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Burmese: Health Beliefs & Practices
Some of the below applies to the Karen and other ethnic groups. Some of the information does not apply. This is the best we can do right now.
Links to Burmese Sites: These were at the end of the article, but in light of the events beginning September 2007, I updated the list, added news sources and moved it to the top (special thanks to M. Montague & Hanuman).
Burma (called Myanmar by Burma's ruling military State Peace and Development Council or SPDC) is in mainland Southeast Asia and is bordered by Thailand and Laos on the East, India and Bangladesh on the West, and China on the North. The primary population centers are along the centrally located Irrawaddy river valley. Most of the rest of the country is mountainous and the climate throughout is tropical monsoonal.
There are more than 48,000,000 people in Burma. Ethnic groups include the Burmese (or Bamar or Burman - 68% of the population); followed by the Shan, Karen (original indigenous people), Rakhine, Chinese, Indian, Mon, and others (e.g., Kachin, Chin, Wa, and other indigenous peoples) (Central Intelligence Agency [CIA], 2002). Many of the ethnic minority groups are "hilltribes" who occupy the mountain jungle areas.
Although there is a legendary list of Kings of Arakan (in Burma) dating to 2666 BC, the first record of a Burmese capital was in 500 BC. For the next several millennia there were a number of Burmese kingdoms of various sizes. Burma became a province of British India in 1886 and gained independence in 1948. A military dictatorship took power in 1962 and in 1988 declared martial law, which continues as this is written.
History of Immigration
There have long been Burmese immigrants to the West, especially Britain. The modern outflow of refugees began after the military took power in 1962; and increased in the late 1980's when Burma's ruling generals annulled an election, declared martial law and crushed the democratically elected opposition led by Nobel Peace Prize winner Daw Aung San Suu Kyi (photo at left). In addition to Burman political refugees, there are more than one hundred thousand Karen, Shan, and other indigenous people who are refugees on the Thai-Burma border (this number increased in 2007). Living conditions on the border, especially within ethnic hilltribe areas such as the Karen (or Kayin) State, are very difficult and there are frequent mass movements of internally displaced people (IDPs), as the SPDC army continues its military campaign to bring the entire country under its control. The Burmese term for refugee is dukkha-the, "one who has to bear dukkha, suffering" (Lang, 1995). Human rights violations in Burma are "massive" and include murder, rape, torture, forced relocation, and forced labor of dissidents and minorities (Petersen et al, 1998; Skidmore, 2002, Karen Human Rights Group, 2007). Here are two external sites on the current situation: Burma: Grace Under Pressure and A Journey of the Heart.
Culture and Social Relations
Burma is primarily an agricultural country with little industry and almost no technology. At one time Burma was the largest rice producer in Southeast Asia. However, economic development has been poor under SPDC rule due to corruption and mismanagement. Even the second largest city, Mandalay, has a distinctly rural or small-town atmosphere. The years of self-imposed isolation since 1962 have meant that in many ways, this traditionally rural, non-industrial culture has remained so. At the same time, however, forty years of repression have had significant negative impact on traditional Burmese culture.
Burmese culture is traditionally family and religion-oriented. This holds true for ethnic minorities as well, though indigenous people such as the Karen may have family and community structures different from the Burmans. Traditionally, families are extended, but among refugees and immigrants, nuclear families are the norm. Parents are held to be sacred and one of the "five objects of worship" in Buddhism, hence disobedience to a parent is considered a sin (Way, 1985). Social class lines are strong and thus there is little opportunity for social mobility.
Marriage is often arranged and arrangement may involve consultation with the family astrologer to determine whether the two young people will be compatible. Initiation to adulthood begins at age nine with the shin-pyu ceremony for boys, which is followed by several weeks in a monastery; and the nahtwin ceremony for girls, which includes having the ears pierced.
A distinctly Burmese cultural practice, carried over in some cases to new lands is the use of thanaka, a pale yellow paste (from the thanaka plant) applied to the cheeks, forehead, and sometimes arms of both genders but more frequently of girls and women. Photo: Child & adult with thanaka. Courtesy of pixelina (see links below).
As noted above, Burmese culture is very old. Interactions between social equals tend to be characterized by politeness and concern for the other person. The Burmese term, a-nah-dah expresses the Burmese cultural value of "an attitude of delicacy, expressive of a solicitousness for other people's feelings or convenience" (Way, p. 279, 1985). An example of the application of a-nah-dah is a tendency to try to convince another person that what cannot be given, e.g., an affirmative answer to a question, is not worth having (Cultural Profiles Project, undated).
The primary language of Burma is Burmese, one of the Tibeto-Burman family of languages. Burmese is tonal and at least to the Western ear, does not have the musicality or softness of most other Southeast Asian languages. The indigenous peoples each have their own language, though most also speak at least some Burmese. Forms of Burmese address are usually couched in terms of relationship and include:
As is common throughout Buddhist Southeast Asia, the head of an adult or child is figuratively the highest part of the body and should not be touched by another person - although exception is made for medical examination. It also is impolite to sit in a seat higher or at the same level as an older or more respected person. Shoes are not worn in the home or pagoda. When sitting on the floor, such as in a pagoda or a formal situations, men and women sit with their legs flexed sideways so that their feet are pointed to the rear rather than at a Buddha image or other people. However, in informal situations, men may sit cross-legged. Pointing one's finger, hand, or foot at another person is considered rude; and calling another person with upraised index finger is insulting.
Almost 90% of Burmese are Theravada Buddhist; with most of the rest of Burmese equally divided between Christians and Muslims (CIA, 2002). Many ethnic hilltribes villagers are animist, or combine animist traditions with one of the three primary religions. Related to the animism that existed before Buddhism, nat (literally, lord) or spirit worship is pervasive among Burmese Buddhists. Readers are referred to the discussion of Theravada Buddhism in the chapter on religions.
Based on tradition and the artifice that nats are themselves devotees of the Buddha, nat worship is very much blended with Buddhism. There are 37 inner nats who are allowed inside the pagoda and hundreds or perhaps thousands of outer nats who are not allowed in the pagoda. Some nats are basically protective, some capable of possessing humans, while others are associated with particular places or activities. The Little Lady of the Flute, for example, acts as a guardian and playmate of children; and makes children smile in their sleep. In general, nats require appeasement, such as maintaining a "house nat" shrine on the south side of the home (Courtauld, 1984).
Astrological computations are commonly used to predict the future and to guide many life decisions such as choosing a child's name, a wedding day, and when to travel. The Burmese astrological system is based upon the Hindu system, and representations of Hindu gods may be found in some Burmese Buddhist homes.
Health Beliefs and Practices
Traditionally, health is considered to be related to harmony in and between the body, mind, and soul and the universe; with the latter encompassing everyday life, socioeconomic conditions, as well as spiritual circumstances. The idea of harmony is most commonly expressed as a balance of "hot" and "cold" elements or states so that illnesses or states of health may be seen as hot or cold. Treatment should then be with opposite medicines or foods. The postpartum period, for example is a cold state, hence hot foods or medicines should be taken. Despite common assertions that hot and cold states are not related to temperature, most Burmans and other Southeast Asians avoid cold drinks for people in a cold state. Photo (by Tao Sheng Kwan-Gett, MD): Karen children in a Burmese refugee camp on the Thai-Burma border. Here are several powerful sites: A Journey of the Heart and Burma: Grace Under Pressure. Also, external site on the Karen and a site on Dr. Cynthia Muang.
Changes in diet are commonly used to treat illness. Depending on the illness, an increase in or reduction of one or more of the six Burmese tastes (sweet, sour, hot, cold, salty, bitter) may be indicated. Yesah is a herbal cure-all substance used by many Burmese.
Culture bound illnesses among Burmese include spirit possession by a Nat or an ancestor and Koro. Koro is the intense fear that the genitalia will recede into the body, and that if the genitalia recede completely, death will occur (Way 1985). Among women, menstrual flow is thought to be critical to health and, depending on the flow, an indication of good or poor health - including mental health (Skidmore, 2002).
The use of betel quid by women and men is ubiquitous in Burma. The basic quid (paan) is made from the betel leaf (Piper betel), with the chopped or crushed nut from the areca palm, and a white (or pink) paste of slaked lime (calcium hydroxide). The areca nut contains psychoactive alkaloids, extracted with the lime; the betel leaf cotains phenolic compounds which probably stimulate the release of catecholamines which, in turn, stimulate parts of the nervous system. Some people add tobacco and/or other substances. The quid provides a mild "high" and helps with dental pain. However, it is associated with oral pathology, including submucosal fibrosis, oral leukoplakia, and squamous cell carcinoma (Chu, 2001; Norton, 1998).
Pregnancy and Childbirth
Traditionally prenatal and neonatal care is often provided by a midwife or let-thare. In cities, however, clinics and hospitals are commonly used; and as in the West, the value of prenatal and neonatal care is well-recognized. Traditional dietary restrictions during pregnancy, especially among the hilltribe ethnic groups, make prenatal nutrition counseling essential. The risk of neonatal sepsis or tetanus is significant in some hilltribe villages, where midwives lacking proper equipment or training may cut the umbilical cord after delivery with a bamboo sliver and paint the umbilical stump with charcoal. The postpartum period (me dwin) is viewed as a time of susceptibility to illness as the mother's body is "cold" from blood loss. The body should be warmed with external heat as well as warm drinks and foods with "hot" properties. Sour and bitter foods are also taken postpartum as these are thought to reduce blood flow (Skidmore, 2002). Oral contraceptives thought by many to cause menstrual irregularity, while Depo-Provera injections are thought to provide regularity (despite the common adverse reaction of irregular bleeding).
Dying and Death
Buddhist philosophy and outlook are the greatest influences on how many Burmese approach dying and death. Equanimity and mindfulness are central to the process, and in some cases may be more valued than measures to manage symptoms. For example, patients or families may elect for a greater degree of alertness over complete pain control and accompanying clouded sensorium. It is thus important to counsel patients and families that with current standards of care, many patients are pain-free and alert.
Health Problems and Health Screening
Burma is an isolated, developing, and largely rural nation that has been in a state of civil war for much of the past half-century. The war, disruption of the country's health services infrastructure, and self-imposed isolation contribute to the Burmese having a healthy life expectancy ten years less than the neighboring Thai (World Health Organization [WHO], 2002a). Life expectancy at birth is 54.6 years for males and 59.9 years for females. The healthy life expectancy (HALE) at birth for males is 46.5 years and 51.4 years for females. The infant mortality rate is 72/1000 and the child mortality per 1000 is 121 for males and 106 for females (CIA, 2002; Population Reference Bureau, 2002; WHO, 2002a). Infectious diseases are the leading causes of morbidity and mortality among the Burmese. Health risks for new Burmese immigrants or refugees (Allden, Poole, Chantavanich, Ohmar, Aung, & Mollica, 1996; Cho-Min-Naing, 2000; Kemp, 2002; Okada et al, 2000: Petersen, Lykke, Hougen & Mannstaedt, 1998; WHO, 2002b; Win et al, 2002; Wongsrichanalai et al, 2001) include:
Last update 9/2007
Links to Burmese Sites (special thanks to M. Montague): I cannot attest to the extent to which any of these sites and organizations achieve their missions. Information on Burmese health beliefs and practices requested: Submit papers by mail to Charles Kemp, Baylor University School of Nursing, 3700 Worth Street, Dallas Texas 75246 or Charles_Kemp@baylor.edu
Allden, K., Poole, C., Chantavanich, S., Ohmar, K., Aung, N.N., & Mollica, R.F. (1996). Burmese political dissidents in Thailand: Trauma and survival among young adults in exile. American Journal of Public Health, 86, 1561-1569.
Central Intelligence Agency (2002). World Factbook 2002. Author. Accessed 12/14/2002 http://www.cia.gov/cia/publications/factbook/geos/bm.html
Cho-Min-Naing, (2000). Assessment of dengue hemorrhagic fever in Myanmar. Southeast Asian Journal of Tropical Medicine and Public Health, 31, 636-641.
Chu, N.S. (2001). Effects of Betel chewing on the central and autonomic nervous systems. Journal of Biomedical Science, 8, 229-236.
Country Watch (undated). Myanmar. Author. Accessed 12/14/2002 http://www.countrywatch.com/
Courtauld, C. (1984). In search of Burma. London: Frederick Muller Limited.
Cultural Profiles Project (undated). Myanmar. University of Toronto. Accessed 12/14/2002 http://cwr.utoronto.ca/cultural/
Hawn, T.R. & Jung, E.C. (2003). Health screening in immigrants, refugees, and internationally adopted orphans. In E.C. Jong & R. McMullen (Eds.) The travel and tropical medicine manual (3rd ed., pp. 255-265). Philadelphia: Saunders.
Kemp, C.E. (2002). Infectious diseases. Retrieved April 12, 2003 from http://www3.baylor.edu/~Charles_Kemp/Infectious_Disease.htm
Lang, H.J. (1995). Women as refugees: Perspectives from Burma. Cultural
Survival Quarterly. 19(1). Accessed 10/7/2002
Norton, S.A. (1998). Betel: Consumption and consequences. Journal of the American Academy of Dermatology, 38, 81-88.
Okada, S., Taketa, K., Ishikawa, T., Koji, T., Swe, T., Win, N., Win, K.M., Mra, R., & Myint, T.T. (2000). High prevalence of hepatitis C in patients with thalassemia and patients with liver diseases in Myanmar (Burma). Acta Med Okayama, 54, 137-138.
Petersen, H., Lykke, J., Hougen, H.P., & Mannstaedt, M. (1998). Results of medical examination of refugees from Burma. Danish Medical Bulletin, 45, 313-316.
Population Reference Bureau. (2002). 2002 world population data sheet. Retrieved May 12, 2003 from http://www.prb.org/pdf/WorldPopulationDS02_Eng.pdf
Skidmore, M. (2002). Menstrual madness: Women's health and well-being in urban Burma. Women & Health, 35, 81-99.
Way, R.T. (1985). Burmese culture, personality and mental health. Australian and New Zealand Journal of Psychiatry, 19, 275-282.
Win, T.T., Lin, K., Mizuno, S., Zhou, M., Liu, Q., Ferreira, M.U., Tantular, I.S., Kojima, S., Ishii, A., & Kawamoto, F. (2002). Wide distribution of Plasmodium ovale in Myanmar. Tropical Medicine and International Health, 7, 231-239.
Wongsrichanalai, C, Sirichaisinthop, J., Karwacki, J.J., Congpuong, K., Miller, R.S., Pang, Lorrin, & Thimasarn, K. (2001). Drug resistant malaria on the Thai-Myanmar and Thai-Cambodian borders. Southeast Asian Journal of Tropical Medicine and Public Health, 32, 41-49.
World Health Organization (2002a). World health report. Retrieved June 5, 2003 from http://www.who.int/whr/2002/en/
World Health Organization (2002b). Myanmar. Accessed 12/14/2002