CARE ON THE VERGE GLOBAL HEALTH INTERVENTIONS FOR MALARIA AND BIOLOGICAL CITIZENSHIP AMONG UNDOCUMENTED KAREN MIGRANTS IN THE THAI- BURMA BORDERLAND A DISSERTATION SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI‘I AT MĀNOA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN ANTHROPOLOGY August 2018 By Asami Nago Dissertation Committee: Eirik J. Saethre, Chairperson Jan Brunson Alex Golub Daniel E. Brown Barbara Watson Andaya Keywords: Biomedicine, global health, The Karen, migration, humanitarianism © Copyright 2018, Asami Nago All rights reserved ii ACKNOWLEDGEMENTS While it seemed like a never-ending journey to complete this dissertation, it finally came to an end. I would like to acknowledge individuals and institutions who provided me with their support to complete this Ph.D. dissertation. Without their unchanging trust and encouragement, I would not have been able to accomplish this task. I owe so much to their academic and personal support. I am indebted to anonymous Karen people, who offered me their valuable time and shared their stories. Many of them were stateless people and eager to gain citizenship. I sincerely hope that their life situation in the borderland improves, and they will have access to the land and resources to live free without the threat of violence. I received so much support from both international doctors and local Karen staff at SMRU. Their dedication to patients, who do not have sufficient access to healthcare in their villages, were tremendous. I thank medical doctors at the SMRU. Francois Nosten, M.D., the charismatic and humorous Director of SMRU, allowed me to conduct fieldwork at SMRU. Rose McGregor, M.D. and Cindy Chu, whose warmth and humor made me realize that doctors are compassionate human beings. Three Burmese medical doctors, Dr. Khin Maung Lwin, Dr. Aung Pyae Pyo, and Dr. Sein Sein also provided me much needed field support. There were many other local Karen staff who gave me their kind friendship during my fieldwork at SMRU. I am thankful to my Thai friend, Ms. Boonyarat Punta (“Ms. Apple”), for offering me her space in the Mae Sot General Hospital’s nurse dormitory. She was not only my Thai language partner, but also a friend who taught me Thai modesty and self-discipline. I also would like to express my gratitude to several Thai individuals and institutions. First, the Faculty of Sociology and Anthropology at the Thammasat University provided me with an iii affiliation as a visiting scholar. I am especially thankful to Professor Annusorn Unno for arranging my academic affiliation at Thammasat University. Dr. Komatra Chuentattiansup and Dr. Valaikanya Plasai offered invaluable support and helped me conduct interviews with officers in the Bureau of Vector-Borne Diseases in the Ministry of Public Health in Thailand. I would like to thank many people at the University of Hawai‘i at Mānoa (UHM) who have helped me through this intellectual journey. My former advisor, Dr. Nina Etkin, was my inspiration. Even though I studied under Dr. Etkin for only two years, I can see her influence in my work. In fact, it was because of her that I chose malaria for my research topic. I also thank my current Chair, Dr. Eirik Saethre, who supported my fieldwork in Thailand and guided me as I completed this dissertation. His intellectual inquisitiveness and knowledge of medical anthropological theories on biomedicine and phenomenology guided me to deepen my understandings of this rich academic field. Dr. Barbara Andaya showed me mentorship by being a critical reader and always being a strong advocate. Dr. Daniel Brown never failed to provide warm encouragement throughout my Ph.D. He also provided careful reviews of my dissertation drafts and strengthened my draft with epidemiological insights. Dr. Jan Brunson and Dr. Alex Golub provided unflagging support, academic expertise, and personal encouragement. I also thank Dr. Jack Bilmes and Dr. Christine Yano who provided me advice even though they were not on my committee. My colleagues at UHM enriched my intellectual journey. I am especially indebted to Michelle Daigle who read through my dissertation draft and gave me invaluable advice. I gained my conceptual frameworks in this dissertation mostly from conversations with Michelle. I truly enjoyed our colleague and friendship, and I will miss our next-door distance at Saunders. I also thank J.D. Baker, Margaret Bodemer, Ruben Campos, Marla Chassels, iv Crystal Cooper, Mark Duvall, Piphal Heng, Hiroaki Izumi, Viacheslav Li, Tamara Luthy, Pamela Runestad, Toru Yamada, and Kinuko Yamazato for cheering me on, giving me personal advice, and offering me editorial support on my early drafts. I took advantage of exploring Oahu’s beautiful nature by going hiking with my friends. It also helped me clear my frustration during my Ph.D. Last but not least, I will be always grateful to my local Hawai‘i oʻhana (family). Betty-Gail and Ron Alford family, Ivie Kumura, Lynnae Li, Sandra and Tony Padua, Izumi and Jimmy Chen, and Christine Walters, to name a few, for offering warm support to my family. This dissertation would not have been possible without generous funding from various institutions for my fieldwork from 2011 through 2013, and during the writing period. I thank the Department of Anthropology, Research Council University of Hawaiʻi, East-West Center, Matsushita Konosuke Memorial Grant, and Soroptimist Founder Region Fellowship. I also benefited from attending the National Science Foundation (NSF), Summer Institute for Research Design (SIRD) workshop in 2010. Finally, I am thankful to my parents whose sacrifice and unchanging support enabled me to complete my Ph.D. journey. My son, Mikola, gave me a hope to bring my Ph.D. to an end and move beyond. v ABSTRACT This dissertation investigates global health interventions for malaria in the borderland, and the ways in which it impacts social relations, identity, and border experiences among the people at international malaria research clinics. The Thai-Burma borderland has become a site of increased malaria control interventions due to the emergence of multidrug-resistant (MDR) malaria parasites and the existence of highly mobile populations without citizenship. As such, they have shaped the landscape of the borderland as an ambiguous and liminal space for local Karen migrants and international medical doctors. I explore the ways in which people perceive of malaria as a biosocial disease in a clinical setting and create a new identity through experiencing the political economy of the borderland. Undocumented Karen migrants from Burma cross the international border to seek health care access at the Shoklo Malaria Research Unit (SMRU), an international malaria research unit in Thailand. They experience malaria as a consequence of political economy of ethnic conflict, poverty, structural violence, and discrimination against them as non-citizens and as undocumented migrants in the borderland. The vulnerability of this population is shaped by their lack of political citizenship by governments. However, medical researchers have neglected the sociocultural, political, and economic aspects of malaria, nor have they considered the social experiences of undocumented Karen migrants. The SMRU clinics provide care opportunities for undocumented Karen migrants, but also assures cosmopolitan medico-humanitarianism opportunities for international doctors as well as local Karen health practitioners. More importantly, access to healthcare at these facilities provides biological citizenship to undocumented Karen migrants. The SMRU vi clinics generate statistical evidence and scientific knowledge of malaria suffering. Despite this, the knowledge produced does not represent patients’ individual experiences of suffering with malaria and social inequalities. Thus, I argue that the inequalities and violence that people experience in their everyday life in the borderland are tactically ignored by the global health paradigm of malaria. vii TABLE OF CONTENTS ACKNOWLEDGEMENTS ..................................................................................................... iii ABSTRACT ............................................................................................................................. vi TABLE OF CONTENTS ....................................................................................................... viii LIST OF FIGURES AND TABLES......................................................................................... x LIST OF ABBREVIATIONS AND FOREIGN WORDS ...................................................... xi INTRODUCTION .................................................................................................................... 1 1. Entering the Field .............................................................................................................. 1 2. Borderland Across Space, Practice, and Discourse........................................................... 6 3. The Undocumented Karen Migrants in the Thai-Burma Borderland ............................. 14 4. Anthropology of Malaria and Global Health .................................................................. 17 5. Ethnographic Approaches to Everyday Violence ........................................................... 24 6. Methodology ................................................................................................................... 25 7. Overview of Dissertation ...............................................................................................