By Dr Jimi Wollumbin, CEO, OHO


The young Burmese girl in front of me looks healthy and happy, perhaps a little small for her age, but with a radiant intelligence that shines in her eyes and is impossible to hide, even with a shy smile. She looks fine, and the health assessments carried out by our team basically confirms this, but The UNESCO statistics I read on the plane say otherwise. Her name is Beauty, she is 14 years old, 151cm, 43kg and she has a one in four chance of not seeing her 40th birthday.

I hand her a small packet of cashew nuts by way of a 
thank you for helping us with our research. Perhaps I 
should give her a multi vitamin as well since she also 
has a 32% chance of contracting HIV by her next
birthday. “Jezu timbare” I say as I shake her hand. Most 
girls her age are now in their last year of school in 
Myanmar. The next child in line is obviously one of the 34% of under 5 year olds with moderate to severe stunting from malnutrition. I look for a larger than average packet of cashews and wave goodbye to Beauty as she heads out the door.

This opening is a literary cheap trick, poorly executed, and riddled with poetic license – yet all the important parts are completely accurate. It summarises my wrestle with the demons of futility that all community workers must face as they inevitably realise that more often than not the critical work of helping those in need is at best a stop gap measure. Nothing I did on this trip affected any of the haunting statistics that Beauty must outrun, although the efforts of our team hopefully positively impacted the drinking water and nutritional risks for the 120 children at the Andrew Youth Development Centre.

The battles we fought were with folate and protein deficiencies, septic tank haemorrhages, and staphylococcus infections, whilst the real harbingers of disease and death in Myanmar went entirely unchallenged. At first glance, the cause of the folate deficiencies is not enough fresh fruit and vegetables in the diet. The cause of the dietary lack however is an overly stretched budget at this refuge for abandoned children. The cause behind most of these children being abandoned or orphaned is the civil war in the north that leaves many families fatherless, and then renders the mother unable to care for her children. The cause of that conflict is one of the worst and most oppressive military dictatorships of the late 20th century. So far this line of observation is trite, and something we are all very aware of, but if you stay with me a few minutes longer I will attempt to take it beyond that.

The take home point is that both here in Myanmar and in every other ‘developed’ country I have visited the vast majority of medical practice and healthcare budget is spent patching up such leaks in the community health bucket, while the deeper causes remain largely unexamined. Those deeper causes are the real forerunners of disease, death, pestilence and famine. They are the real horsemen of the apocalypse, and the explanation of my chosen metaphor is already well over due.

The expression ‘horsemen of the apocalypse’ is unsurprisingly biblical in origin, and is generally used to describe the forerunners of something bad happening of biblical proportions. Traditionally, the first horseman is the white rider and is referred to either as ‘Conquest’ or ‘Pestilence’, but with both interpretations is often insightfully associated with military conquest. The second horseman is the red rider and is generally known as ‘War’. The third horseman rides a black horse and is called Faminei, whilst the fourth and final horseman is named Death and rides a pale, corpse coloured horse. Interestingly, the third horseman, ‘famine’ carries a pair of weighing scales, which indicates that the price of grain is about ten times normal. During the time that this passage of the bible was written it meant that a day’s wages would only buy enough wheat for one person, not an entire family. To add insult to injury, the horse is heard to say “and see thou hurt not the oil and the wine” suggesting a continuing abundance of luxuries for the wealthy while even staples such as bread are almost out of reach for average workers. Although this is all too relevant for Myanmar today, I would suggest that the metaphor still needs to be slightly amended for use in the twenty-first century.

The traditional four horsemen of the apocalypse as I currently perceive them follow in the wake of two far more insidious hadean forces that pave their way. They are as far down the rabbit hole of causes as I have ventured to date, and although others have named them long before me, whilst I am in a biblical mood I will do so again, for to know a devil’s name is to have power over it. The harbingers of all suffering, discord and disease that I have encountered as a physician and community worker are none other than ‘Ignorance’ and ‘Inequality’.

To return to the case study of the military dictatorship in Myanmar: it was Ignorance that lead the charge when the British invaded Burma and officially rendered it a part of colonial Britain’s Indian empire in 1886. These were the days when as Emma Larkin notes in her analysis of George Orwell’s first novel ‘Burmese Days’, “natives were natives – interesting, no doubt, but finally…an inferior people.” ‘Inequality’ is only ever a hoof-beat behind Ignorance, and as Orwell states through the lead character, this book explores “the lie that we’re here to uplift our poor black brothers instead of to rob them.” This is attested to by modern consensus as documented by Wikipedia:

“While the Burmese economy grew, all the power and wealth remained in the hands of several British firms, Anglo- Burmese and migrants from India. The civil service was largely staffed by the Anglo-Burmese community and Indians. Though the country prospered, the Burmese people failed to reap the rewards. Throughout colonial rule through the mid- 1960s, the Anglo-Burmese were to dominate the country, causing discontent among the local populace”

Somewhat prophetically Orwell has one of the colonialists in Burmese Days later suggest that the British should simply leave the country to descend into anarchy, a sentiment that is met by general approval by his peers. In 1962, a mere decade and a half after the Burmese gained their independence and the British did leave, anarchy descended and a military coup took control of Burma, with the government to this day continuing to be under its direct control. Riding at the forefront of that coup was Ignorance once again, hotly followed by Inequality, then Conquest, then War, then Famine and Pestilence. Finally of course, Death always arrives.

It is through this lens that I looked down at my bag of cashews as the severely stunted child next in line approaches. Another highly emotive, but accurate portrayal of my inner experience. When staring the social causes of disease straight in the eye it becomes difficult to focus on the real and necessary tasks of helping human beings with their immediate needs. Outrage, as the Confucians repeatedly asserted in 10th century debates with Buddhists, is an appropriate human response to outrageous acts.

In the spirit of blogging I am going to now foreswear all scholarly moderation and publicly attempt to leap even further down the causal rabbit hole. I will do this by asserting that there is ultimately only one social cause of disease, and it is the very same noxious social ‘influenza’ for all people in all times. It is a difficult devil to name, but I have an increasing sense of its gestalt, and will attempt to paint it quickly in broad brush strokes. It is the breaker of the seven seals, the unleasher of the Horsemen.

It is the deadly folly of thinking that in a marriage, family, community, nation or global village, that we are separated from anyone else to the extent that it is possible for them to suffer without us also suffering. As Martin Luther King Jr. succinctly wrote in a letter from Birmingham Jail in 1963: ‘Injustice anywhere is a threat to justice everywhere’. The suffering of the hungry orphan may appear to be of a different nature to the suffering of the anxious General, but what I am suggesting is that in the inescapable community of the human condition they are in fact two sides of the one coin. This is the profound ignorance that tolerates inequality, that believes that wars have winners, that hordes wealth to increase safety, that conquers to liberate. It is the illusion of social separation. It is a metaphor with fences and gates, when what is needed is one spun by the Golden Orb Weaving Spider.

In this regard it is something akin to the horsemen of Ignorance, Inequality and Conquest all on the same donkey. It is the tragic theatre of the absurd that has filled our history books. Fortunately, and just in time for the overdue conclusion of this late night blog entry, I genuinely believe it will fill less pages of our future history, than of our past. Metaphors are blossoming in the popular culture of the global village in a spring time riot of hope and wisdom, as the hundredth monkey finally starts dancing to the butterfly effect – soaring across Gaia in complex, fractal patterns.

The formula a la mode for pieces such as this is to return after a long and wayward journey to the human interest paragraph that the article opened with. In tipping my hat to the social forces that be, I will close by affirming that the statistics I quoted that haunt Beauty are already starting to fall. A generation of Aung Sang Su Kyi’s is coming of age in a connected world. Her eyes alone are a profound testimony to the fact that the tide of Ignorance is receding at last.