Karen People
A Cultural Profile (Burma Refugees site)

"Gross human rights violations, including forced displacement, forced labor, attacks by soldiers on civilians, injury from landmines and destruction or theft of food supplies, have been widespread in eastern Burma (also known as Myanmar) ... in displaced areas (Mullany et al., 2007). The Karen in Dallas are all from "displaced areas."



We are publishing this cultural profile on the Burma Refugees website as quickly as possible because the number of Karen refugees coming to our community has rapidly increased. We expect to add to the profile at some point in the future and welcome additional information or sources of information! Other sources of information include:


There are a number of ethnic groups in Burma, most with their own language and customs. Among these are the Bamar or Burman (68%), Shan (9%), Karen (7%), Rakhine (4%), and Chinese (3%). Other groups include the Chin, Kachin, Mon, Wa and others. In older sources of information and in current parlance some of these, e.g., Kachin, Chin and Karen are referred to as “hill tribes.” Another term for groups such as Karen and Kachin is “indigenous people.” We prefer to say Karen or Karen people. The Karen do not refer to themselves as "Burmese."


In Burma, the Karen are concentrated primarily in the Karen (or Kayin) State in southeastern Burma near or on the Thai border. However, many Karen live elsewhere in southern Burma, both in rural and urban areas. There are 3,000,000 to 6,000,000 Karen in Burma.


In 1948 Burma won independence from the British. From then until 1962 the country (Union of Burma) was governed by several administrations which were assailed by insurgencies and splinter groups, including communists, ethnic groups and even remnants of the Chinese Nationalist Army or Kuomintang. In 1962, the Burmese military under the leadership of the Revolutionary Council seized control of the country and instituted a military government which ran the once prosperous nation into widespread poverty. In 1988, student protests (the 8888 Movement) spread and triggered a military crackdown in which thousands were killed (accurate numbers are not available). An election was held in 1990 and the National League for Democracy (NLD), headed by Aung San Suu Kyi won a landslide victory. The military immediately jailed, tortured and/or killed many NLD leaders, including Aung San Suu Kyi who has been under house arrest since that time.


“It is not power that corrupts but fear. Fear of losing power corrupts those who wield it and fear of the scourge of power corrupts those who are subject to it.” Aung San Suu Kyi


The military government was initially termed the Law and Order Restoration Council (SLORC). This name was later changed to the "State Peace and Development Council" (SPDC). The name of the country was also changed from Burma to Myanmar (although many Burmese, some governments, and some writers, including this author, continue to use the name Burma).


Currently, the SPDC rules Burma with an iron fist and has an ongoing military campaign to bring the entire country under its control. Most of the insurgent groups have been conquered and there are frequent mass movements of internally displaced people (IDPs) as the army continues its campaign. Human rights violations in Burma are massive and include murder, rape, torture, forced relocation, and forced labor of dissidents and minorities (Kemp & Rasbridge, 2004).


History of Migration

The Karen people are one of the primary targets of the Burmese military and are hunted through the jungles and mountains on the Thai-Burma border. Many Karen and other refugees have found their way to refugee camps in or near Mae Sot in Thailand. See http://www.maetaoclinic.org/ for information on the clinic at Mae Sot headed by Dr. Cynthia Muang.  


There are an unknown number of Karen (as well as Shan and other indigenous people) living as refugees or in temporary villages on the Thai-Burma border. Living conditions on the border are extraordinarily difficult and refugees are forced back and forth across the border into Thailand by the Burmese and Thai armies.


Beginning around 2004, refugees from Burma began coming to the United States. The earliest were Chin – who continue to come to the U.S. More recently, Karen refugees began arriving. There also are lesser numbers of Bamar and others coming to the U.S. The number of refugees from Burma to the U.S. is relatively small, probably less than 10,000 and a large influx is unlikely.


Culture and social relationships

Most Karen are from mountainous rural backgrounds (hence the term hill tribe) where they grow rice, vegetables, hunt, fish, and otherwise follow traditional lives during peaceful times. Many of these Karen have little education and have a conservative outlook on life and relationships. There are Karen who are well educated but these are usually found in urban areas such as Rangoon (Yangon) or in refugee camps.


There are several branches of Karen, the most numerous of whom are the Sgaw (about 70% of refugees) and Pwo. There are also several political and/or military groups, including the Karen National Union (KNU), Karen National Liberation Army (KNLA), and the Democratic Karen Buddhist Army (DKBA).


As is common among traditional or indigenous people, relationships, especially between women and men are guided by strict and conservative expectations. For example, unmarried women and men do not touch (although handshaking is common when greeting westerners, regardless of sex). Women are affectionate between one another (hugging and hand-holding), including westerners. Dress is conservative and at least early in resettlement, traditional, with women wearing distinctive sarongs and both men and women carrying woven shoulder bags. 


The Karen are traditionally matrilineal, though Christians may not follow this practice (of tracing ancestors through the female line). 


Meals are taken in family groups and may also include neighbors. A large container of rice is served with smaller side bowls of meat or fish, vegetables, chillis, fermented fish paste, and other foods. We have found that in the U.S., food is a problem for newly arrived refugees. The sooner they can get to a market catering to Southeast Asians, the better. Fermented fish paste, chillis, and other spices are essential component of Karen foods.



There are two major dialects (both tonal) among the Karen, Sgaw and Pwo, corresponding to the larger groups of Karen. As noted above, behavior, including communication tends to be governed by traditional expectations, which includes indirect communications. However, our experience is that communications are often direct - at least between Karen and westerners. Translation/interpretation is often a problem between the Karen and westerners. A common problem is expecting one person from Burma to understand another. This is not always the case as some Karen do not speak Burmese or another ethnic group language.


In contradistinction to some other Southeast Asians (who seldom say “no”), the Karen may say “no” as a demonstration of modesty. Public displays of anger or other negative emotion are shameful.


The Karen tend to be hospitable. Interest expressed by a visitor in (for example) what a family is having for a meal will usually mean food is offered to the visitor. Shoes are usually taken off and left at the door and though some Karen  will indicate this is not necessary for a visitor, it is probably best to go ahead and remove shoes. When walking between others it is polite to bend over so that one's head is not above others. Stepping over people or passing things over others is impolite (sometimes a challenge on outreach when people crowd into an apartment). Women are often physically affectionate with women, very naturally holding hands or hugging with a female visitor; and men may hold hands with one another. However, touching between opposite-sex people is uncommon. Our experience is that women are comfortable shaking hands with men, but any further physical contact is inappropriate under any circumstance.   


Readers should note that the translator/interpreter role is very powerful and has at times been used to the translator’s advantage or the person of limited English proficiency (LEP)’s disadvantage - regardless of ethnic or language background. For example, we were assisting a pregnant woman with abdominal pain and severe nausea and vomiting. The translator/interpreter working with her told the doctor that the woman’s only problem was headaches.



Most Karen in Burma are Theravada Buddhist with some elements of animism. In the U.S., most of the Karen we see are evangelical Christian. The Baptist Church is very active among the Karen in Burma, Thailand and overseas (in the U.S.). We will review Buddhism here, on the assumption that most readers will be better acquainted with Christianity.


The essence of Buddhism is found in the Four Noble Truths, which are:

  • All sentient beings suffer. Birth, illness, death, and other separations are inescapably part of life.
  • The cause of suffering is desire (tanha). Desire is manifested by attachment to life, to security, to others. One of the primary desires is the desire to be or to exist.
  • The way to end suffering is to cease to desire.
  • The way to cease to desire is to follow the Eightfold Path: (1) right belief, (2) right intent, (3) right speech, (4) right conduct or action, (5) right endeavor or livelihood, (6) right effort, (7) right mindfulness, and (8) right meditation.

Following the Eightfold Path leads to cessation of desire and to nirvana, or emancipation from rebirth. Note that this is not a path of complete renunciation; Buddhism advocates a Middle Way between extreme asceticism and self-indulgence, and teaches tolerance and acceptance of life (non-attachment). The principle of karma (or kamma) is basic to the practice of Buddhism. Karma is popularly interpreted as a moral precept: do right and you will be reborn into a higher state; do wrong and rebirth will be to a lower state.


The Burmese term for refugee is dukkha-the, "one who has to bear dukkha, suffering"


Although Buddhist scripture has nothing to say about magic, belief in magic is common among many Buddhists, especially people from the Theravada countries of Burma, Thailand, Cambodia, and Laos. Magico-religious practices are well-integrated into Buddhism, and include use of amulets, spells, and recognition of the presence and power of spirits. The Bamar of Burma, for example, often include Nat or spirit (of which there are 37 major ones) worship in their daily religious lives. The Karen are less involved with Nat worship, but may believe in the presence of spirits in nature and that these spirits must be appeased.


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

While traditional beliefs about health and illness are likely present among many Karen, a concurrent strong, almost magical belief in western medicine is common. Many have had the benefit of healthcare at the Mae Sot Clinic (see above) and hope for even greater benefit in the U.S. Key issues in healthcare for the Karen include:


Relationships: Health providers and those associated with providers are being evaluated by the Karen from the moment of first contact. A brusque or impersonal approach leads to mistrust and less than optimal outcomes. A warm, personal (yet business-like) approach is far more effective. We are seeing people make a conscious choice for healthcare that is relational in nature, yet less comprehensive over non-relational care with greater resources.


Communications: Strongly associated with relationships is the challenging issue of translation/interpretation in cross-cultural health encounters. Efforts at communication are handicapped by attempts to use translators from different ethnic groups, e.g., a Bamar assisting a Karen. We have been told on several occasions that people would prefer no assistance to assistance from a Bamar. (Readers should note that it is the Bamar who make up most of the Burmese army, so the resistance to help from a Bamar may be based on bitter experience.)


Compliance: All health encounters should address the issue of understanding, capacity and related compliance with treatment issues. This is especially true of cross-cultural encounters when cultures are as radically different as Karen and western. Our attempts to improve compliance include choosing the simplest regime possible, carefully explaining (for example) medications prescribed, eliciting return explanation or demonstration of the treatment, and printing the plan on a separate sheet of paper vs. simply giving the labeled medications. Even when the patient does not read, often they will find someone near their home who does read. Follow-up, including home visits, is helpful in many respects, including to determine or reinforce compliance.   


Traditional health beliefs are related to (1) an almost complete lack of medical resources for Karen living in Burma, (2) life in the mountains and rural areas, and (3) the previously noted animism. The Karen are in most cases an already isolated people and and in the case of refugees, hunted by soldiers in Burma, so the only modern healthcare for most has been the community health workers sent by the Mae Sot clinic and other organizations into the frontier (at significant risk to the health workers!). The Karen have thus been largely dependent on traditional medicines (herbs and the like) available in the mountains. Some of these traditional medicines have been brought to the U.S. in very limited quantities and some are probably also available at Asian herbalists or flea markets.


Traditional health-related beliefs include that each person has 37 souls (kla), some of which are found in the body and some of which are in the external world. Similarly to beliefs in rural Laos and Thailand, there is the belief that these kla can be lost or taken. It is worth noting (though we do not know what, if any connection exists) that there are also believed to be 37 Great Nats in Burma (see religion above). Wearing a string, tied with prayer and ceremony, around the wrist indicates an attempt to hold on to kla. Traveling a great distance, e.g., to the U.S. would endanger kla and thus be an added stressor.


Like many others from Southeast Asia, Karen may attribute illness to imbalance in natural forces – including wind, fire and water. The abdomen is significant in causation or understanding of illness among men and women. Menstrual flow and related issues are highly significant among women.


Betel Nut: The use of betel quid by women and men is ubiquitous in Burma, including among many Karen. 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 relieve dental pain. However, it is associated with oral pathology, including submucosal fibrosis, oral leukoplakia, and squamous cell carcinoma. Use of paan by Karen in Dallas is less common, though necessary ingredients are readily available in markets and some people continue to use. 

Health problems and screening

Burma is an isolated (“least developed”) rural nation that has been in a state of civil war for much of the past half-century. These factors contribute to the Burmese having a healthy life expectancy ten years less than the neighboring Thai. Infectious diseases are the greatest health problem among the Burmese.


Accurate vital statistics are difficult to obtain because of Burma’s ongoing civil war and disruption of the country’s health services infrastructure. Moreover, there are doubts about the accuracy of anything generated by the State Peace and Development Council. Life expectancy at birth is 62.5 years, but groups such as the Karen will have  shorter lives. The total infant mortality rate is 50.7 deaths/1000 live births, but again, groups such as the Karen will have poorer numbers.


Health risks for new Burmese immigrants or refugees (Kwan-Gett, Kemp, & Kovarik, 2005) include:

·         Amebiasis

·         Angiostrongyliasis

·         Anthrax

·         Capillariasis

·         Chikungunya

·         Cholera

·         Cryptococcosis

·         Cryptosporidiosis

·         Cysticercosis (tapeworm)

·         Dengue Fever (including dengue hemorrhagic fever)

·         Filariasis: (Bancroftian filariasis and Malayan filariasis)

·         Gnathostomiasis

·         Helminthiasis (ascariasis, echinococcosis/hydatid disease, schistosomiasis)

·         Hepatitis B (15% carriage rate)

·         HIV/AIDS

·         Hookworm

·         Leishmaniasis

·         Leprosy

·         Leptospirosis

·         Malaria, including multi-drug resistant (MDR) from Plasmodium falciparum resistant parasites and especially from malaria re-infection. MDR malaria is especially common on the Thai-Burma border, where most refugees are found. Other malaria-causing parasites in Burma include P. Vivax, and much less commonly P. malariae, and P. ovale. We have seen children as young as four years with a history of multiple malaria episodes.

·         Melioidosis

·         Mycetoma

·         Paragonimiasis

·         Sexually transmitted infections, including HIV/AIDS, cervical cancer, chancroid, gonorrhea, granuloma inguinale, lymphogranuloma venereum, syphilis)

·         Strongylodiasis

·         Thalassemias

·         Trematodes (liver-dwelling: clonorchiasis and opisthorchiasis; blood-dwelling: schistosomiasis or bilharzia; intestine-dwelling; and lung-dwelling)

·         Tropical sprue

·         Tuberculosis (Burma is one of 22 countries worldwide designated by WHO as “high burden” for tuberculosis)

·         Typhus, Scrub

·         Yaws (frambesia)

·         Post-traumatic stress disorder secondary to war, torture, rape and related

·         Physical sequelae of torture

·         Injuries from a variety of trauma

·         Malnutrition

·         Anemia

·         Thalassemia


Health-Related Comparison of Hispanic and Karen People (M. Vu)

Health-Related Issues



Common Health Problems

HTN & Diabetes, depression, ETOH (primarily men), early pregnancy

PTSD, malnutrition, parasitic infections, malaria, chronic mental health problems, TB, Hepatitis B, HTN, DM-2



Malnourished, some with obesity and related problems



Karen, Burmese


Roman Catholic or “Cristiana”

Buddhism or Christian

Health Beliefs & Practices

Home remedies, hot & cold practices, folk remedies

Herbal remedies, belief that Western medicine can heal everything


Family Oriented & extended family

Father has the power & mother – homemaker


Hugging & hand shaking among the woman

No shoes in the house

Sit with feet faced away from others

Family oriented



Nutrition (obesity)

Management of HTN & do not stop abruptly with HTN meds

Diabetes Care: foot care, blood sugar monitoring, signs & symptoms of diabetes, long term effects of diabetes.

Herbal remedies consult with doctor



Hand hygiene


Job training

Emergent care- 911 & contact #

Taking medications correctly

How to use the pay phone or phone cards

Money conversion

Local Asian grocery shopping centers



Barron, S. et al. (2007). Refugees from Burma: Their backgrounds and refugee experiences, http://www.cal.org/co/pdffiles/refugeesfromburma.pdf. Washington DC: Center for Applied Linguistics.

CIA (2007). Burma. In World Factbook. https://www.cia.gov/library/publications/the-world-factbook/geos/bm.html

Karen People.org: http://www.karenpeople.org/

Karen website.org: http://www.karen.org/main.htm

Kemp, C. & Rasbridge, L. (2004). Refugee and Immigrant Health. Cambridge: Cambridge University Press.

Kwan-Gett, T.S.C., Kemp, C. & Kovarik, C. (2006). Infectious and Tropical Diseases. St. Louis, MO: Elsevier Scientific.

Mullany, Suwanvanichkij, & Beyrer (2007). Population-based survey methods to quantify associations between human rights violations and health outcomes among internally displaced persons in eastern Burma. (Article reported in Johns Hopkins University website) http://www.jhsph.edu/publichealthnews/press_releases/2007/mullany_burma.html

Refugee Health: