Memorandum submitted by the Women's Commission
for Refugee Women and Children
1. AGENCY OVERVIEW
1.1 The Women's Commission for Refugee Women
and Children (Women's Commission), founded in 1989. [51]is
the first organization in the United States dedicated solely to
speaking out on behalf of women, adolescents and children uprooted
by armed conflict and persecution. It seeks to improve the lives
of refugee women and children through a vigorous program of research,
technical assistance, public education and advocacy. In 1994 the
Women's Commission put reproductive health for refugees and internally
displaced persons (IDPs) on the international agenda when it released
its groundbreaking study, Refugee Women and Reproductive Health
Care: Reassessing Priorities. Since 1994 the Women's Commission
has collaborated with UN agencies, donors, international and local
nongovernmental organizations (NGOs) and refugees themselves to
advance reproductive health for displaced populations. The Women's
Commission works closely with local organizations on the Thai-Burmese
border and released a comprehensive report, Thai-Burma Border
Reproductive Health Assessment, in 2006.
2. BACKGROUND
2.1 The Burmese military's campaign against
ethnic minorities encompasses a range of abuses: confiscating
cash and goods; forced labour, including the use of human landmine
sweepers; forced relocation and burning of villages and crops;
torture; rape and other forms of sexual violence; and arbitrary
executions. After half-century of civil war in Burma, hundreds
of thousands of people of various ethnic nationalities have been
displaced. Some have faced forced relocations; others flee their
homes and go into hiding, resulting in large numbers of refugees
and IDPs.
2.2 Although numbers of refugees and IDPs
are difficult to confirm, UNHCR estimates that approximately 290,000
refugees have fled Burma, the majority of whom (51%) have sought
refuge in neighbouring Thailand. In addition, an estimated 500,000
to one million people are internally displaced within Burma. It
is significant to note that there is a large IDP population in
Burma in regions other than the border area. The government's
policies have lead to massive dislocation and relocation of people
in many areas, including the central dry zone, and this is rarely
recognised or acknowledged. Many of the returnees, such as the
Rohingyas, are relocated in areas other than their original homelands.
2.3 While the health situation for IDPs
in Burma remains desperate, some improvements have been made in
health services for refugees and forced migrants on the Thai side
of the border. Health services for refugees in the camps are provided
by local and international NGOs and immunization programs have
become well established with standard coverage above 90% in most
camps.
2.4 An outstanding health need on both sides
of the border is that of sexual and reproductive health (SRH).
SRH is often inadequately addressed in humanitarian response,
and the situation on the Thai-Burmese border is no exception.
High rates of maternal mortality among IDPs are a consequence
of inadequate access to modern contraception methods, emergency
obstetric care, safe abortion services and post-abortion care.
Thailand and Burma also suffer from the second and third highest
levels of HIV prevalence in South-East Asia respectively. [52]In
addition, the Burmese military have employed systematic mass rape
as a weapon of war. [53]This
submission pays particular attention to the sexual reproductive
health needs of Burmese displaced by conflict.
3. REFUGEE SRH
NEEDS
3.1 The Burmese who have fled to Thailand,
primarily from the Karen, Karenni, Mon and Shan ethnic groups,
as well as pro-democracy activists, number approximately 150,000.
They live either in one of nine refugee camps along the border
area or are dispersed outside the camps along the Thailand border
across from their respective states in Burma. Approximately one-third
of these migrants are registered with the Thai government for
work permits and health insurance, and the remainder are subject
to deportation efforts.
3.2 Inside the Thai-border camps
SRH services for refugees in the Thai camps
have significantly improved since the late 1990s. In general,
adequate safe motherhood services are available within the camps
with high antenatal coverage and most deliveries attended by a
trained attendant. In addition, emergency obstetric care is available
in most sites 24 hours a day, seven days a week. Although a range
of family planning options is available, cultural constraints
and lack of awareness among the population keep user rates low.
The newer technical areas of sexually transmitted infections,
including HIV/AIDS (with the exception of comprehensive HIV/AIDS
programming in Mae La camp) and gender-based violence (GBV) are
the least developed of the services available in the Thai border
camps.
3.3 Burmese migrants outside the refugee camps
However, for Burmese refugees and migrants outside
of the camps but still within the Thai border, access to health
services is far more restricted. This is partly because many of
the refugees lack the work permits that would qualify them for
Thai health insurance. Registering with the Thai government is
prohibitively expensive for Burmese migrants and awareness that
registration confers health entitlements is low. Even those who
are able to register suffer from a lack of information about available
health services, often exacerbated by language barriers. Thailand
is also in breach of international agreements (the International
Covenant on Civil and Political Rights and the Convention on the
Rights of the Child) by denying citizenship to the children of
Burmese migrants in Thailand. This leaves the infants of Burmese
refugees without access to public health services or education.
3.3a Consequently, although NGOs, international
NGOs and the Thai Ministry of Public Health (MOPH) have been providing
health services to Burmese refugees in Thailand, particularly
since 2000, migrant populations—especially those outside
the refugee camps—have very limited access to even the most
basic services.
3.3b One of the ramifications is unnecessary
levels of extremely ill migrants in tertiary care centres, where
the MOPH responds to migrants' needs for critical care. This puts
undue strain on MOPH resources since critical illness can often
be prevented with access to less expensive basic services. For
example, the lack of access to family planning results in high
levels of migrant women suffering the trauma of unwanted pregnancies
and unsafe abortion, with subsequent referrals to Thai hospitals
for expensive emergency obstetrics and post-abortion care.
3.3c There is also a particular need for
SRH education. Many Burmese refugees have had no prior sexual
or SRH education and know little about basic sexual anatomy, physiology,
behaviour and contraception to safeguard their health. Ignorance
about HIV/AIDS and its causes is also widespread. Among the most
vulnerable are adolescents, particularly girls, who have left
Burma and have become trapped in sex-work in Thailand. Some are
forcibly recruited by brothels and others seek sex-work in order
to raise money for their families' survival needs.
3.3d Linked to this issue of SRH education
is the fact that in the absence of modern methods of birth control
or safe abortion, Burmese women adopt unsafe practices such as
taking home remedies from the local market, drinking alcohol,
inserting sticks and other objects in the uterus and severe pelvic
pummelling. The results of these extreme measures are reflected
in the high number of women presenting at local clinics and Thai
hospitals with life-threatening complications of unsafe abortions,
such as infection and haemorrhage.
4. IDP SRH NEEDS
4.1 Ethnic minority groups residing inside
the Burma border and in the remote interior of Burma live in constant
fear of military oppression, and their basic human right to health
does not exist. The populations' health status in these areas
is known to be appalling, but due to volatile and constantly changing
circumstances, accurate figures and information are almost impossible
to obtain.
4.2 Some hospitals and clinics are located
in IDP-populated areas, but they cannot serve all in need of care
and they tend to lack medicines and laboratory facilities. Limited
health services are provided in ethnic minority areas of the Thai-Burma
border by a few in-country organizations and by 70 Backpack Health
Worker Teams (BPHWT) comprising two medical assistants and a traditional
birth attendant (TBA). The BPHWTs provide preventive and curative
health services, at great peril to their own lives from landmine
injuries and military attacks, in 15 IDP areas of Burma where
government services are not available and international NGOs are
not allowed to go. SRH is often overlooked, although the needs
are great.
4.3 WHO and UNICEF report very high maternal
mortality and HIV infection rates, concentrated in the east and
south, along the Thai border. Maternal mortality in Burma is estimated
at 360 per 100,000 live births4[54]
and this figure is much higher for IDP women and for those living
in remote areas. A BPHWT survey found that only one in three IDP
women in Burma live within two hours of antenatal care and life-saving
emergency obstetric care.
4.4 It is thought that about half of maternal
mortality is related to complications of abortion, with 10% of
IDP women surveyed by BPHWTs reporting having induced an abortion
at home. Additionally, modern methods of contraception are not
widely used. UNFPA estimates that about 33% of reproductive-age
women use modern contraception, which indicates the potentially
huge impact that contraception distribution could have in reducing
maternal mortality. [55]It
is important that programmes for family planning go beyond condom
distribution since women are not often able to insist on condom
use during intercourse, particularly given high levels of sex-work
and sexual violence.
4.5 The HIV situation in Burma can only
be speculated on as information is controlled and closely held
by the government. Various prevalence studies have resulted in
vastly different estimates, ranging from 1 to 3.5% of the adult
population being infected. Heterosexual transmission, IV drug
use and infected blood supplies appear to account for a majority
of the transmissions. Access to condoms, voluntary counselling
and testing and preventative education are very rare.
5. GENDER-BASED
VIOLENCE
5.1 Rape and other forms of sexual violence
are well documented as widespread weapons of war viciously used
by the Burmese army against local women and girls.[56],[57]
,[58]
,[59]
Women and girls often flee Burma because they have been raped
or to escape being raped. Rape and other forms of sexual violence
have been used as weapons of war by the Burmese army against Burma's
ethnic minority women for more than 50 years and have been integral
parts of the SPDC's campaign to "Burmanize" and subjugate
the ethnic minority population. Women tell of rape during flight,
in the course of incarceration in military camps, during forced
labour and while farming. The SPDC has refuted the reports of
rape against ethnic women and despite the number of international
human rights instruments to which it is obligated to comply, no
action is expected to be taken to end the widespread violence
against women.
5.2 Those who have survived this brutality
in Burma and made their way to Thailand are still not safe from
GBV. Lack of legal protection for Burmese refugees and migrants
contributes to abuse and violence wielded by Thai officials at
checkpoints and border crossings, by police and military in and
near refugee camps, brothels and detention centres, by Thai citizens
in villages and by factory bosses in exploitive work environments.
In addition, an estimated 80% of the commercial sex worker population
in northern Thailand is Burmese, with 40,000 Burmese girls and
women forced into Thailand's sex industry each year. [60]
5.3 With the exception of the refugee camps,
where women who report GBV can be referred to hospitals, the lack
of services for women who have suffered from GBV—including
emergency contraception to prevent pregnancy and post-exposure
prophylaxis to prevent HIV transmission—is a major shortcoming
of humanitarian assistance on both sides of the border.
6. RECOMMENDATIONS
6.1 On the Thai side of the border, a stark
divide exists between those with access to health services due
to residence in refugee camps and/or Thai work permits, and those
without. On the Burmese side, access to health services remains
minimal. Maternal mortality, HIV/AIDS and GBV should be prioritised
as areas for new interventions on both sides of the border.
6.2 International, national and local organizations
should work together to support comprehensive education for ethnic
community leaders about SRH and gain their support for condom
availability, for all men, women and youth, not just married couples,
to prevent the transmission of sexually transmitted infections
including HIV/AIDS and to address other controversial SRH issues,
such as adolescent SRH and emergency contraception. All organizations
including: community groups and leaders, local and international
NGOs, MOPH and UN agencies should increase coordination and collaboration
at all levels to support the provision of SRH services to migrants,
refugees and IDPs in Burma. One organization should establish
an SRH task force representing community groups and other local,
national and international organizations to collaboratively establish
standard SRH protocols and a training curriculum; and conduct
training workshops on RH education and services including clinical
care, adolescent SRH and program monitoring and evaluation. All
organizations should seek to increase funding for SRH services.
6.3 Donors and NGOs should support the BPHWTs
to increase the number of stationary referral centres in the most
stable IDP areas for more comprehensive safe motherhood programming,
including safe blood transfusion, oxytoxic drugs, manual vacuum
aspiration (MVA) and support for emergency transport of women
requiring caesarean sections. Donors, in particular DFID, and
NGOs should support the Mae Tao Clinic which has strong capacity
for providing SRH to IDP on the Burmese side of the border. MTC
maintains two primary healthcare outpatient and inpatient clinics
for populations inside Burma and also partners with the BPHWTs
to provide health seminars, workshops, and trainings every six
months. This would support DFID's excellent decision to allow
funding for activities on the Burmese side of the border in an
effort to support cross-border assistance. UNHCR and donors should
increase funding and technical support to local NGOs to increase
their capacity to provide medical, psychosocial and legal care
for survivors of GBV and to support education about human rights.
Additional support is needed for safe houses, job skills training,
education and income generation opportunities for women and girls
who have survived GBV, including rape, sexual exploitation, commercial
sex work and trafficking. Increased funding for family planning
is also essential.
6.4 The Thai government must reduce barriers
to health care for Burmese migrants in Thailand. Registration
fees need to be lowered and greater information dissemination
efforts are required. Importantly, the children of Burmese refugees
should be issued Thai birth certificates. DFID should encourage
the Thai government to take these steps. Levers to be used include:
— Financial support for meeting
the health needs of greater numbers of Burmese migrants.
— Thailand's commitments to the
Conventions on the Rights of the Child and the International Covenant
on Civil and Political Rights.
— The fact that denying basic
health care to thousands of Burmese migrants, far from saving
costs, has led to increased expenditure on more costly health
services for migrants with dire health needs.
51 The Women's Commission is legally part of the International
Rescue Committee, a non-profit 501(c)(3) organization. The Women's
Commission receives no direct financial support from the IRC. Back
52
UNFPA State of the World Population, 2006. Back
53
Shan Women's Action Network and Shan Human Rights Foundation,
License to Rape: The Burmese Military Regime, May 2002. Back
54
UNFPA, State of the Word Population, 2006. Back
55
Ibid. Back
56
Shan Women's Action Network and Shan Human Rights Foundation,
License to Rape: The Burmese Military Regime, May 2002. Back
57
Refugees International, No Safe Place: Burma's Army and the
Rape of Ethnic Women, April 2003. Back
58
Women's League of Burma, System of Impunity, 2004. Back
59
Women's League of Chinland, Hidden Crimes against Chin Women,
2007. Back
60
Human Rights Documentation Unit and Burmese Women's Union, Cycle
of Suffering, 2000. Back
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