Memorandum submitted by the Mae Tao Clinic,
The Back Pack Health Worker's Team and Burma Medical Association
SUMMARY
1. We welcome the International Development
Committee of the British Parliament's recognition of the severity
of the displacement of populations in Burma and the call for information
regarding UK assistance to the displaced populations.
2. We believe that it is essential that
the UK government increases its support to these populations and
that the most effective way to do this is by supporting community
organisations and civil society groups who are already working
together to access the most vulnerable. It is impossible to access
these populations without including organisations which work from
outside of Burma's borders providing cross-border assistance.
The SPDC prohibits access to these populations by any government
or NGO, yet these are the areas where the heart of Burma's humanitarian
crisis is unfolding. There are organizations working both cross
border and inside Burma who have been working for many years to
provide services to the vast populations neglected by the SPDC.
Increased support to these groups would increase the access to
health, education, food security and livelihoods of displaced
populations.
3. At the same time, the international donor
communities and governments must take a stance on the human rights
abuses perpetrated by the military. Without addressing the misgovernance
and abuse of its people by the Burmese government, there can be
no long term impact on the humanitarian crisis.
4. SPDC's Four Cuts Policy of 1974, is still
being carried out. This policy allows them to burn villages and
crops, detain and torture villagers and employ villagers as porters
and landmine sweepers. The health and welfare of the people is
not a concern of the government's. These populations are displaced
as a direct result of the SPDC's actions; people are either forcibly
relocated to make way for SPDC troops or development projects
or flee to the jungle to escape the abuses of the military regime.
Populations living in the border areas as internally displaced
people are constantly having to flee SPDC's forced labour, forced
relocations, landmines and a host of well documented human rights
abuses. The Burmese military has expanded its abuses against civilians,
particularly in northern Karen State, and denies the existence
of displaced populations, branding such migrants as "illegal
workers" or "families of insurgents." No aid to
displaced persons was sent from the new jungle capital of Naypyidaw.
Today, IDPs in eastern Burma have amongst the worst health indicators,
far worse than Burma's official figures, already amongst the bottom
amongst all ASEAN countries.
RECOMMENDATIONS
5. That the UK Government:
— fund border-based community-managed
health programmes providing humanitarian services and capacity
building for displaced communities in Burma;
— develop strategies to foster
collaboration among all organisations providing humanitarian services
on both sides of the border;
— take a no tolerance stance on
the human rights abuses perpetrated by the military regime and
develop policy to increase pressure on the regime to halt these
abuses; and
— not support government development
projects which are likely to result in human rights abuses.
WHO WE
ARE
6. We represent a group of organisations
based in Thailand working to provide quality health care to Burmese
people displaced as a result of SPDC actions. We are: Mae Tao
Clinic, The Back Pack Health Workers Team and Burma Medical Association
(further information regarding our organisations is provided at
the end of this document). Mae Tao Clinic is based in Mae Sot,
Thailand and provides health care to Burmese migrant workers residing
in Thailand, as well as Burmese people who cross the border seeking
our health care. It also serves as a training centre for health
workers from ethnic border regions of Burma who then return to
their areas to set up their own community health services. The
Back Pack Health Workers Team provides mobile health care in areas
where clinics cannot be established due to the affects of war
and the remoteness of villages. Their target population are Internally
Displaced Populations. They visit their villages regularly and
train village health volunteers to increase access to health education
and basic health treatment. The Burma Medical Association is an
association of health professionals from Burma who work together
to develop health worker training curriculum, health policy and
to provide support to clinics in rural border areas in both ceasefire
and non ceasefire areas, run by ethnic health organisations or
communities.
7. All of us have our administrative offices
in Thailand rather than Burma and work cross border from Thailand.
We coordinate our efforts to provide health care to displaced
people from Burma by holding regular meetings, standardising monitoring
and evaluation methods, sharing health information and standardising
health worker trainings.
GOVERNMENT APPROVED
PROGRAMMES DO
NOT PROVIDE
FOR THE
MOST VULNERABLE
POPULATIONS
8. We are submitting this document to emphasise
that there are ways to address the humanitarian crisis in Burma
that do not involve the military regime. Today, despite record
energy sales and foreign exchange earnings, the junta has chosen
to move its capital for lack of rational reason, purchase more
military hardware, and expand its war against perceived enemies,
particularly ethnic minorities living along the country's frontiers.
War and widespread abuses of civilians by the Burmese military
regime have driven at least one million to live as IDPs and 350,000
into forced relocation camps. Another 150,000 live in nine official
refugee camps in Thailand while perhaps another two million work
as migrant workers, most of them without documents. The State
Peace and Development Programme (SPDC) provides nothing for these
people and denies their existence. These populations account for
some of the worst health statistics internationally, far worse
than Burma's official figures.
9. The following tables show the demographics
of the populations living in Eastern Burma in comparison to those
in Thailand. Notably absent are 15-25 year old men. In this age
range the male: female ratio is only 0.88 a ratio most commonly
found in prolonged conflict areas. The other striking aspect of
the graph for Eastern Burma is the triangular shape, showing many
children but with the age range rapidly narrowing. Only 1.38%
are over 65 years. This is usually seen in areas with high birth
rates and high death rates which generally indicates low life
expectancy.
In a survey conducted by the Back Pack Health Workers Team in Eastern Burma, the following mortality data was collected:
| Infant Mortality Rates (per 1,000 live births)
| Under five Mortality Rates (per 1,000 live births)
|
| Eastern Burma conflict zones | 91
| 221 |
| Burma national rates (UNICEF) | 76
| 106 |
| Thailand | 18 | 21
|
| Angola | 154 | 260
|
| Congo (DRC) | 129 | 205
|
10. These populations cannot be accessed through government
approved programmes. They spend their lives fleeing SPDC's troop
movements, forced labour, forced relocations, landmines and a
host of well documented human rights abuses. Perhaps one in five
children will not live to see age five, and one in 12 women will
die from pregnancy-related complications, and over half of all
deaths are from malaria. Malnutrition and landmine injuries are
rife, as crops are seized and destroyed by the Burmese military,
forcing villagers to forage in the jungles. The humanitarian health
crisis in these areas is inextricably linked to the human rights
abuses perpetrated by the regime, as well as misgovernance and
lack of commitment to the welfare of its populations.
11. The Back Pack team found that families who had been
forced to move have:
| Outcome | Increased Risk
|
| Child death | >2 times |
| Child malnutrition | >3 times
|
| Landmine injury | >4 times
|
Families with poor food security have:
| Outcome | Increased Risk
|
| Overall mortality | 1.5 times
|
| Child malnutrition | 4 times
|
| Severe child malnutrition | 2 times
|
| Landmine injury/death | 4 times
|
| Malaria | 1.7 times |
12. The following table shows that one in 12 women are
likely to die in childbirth, a figure more akin to other countries
facing humanitarian disasters, once again illustrating the impact
of prolonged civil war. With a functioning health system most
maternal death is preventable.
| MMRper 100,000 live births
| Lifetime Risk of Maternal Death (1 in xx)
|
| Eastern Burma conflict zones | 1,000-1,200
| 12 |
| Burma | 360 | 75
|
| Thailand | 44 | 900
|
| Congo | 990 | 13
|
| Somalia | 1,100 | 10
|
| Rwanda | 1,400 | 10
|
13. This information clearly reveals that without addressing
the human rights abuses and lack of access to health care of the
most vulnerable populations a sustainable solution to the crisis
facing Burma right now cannot be reached.
14. Ethnic groups are affected differently by displacement.
The two main causes of displacement are areas affected by civil
war and areas affected by SPDC development projects. Many development
projects happen in ceasefire areas. Around mega development sites,
displacement rates are always high, Karen River Watch found that
in Eastern Papun District around the site of the planned Salween
Dam, "210 villages have been destroyed, and villagers forcibly
relocated to 31 relocation sites, where movement has been strictly
controlled, and villagers are subject to forced labour and other
human rights abuses". Research by the Back Pack Health Workers
Team indicates that although rates of displacement are higher
in war affected areas, rates of forced labour are much higher
in ceasefire areas, as the SPDC has more solid control of these
areas.
15. Mae Tao Clinic has seen increases every year in the
numbers of people accessing its services (see table: annual caseload
in 2006 was 79,096). In the last couple of years Mae Tao Clinic,
has seen a slight reduction in the number of migrants residing
in Thailand who are accessing the services, and an increase in
the number of people crossing the border from Burma for health
care. This is likely to reflect a slight improvement in services
for migrant workers residing in Thailand, but also indicates the
difficulties that people in Burma have in accessing health services.
The cases that cross the border from Burma to access Mae Tao Clinic's
services, make up the majority of cases in our inpatients departments
requiring intensive care. The journey from Burma to Thailand to
access health services is difficult, expensive and dangerous.
But for many it is the only option.
| Health Service | Number
| Percentage come form Burma |
| Total Visits | 107,137 |
48% |
| Referral | 675 | 66%
|
| Blood Transfusion | 1,480 |
71% |
| Tubal Ligation | 177 | 72%
|
| Eye Surgery | 274 | 86%
|
| Malaria (PF) | 6,088 | 75%
|
| Severe Malnutrition | 47 |
61% |
| ANC Client | 4,069 | 29%
|
| Delivery Admission | 1,798 |
40% |
16. The caseload of cross-border health seekers represent
the most severe cases. The following table provides some insight
into this. Although the people crossing from Burma represent just
under half of our total cases (in 2003 and 2004, it was less than
40%), the majority of cases needing blood transfusions, with PF
malaria or severe malnutrition have traveled from Burma. Due to
the dangers and expenses that need to be faced on route to Mae
Tao Clinic, patients often wait until they are desperately ill
before making the journey to Thailand. This is a clear reflection
of the lack of government provided health services across the
border.
ALTERNATIVES TO
GOVERNMENT APPROVED
PROGRAMMES
17. Several donors have been supporting effective local
community and civil society organisations that have initiated
programs to provide healthcare and education in cease-fire and
non cease-fire areas, to address the humanitarian crisis. Community
organisations manage their own clinics, mobile health teams and
schools unassisted by the SPDC. As well as the work of the organisations
presenting this document, groups such as the Karen Office for
Relief and Development (KORD), Mon Relief and Development Committee,
and Karenni Social Welfare and Development Committee provide food
relief, and work with communities to organize their own village
development. Ethnic women's organisations provide vocational skills
training, literacy training, health education and relief to women
and children living under the regime. The women's organisations
have extensively documented the human rights abuses perpetrated
by the military against women living in ethnic areas of Burma
and distributed the information internationally. The Karen Teachers
Working Group provides teacher training and support for hundreds
of schools for children living in internally displaced areas.
Ethnic health organisations have established clinics for IDPs
in all of the ethnic areas. In ceasefire areas the government
still does not provide health services and communities have found
ways to set up their own health services, either with mobile medical
teams or by establishing rural clinics. In areas affected by mega
development projects such as the Salween Dam project, gas pipelines
and mining, communities in Shan, Karenni, Karen, Mon, Kachin and
Arakan State have organized themselves to document the human rights
abuses, protest against the loss of homes and livelihoods and
to notify the international community of the atrocities and abuses
always associated with this kind of false development in Burma.
18. Donors should increase their support for these organisations
to help improve the livelihoods of the most vulnerable populations.
The Burmese government in general refuses any outside involvement
in its border areas and does not allow access to war affected
populations by international organisations. Some 40 UN agencies
and international NGOs are operating inside Burma, but few have
direct access to displaced populations. The work of communities
and organisations addressing the needs of IDPs has been going
on for many years, with the support of only a few donors. With
more support, more of the population can be reached. For example,
the ability to set up more back pack teams, clinics, and training
for more health workers.
19. Some donors express concern about the inability to
monitor projects in these areas. Organisations like ours who have
been working to improve the quality of services for many years,
consider effective monitoring and evaluation to be integral to
our work. Routine data collection is carried out as well as regular
health assessments. Patients and villagers are interviewed to
assess patients knowledge and attitudes towards health and the
impact of our work on the populations. Focus group discussions
are organised with health workers and patients and health workers
must conduct regular medical record reviews to monitor correct
diagnosis and treatment. Staff from Mae Sot visit fields sites
on a regular basis. Every 6 months, health workers from the field
come to Mae Sot for skills upgrading training, data reporting,
financial reporting and to discuss coordination of services. Photographic
and video documentation is also collected.
20. Our organisations receive technical input from a
variety of local and international institutions on areas such
as health information systems, epidemiology, financial management
and survey design. We partner with Johns Hopkins University, Columbia
University, the International Rescue Committee, Global Health
Access Programme and Thai Public Health to strengthen our work.
21. There are risks involved in supporting cross-border
assistance. Troop movement and displacement create difficulties
in transporting supplies, most supplies have to be transported
on foot as there are no car roads in the areas most affected by
displacement. The security of the entire population in those areas
is not safe, our health workers as part of that population are
as subject to the human rights abuses perpetrated by the regime
in those areas as all of the villagers are living in those areas.
However, to reach these populations, it is essential to have health
workers who are part of the communities, who are displaced with
the communities, and can therefore reach them and provide emergency
health care where necessary.
22. Any donors supporting humanitarian work in Burma
need to include strategies to develop collaboration. The necessary
infrastructure for effective health strategies currently does
not exist. In order for that infrastructure to exist, there must
be coordination between government, civil society organisations
providing services from the border areas and those working inside
and the international donor community. At the moment, coordination
and collaboration are actively discouraged by the regime and NGOs
have to work in isolation. In order to have an effective strategy
to impact the humanitarian crisis all of these actors need to
be involved.
23. It is essential that there is a focus on strengthening
human resources at a grassroots level with community managed organisations,
for the long-term development which is based on the actual needs
of the people.
24. The root causes of the humanitarian crisis in Burma
is the government itself. The government has been failing its
people for decades. Working through the military regime must not
be the only strategy. Some of the most vulnerable populations
cannot be accessed through government approved programmes. The
recent pullout of major organisations, like the International
Committee of the Red Cross and Medecins Sans Frontiers, indicate
that SPDC restrictions are too imposing to do their jobs. The
human rights abuses and misgovernance by the SPDC cannot be ignored.
International donors must bear witness to this. A neutral stance
is unacceptable.
BACKGROUND TO
ORGANISATIONS SUBMITTING
REPORT
Mae Tao Clinic
25. The Mae Tao Clinic has been serving displaced populations
from Burma for 17 years. The Director, Dr Cynthia Maung, has won
international recognition for her humanitarian work in health
for the displaced. The clinic began in 1989 as a small makeshift
clinic to treat the thousand of people who were fleeing from a
massive military crackdown on attempts to establish democracy
and human rights in Burma. Gradually it began to treat the Burmese
people who left Burma seeking work in Thailand in order to provide
for their families struggling to survive under the dire economic
situation in Burma. After some years, families began to join the
individuals coming to Thailand in search of a better life. To
meet this change the clinic added maternal and child health services.
Over the years in response to the growing caseload and changing
populations, the clinic has grown from an emergency health care
provider to a comprehensive health care clinic with 120 inpatient
beds. Aside from our clinical services in Mae Sot, we support
two clinics in Karen State, provide outreach health services in
the migrant areas and support a school and boarding houses for
unaccompanied children.
26. The clinic's second main function is as a training
centre. People from diverse ethnic groups in Burma come to the
clinic to train as health workers, or to upgrade or specialise
their existing health skills. They then return to the border regions
of Burma to provide much needed health services in rural or war
affected areas.
Back Pack Health Worker Team
27. The Back Pack Health Worker Team (BPHWT) has been
providing primary health care in ethnic armed conflict areas and
rural areas, where access to healthcare is otherwise unavailable.
The BPHWT provides a range of medical care, community health education
and prevention, and maternal and child healthcare services to
internally displaced persons in Burma. Doctors and health workers
from the Karen, Karenni, and Mon States established the BPHWT
in 1998. At the beginning of establishing BPHWT, there were 32
backpack teams with 120 health workers. The number of Back Pack
Teams has gradually increased. There are currently 76 teams with
between two to five health workers in each team, who deliver a
range of health care programs to a target population of 150,000
displaced people. The BPHWT aims to equip people with the skills
and knowledge necessary to manage and address their own health
problems, while working towards long-term sustainable development.
The following table documents the morbidity rates in the
areas where the Back Pack Health Workers Teams work and how their
work has impacted on the populations:
Burma Medical Association
28. The Burma Medical Association (BMA) was founded in
Karen State, Burma, in June 1991 by a group of medical professionals
from Burma. BMA serves as a leading body in the coordination of
public health policy and promotion of health care among refugees,
migrants, and internally displaced persons from Burma. Since its
inception, BMA has provided medical and first aid trainings to
community health workers and mobile medical teams, community health
education workshops, HIV prevention education, and health educational
materials in appropriate languages. BMA has conducted relief efforts
to provide medicine and basic needs to affected villagers in IDP
areas in Burma. For over five years BMA has coordinated with Mae
Tao Clinic (MTC) to reduce maternal mortality and morbidity among
women from Burma living along the Thai-Burma border. Most recently,
BMA has partnered with Johns Hopkins University's Center for Public
Health and Human Rights to deliver maternal and child health services
in more than 15 clinics in different ethnic areas inside Burma.
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