibit a diversity of other folk healing traditions. Herbal medicine remains of great importance in Burma due to the lack of money for occidental medicine and the anti-imperialist (and anti-modernization) notions of the Military regime.
However, the Karen refugee community is accustomed to accessing health care through a clinic setting, as they have lived in the refugee camps where health care is provided by NGOs (non-governmental organizations). The majority of refugees prefer the services of the International NGO health centers in the camps. Still, there are traditional services available, though in insufficient quantity. There is a small network of traditional healers along the border.
Healing traditions of herbalism have been somewhat opposed by the Christian Karen, though there are efforts to revive the ancient practices. Barriers include a lack of access to the needed plants, a general resignation to apathy in the camps, and a decreased value placed on tradition especially by the youth. The health NGOs have contributed to this by not working with local healers or encouraging proven traditional practices, and prohibiting traditional midwifery.
Some people believe that modern medicine can cure their ailments, while others would prefer to use their traditional remedies if available. Sometimes people think they have bad blood and need to be bled.
There isn’t a fear of occidental medicine found in other ethnic groups. Most Karen refugees have had enough contact with Western people and doctors to understand their ways quite well, and these populations probably won’t have as many problems adjusting to Western care upon arrival in the States. However, refugees coming who haven’t lived in the camps for very long or at all will be more likely to be afraid of any modern practices.
One interesting note is the confusion between vitamins and other medications. Karen use the same word for both and only a few people understand the difference.
Karen have a certain leaning for bitter and sour foods, especially vegetables, and many of these are eaten as a preventative. There are concepts of hot and cold, and if one is sick, it is good to have things that are thought to make the body hot. Tumeric is used medicinally both internally and on the skin. There are many food taboos (e.g. if you eat papaya it will trigger malaria). As in Thai and Ayurvedic traditions, food plays a major role in healing and maintaining health. Help adjusting to the American diet would be important for Karen.
A CDC 2009 investigation indicates that for Burmese refugee children there is a relatively high risk of lead exposure in the camps. Cultural practices and traditional medicines are among the risk factors for elevated BLLs among Burmese refugees in the U.S. Read more: Working with Refugees from Burma to Prevent Childhood Lead Poisoning.
Experience with Western Medicine
Many Karen have experienced stomach problems and diarrhea.
A major issue among the Karen is the prevalence of gastric ulcers. It seems that it is mainly the result of mental stress in their lives and a diet high in hot chili peppers. Many meals in the past may have been simply rice and chili.
A lot of people have intestinal parasites. They don’t have energy even though they eat. Some common parasites include hookworm, which can contribute to iron deficiency, and giardia.
Most Karen people have had malaria. Other health issues may be complicated by residual effects of malaria. In Thailand, malaria is rare but in the IDP areas, malaria is rampant. If one gets malaria and medication is available, a seven day course is taken and the symptoms of the disease is gone. However, many Karen think that that when they have a fever that they have a reoccurrence of malaria. In Karen, the terms for malaria is (Ta Nya Gho) and for fever is (Ta Go Taw). Malaria is so rampant that any fever is automatically considered malaria though it could be dengue fever or any other kind of fever. If you want to ask about malaria, you have to ask clearly do you have malaria with the kind of parasite that you have to take quinine treatment for. This can be very confusing for doctors as patients may come to the doctor saying that they have malaria.
Hepatitis A, B, and C are common and people are aware of Hepatitis but there is little testing for it in the refugee camps and people don’t really understand the disease. The Karen Community in Minnesota related that the doctors are very sensitive when they tell a Karen person that they have Hepatitis and explain that they are carriers of the disease (if B or C). The doctors tell them not to worry and the patients feel more comfortable if the doctor will tell them directly what to do. They listen to the doctor, have check ups every six months and the doctors let them know that they can have medicine if they are bothered by the symptoms.
When people find out they have Hepatitis, they will have many questions about food. In Karen culture, there are a lot of rules about you can eat this, you cannot eat that. With Hepatitis, one can’t eat any yellow fruit. As Karen have pretty limited knowledge about Hepatitis, they see one’s eyes turn yellow with Hepatitis so food that is yellow is avoided. Hepatitis is called “liver disease”. There is fruit and meat you cannot eat. One cannot eat fish paste. If people hear that they have Hepatitis, they will think, “now I cannot eat this” so it’s good for doctors to explain food and diet information.
See: from Public Health – Seattle & King County
The Karen refugee population is tested for active TB in the refugee camps before resettlement in the United States. There are programs to treat TB. However, many of the refugees who come to the United States, will test positive for latent TB when given a PPD skin test. Medication is prescribed that needs to be taken for 9 months to lessen the chance that they will develop active TB.
Hemoglobin E Trait / Thallassemia
Anemia, especially mild anemia with microcytocis, is a commonly encountered problem among recently arrived Southeast Asian immigrants. Unnecessary work-ups, including hemoglobin electrophoresis get ordered if the clinician is not aware of the increased prevalence of these lab findings in an otherwise normal person. (for more details see a landmark paper on the topic by VF Fairbanks, 1979 – see reference below). The Washington State Department of Health’s newborn screening program has excellent information sheets available. The information sheets for providers include detailed information about how to interpret results, workup cases, statistics (so far only 3 significant hemoglobinopathies in 2008 in WA state) and also parent handouts are available in many languages (Khmer/Cambodian, Chinese, English Laotian, Spanish, Vietnamese).
Medical Care within Karen State
“According to a UN envoy, Burma has the lowest per capita spending on health care in the world. Malaria, respiratory infections and diarrhea, and anemia are devastatingly common in Burma. It is also a regional incubator for HIV/AIDS, TB, measles and typhoid fever. Due to the civil war, there are many victims of landmines as well.” (World Aid Foundation)
Backpack Relief teams bring cross border aid and medication into the conflict areas. These backpack medics are often targeted by the Burmese military.
There is a clinic located on the Thai- Burma border called the Mae Tao clinic or “Dr. Cynthia’s clinic” (after the woman who started the clinic as an emergency measure to treat those affected by the massacres following the 1988 uprising) and sick individuals often walk for days to this destination.
Medical Care in the Refugee Camps
Non-Governmental Organizations (NGOs) run clinics in the camps including Medicine San Frontiers, American Refugee Committee, International Rescue Committee, Malteser of Germany. These clinics provide limited healthcare, maternal and child health, family planning information, vaccinations and nutrition programs. People can be tested for TB and HIV/ AIDS.
For more about tuberculosis program services in the camps, see on EthnoMed: Evaluation of Tuberculosis Program Services for Burmese-Refugees-in-Thailand-Resettling-to-the-United-States, May 2007.
The most common medication given is paracetemol (like our acetaminophen) and the Karen will often ask if you have any ‘PARA’?
Experience with Western Medicine in the United States
Karen people are mostly from rural areas. They may be ashamed, embarrassed and hesitant to tell information to their health care providers, and this may be true especially for female patients. Most Karen agree with and accept the western health care system and practices, but still are very hesitant to visit American doctors. The patient-provider interaction may benefit from having a Karen caseworker, when possible, consult with the patient after they see the doctor, to clarify confusion or misunderstanding and discuss issues in preparation for next doctor’s appointments.
Refugees living in the border region are not allowed out of the refugee camps and cannot work. However, refugees serve on camp committees which are the “administrative and management bodies of the camps. They coordinate the day-to-day running of the camp and its services in collaboration with local officials, and provide the main link between the camp population, NGOs, UNHCR and local Thai authorities.” (Thailand Burma Border Consortium, 2007)
Committees organize the storage and distribution of supplies such as food, fuel and other items and work on safeguarding the camps’ physical environment and infrastructure. Committees oversee community health clinics, support the school system, run camp security systems and oversee the administration of justice. Women’s organizations are active. People maintain traditional crafts such as weaving.
Burmese Refugee Health Profile
The information in this refugee health profile is intended to help resettlement agencies, clinicians, and public health providers understand the health issues of greatest interest or concern pertaining to Burmese refugee populations in the United States, as well as their cultural background and circumstances.
Invisible Newcomers: Refugees from Burma/Myanmar and Bhutan in the United States
A report (2014) from the Association for Asian American Studies (AAAS) highlighting the demographic characteristics, challenges and policy implications of the two largest refugee arrivals to the U.S., who are largely invisible in the current national discourse on Asian American socioeconomic outcomes.
Refugee Wellness Country Guide - Burma (Myanmar)
Published by the Gulf Coast Jewish Family & Community Services, this 2 page report provides historial timeline, overview and context, helpful tips foro resettlement workers and mental health providers, information about healthcare in refugee camps, beliefs and customs and more.
Drum Publication Group: Promoting Education, Preserving Culture
Website with basic Karen phrases
World Culture Encyclopedia: Karen
More information about Karen culture, history, kinship, religion, economy. Section on Religion and Expressive Culture gives information about spiritual beliefs, practitioners, ceremonies, arts, medicine and afterlife.
Karen-Burmese Refugees - An orientation for health workers and volunteers
Information about the Karen-Burmese refugees culture, living conditions and health risks. Series of 3 Power Point presentations (PDFs) from Queensland Health, Australia. 2006.
Refugee Families from Burma
Bridging Refugee Youth and Children’s Services (BRYCS) and the Office of Head Start’s National Center on Cultural and Linguistic Responsiveness (NCCLR) have partnered to create a cultural backgrounders focused on early childhood in Refugee Families from Burma. This resource provide general cultural information, while recognizing that every family is unique and that cultural practices will vary by household and by generation.
Patient Education Resources
The Healthy Living Toolkit from the United States Committee for Refugees and Immigrants (USCRI) includes these topics:
- Communicable Diseases: What is HIV?; What Everyone Needs to Know About Sexually Transmitted Disease (STDs); Cold and Flu
- Respiratory Diseases: What is Tuberculosis?; Live Longer: Quit Smoking Now!
- Nutrition Related Diseases: What is Diabetes?; Heart Disease; What is Obesity?; Childhood Obesity
Maternal and Child Health: Routine Health Exams for Women (Pap Test, Mammograms); What Every Woman Should Know about Her Body (Menstrual Cycle)
- Health Care: Patient’s Rights and Responsibilities; Emergency Room Use
This food and nutrition handout from USCRI is designed to communicate basic nutrition information to refugees and immigrants in order to help develop positive nutrition and lifestyle habits.
Infomekong. (2008). Pwo Karen Profile. Mekong Peoples Groups , 2008, from http://www.infomekong.com/karenpwo.htm
International Rescue Committee. (2007). IRC Has Helped 10,000 Burmese Refugees Resettle in the U.S., from http://www.theirc.org/news/irc-has-helped-10000-burmese0916.html
Jinnah. Karen. 2008, from http://www.burmaissues.org/En/karen.html
Keenan, P. (2005). Museum of Karen History and Culture. Religion , from http://burmalibrary.org/docs3/karenmuseum-01/Culture/christianity.htm
Neiman, A. (2007). Verbal communication with members of Minnesota Karen Community. Minneapolis.
Thailand Burma Border Consortium. (2007). Camp management: Refugee Camp Organisational Structures 2008, from http://www.tbbc.org/camps/management.htm
Thailand Burma Border Consortium. (2008). Update: TBBC & UNHCR Border Map & Populations (Apr 2008). Retrieved May 30, 2008, 2008, from http://www.tbbc.org/index.htm
The Karen Konnection. (2007). Cultural tips and trends.
VF Fairbanks, G. G., B Brimhall, JA Jereb and EC Goldston (1979). Hemoglobin E trait reexamined: a cause of microcytosis and erythrocytosis. Blood, 53, 109-115.
Ward, J. (2002). If Not Now, When? Addressing Gender-based Violence in Refugee, Internally Displaced and Post-conflict Settings. A Global Overview. 2002 The Women’s Commission for Refugee Women and Children and the International Rescue Committee.
World Aid Foundation Brochure